Angiogram before carotid endartectomy; yes or no??

[jamie, for marcus]

My mother is 84; active, normal EKG, normal BP.  She had a mild stroke on 11/28; woke up with a "dead" left arm; arm feels fine now; residual stuff in her left hand; slowly improving.  She had MRI/MRA/Carotid US/and Circle of Willis tests.

I have copies of her test results.  \

Carotid US impression: "finding of a high grade (90% or greater) stenosis involving right internal carotid artery.  Correlation with carotid MRA performed same day confirms this finding.  No evidence of hemodynamically significant stenosis with the left internal carotid artery.  An area of reported stenosis on MRA within the left internal carotid artery is likely artifactual in nature.  Mild to moderate stenosis right external carotid artery."

MR Brain w/wo cont. impression: "Single focus of intensely increased activity on diffusion sequences with the right parietal lobe deep white matter, consistent with an area of acute/subacute ischemia.  Extensive chronic small-vessel ischemic disease with brain volume loss commensurate with age.  No mass or other area of pathologic contrast enhancement is evident."

MR Carotid: Two-D time of flight imaging was performed.  Both vertebral arteries are patent.  The left vertebral artery is dominant.  Carotid imaging is somewhat limited by patient motion related artifact.  Unfortunately, the patient moved during a critical portion of the exam.  There is extensive signal drop out within the proximal 4cm of the right internal carotid artery.  There does appear to be stenosis within this region on source images and this is felt to be a real finding suggsting significant stenosis of the proximal right internal carotid artery.  There appears to be moderate stenosis involving the proximal right external carotid artery as well.  There is evidence of a least moderate stenosis involving the proximal left internal carotid artery which appears to be focal in nature.  Mild to moderate stenosis involves the proximal left external carotid artery.  Visualized portions of both common carotid arteries appear unremarkable.  Impression:  Somewhat technically limitd study.  However, the findings are suggestive of high grade stenosis involving the proximal right internal carotid artery and moderate stenosis within the proximal left internal ca as detailed above.  There are also apparent stenoses within both proximal external carotid arteries.  Depending on the patient's clinical status and if she is a surgical candidate, consider better anatomic delineation with eith CR angiography of the carotid arteries or catheter angiography."

Circle of Willis: unremarkable.

Now, for my dilemma.  Take a deep breath, this will take a minute!  On 11/28, the day of waking up with this "dead arm" episode, my mom had a previously scheduled appt. with her primary care doc.  She had been to him a week previous, complaining of "gait" problems; did some muscle testing (push, pull, etc.) and told me to take her to a neurologist.  On 11/28, he did NO muscle testing, did not look at her arm/hand in any manner.  She was very explicit about her symptoms.  He handed me a referral for cervical spine x-rays, saying "I think your mother's problem is tied up with some nerve compression."

Cervical spine xray impreessions: 1)Spondylosis w/ degenerative disc change @ C5-6 and C6-7.  2)Extennsive facet arthopathy.  3)  Poitential spinal stenosis @ C5-6.

First appt with neuro doc was 12/11.  He looked at the films, dismissed them as "lousy film."   He did muscle testing on mother and said "I am 100% positive that she's had a mild stroke, but will have to do testing to prove this."  My mom said
"I was hoping to go to Cailf for Christmas to be with my son; can I still go?"  He told her to make her reservations and go, but to take an aspirin every day.  So, she did; departure date; 12/20; his office was informed of this.

Testing was done on 11/15.  The day of the tests, we ran into him as we were leaving Outpatient testing.  He said "If there is a problem, I will call you this weekend.  If not, I will call you on Monday."  We heard nothing.  Numerous, numerous calls were placed to obtain results; days were spent going nowhere in order to be home to receive calls; calls promised by nurse and office manager during specific times.  With each call I placed, I reminded them that she was departing and when.

We never heard a word.  I had my mom sign a release so I could obtain her test results, which I did after I put her on the plane.  I went to her primary care docs office; he was out of the country; I just wanted a doctor, ANY DOCTOR, to help me with the test results.  She got on the phone and after almost 2 hours, the neuro doc phoned her.  She put me on the phone with him and he said to me "I have read your mother's test results.  I don't have them in front of me right now, but I don't recall any abnormalities; nothing of signifcance.  Call me in the morning at the office."  When I left the primary doc's office, his office manager apparently called him back; he phoned his office, had the test results faxed to his house and called me in 15 minutes.  "Your mother needs to come home; we need to act on this fairly quickly; she needs surgery."

I faxed the test results to my brother.  When mom found out, she was extremely upset; they took her to the ER for observation, with test results in hand.  Her BP was all over the place; 205/55, then down, then up.  They attributed it to severe anxiety.  They discharged her with normal BP and told my brother to take her to a doc in the AM.

He took her to a Vascular Surgeon; test results in hand.  "Yes, she needs surgery, but not yet; brain needs time to cool off. (neuro doc here told me that enough time has passed for cooling off; the need for action is fairly urgent.) He scheduled surgery for 1/4.  

When neuro doc called, he had all the time in the world for me at that point.  One of the things he said is "We need to do a formal cerebral angiogram on your mother before we do surgery; the testing to date is fine for an initial study, but if we are to proceed with surgery, it's not enough."

VS doc says "Unnecessary; unneeded.  All the information I need is contained in her test results."  So, other than pre surgery blood work, he is doing no testing of his own.  He's using written test results from hospital/techs he has no knowledge of.  This seems scary to me.

So, my questions are:

1)  Have things "cooled" off enough??  Or is it okay to wait?

