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Noninvasive cerebrovascular imaging technologies, including magnetic resonance angiography (MRA), computed tomographic angiography (CTA), and to a lesser extent transcranial Doppler ultrasound (TCD), have been widely embraced by neurologists and neuroradiologists because of their ease of use and low adverse event profile. The gold standard, formal selective digital subtraction angiography (DSA), has an associated low but real rate (<1%) of stroke and like MRA and CTA a similarly low risk of contrast-related nephropathy. Due to the speed of technical advancement, rigorous assessment of noninvasive imaging has lagged.
In this issue of Neurology, Feldmann et al. report the findings of the Stroke Outcomes and Neuroimaging of Intracranial Atherosclerosis (SONIA) study,1 a companion report to the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) study utilizing the same patient population to evaluate noninvasive imaging with TCD and MRA. The study used standardized TCD techniques and central reading to minimize technique dependent results. Similar approaches were taken with MRA. The fundamental finding of this study is that both TCD and MRA show high negative predictive value. They reliably exclude significant intracranial stenosis. However, the …
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