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Meta-Analysis
. 2022 Jul 11;7(7):CD013172.
doi: 10.1002/14651858.CD013172.pub2.

Duplex ultrasound for diagnosing symptomatic carotid stenosis in the extracranial segments

Nicolle Cassola  1 , Jose Cc Baptista-Silva  2 , Luis Cu Nakano  1 , Carolina Dq Flumignan  1 , Ricardo Sesso  3 , Vladimir Vasconcelos  1 , Nelson Carvas Junior  4 , Ronald Lg Flumignan  1
Affiliations
Meta-Analysis

Duplex ultrasound for diagnosing symptomatic carotid stenosis in the extracranial segments

Nicolle Cassola et al. Cochrane Database Syst Rev. .

Abstract

Background: Carotid artery stenosis is an important cause of stroke and transient ischemic attack. Correctly and rapidly identifying patients with symptomatic carotid artery stenosis is essential for adequate treatment with early cerebral revascularization. Doubts about the diagnostic value regarding the accuracy of duplex ultrasound (DUS) and the possibility of using DUS as the single diagnostic test before carotid revascularization are still debated.

Objectives: To estimate the accuracy of DUS in individuals with symptomatic carotid stenosis verified by either digital subtraction angiography (DSA), computed tomography angiography (CTA), or magnetic resonance angiography (MRA).

Search methods: We searched CRDTAS, CENTRAL, MEDLINE (Ovid), Embase (Ovid), ISI Web of Science, HTA, DARE, and LILACS up to 15 February 2021. We handsearched the reference lists of all included studies and other relevant publications and contacted experts in the field to identify additional studies or unpublished data.

Selection criteria: We included studies assessing DUS accuracy against an acceptable reference standard (DSA, MRA, or CTA) in symptomatic patients. We considered the classification of carotid stenosis with DUS defined with validated duplex velocity criteria, and the NASCET criteria for carotid stenosis measures on DSA, MRA, and CTA. We excluded studies that included < 70% of symptomatic patients; the time between the index test and the reference standard was longer than four weeks or not described, or that presented no objective criteria to estimate carotid stenosis.

Data collection and analysis: The review authors independently screened articles, extracted data, and assessed the risk of bias and applicability concerns using the QUADAS-2 domain list. We extracted data with an effort to complete a 2 × 2 table (true positives, true negatives, false positives, and false negatives) for each of the different categories of carotid stenosis and reference standards. We produced forest plots and summary receiver operating characteristic (ROC) plots to summarize the data. Where meta-analysis was possible, we used a bivariate meta-analysis model.

Main results: We identified 25,087 unique studies, of which 22 were deemed eligible for inclusion (4957 carotid arteries). The risk of bias varied considerably across the studies, and studies were generally of moderate to low quality. We narratively described the results without meta-analysis in seven studies in which the criteria used to determine stenosis were too different from the duplex velocity criteria proposed in our protocol or studies that provided insufficient data to complete a 2 × 2 table for at least in one category of stenosis. Nine studies (2770 carotid arteries) presented DUS versus DSA results for 70% to 99% carotid artery stenosis, and two (685 carotid arteries) presented results from DUS versus CTA in this category. Seven studies presented results for occlusion with DSA as the reference standard and three with CTA as the reference standard. Five studies compared DUS versus DSA for 50% to 99% carotid artery stenosis. Only one study presented results from 50% to 69% carotid artery stenosis. For DUS versus DSA, for < 50% carotid artery stenosis, the summary sensitivity was 0.63 (95% confidence interval [CI] 0.48 to 0.76) and the summary specificity was 0.99 (95% CI 0.96 to 0.99); for the 50% to 69% range, only one study was included and meta-analysis not performed; for the 50% to 99% range, the summary sensitivity was 0.97 (95% CI 0.95 to 0.98) and the summary specificity was 0.70 (95% CI 0.67 to 0.73); for the 70% to 99% range, the summary sensitivity was 0.85 (95% CI 0.77 to 0.91) and the summary specificity was 0.98 (95% CI 0.74 to 0.90); for occlusion, the summary sensitivity was 0.91 (95% CI 0.81 to 0.97) and the summary specificity was 0.95 (95% CI 0.76 to 0.99). For sensitivity analyses, excluding studies in which participants were selected based on the presence of occlusion on DUS had an impact on specificity: 0.98 (95% CI 0.97 to 0.99). For DUS versus CTA, we found two studies in the range of 70% to 99%; the sensitivity varied from 0.57 to 0.94 and the specificity varied from 0.87 to 0.98. For occlusion, the summary sensitivity was 0.95 (95% CI 0.80 to 0.99) and the summary specificity was 0.91 (95% CI 0.09 to 0.99). For DUS versus MRA, there was one study with results for 50% to 99% carotid artery stenosis, with a sensitivity of 0.88 (95% CI 0.70 to 0.98) and specificity of 0.60 (95% CI 0.15 to 0.95); in the 70% to 99% range, two studies were included, with sensitivity that varied from 0.54 to 0.99 and specificity that varied from 0.78 to 0.89. We could perform only a few of the proposed sensitivity analyses because of the small number of studies included.