2)  And the big question is the angiogram.  I searched your site and found a question regarding this, dated 8/98, where the doc who answered called it the "Gold Standard."  Things change quickly in the world of medicine; is it still considered the Gold Standard??  By neurologists, but not by VS docs?  Is this a serious enough difference of opinion that I need to take assertive action by calling this doc in Calif, whom I've never met and will undoubtedly be put off by me??  I called the hospital where this surgery is to be done to ask about stats with this surgery, etc., they laughed at me!!  "No one has ever asked this before; I wouldn't know where to even begin to look for the answer."  This was the "surgical secretary" who put someone else on, also; have no clue who she was.

This is supposedly a well known hospital, says my brother.  They aren't rated in US NEWS report of hospitals.  I don't know where else to look.  I checked the doc out; he's board certified; no complaints.

Should I just chill out??  Sorry this is so long, but...:)

Thanks.  P.S.  Is it significant or worrisome that mother moved during the MR Carotid test???  And, I asked the neuro doc here if her gait problems (comes and goes, legs feel "funny", like they won't listen to what she's telling them to do"; balance is off at times)were related to this sroke episode; could she have had a previous small stroke that affected both legs in this small, yet bothersome, way.  One time he told me he though they were related, another time he said he thought they were separate in nature.  Any opinion on this?

[CCF Neuro[P] MD, RPS]

Dear Bernadette:

Sorry to hear about your mother.  The gold standard for carotid stenosis is angiography.  However, there is a 1-2% risk of a bad event occurring during the procedure.  Your grandmother likely had a small stroke, judging from the immediate loss of her left arm/hand, the subsequent betterment of movement, and the diffusion weighted scan.  This makes her carotid stenosis symptomatic.  Although there is a risk of angiography, it is the test to do if one is hesitant to do the carotid surgery.  Since she has had an event, the MRA suggests a significant stenosis as does the ultrasound then surgery might be warranted.  The most definitive study used angiography for its data suggesting that stenosis over 70% with related events that surgery was better than medical therapy.  Was the plaque heterogeneous or homogeneous on ultrasound? I am not sure what to tell you.  If the hospital she is at is not routinely doing angiography for carotid stenosis, then I might not do the test.  If the place routinely does these and has a good track record, I might do this to verify the stenosis.  But, since she is symptomatic she needs the surgery.  I might feel uncomfortable having the surgery done at a place that doesn't do angiographies enough to feel confident of the surgeries they perform.  

I know I am not being that helpful.  One does need about 6 weeks after an event to perform surgery (at least that is what we do at the Cleveland Clinic).  

Sincerely,

CCF Neuro MD

[jamie, for marcus]

Thank you for your response.  In answer to your question "was the plaque heterogeneous or homogenous on ultrasound", I have called the hospital here where the study was done.  They are going to pull it up, have the radiologist take another look, and make an addedum to the report, which I can pick up in a few days.

I have read your response very carefully and I think that my problem is that I do not understand enough about angiograms and why they are important.  I am not questioning my mom's need for this surgery, for the reasons you stated; symptomatic episode, findings of 90% or greater stenosis with testing to date.  Her chances of another stroke, of major significance, increase by the day; the artery needs to be cleaned out.  I have read of the studies you mentioned regarding 70% stenosis or greater benefiting from surgery rather than medications alone.  

What is the risk of doing this surgery without an angiogram??  What exactly will the angiogram tell?  I am wondering if it has been found, either through clinical trials or studies, that MRI/MRA and Ultrasound are not very reliable indicators of the degree of stenosis??  And so, if these tests show a 90% stenosis, and surgery is done without the aid of an angiogram, the surgeon may well find a significantly less stenosis, which if less than 70%, studies have shown it is not beneficial and puts the patient at unnecessary risk of a very delicate surgery??

You say that it is the test to do if one is hesitant to do carotid surgery.  Other than a very frail patient, which my mom is not, am I understanding that the only other reason to be hesitant (excluding risk factor of the surgery itself) would be to doubt the findings of the initial battery of tests, as to the actual % of stenosis??

Does the Cleveland Clinic use carotid angiograms on all of it's patients undergoing this surgery?

As I mentioned previously, the neuro doc here used the words "formal cerebral angiogram".  I am 100% positive of this; the word "carotid angiogram" was not said.  Was he just temporarily mixed up??  From the test results that I gave you, is a cerebral angiogram needed?  I'm thinking he was momentarily confused and he meant to say "carotid"; that's the road I'm traveling down.

Thank you ever so much for your time.  If I can just understand and get some questions answered, I'll be more at peace, no matter which direction I need to go; chill or make some phone calls. :)

[CCF Neuro[P] MD, RPS]

Dear Bernadette:

The question is whether the carotid is now occluded.  The ultrasound and MRA sometimes can overcall or undercall the true stenosis.  Usually, it is an overcall.  If the carotid is occluded, then surgery is not indicated as the carotid has done it's own surgery and the collateral blood flow is good enough to perfuse the brain.  As previously stated the diffusion weighted scan demonstrates that there was a stroke on the right.  Given the stenosis of the carotid, most likely it was the carotid.  But, one has to rule out other sources such as atrial fibrillation (but since your mother has no history of cardiac problems, I would think this is unlikely).

My hedging was whether the surgeon has a good track record of outcomes with CEA.  If the hospital does not routinely do carotid angiograms, then likely the surgeon doesn't do alot of CEA surgeries and therefore I would suspect of having the surgeon doing the surgeries on my mother.  She needs the surgery if there is significant stenosis and an event related to it.  

The only risk of not doing the angiogram before surgery is doing surgery on an occluded carotid.  This would not be likely as a quick ultrasound would rule this out, and also no further events happening.  We would probably not do an angiogram prior to surgery but would do one post operation to fromulate a baseline on both sides to correlate with the ultrasound and hence be able to follow via ultrasound in the future.

Sincerely,

CCF Neuro MD