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AJNR - American Journal of Neuroradiology

Published ahead of print on July 24, 2008
doi: 10.3174/ajnr.A1210

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American Journal of Neuroradiology 29:1677-1683, October 2008
© 2008 American Society of Neuroradiology

BRAIN

Classification of Carotid Stenosis by Millimeter CT Angiography Measures: Effects of Prevalence and Gender

E.S. Bartlett^a, T.D. Walters^b, S.P. Symons^c, R.I. Aviv^c and A.J. Fox^c

^a University of Toronto, Princess Margaret Hospital, Toronto, Ontario, Canada
^b University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
^c University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

Please address correspondence to Eric S. Bartlett, MPH, MD, University of Toronto, Princess Margaret Hospital, 610 University Ave, 3rd Floor, Room 3–973, Toronto, Ontario M5G 2M9, Canada: e-mail: eric.bartlett{at}uhn.on.ca

BACKGROUND AND PURPOSE: Previous studies quantifying moderate and severe carotid stenosis by direct millimeter measures on CT angiography (CTA) did not consider how prevalence and gender may influence classification cutoff values.

MATERIALS AND METHODS: Three hundred nineteen carotid arteries were evaluated in consecutive patients with known or suspected carotid artery disease. Millimeter measures were obtained of the stenotic carotid bulb lumen and distal internal carotid artery (ICA). Interclass correlation coefficients (ICC) defined interobserver and intraobserver agreement. North American Symptomatic Carotid Endarterectomy Trial (NASCET)-style percent stenosis ratios were calculated per carotid artery and used in linear regression and receiver operating characteristic (ROC) curve analysis to define equivalent millimeter quantification and classification values. Likelihood ratios and prevalence-specific positive/negative predictive values (PPV/NPV) were calculated to determine the most appropriate millimeter cutoff values to classify stenosis.

RESULTS: Interobserver agreement was excellent for stenosis measures (0.90) and good for distal ICA measures (0.79). Gender-specific regression curves and ROC curves indicated that millimeter stenosis is an excellent tool to quantify and classify carotid stenosis. Assuming a 10% prevalence of severe stenosis, we found that the cutoff value maximizing NPV and PPV was 1.1 mm for both genders (female: PPV = 86.2, NPV = 97.7; male: PPV = 83.2, NPV = 95.9). Assuming a 40% prevalence of moderate stenosis, we found that the cutoff values differed between genders: female = 2.0 mm (PPV = 91.3, NPV = 91.5), male = 2.1 mm (PPV = 91.6, NPV = 92.4). Specific millimeter cutoffs will vary depending upon the clinical scenario, prevalence, and gender.

CONCLUSIONS: Direct millimeter stenosis measures are an excellent tool to classify moderate and severe carotid artery stenosis. Millimeter classification cutoff values that best approximate NASCET classifications vary depending on prevalence and gender.