Angiographic reversed flow ratio as an indicator of high-grade internal carotid stenosis

Wilson P. Daugherty, J. Bradley White, Harry J. Cloft, David F. Kallmes

Research output: Contribution to journalArticlepeer-review


Purpose: To examine differential flow through internal carotid artery (ICA) and external carotid artery (ECA) circulations on digital subtraction angiography (DSA) as an indicator of carotid stenosis. Materials and Methods: Carotid and cerebral angiograms (N = 148) were retrospectively evaluated, with flow through ICA and ECA circulations scored on a five-point flow scale ratio: a score of 1 indicated ICA flow arrived at the vertex at least 1 second before ECA flow, a score of 3 indicated ICA and ECA flow arrived at the same time, and a score of 5 indicated ECA flow reached the vertex at least 1 second before ICA flow. Sensitivities and specificities for ICA stenosis detection were determined for flow ratios. Results: Sensitivity and specificity varied with stenosis severity and flow grade. In general, deranged flow was an insensitive marker for stenosis; however, flow ratio equalization or frank ratio reversal was a highly specific indicator of ICA stenosis. A flow grade of 35 was 88% specific (95% CI, 79%94%) and 66% sensitive (95% CI, 53%77%) for stenosis of 70% or greater. A grade of 4 or 5 was 99% specific (95% CI, 93%99%) and 24% sensitive (95% CI, 15%37%) and a grade of 5 was 100% specific (95% CI, 94%100%) and 18% sensitive (95% CI, 9%29%) for carotid stenosis of 70% or greater. Conclusions: Identification of deranged differential flow between the ICA and ECA circulations is an insensitive but highly specific marker for high-grade stenosis. Therefore, if flow reversal is identified but the apparent carotid stenosis is mild, further angiographic projections should be used to uncover a highly probable severe carotid stenosis.

Original languageEnglish (US)
Pages (from-to)1083-1088
Number of pages6
JournalJournal of Vascular and Interventional Radiology
Issue number8
StatePublished - Aug 2011

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine


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