Duplex Ultrasonography for the Evaluation of Extracranial Vertebral Artery: A Prospective Comparison With Digital Subtraction Angiography

Duplex Ultrasonography for the Evaluation of Extracranial Vertebral Artery: A Prospective Comparison With Digital Subtraction Angiography.

Up to 20% of ischemic cerebrovascular events involving the posterior circulation are related to vertebral artery (VA) disease (1). Data from the Oxford Vascular Study and St. George Study showed that symptomatic ≥50% VA stenosis was a strong independent predictor of stroke recurrence (2). Furthermore, stroke patients with ≥70% responsible artery stenosis are at a higher risk of stroke recurrence (3–6). Endovascular treatment in extracranial VA stenosis appears safe and beneficial, with low complication rates, when compared to intracranial VA stenosis, which is more suitable for medical therapy (7–11). In patients with symptomatic extracranial VA stenosis, revascularization may be considered for ≥50% stenosis of the lesion in patients with recurrent ischaemic events despite optimal medical management (1). The majority of asymptomatic patients do not require revascularization procedures. However, there are a few groups of asymptomatic patients that have indications for treatment because of their elevated risk of stroke. It includes patients with bilateral VA stenosis ≥70%, or with unilateral VA stenosis ≥70% in the presence of an occluded or hypoplastic contralateral VA, and patients with significant dependence on collateral flow from the posterior circulation, such as in cases of carotid occlusion (12, 13). Therefore, the accurate evaluation of extracranial VA stenosis is particularly important, including ≥50% stenosis and ≥70% stenosis.

Duplex ultrasonography (DUS) is the first-line examination for patients with cerebrovascular disease not only due to its convenience and noninvasiveness but also since it can be used for real-time evaluation at the bedside, especially for critically ill patients. In patients with known VA stenosis, it is reasonable to use DUS to assess stenosis progression and to follow patients after revascularization therapies (1). Currently, Stroke Outcomes and Neuroimaging of Intracranial Atherosclerosis (SONIA) criteria are widely used to predict the intracranial VA stenosis by transcranial Doppler, while there is a lack of consensus on the ultrasonic evaluation of extracranial VA stenosis in clinical practice (14). Only two retrospective studies evaluated ≥70% stenosis of the V1 segment of VA, and they showed conflicting results (15, 16). In addition, there is a paucity of published literature on the ultrasonic evaluation of V2 and V3 segments of VA. Thus, it is necessary to carry out a prospective study with a large sample size to completely evaluate extracranial VA stenosis by DUS.

Therefore, the purpose of this study was to prospectively evaluate extracranial VA stenosis using DUS, with digital subtraction angiography (DSA) as the reference. We aimed to validate the sensitivity and specificity of DUS and assess the optimal thresholds for ≥50% and ≥70% extracranial VA stenosis. Furthermore, the positive predictive value [PPV], negative predictive value [NPV], and accuracy were calculated to thoroughly validate DUS’s efficiency.

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