The role of duplex carotid sonography, digital subtraction angiography, and arteriography in the evaluation of transient ischemic attack and the asymptomatic carotid bruit

An effective strategy for the diagnostic evaluation of patients with cerebrovascular disease is often elusive. Clinicians turning to the literature for guidance are confronted with conflicting recommendations. In a recent issue of Neurologic Clinics devoted to cerebrovascular disease, two authors writing in the same volume disagreed on the screening approach to the asymptomatic carotid bruit, one recommended venous digital subtraction angiography, the other, noninvasive methods including Doppler ultrasound. This article will review the uses of arteriography, venous digital subtraction angiography (V-DSA), and duplex carotid sonography (DCS) in the evaluation of patients with an asymptomatic carotid bruit or carotid system transient ischemic attack (TIA). We will describe DCS in more detail because it is less well understood. Finally, we will conclude with our own guidelines for their use. This is intended as just that - a guide. Patients with TIAs often fall outside the borders of a guide. Hopefully, by better understanding the risk/benefit factors involved, the diagnostic work-up of such patients can be appropriately individualized.