Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators

Predicting transient ischemic attack risk in patients with mild carotid stenosis using machine learning and CT radiomics

Objective

This study aims to establish a radiomics-based machine learning model that predicts the risk of transient ischemic attack in patients with mild carotid stenosis (30-50% North American Symptomatic Carotid Endarterectomy Trial) using extracted computed tomography radiomics features and clinical information.

Methods

A total of 179 patients underwent carotid computed tomography angiography (CTA), and 219 carotid arteries with a plaque at the carotid bifurcation or proximal to the internal carotid artery were selected. The patients were divided into two groups; patients with symptoms of transient ischemic attack after CTA and patients without symptoms of transient ischemic attack after CTA. Then we performed random sampling methods stratified by the predictive outcome to obtain the training set (N = 165) and testing set (N = 66). 3D Slicer was employed to select the site of plaque on the computed tomography image as the volume of interest. An open-source package PyRadiomics in Python was used to extract radiomics features from the volume of interests. The random forest and logistic regression models were used to screen feature variables, and five classification algorithms were used, including random forest, eXtreme Gradient Boosting, logistic regression, support vector machine, and k-nearest neighbors. Data on radiomic feature information, clinical information, and the combination of these pieces of information were used to generate the model that predicts the risk of transient ischemic attack in patients with mild carotid artery stenosis (30-50% North American Symptomatic Carotid Endarterectomy Trial).

Results

The random forest model that was built based on the radiomics and clinical feature information had the highest accuracy (area under curve = 0.879; 95% confidence interval, 0.787-0.979). The combined model outperformed the clinical model, whereas the combined model showed no significant difference from the radiomics model.

Conclusion

The random forest model constructed with both radiomics and clinical information can accurately predict and improve discriminative power of computed tomography angiography in identifying ischemic symptoms in patients with carotid atherosclerosis. This model can aid in guiding the follow-up treatment of patients at high risk.

Revisiting carotid endarterectomy: Neobulb technique using external carotid artery as a patch

OBJECTIVES

This study describes an alternative carotid bifurcation endarterectomy technique in which the external carotid artery is used as a suture patch.

METHODS

Charts of ten patients with atherosclerotic carotid stenosis that were treated using the neobulb technique between 2002 and 2019 were reviewed.

RESULTS

No major surgical adverse event was observed in the postoperative assessments. No postoperative common or internal carotid stenosis was observed in the mid- or long-term follow-up.

CONCLUSIONS

The neobulb technique allows carotid endarterectomy closure without a synthetic or venous patch, using the external carotid artery as an autologous patch, while preserving distal flow into the external carotid artery branches.

Analysis of Etiology, Diagnosis, and Treatment Strategy and Efficacy of Pulsatile Tinnitus Caused by Abnormal Vascular Anatomy

OBJECTIVE

To investigate the etiology, clinical characteristics, diagnosis, and treatment strategies and efficacy of pulsatile tinnitus (PT) caused by vascular anatomy abnormality.

METHODS

The clinical data of 45 patients with PT in our hospital from 2012 to 2019 were collected and retrospectively analyzed.

RESULTS

All 45 patients had vascular anatomical abnormalities. The patients were divided into 10 categories according to the different locations of vascular abnormalities: sigmoid sinus diverticulum (SSD), sigmoid sinus wall dehiscence (SSWD), SSWD with high jugular bulb, pure dilated mastoid emissary vein, aberrant internal carotid artery (ICA) in the middle ear, transverse-sigmoid sinus (TSS) transition stenosis, TSS transition stenosis with SSD, persistent occipital sinus stenosis, petrous segment stenosis of ICA, and dural arteriovenous fistula. All patients complained of PT synchronous with heartbeat rhythm. Endovascular interventional therapy and extravascular open surgery were used according to the location of the vascular lesions. Tinnitus disappeared in 41 patients, was significantly relieved in 3 patients, and was unchanged in 1 patient postoperatively. Except for one patient with transient headache postoperatively, no obvious complications occurred.

CONCLUSION

PT caused by vascular anatomy abnormalities can be identified by detailed medical history and physical and imaging examination. PT can be relieved or even completely alleviated after appropriate surgical treatments.

