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Diagnostic Tests

  My mother is 70 years old, active (still working), and in otherwise fairly good health.  She does have hypertension, controlled with medication, and is on aspirin and a cholesterol lowering medication.   A coronary arteriogram a few years ago demonstrated clear coronary arteries, but in 1996, a carotid ultrasound indicated stenosis.  Occlusion of 49-69% in the left carotid, and 70-89% in the right.  An ultrasound last month demonstrated 70-75% occlusion now in the left, and 85% in the right.  With the wide range of the 1996 results, it is difficult to determine how much this has actually progressed in two years.  The neurologist has recommended a cerebral angiogram to evaluate whether or not she is a candidate for surgery, although he stresses that it is her call, and advises that she think about it.  He evaluates her as asymptomatic at this time, although she occasionally has some worrisome visual and balance disturbances, and believes some mild weakness of her left arm.  I have recently read a few reports that suggest that an MRA, or MRA with TCCD may be an alternative to the angiogram, and definitely safer.  Her neurologist says these tests are not good enough.  At this point, she has not decided whether to pursue further treatment or wait.  She is not convinced that the risk is that much less with angiogram and surgery compared to doing nothing at this time.  My questions are: 1) what is your opinion of the quality and usefullness of more non-invasive diagnostic tests, such as the MRA before making a final decision, and 2) does the Cleveland Clinic (or anywhere else) offer diagnostic refinements in these procedures that may not yet be available in Indiana?
  Thank you for any insight you can give us.
Dear Laura,
The 'Gold Standard' exam for carotid disease is a carotid angiogram.  It is
more invasive than an MRI/MRA, but the angiogram provides much better detail
in the anatomy.  A carotid angiogram has been the standard on which most studies
for carotid disease have been based.  Some surgeons will operate based on a
preoperative MRI/MRA, but this is not standard with all surgeons.  The drawbacks
of an angiogram are that it is more invasive and the risk of complications
is higher.  At the Cleveland Clinic the risk of complications with a carotid
angiogram is less than 1%.  We routinely perform angiograms and MRI's on a
daily basis at the Cleveland Clinic.  If your physician is considering surgery
for your mother's carotid disease, the angiogram may be a better way to go.  
You should have this discussion with your mother's physician to discuss the
risks and benefits of each.
Good luck.

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