Objective: With routine use of non-invasive methods to assess the internal carotid artery, it becomes increasingly important to clarify the diagnostic accuracy of transcranial Doppler (TCD) ultrasound and magnetic resonance angiography (MRA) compared with intra-arterial digital subtraction angiography (iaDSA) for the detection of collateral flow via the major intracerebral collateral branches. Subjects and Methods: In a prospective study, we compared TCD via a temporal bone window and MRA (flow direction sensitive phase contrast and time of flight) examinations of the intracranial collateral flow with iaDSA in a cohort of 97 consecutive patients with recent transient or minor disabling cerebral ischaemia associated with an occlusion of the carotid artery (38 contralateral stenosis >70%). Results: iaDSA allowed the evaluation of collateral flow via the anterior and posterior circle of Willis in 97 and 67 patients, respectively, TCD in 76 of 97 and 66 of 67 patients, MRA in 95 of 97 and 66 of 67 patients. MRA and TCD collateral flow measurements via the anterior part of the circle of Willis yielded a sensitivity of 83 and 82%, a specificity of 77 and 79% and a similar accuracy of 80%. MRA and TCD collateral flow measurements via the posterior communicating artery yielded a sensitivity of 33 and 76%, a specificity of 88 and 47% and an accuracy of 47 and 68%. Conclusion: As compared with iaDSA, combined MRA and TCD has a moderate to good diagnostic value for the examination of intracranial collateral flow in patients with symptomatic carotid occlusion.

1.
Kent KC, Kuntz KM, Patel MR, Kim D, Klufas RA, Whittemore AD, Polak JF, Skillman JJ, Edelman RR: Perioperative imaging strategies for carotid endarterectomy: an analysis of morbidity and cost-effectiveness in symptomatic patients. JAMA 1995;274:888–893.
2.
Nederkoorn PJ, van der Graaf Y, Hunink MG: Duplex ultrasound and magnetic resonance angiography compared with digital subtraction angiography in carotid artery stenosis: a systematic review. Stroke 2003;34:1324–1332.
3.
Barth A, Arnold M, Mattle HP, Schroth G, Remonda L: Contrast-enhanced 3-D MRA in decision making for carotid endarterectomy: a 6-year experience. Cerebrovasc Dis 2006;21:393–400.
4.
Malferrari G, Bertolino C, Casoni F, Zini A, Sarra VM, Sanguigni S, Pratesi M, Lochner P, Coppo L, Brusa G, Guidetti D, Cavuto S, Marcello N: The eligible study: ultrasound assessment in acute ischemic stroke within 3 hours. Cerebrovasc Dis 2007;24:469–476.
5.
Fujimoto S, Toyoda K, Kishikawa K, Inoue T, Yasumori K, Ibayashi S, Iida M, Okada Y: Accuracy of conventional plus transoral carotid ultrasonography in distinguishing pseudo-occlusion from total occlusion of the internal carotid artery. Cerebrovasc Dis 2006;22:170–176.
6.
Mount LA, Taveras JM: Arteriographic demonstration of the collateral circulation of the cerebral hemispheres. AMA Arch Neurol Psychiatry 1957;78:235–253.
7.
Vernieri F, Pasqualetti P, Matteis M, Passarelli F, Troisi E, Rossini PM, Caltagirone C, Silvestrini M: Effect of collateral blood flow and cerebral vasomotor reactivity on the outcome of carotid artery occlusion. Stroke 2001;32:1552–1558.
8.
Kappelle LJ, Klijn CJ, Tulleken CA: Management of patients with symptomatic carotid artery occlusion. Clin Exp Hypertens 2002;24:631–637.
9.
Patrux B, Laissy JP, Jouini S, Kawiecki W, Coty P, Thiebot J: Magnetic resonance angiography (MRA) of the circle of Willis: a prospective comparison with conventional angiography in 54 subjects. Neuroradiology 1994;36:193–197.
10.
Stock KW: Anatomic evaluation of the circle of Willis: MR angiography versus intraarterial digital subtraction angiography. AJNR Am J Neuroradiol 1996;7:1495–1499.
11.