Endovascular treatment of patients with acute ischemic stroke and tandem occlusion due to internal carotid artery dissection: A multicenter experience

BACKGROUND

The optimal management of patients with acute ischemic stroke (AIS) due to tandem occlusion (TO) and underlying carotid dissection (CD) remains unclear.

OBJECTIVE

We present our multicenter-experience of endovascular treatment (EVT) approach used and outcomes for AIS patients with CD-related TO (CD-TO).

METHODS

Consecutive AIS patients underwent EVT for CD-TO at five Italian Neuro-interventional Tertiary Stroke Centers were retrospectively identified. TO from atherosclerosis and other causes of, were excluded from the final analysis. Primary outcome was successful (mTICI 2b-3) and complete reperfusion (mTICI 3); secondary outcome was patients' 3-months functional independence (mRS≤2).

RESULTS

Among 214 AIS patients with TO, 45 presented CD-TO. Median age was 54 years (range 29-86), 82.2% were male. Age <65 years (p < 0.0001), lower baseline NIHSS score (p = 0.0002), and complete circle of Willis (p = 0.0422) were associated with mRS ≤ 2 at the multivariate analysis. Comparisons between antegrade and retrograde approaches resulted in differences for baseline NIHSS scores (p = 0.001) and number of EVT attempts per-procedure (p = 0.001). No differences in terms of recanalization rates were observed between antegrade and retrograde EVT approaches (p = 0.811) but higher rates of mTICI3 revascularization was observed with the retrograde compared to the antegrade approach (78.6% vs 73.3%), anyway not statistically significant. CD management technique (angioplasty vs aspiration vs emergent stenting) did not correlate with 3-months mRS≤2.

CONCLUSION

AIS patients with CD-TO were mostly treated with the retrograde approach with lower number of attempts per-procedure but it offered similar recanalization rates compared with the antegrade approach. Emergent carotid artery stenting (CAS) proved to be safe for CD management but it does not influence 3-months patients' clinical outcomes.

Endovascular treatment of patients with acute ischemic stroke and tandem occlusion due to internal carotid artery dissection: A multicenter experience

BACKGROUND

The optimal management of patients with acute ischemic stroke (AIS) due to tandem occlusion (TO) and underlying carotid dissection (CD) remains unclear.

OBJECTIVE

We present our multicenter-experience of endovascular treatment (EVT) approach used and outcomes for AIS patients with CD-related TO (CD-TO).

METHODS

Consecutive AIS patients underwent EVT for CD-TO at five Italian Neuro-interventional Tertiary Stroke Centers were retrospectively identified. TO from atherosclerosis and other causes of, were excluded from the final analysis. Primary outcome was successful (mTICI 2b-3) and complete reperfusion (mTICI 3); secondary outcome was patients' 3-months functional independence (mRS≤2).

RESULTS

Among 214 AIS patients with TO, 45 presented CD-TO. Median age was 54 years (range 29-86), 82.2% were male. Age <65 years (p < 0.0001), lower baseline NIHSS score (p = 0.0002), and complete circle of Willis (p = 0.0422) were associated with mRS ≤ 2 at the multivariate analysis. Comparisons between antegrade and retrograde approaches resulted in differences for baseline NIHSS scores (p = 0.001) and number of EVT attempts per-procedure (p = 0.001). No differences in terms of recanalization rates were observed between antegrade and retrograde EVT approaches (p = 0.811) but higher rates of mTICI3 revascularization was observed with the retrograde compared to the antegrade approach (78.6% vs 73.3%), anyway not statistically significant. CD management technique (angioplasty vs aspiration vs emergent stenting) did not correlate with 3-months mRS≤2.

CONCLUSION

AIS patients with CD-TO were mostly treated with the retrograde approach with lower number of attempts per-procedure but it offered similar recanalization rates compared with the antegrade approach. Emergent carotid artery stenting (CAS) proved to be safe for CD management but it does not influence 3-months patients' clinical outcomes.

Multimodal ultrasound-based carotid plaque risk biomarkers predict poor functional outcome in patients with ischemic stroke or TIA

BACKGROUND

Carotid vulnerable plaque is an important risk factor for stroke occurrence and recurrence. However, the relationship between risk parameters related to carotid vulnerable plaque (plaque size, echogenicity, intraplaque neovascularization, and plaque stiffness) and neurological outcome after ischemic stroke or TIA is unclear. This study investigates the value of multimodal ultrasound-based carotid plaque risk biomarkers to predict poor short-term functional outcome after ischemic stroke or TIA.

