Prospective Evaluation of Extracranial Carotid Stenosis: MR Angiography with Maximum-intensity Projections and Multiplanar Reformation Compared with Conventional Angiography

Objective: The purpose of this prospective study was to compare MR angiography of the carotid artery from the aortic arch through the circle of Willis using maximum-intensity projection (MIP) and multiplanar reformation (MPR) images with intraarterial angiography in the depiction of extracranial carotid atherosclerosis.

Subjects And Methods: The carotid arteries in 20 patients were studied with MR and intraarterial angiography. MR angiography included two-dimensional (2D) time-of-flight (TOF) sequences from the aortic arch through the skull base and three-dimensional (3D) TOF sequences centered at the carotid bifurcation and multiple overlapping thin slab acquisition (MOTSA) from the skull base to above the circle of Willis. Targeted MIP images of the 2D and 3D TOF MR angiograms through each carotid bifurcation were obtained. Last, MPR images of the 3D TOF MR angiograms at the obliquity that showed the greatest stenosis were obtained. All studies were reviewed in a double-blinded fashion by two neuroradiologists. Caliper measurements of MR angiograms and intraarterial angiograms were made by using North American Symptomatic Carotid Endarterectomy Trial criteria. Global MIPs of the aortic arch and common carotid arteries from the 2D TOF MR angiograms and targeted MIPs of the intracranial carotid arteries from the MOTSA MR angiograms were compared with the intraarterial angiogram and graded as normal, mild, moderate, severely stenotic, or occluded.

Results: MPR of the 3D TOF MR angiograms was highly correlated with intraarterial angiograms for both observers 1 and 2 (0.94/p < .001, 0.96/p < .001 [Pearson correlation/p value]). No statistically significant difference between 3D TOF MPR and intraarterial angiography was seen with a paired t-test. With an alpha = 0.05 (5% probability of type 1 error), the power to detect a difference as small as +/- 5% stenosis between 3D TOF MPR and intraarterial angiogram was 80% for observer 1 and 90% for observer 2. Although both MIPs of the 2D and 3D TOF MR angiograms showed high Pearson correlation coefficients (0.83, 0.90) with intraarterial angiography, the paired t-test revealed a statistically significant difference in the estimation of carotid stenosis. Both observers thought the global MIPs of the 2D TOF MR angiogram allowed good to excellent visualization of the common carotid arteries. The aortic arch was seen in 70% of patients; most of the missed cases occurred early in our experience, when the 2D axial images were not placed sufficiently inferior to include the arch. No stenosis of the great vessel origins was seen in this study. All four stenoses of the intracranial internal carotid artery identified with intraarterial angiography were seen with the MOTSA MR angiogram but with a tendency to overestimate stenosis. Only one carotid siphon was thought to show severe stenosis on the MR angiogram. Intraarterial angiography showed a 50% stenosis.

Conclusion: It is possible to image the entire carotid artery from the aortic arch through the circle of Willis with MR angiography in a clinically acceptable time. MPR of the 3D TOF MR angiogram reliably shows the percentage of carotid stenosis with no statistically significant difference compared with intraarterial angiography. The role of MR angiography in showing lesions in the circle of Willis or the aortic arch is promising, but the limited number of tandem lesions in this study makes it difficult to draw any conclusions.