Authors' conclusions: This review provides evidence that the diagnostic accuracy of DUS is high, especially at discriminating between the presence or absence of significant carotid artery stenosis (< 50% or 50% to 99%). This evidence, plus its less invasive nature, supports the early use of DUS for the detection of carotid artery stenosis. The accuracy for 70% to 99% carotid artery stenosis and occlusion is high. Clinicians should exercise caution when using DUS as the single preoperative diagnostic method, and the limitations should be considered. There was little evidence of the accuracy of DUS when compared with CTA or MRA. The results of this review should be interpreted with caution because they are based on studies of low methodological quality, mainly due to the patient selection method. Methodological problems in participant inclusion criteria from the studies discussed above apparently influenced an overestimated estimate of prevalence values. Most of the studies included failed to precisely describe inclusion criteria and previous testing. Future diagnostic accuracy studies should include direct comparisons of the various modalities of diagnostic tests (mainly DUS, CTA, and MRA) for carotid artery stenosis since DSA is no longer considered to be the best method for diagnosing carotid stenosis and less invasive tests are now used as reference standards in clinical practice. Also, for future studies, the participant inclusion criteria require careful attention.

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Conflict of interest statement

NC: none known.

JCCBS: none known.

CDQF: none known.

RS: none known.

VV: none known.

NCJ: none known.

LCUN: none known.

RLGF: none known.

Figures

1
1
Longitudinal view of carotid bifurcation with methods of measuring carotid stenosis at angiography A : narrowest ICA diameter
B : normal distal cervical ICA diameter
C : estimated original diameter at the site of the most stenosis
CCA : common carotid artery
ECA : external carotid artery
ECST : European Carotid Surgery Trial
ICA : internal carotid artery
NASCET : North American Symptomatic Carotid Endarterectomy Trial
2
2
Study flow diagram
3
3
Risk of bias and applicability concerns graph: review authors' judgements about each domain presented as percentages across included studies
4
4
Risk of bias and applicability concerns summary: review authors' judgements about each domain for each included study
5
5
Forest plot of paired sensitivity and specificity estimated for studies assessing < 50% carotid artery stenosis with DSA as reference standard
6
6
Summary ROC Plot of studies assessing < 50% carotid artery stenosis with DSA as reference standard
7
7
Forest plot of paired sensitivity and specificity estimated for studies assessing 50‐99% carotid artery stenosis with DSA as reference standard
8
8
Summary ROC Plot of studies assessing 50‐99% carotid artery stenosis with DSA as reference standard
9
9
Forest plot of paired sensitivity and specificity estimated for studies assessing 70‐99% carotid artery stenosis with DSA as reference standard
10
10
Summary ROC Plot of studies assessing 70‐99% carotid artery stenosis with DSA as reference standard
11
11
Forest plot of paired sensitivity and specificity estimated for studies assessing carotid artery occlusion with DSA as reference standard
12
12
Summary ROC Plot of studies assessing carotid artery occlusion with DSA as reference standard
13
13
Forest plot of paired sensitivity and specificity estimated for studies assessing 70‐99% carotid artery stenosis with CTA as reference standard
14
14
Forest plot of paired sensitivity and specificity estimated for studies assessing carotid artery occlusion with CTA as reference standard
15
15
Summary ROC Plot of studies assessing carotid artery occlusion with CTA as reference standard
16
16
Forest plot of paired sensitivity and specificity estimated for studies assessing 70‐99% carotid artery stenosis with MRA as reference standard
17
17
DSA < 50%: Hypothetical cohort of 1000 symptomatic patients assessed for carotid artery stenosis. We considered pretest probability the median prevalence of the included studies (0.46). tp: true positive; fp: false positive; tn: true negative; fn: false negative
18
18
DSA 50‐99%: Hypothetical cohort of 1000 symptomatic patients assessed for carotid artery stenosis. We considered pretest probability the median prevalence of the included studies (0.51). tp: true positive; fp: false positive; tn: true negative; fn: false negative
19
19
DSA 70‐99%: Hypothetical cohort of 1000 symptomatic patients assessed for carotid artery stenosis. We considered pretest probability the median prevalence of the included studies (0.45). tp: true positive; fp: false positive; tn: true negative; fn: false negative
20
20
DSA Occlusion: Hypothetical cohort of 1000 symptomatic patients assessed for carotid artery stenosis. We considered pretest probability the median prevalence of the included studies (0.18). tp: true positive; fp: false positive; tn: true negative; fn: false negative
21
21
CTA occlusion: Hypothetical cohort of 1000 symptomatic patients assessed for carotid artery stenosis. We considered pretest probability the median prevalence of the included studies (0.60). tp: true positive; fp: false positive; tn: true negative; fn: false negative
1
1. Test
DSA < 50%
2
2. Test
DSA 50‐99%
3
3. Test
DSA 50‐69%
4
4. Test
DSA 70‐99%
5
5. Test
DSA Occlusion
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6. Test
CTA 70%‐99%
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7. Test
CTA Occlusion
8
8. Test
MRA 70‐99%
9
9. Test
MRA 50‐99%
See this image and copyright information in PMC

Update of

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Carpenter 1996 {published data only}
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Chen 1998 {published data only}
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Connolly 1985 {published data only}
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Criswell 1998 {published data only}
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Dilley 1986 {published data only}
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Flanigan 1985 {published data only}
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Furst 1999 {published data only}
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Geuder 1989 {published data only}
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Gmelin 1985 {published data only}
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Gortler 1994 {published data only}
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Jogestrand 2002 {published data only}
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Kuhn 1981 {published data only}
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Macheers 1986 {published data only}
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Qureshi 2001 {published data only}
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Ricotta 1987 {published data only}
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References to other published versions of this review

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