METHODS

This study was a single-center, prospective, continuous, cohort study to observe the occurrence of adverse functional outcomes (mRS 2-6/3-6) 90 days after ischemic stroke or TIA in patients, where the exposure factors in this study were carotid plaque ultrasound risk biomarkers and the risk factors were sex, age, disease history, and medication history. Patients with ischemic stroke or TIA (mRS ≤3) whose ipsilateral internal carotid artery stenosis was ≥50% within 30 days were included. All patients underwent multimodal ultrasound at baseline, including conventional ultrasound, superb microvascular imaging (SMI), and shear wave elastography (SWE). Continuous variables were divided into four groups at interquartile spacing for inclusion in univariate and multifactorial analyses. After completion of a baseline ultrasound, all patients were followed up at 90 days after ultrasound, and patient modified neurological function scores (mRSs) were recorded. Multivariate Cox regression and ROC curves were used to assess the risk factors and predictive power for predicting poor neurological function.

RESULTS

SMI revealed that 20 (30.8%) patients showed extensive neovascularization in the carotid plaque, and 45 (69.2%) patients showed limited neovascularization in the carotid plaque. SWE imaging showed that the mean carotid plaque stiffness was 51.49 ± 18.34 kPa (23.19-111.39 kPa). After a mean follow-up of 90 ± 14 days, a total of 21 (32.3%) patients had a mRS of 2-6, and a total of 10 (15.4%) patients had a mRS of 3-6. Cox regression analysis showed that the level of intraplaque neovascularization and plaque stiffness were independent risk factors for a mRS of 2-6, and the level of intraplaque neovascularization was an independent risk factor for a mRS of 3-6. After correcting for confounders, the HR of intraplaque neovascularization level and plaque stiffness predicting a mRS 2-6 was 3.06 (95% CI 1.05-12.59, P = 0.041) and 0.51 (95% CI 0.31-0.83, P = 0.007), respectively; the HR of intraplaque neovascularization level predicting a mRS 3-6 was 6.11 (95% CI 1.19-31.45, P = 0.031). For ROC curve analysis, the mRSs for intraplaque neovascularization level, plaque stiffness, and combined application to predict 90-day neurological outcome ranged from 2 to 6, with AUCs of 0.73 (95% CI 0.59-0.87), 0.76 (95% CI 0.64-0.89) and 0.85 (95% CI 0.76-0.95), respectively. The mRSs for the intraplaque neovascularization level to predict 90-day neurological outcome ranged from 3 to 6, with AUCs of 0.79 (95% CI 0.63-0.95).

CONCLUSION

Intraplaque neovascularization level and plaque stiffness may be associated with an increased risk of poor short-term functional outcome after stroke in patients with recent anterior circulation ischemic stroke due to carotid atherosclerosis. The combined application of multiple parameters has efficacy in predicting poor short-term functional outcome after stroke.

Cost-effectiveness of carotid endarterectomy in symptomatic patients

BACKGROUND

Medical therapy for stroke prevention has improved significantly over the past 30 years. Recent analyses of medically treated cohorts have suggested that early rates of stroke may have reduced, and reports of the safety of carotid surgery have also shown improvements. Since the effectiveness of carotid surgery versus medical therapy was established in the 1990s, there is an urgent need to evaluate whether surgery remains cost-effective in the UK.

METHODS

A decision model was developed to estimate the lifetime costs and utilities of modern medical therapy with and without carotid endarterectomy in patients with symptomatic stenosis from the perspective of the UK National Health Service. The base-case population consisted of adults aged 70 years with 70-99 per cent stenosis. Model data were obtained from clinical studies and wider literature. Univariate and probabilistic sensitivity analyses were carried out.

RESULTS

In the base-case scenario, the 5-year absolute risk reduction with carotid endarterectomy was 5 per cent, and the incremental cost-effectiveness ratio was €12 021 (exchange rate £1 GBP = €1.1125 (Tuesday 1 January 2019)) per quality-adjusted life-year. Surgery was more cost-effective if performed rapidly after presentation. In patients with 50-69 per cent carotid stenosis, surgery appeared less clinically effective. However, there was considerable uncertainty.

CONCLUSION

Surgery may not now be clinically effective and cost-effective in those with moderate carotid stenosis. However, these results are uncertain because of the limited data on modern medical therapy and an RCT may be justified.