Baumgartner RW, Baumgartner I, Mattle HP, Schroth G: Transcranial color-coded duplex sonography in the evaluation of collateral flow through the circle of Willis. AJNR Am J Neuroradiol 1997;18:127–133.
12.
Klotzsch C, Popescu O, Berlit P: Assessment of the posterior communicating artery by transcranial color-coded duplex sonography. Stroke 1996;27:486–489.
13.
Muller M, Hermes M, Bruckmann H, Schimrigk K: Transcranial Doppler ultrasound in the evaluation of collateral blood flow in patients with internal carotid artery occlusion: correlation with cerebral angiography. AJNR Am J Neuroradiol 1995;16:195–202.
14.
Liebeskind DS: Collateral circulation. Stroke 2003;34:2279–2284.
15.
Bamford JM, Sandercock PAG, Warlow CP, Slattery J: Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1989;20:828.
16.
Fox AJ: How to measure carotid stenosis. Radiology 1993;186:316–318.
17.
Vriens EM, Wieneke GH, Hillen B, Eikelboom BC, van Huffelen AC, Visser GH: Flow redistribution in the major cerebral arteries after carotid endarterectomy: a study with transcranial Doppler scan. J Vasc Surg 2001;33:139–147.
18.
Pernicone JR, Siebert JE, Laird TA, Rosenbaum TL, Potchen EJ: Determination of blood flow direction using velocity-phase image display with 3-D phase-contrast MR angiography. AJNR Am J Neuroradiol 1992;13:1435–1438.
19.
Schomer DF, Marks MP, Steinberg GK, Johnstone IM, Boothroyd DB, Ross MR, Pelc NJ, Enzmann DR: The anatomy of the posterior communicating artery as a risk factor for ischemic cerebral infarction. N Engl J Med 1994;330:1565–1570.
20.
Simel DL, Samsa GP, Matchar DB: Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol 1991;44:763–770.
21.
Liebeskind DS: Collateral therapeutics for cerebral ischemia. Expert Rev Neurother 2004;4:255–265.
22.
Waaijer A, van Leeuwen MS, van der Worp HB, Verhagen HJ, Mali WP, Velthuis BK: Anatomic variations in the circle of Willis in patients with symptomatic carotid artery stenosis assessed with multidetector row CT angiography. Cerebrovasc Dis 2007;23:267–274.
23.
Hoksbergen AWJ, Legemate DA, Ubbink DT, Jacobs MJHM: Collateral variations in circle of Willis in atherosclerotic population assessed by means of transcranial color-coded duplex ultrasonography. Stroke 2000;31:1656–1660.
24.
Halsey JH: Effect of emitted power on waveform intensity in transcranial Doppler. Stroke 1990;21:1573–1578.
25.
Ross MR, Pelc NJ, Enzmann DR: Qualitative phase contrast MRA in the normal and abnormal circle of Willis. AJNR Am J Neuroradiol 1993;14:19–25.
26.
Edelman RR, Mattle HP, O’Reilly GV, Wentz KU, Liu C, Zhao B: Magnetic resonance imaging of flow dynamics in the circle of Willis. Stroke 1990;21:56–65.
27.
Furst G, Steinmetz H, Fischer H, Skutta B, Sitzer M, Aulich A, Kahn T, Modder U: Selective MR angiography and intracranial collateral blood flow. J Comput Assist Tomogr 1993;17:178–183.
28.
Van Laar PJ, van der Grond J, Mali WP, Hendrikse J: Magnetic resonance evaluation of the cerebral circulation in obstructive arterial disease. Cerebrovasc Dis 2006;21:297–306.
29.
Hoksbergen AW, Majoie CB, Hulsmans FJ, Legemate DA: Assessment of the collateral function of the circle of Willis: three-dimensional time-of-flight MR angiography compared with transcranial color-coded duplex sonography. AJNR Am J Neuroradiol 2003;24:456–462.
30.
Nornes H, Sorteberg W, Nakstad P, Bakke SJ, Aaslid R, Lindegaard KF: Haemodynamic aspects of clinical cerebral angiography: concurrent two vessel monitoring using transcranial Doppler ultrasound. Acta Neurochir (Wien) 1990;105:89–97.
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