Proposing a reporting method for neurosonological assessments in case of carotid stenosis to try to clear the clutter. This is how we do...what about you?

Objective: Sharing research on establishing a standardized language for ultrasound (US) evaluation of carotid stenosis, based on examination reports, addressing the current heterogeneity in terminology and measurements. Materials: Carotid US reports often mention stenosis percentages and severity adjectives. However, the variability in calculating steno- sis range and lack of reproducibility with digital angiography pose challenges, resulting in ambiguous conclusions and interpretation-dependent outcomes. Methods: We retrospectively collected carotid stenosis Doppler US reports from patients admitted to our Neurology department between January and December 2022. Definitions of stenosis degree, method used (NASCET or ECST), severity adjectives, and terms related to hemodynamic significance, near occlusion and collateral circulation were examined. Results: A total of 104 carotid US reports were collected, with 54 also including transcranial color Doppler US for cerebral circulation evaluation. Neurologists conducted 48 examinations, while other specialists performed the rest. Precise percentage diagnoses were reported in 43 exams, while stenosis range was mentioned in 26 exams. NAS- CET and ECST methods were used in 41 and 23 exams, respectively. Severity adjectives like "moderate" and "critical" were present in 22 and 13 exams respectively. "Collateral circulation" and "near occlu- sion" were noted in 42 and 9 exams respectively. Discussion: US has been used for detecting carotid plaques for decades, but discrepancies exist in how carotid stenosis is assessed and defined, not only because of the differences between angiography and US metrics but also because of the high heterogeneity of findings descriptions in the reports. In our opinion, in advanced settings with adequate expertise, it may be feasible to abandon the dichotomous description extracranial/intracranial findings and adopt a new definition: neurosonological study of carotid and vertebro-basilar circulation. Usage of NASCET stenosis range based on velocity criteria and consideration of "unstable plaque" characteristics would be beneficial. Also, different velocity cut-off in symptomatics and asymptomatics for < and > 50%, < and > 70% carotid stenosis should probably be considered. Conclusions: Accurate carotid stenosis diagnosis with US requires integrating pathophysiological knowledge, clinical evaluation and multiparametric US measurements. Reports should not be limited to measurements but should represent a synthesis of information. In the case of stenosis, the report should encompass local findings as well as those from upstream and downstream circulation, following the pathophysiology of cerebral circulation rather than relying solely on topographical anatomy. Categorizing stenosis within a range helps estab- lish treatment boundaries, although overall clinical and instrumental assessments remain crucial for decision-making both in symptomatics and asymptomatics.