The role of patch closure in current-day carotid endarterectomy

BACKGROUND

It has long been debated whether it is preferable to perform conventional carotid endarterectomy (CEA) with or without patch closure. Although most contemporary surgeons patch, many still do not. Recent small studies have surfaced implying patching is unnecessary. The objective of our analysis was to determine the difference in short- and long-term outcomes according to patch use in a large modern, cross-specialty database.

METHODS

Analyzing more than 118,000 records from the Vascular Quality Initiative, multimodel inference was used to evaluate the effect of patch use on important outcomes of conventional CEA. The composite short-term outcome included any ipsilateral neurological event, return to the operating room for a neurological event, and an increase in the Rankin score postoperatively. Late composite outcome incorporated restenosis as well as early and late ipsilateral neurological events.

RESULTS

Patch use for conventional CEA closure was found to be a strong predictor of both early and late outcomes, as evidenced by its Akaike importance weight of 0.99. Examining predischarge events, patch closure is associated with a decrease in major negative events (odds ratio, 0.5; 95% confidence interval, 0.4-0.6). For long-term events, such closure offers a decrease in untoward outcome (odds ratio, 0.8; 95% confidence interval, 0.7-0.9).

CONCLUSIONS

Analysis in a large current-day database suggests that patch closure of conventional CEA effects superior short- and long-term outcomes.

Etiologic reclassification of cryptogenic stroke after implantable cardiac monitoring and computed tomography angiography re-assessment

INTRODUCTION

Different mechanisms may underlie cryptogenic stroke, including subclinical atrial fibrillation (AF), nonstenotic carotid plaques (NCP), and aortic arch atherosclerosis (AAA). In a cohort of cryptogenic stroke patients, we aimed to: (1) evaluate the prevalence of subclinical AF, NCP, and AAA, and reclassify the etiology accordingly; (2) compare the clinical features of patients with reclassified etiology with those with confirmed cryptogenic stroke.

METHODS

Data of patients hospitalized for cryptogenic stroke between January 2018 and February 2021 were retrospectively analyzed. Patients were included if they received implantable cardiac monitoring (ICM) to detect subclinical AF. Baseline computed tomography angiography (CTA) was re-evaluated to assess NCP and AAA. Since aortic plaques with ulceration/intraluminal thrombus were considered pathogenetic during the initial workup, only patients with milder AAA were included. Stroke etiology was reclassified as "cardioembolic", "atherosclerotic", or "mixed" based on the detection of AF and NCP/AAA. Patients with "true cryptogenic" stroke (no AF, ipsilateral NCP, or AAA detected) were compared with those with reclassified etiology.

RESULTS

Among 63 patients included, 21 (33%) were diagnosed with AF (median follow-up time of 15 months), 12 (19%) had ipsilateral NCP, and 6 (10%) had AAA. Stroke etiology was reclassified in 30 patients (48%): cardioembolic in 14 (22%), atherosclerotic in 9 (14%), and mixed in 7 (11%). Patients with true cryptogenic stroke were younger compared to those with reclassified etiology (p = 0.001).

DISCUSSION

One or more potential covert stroke sources can be recognized in half of the patients with a cryptogenic stroke through long-term cardiac monitoring and focused CTA re-assessment.

Assessment of Atherosclerosis in Ischemic Stroke by means of Ultrasound of Extracranial/Intracranial Circulation and Serum, Urine, and Tissue Biomarkers

It is a common practice to take into consideration age, diabetes, smoking, treated and untreated systolic blood pressure, total cholesterol, and high-density lipoprotein cholesterol for the prediction of atherosclerosis and stroke. There are, however, ultrasound markers in use for the assessment of atherosclerosis and the evaluation of stroke risk. Two areas of investigation are of interest: the carotid artery and the intracranial arterial circulation. Again, within the domain of the carotid artery, two ultrasonic markers have attracted our attention: intima media thickness of the carotid artery and the presence of carotid plaque with its various focal characteristics. In the domain of intracranial circulation, the presence of arterial stenosis and the recruitment of collaterals are considered significant ultrasonic markers for the above-mentioned purpose. On the other hand, a series of serum, urine, and tissue biomarkers are found to be related to atherosclerotic disease. Future studies might address the issue of whether the addition of proven ultrasonic carotid indices to the aforementioned serum, urine, and tissue biomarkers could provide the vascular specialist with a better assessment of the atherosclerotic load and solidify their position as surrogate markers for the evaluation of atherosclerosis and stroke risk.

