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Print this pageCAROTID ARTERY STRING SIGN: DOES END DIASTOLIC VELOCITY SUGGEST NEED FOR TREATMENT
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Jonathan N. Bowman, M.D., Alfio Carroccio, M.D., Victoria J. Teodorescu, M.D., Jeffrey W. Olin, D.O., Tikva S. Jacobs, M.D., Peter L. Faries, M.D..
Mount Sinai School of Medicine, New York, NY, USA.
CASS was identified in 0.28% of duplex studies. EDV ranged from undetectable to 231cm/s. The proximal systolic velocity ranged from 12cm/s to 625cm/s with a median of 140cm/s. Seven of the eleven patients with EDV < 135cm/s had occlusions or functional occlusions (no intracranial flow of contrast) on their contrast studies. Two had stenoses extending to the intra-cerebral circulation. One had a successful CEA and one had a successful CAS. In the patients with EDV > 135cm/s, two underwent successful CEAs and one patient refused treatment. The average follow-up period was 11.5 months (1-33 months). One medically treated patient had a non-stroke related death. No patient developed a TIA or stroke during the follow-up period.
CONCLUSIONS: EDV is a measure of cerebral outflow of the ICA. In the setting of a string sign, a low EDV may represent an anatomic configuration not requiring intervention. Medical treatment may be most appropriate in this subset of patients.
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Jonathan N. Bowman, M.D., Alfio Carroccio, M.D., Victoria J. Teodorescu, M.D., Jeffrey W. Olin, D.O., Tikva S. Jacobs, M.D., Peter L. Faries, M.D..
Mount Sinai School of Medicine, New York, NY, USA.
OBJECTIVE: Carotid artery string sign (CASS) is a rare finding. The association with stroke is unclear and indications for treatment need further clarification. We reviewed our institution’s experience with CASS, to investigate whether internal carotid artery (ICA) end-diastolic velocity (EDV) as measured by color duplex ultrasonography was a valid predictor of need for further intervention.
METHODS: From February 2003 to September 2007, 6635 patients underwent duplex ultrasonographic evaluation of their carotid arteries. Fourteen patients were identified as having CASS based on ultrasonographic B mode images, color flow images and power doppler demonstrating a narrow flow jet in the ICA.
RESULTS:
| EDV | Patients (n) | Neurologic Symptoms (Pre-Evaluation) | Imaging | Treatment | Neurologic Symptoms (Post-treatment) |
| < 135 cm/s | 11 | 0% (0/11) | 7- CA, 2 - MRA, 1 - CTA 1 - None | 1 - CEA 1 - CAS 9 - Medical | 0/10 |
| >135 cm/s | 3 | 66.7% (2/3) | 2 - CTA | 2 - CEA 1 - Medical | 0/3 |
| CEA - Carotid Endarterectomy, CAS - Internal Carotid Artery Stent, CA - Cerebral Angiography, MRA - Magnetic Resonance Angiography, CTA - Computed Tomographic Angiography | |||||
CASS was identified in 0.28% of duplex studies. EDV ranged from undetectable to 231cm/s. The proximal systolic velocity ranged from 12cm/s to 625cm/s with a median of 140cm/s. Seven of the eleven patients with EDV < 135cm/s had occlusions or functional occlusions (no intracranial flow of contrast) on their contrast studies. Two had stenoses extending to the intra-cerebral circulation. One had a successful CEA and one had a successful CAS. In the patients with EDV > 135cm/s, two underwent successful CEAs and one patient refused treatment. The average follow-up period was 11.5 months (1-33 months). One medically treated patient had a non-stroke related death. No patient developed a TIA or stroke during the follow-up period.
CONCLUSIONS: EDV is a measure of cerebral outflow of the ICA. In the setting of a string sign, a low EDV may represent an anatomic configuration not requiring intervention. Medical treatment may be most appropriate in this subset of patients.
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