SUMMARY Duplex scanning prorides real time B-raode images of the carotid bifurcation Teasels along with a single gate pulsed Doppler flow Telocity detector. By using the B-mode output of the duplex system to measure the Doppler angle and spectrum analysis to measure the frequency content of the Doppler signal, instantaneous flow Telocity can be calculated.Mean Telocity at peak systole was calculated retrospecthely in 68 common (CCA) and internal (ICA) carotid arteries of 39 patients who had undergone prior angiography and prospecthely in 30 arteries of 15 healthy young controls. The ratio of mean peak ICA Telocity to mean peak CCA Telocity at systole (VlCA/VCCA) was below 0.8 in all 36 normal arteries and above 1.5 in all 21 high-grade stenoses of 60% or greater diameter reduction. Sixty-one percent of 41 Tessels with less than 10 to 55% diameter redaction had a velocity ratio between 0.8 and 1.5. Only 10% of all ICA's with any stenotic lesion were incorrectly classified as normal. VlCA/VCCA appears to be an accurate Indicator of the degree of ICA stenosis.

The arteriograms of 109 patients with symptomatic cerebral ischemia were analyzed to determine the distribution of extracranial and intracranial vascular abnormalities. In the 66 patients with transient hemispheric or ocular ischemia, potentially embolic lesions were more common than hemodynamically significant lesions (84% versus 50%). In the 29 patients with fixed neurologic deficits, 25% had occlusion of the internal carotid artery on the appropriate side; ulcerated lesions were again more common in the remaining patent arteries than were hemodynamically significant lesions. The major difference between the transient group and the fixed group was the 29% incidence of intracerebral disease or anomaly in the transient group, with similar lesions in 90% of the group with fixed neurologic deficit. Symptoms of cerebral ischemia are more likely to be related to ulceration than to hemodynamically significant lesions. The risk of stroke seems greatest when there is also intracerebral siphon disease or anatomic anomaly of the circle of Willis.

The duplex ultrasonic scanner combines real-time B-mode imaging with a single-gate, variable-range pulsed Doppler. The detection and categorization of the severity of carotid artery atherosclerosis is achieved by performing spectral analysis of the pulsed Doppler velocity signal obtained from vessels of interest. Using this technique, 750 patients with suspected extracranial carotid artery disease were evaluated between January 1978 and January 1980. One hundred thirty-five of these 750 patients (18%) underwent cerebral arteriography performed with biplanar views of the carotid bifurcation. The degree of stenosis was measured independently in these patients and was available for comparison with the results of duplex scanning and spectral analysis. Duplex scanning correctly detected the presence of disease in 252 of 259 carotid arteries studied (97%). The extent of involvement varied from plaques that produced less than 10% diameter reduction to those that resulted in a total occlusion. The technique was less accurate with lesions that produced less than 10% diameter reduction.

ANGIOGRAPHY AND CAROTID ULCERATION/ErteSUMMARY One hundred twenty eight cervical carotid arteriograms were twice viewed by three readers for the evaluation of atherosclerotic disease at the carotid bifurcation. Stenoses were estimated using calipers to the nearest 5% and lesions were qualitatively characterized as smooth, irregular, or ulcerated. The intraobserver correlation coefficient between estimates of percent stenosis was .94 overall and .98 for the internal carotid artery. The average intraobserver variability in estimating percent stenosis was 5.23% for all vessels and 6.04% with a standard deviation of 8.09% for the internal carotid artery. The intraob server percent agreement at a fixed stenosis is denned as the percent of the time one reader on two readings would read at least the fixed percent stenosis among cases that might be read as having the fixed percent stenosis. The intraobserver percent agreement rate for the internal carotid artery was 95.9% at > 0% stenosis, 90.4% for 50% or greater stenosis, and 96.8% for 100% stenosis (total occlusion). The interobserver correlation coefficient between readers was .92 overall and .97 for the internal carotid artery. The absolute difference in percent stenosis between readers was 7.21% for all vessels and 8.64% for the internal carotid artery with a standard deviation of 9.5%. The interobserver agreement rate for the internal carotid artery at > 0% stenosis was 93.0%, 85.4% for 50% or greater stenosis and 96.8% at 100% stenosis. The addition of oblique views had no statistical effect on estimates of percent stenosis but increased the frequency with which irregularity and ulceration were diagnosed in the internal carotid artery. Stroke Vol 14, No. 6, 1983CEREBRAL ANGIOGRAPHY remains the major di agnostic tool in evaluating symptomatic patients with extracranial occlusive disease and is also used as a reference standard for evaluating newer noninvasive diagnostic modalities.1-12 Although major patient man agement decisions and evaluations of new techniques and equipment are based on angiographic interpreta tions, no detailed statistical analysis of observer vari ability has been performed. This study was designed to assess this variability and in addition to evaluate the contribution of oblique views to the characterization of stenotic lesions of the carotid bifurcation. Materials and MethodsThe angiograms of 100 consecutive patients who underwent cerebral angiography which included serial biplane filming of the cervical carotid arteries were reviewed. From this population, 64 cases were select ed on the basis of having AP, lateral and two oblique views of each carotid bifurcation which were of suffi cient technical quality to permit careful evaluation un der normal viewing conditions. AP and lateral films were obtained on 10 by'12 inch Schonander changers with the patient supine. The patient was then rotated en bloc 20 degrees away from the side of the catheter and the filming repeated producing "AP" and "lateral" oblique views. The 20 degree angle of ro...

SUMMARYWe assessed the prognostic value of cardiothoracic ratio and plain film heart volume in relation to other clinical, exercise, hemodynamic and quantitative angiographic variables. Both cardiothoracic ratio and plain film heart volume are highly sensitive, but nonspecific, indicators of abnormal left ventricular end-diastolic volume and ejection fraction. Both variables are univariately important predictors of survival in cohorts of medically and surgically treated heart disease patients. Plain film heart volume significantly adds to the multivariate prediction of prognosis obtained from groups of clinical, exercise, hemodynamic and quantitative angiographic variables. These measurements from the routine chest roentgenogram are sensitive detectors of abnormal left ventricular function or volume and important predictors of long-term survival. The fact that they contribute prognostic information in addition to left ventricular volume and ejection fraction suggests that other cardiac chamber volumes are of prognostic importance.PREVIOUSLY, WE HAVE DEMONSTRATED the significance of left ventricular end-diastolic volume and related variables such as ejection fraction in the prediction of survival of patients with heart disease.', 2 Chikos et al.3 showed a high correlation between total heart volume measured from the standard chest roentgenogram (plain film heart volume) and left ventricular end-diastolic volume measured angiographically in patients with aortic valve disease. In this study we examined the prognostic value of plain film heart volume and cardiothoracic ratio with respect to late survival and compared the prognostic value of these noninvasive parameters with other clinical, exercise, hemodynamic and quantitative angiographic variables frequently obtained in the evaluation of the patient with heart disease.