Modern imaging in the management of cervical carotid stenosis

Most carotid artery disease is now imaged noninvasively given the availability of modern neuroimaging techniques. Concordance between noninvasive imaging modalities is sufficient in most cases to allow appropriate patient treatment. However, in the face of discordant noninvasive data where the degree of stenosis and presence of a complete occlusion are in question brachiocephalic angiography is employed. Additionally angiography allows for the morphological delineation of the stenosis, tandem lesions and extent of collateral circulation, and proximal lesions that may account for the patient's symptoms. In the hands of experienced operators using meticulous neuroangiographic techniques, modern catheters, and digital subtraction imaging techniques the risks of angiography are reduced, and the diagnostic or therapeutic benefit is enhanced. Angiography should be employed when lesion morphology is unclear due to discordant noninvasive data, clinical diagnosis is in question, or additional complicating factors are involved (i.e., associated intracranial aneurysms, tandem stenosis, symptomatic posterior circulation stenosis, and proximal origin stenosis of the brachiocephalic vessels).