Grayscale median (GSM) post-processing, posterizing, and color mapping for carotid ultrasound

Abstract Factors related to atherosclerotic plaques may indicate instability, such as ulcerations, intraplaque hemorrhages, lipid core, thin or irregular fibrous cap, and inflammation. The grayscale median (GSM) value is one of the most widespread methods of studying atherosclerotic plaques and it is therefore important to comprehensively standardize image post-processing. Post-processing was performed using Photoshop 23.1.1.202. Images were standardized by adjusting the grayscale histogram curves, setting the darkest point of the vascular lumen (blood) to zero and the distal adventitia to 190. Posterization and color mapping were performed. A methodology that presents the current state of the art in an accessible and illustrative way should contribute to the dissemination of GSM analysis. This article describes and illustrates the process step by step.

Motor sequela of adult and pediatric stroke: Imminent losses and ultimate gains

Stroke is the leading cause of neurological disability in the United States and worldwide. Remarkable advances have been made over the past 20 years in acute vascular treatments to reduce infarct size and improve neurological outcome. Substantially less progress has been made in the understanding and clinical approaches to neurological recovery after stroke. This chapter reviews the epidemiology, bedside examination, localization approaches, and classification of stroke, with an emphasis on motor stroke presentations and management, and promising research approaches to enhancing motor aspects of stroke recovery.

Predictors of 30-day mortality using machine learning approach following carotid endarterectomy

BACKGROUND

Preoperative prognostication of 30-day mortality in patients with carotid endarterectomy (CEA) can optimize surgical risk stratification and guide the decision-making process to improve survival. This study aims to develop and validate a set of predictive variables of 30-day mortality following CEA.

METHODS

The patient cohort was identified from the American College of Surgeons National Surgical Quality Improvement Program (2005-2016). We performed logistic regression (enter, stepwise, and forward) and least absolute shrinkage and selection operator (LASSO) method for the selection of variables, which resulted in 28-candidate models. The final model was selected based upon clinical knowledge and numerical results.

RESULTS

Statistical analysis included 65,807 patients with 30-day mortality in 0.7% (n = 466) patients. The median age of our cohort was 71.0 years (range, 16-89 years). The model with 9 predictive factors which included age, body mass index, functional health status, American Society of Anesthesiologist grade, chronic obstructive pulmonary disorder, preoperative serum albumin, preoperative hematocrit, preoperative serum creatinine, and preoperative platelet count-performed best on discrimination, calibration, Brier score, and decision analysis to develop a machine learning algorithm. Logistic regression showed higher AUCs than LASSO across these different models. The predictive probability derived from the best model was converted into an open-accessible scoring system.

CONCLUSION

Machine learning algorithms show promising results for predicting 30-day mortality following CEA. These algorithms can be useful aids for counseling patients, assessing preoperative medical risks, and predicting survival after surgery.

Influences of age and gender on operative risks following carotid endarterectomy: A systematic review and meta-analysis

OBJECTIVES

This review aims to undertake a comprehensive review of the literature and investigate associations of age and gender on 30 days post carotid endarterectomy (CEA) and up to 5 years post CEA stroke, death, and combined stroke and death.

DESIGN

A systematic review and meta-analysis.

METHODS

Three main electronic databases including the Cochrane Library, MEDLINE, and Embase were searched from their inception to July 2022. Studies examining operative risks (i.e., stroke, death, and combined stroke and death following CEA) linked to age or gender were included. Two independent reviewers were responsible for study selection, quality assessment, and data extraction. Odds ratio (OR) and 95% confidence interval (CI) of all outcomes were calculated.

RESULTS

44609 studies were retrieved from the search. There were 127 eligible studies (80 studies of age, 72 studies of gender, 25 studies of age and gender) for pooling in the meta-analysis. With regards to stroke and death risks within 30 days post CEA; patients aged ≥75 had higher death (OR 1.38; 95% CI 1.10-1.75) than patients aged <75. Patients aged ≥80 had higher stroke risk (OR 1.17; 95% CI 1.07-1.27) and death risk (OR 1.85; 95% CI 1.48-2.30) particular in asymptomatic patients (OR 2.4; 95% CI 1.56-3.81). Pooled effect estimates by gender, at 30 days post CEA, showed that female was associated with increased risk of stroke (OR 1.28; 95% CI 1.16-1.40), with more risk in asymptomatic female patients (OR 1.51; 95% CI 1.14-1.99).

