Duplex ultrasound of carotid arteries in acute ischemic stroke: efficacy of a screening protocol for assessing indications for carotid endarterectomy

Introduction. Ischemic stroke remains one of the leading causes of mortality and persistent disability worldwide. Early carotid endarterectomy (CEA) within 14 days of symptom onset significantly reduces stroke recurrence in patients with symptomatic carotid stenosis. Rapid and reliable identification of surgical candidates in the acute stroke setting is crucial. This study aimed to develop a short screening protocol for duplex ultrasound of carotid arteries and assess the agreement between the results of the short protocol and those of extended ultrasound examination and computed tomography angiography (CTA) in patients with acute stroke.

Materials and methods. This prospective study included 76 patients who were admitted at the Botkin Hospital in 2023–2024 with acute ischemic stroke and who underwent CEA within 14 days of symptom onset. All patients underwent carotid duplex ultrasound using a screening protocol within 30 minutes of admission, assessing stenosis degree per ECST criteria. If stenosis exceeded >50 %, a comprehensive duplex scan was performed. All patients also underwent CTA as part of preoperative workup.

Results. The screening protocol identified 50–69 % stenosis in 29 (38 %) patients, 70–99 % stenosis in 41 (54 %), and ICA occlusion in 5 (7 %) patients. Agreement between the shortened and comprehensive duplex protocols was high, with a weighted Cohen’s kappa (κ) of 0.73 (95 % CI 0.59–0.87). Agreement between ultrasound and CTA was also good (κ=0.61 for comprehensive protocol and κ=0.58 for screening protocol). The mean examination time was 15 (±3.2) minutes for the screening protocol and 40 (±6.8) minutes for the standard examination.

Conclusion. A shortened, focused duplex ultrasound protocol demonstrates substantial agreement with a comprehensive protocol for grading carotid stenosis in acute stroke patients. The use of the screening protocol significantly reduces examination time without compromising diagnostic accuracy. Implementation of the screening protocol in the emergency hospital setting facilitated the early identification of patients with indications for surgical intervention and the selection of patients for CEA in acute stroke.

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