Abstract
IntroductionPatients with severe, symptomatic carotid stenosis can have their subsequent stroke risk reduced by surgical intervention if performed soon after a transient ischemic attack (TIA) or stroke. Patients presenting to an emergency department (ED) without computed tomography angiography (CTA) with TIA/stroke, may require transfer to another hospital for imaging to rule out carotid artery stenosis. The objective of this study was to determine the test characteristics of carotid artery point-of-care ultrasound (POCUS) in detecting greater than 50% stenosis in patients presenting with TIA/stroke.MethodsWe conducted a prospective cohort study on a convenience sample of adult patients presenting to a comprehensive stroke centre with TIA or stroke between June–October 2017. Carotid POCUS was performed. Primary outcome measure, stenosis ≥ 50%, was determined by the final radiology report of CTA. A blinded POCUS expert separately reviewed the archived carotid POCUS scans. We calculated sensitivity and specificity for stenosis ≥ 50%.ResultsWe conducted POCUS on 75 patients, of which 70 were included in our analyses. Of those 70, 14.3% were diagnosed with greater than 50% stenosis. Carotid POCUS performed as follows: sensitivity 70.0% (95% confidence interval [CI], 34.8%–93.3%); specificity 86.7% (95% CI, 75.4%–94.1%); positive likelihood ratio (LR +) 5.3 (95% CI, 1.2–9.3); negative likelihood ratio (LR−) 0.4 (95% CI, 0.0–0.7). The inter-rater reliability between POCUS performer interpretation and expert interpretation had moderate agreement (k = 0.68). Scans took a mean 6.2 ± 2.2 minutes to complete.ConclusionCarotid POCUS has low to moderate association with CTA for detection of carotid artery stenosis ≥ 50%. Further research and investigation is needed prior to widespread use of carotid POCUS in patients with acute cerebral ischemia. Additionally, external validity is likely affected by availability of training, maintenance of competency, and experience in more rural centres.
Highlights
Patients with severe, symptomatic carotid stenosis can have their subsequent stroke risk reduced by surgical intervention if performed soon after a transient ischemic attack (TIA) or stroke
Patients presenting to an emergency department (ED) without computed tomography angiography (CTA) with TIA/stroke, may require transfer to another hospital for imaging to rule out carotid artery stenosis
Carotid point-of-care ultrasound (POCUS) has low to moderate association with CTA for detection of carotid artery stenosis ≥ 50%
Summary
Symptomatic carotid stenosis can have their subsequent stroke risk reduced by surgical intervention if performed soon after a transient ischemic attack (TIA) or stroke. Patients presenting to an emergency department (ED) without computed tomography angiography (CTA) with TIA/stroke, may require transfer to another hospital for imaging to rule out carotid artery stenosis. The objective of this study was to determine the test characteristics of carotid artery point-of-care ultrasound (POCUS) in detecting greater than 50% stenosis in patients presenting with TIA/stroke. While TIA patients, by definition, fully recover, up to 23% will go on to have a subsequent stroke with 92% occurring in the following seven days.[1,2,3] Carotid artery stenosis is a well-established etiology of TIA and stroke.[4] Secondary stroke and death risk can be significantly reduced with carotid revascularization. Intervention is most beneficial for patients with 70-99% stenosis, with maximal benefit if completed within 14 days of the ischemic event and no further benefit after three months.[1,2,3,5] There is some benefit for patients with moderate stenosis (50-69%); the benefit is only present if surgery is performed within two weeks of the cerebral ischemic event.[1,2,3,5]
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