Multiplane Reconstruction Modifies the Diagnostic Performance of CT Angiography in Carotid Webs

Introduction Carotid Web (CaW) represents an overlooked stroke etiology and has been associated with high recurrency rates and to be amenable to stenting. We evaluated the diagnostic performance of different computed tomography angiography (CTA) projections in CaW. Methods Consecutive patients <65 years-old with symptomatic CaW (n=31), carotid atherosclerosis (n=27), or normal carotids (n=49) diagnosed with a thin-cut CTA were included. Deidentified CTAs were independently reviewed by three readers, who recorded the diagnosis and level of certainty after evaluating the axial plane alone, after adding sagittal/coronal maximum intensity projection (MIP), then after oblique MPR reformats. Results There were 93 total CaW, 81 atherosclerosis, and 147 normal carotid reads. With CTA axial projection alone, less CaW cases (44.1%) were appropriately diagnosed as compared to atherosclerosis (87.7%; p<0.001) and normal carotid (83%; p<0.001) cases. Sagittal/coronal MIPS increased the rate of accurate CaW diagnosis (44.1% to 76.3%; p<0.001). Inter-rater agreement in CaW detection increased from k= 0.46 (0.35-0.57) using axial to k= 0.80 (0.69-0.91) with sagittal/coronal planes. Axial alone had lower sensitivity (44% vs. 76%) but similar specificity (95% vs. 96%) in CaW detection compared to axial+ sagittal/coronal MIPS. The accuracy in detecting atherosclerosis or normal carotids did not increase after adding sagittal/coronal MIPS and oblique MPRs. The certainty level for CaW diagnosis was lower when compared to atherosclerosis and normal carotids using axial alone (3.0 [3.0-4.0] vs. 4.0 [3.0-5.0]; p<0.001 and 4.0 [3.0- 5.0]; p<0.001) as well as after adding sagittal/coronal MIPS (4.0 [3.0-5.0] vs. 5.0[4.0-5.0]; p=0.01 and 4.0 [4.0-5.0]; p<0.001). Conclusion CTA axial plane alone was insufficient for CaW detection. CTA sagittal/coronal MIP reconstructions as well as oblique MPR reformats enhanced the accuracy and confidence related to CaW diagnosis.