CONCLUSIONS

This meta-analysis highlights that older people is associated with increased stroke risk, particularly asymptomatic octogenarians who had higher likelihood of death within 30 days post CEA. In addition, female especially those with asymptomatic carotid stenosis had greater likelihood of stroke within 30 days post CEA surgery.

Long-term functional consequences of cranial nerve injuries after carotid endarterectomy

BACKGROUND

The aim of the study was to investigate long-term patient consequences of cranial nerve injury (CNI) caused by carotid endarterectomy (CEA) in patients with identified CNI at the 30-day follow-up.

METHODS

Consecutive patients operated for symptomatic carotid artery stenosis 2015-2019 with a documented CNI at the 30-day follow-up after CEA were recruited to this cross-sectional survey. Telephone interviews were conducted >1 year after CEA utilizing survey instruments developed to uncover CNI symptoms. Patients graded their symptoms on a 4-point scale: 1) no symptoms; 2) mild symptoms; 3) moderate symptoms; and 4) severe symptoms.

RESULTS

Altogether, 477 patients underwent CEA, of which 82 were diagnosed with CNI; 70/82 patients remained alive at the time for the survey and 68 patients completed the interview. The mean follow-up time was 3.7 years. Severe persistent CNI symptoms were reported in 2/68 (2.9%), moderate symptoms in 1/68 (1.5%) and mild symptoms in 14/68 (21%) whereas 51/68 patients (75%) reported no residual symptoms. When extrapolating these findings to all patients, approximately 4.4% reported persistent symptoms at the long-term follow-up and only 0.8% reported moderate or severe symptoms.

CONCLUSIONS

The long-term consequences of CNI following CEA are benign in most patients, with a high rate of symptom resolution and a very low rate of persistent clinically significant symptoms.

Ultrasonography Grading of Internal Carotid Artery Disease: Multiparametric German Society of Ultrasound in Medicine (DEGUM) versus Society of Radiologists in Ultrasound (SRU) Consensus Criteria

PURPOSE

 We sought to determine the diagnostic agreement between the revised ultrasonography approach by the German Society of Ultrasound in Medicine (DEGUM) and the established Society of Radiologists in Ultrasound (SRU) consensus criteria for the grading of carotid artery disease.

MATERIALS AND METHODS

 Post-hoc analysis of a prospective multicenter study, in which patients underwent ultrasonography and digital subtraction angiography (DSA) of carotid arteries for validation of the DEGUM approach. According to DEGUM and SRU ultrasonography criteria, carotid arteries were independently categorized into clinically relevant NASCET strata (normal, mild [1-49 %], moderate [50-69 %], severe [70-99 %], occlusion). On DSA, carotid artery findings according to NASCET were considered the reference standard.

RESULTS

 We analyzed 158 ultrasonography and DSA carotid artery pairs. There was substantial agreement between both ultrasonography approaches for severe (κw 0.76, CI95 %: 0.66-0.86), but only fair agreement for moderate (κw 0.38, CI95 %: 0.19-0.58) disease categories. Compared with DSA, both ultrasonography approaches were of equal sensitivity (79.7 % versus 79.7 %; p = 1.0) regarding the identification of severe stenosis, yet the DEGUM approach was more specific than the SRU approach (70.2 % versus 56.4 %, p = 0.0002). There was equality of accuracy parameters (p > 0.05) among both ultrasonography approaches for the other ranges of carotid artery disease.

CONCLUSION

 While the sensitivity was equivalent, false-positive identification of severe carotid artery stenosis appears to be more frequent when using the SRU ultrasonography approach than the revised multiparametric DEGUM approach.

The Unstable Carotid Plaque

Carotid revascularization is performed to prevent cerebrovascular events in patients with symptomatic (>50%) and asymptomatic high degree (>70%) carotid stenosis. As this operation carries significant risks for perioperative stroke, careful selection of patients who will benefit from the procedure is essential. Certain plaque characteristics, including texture, are associated with increased tendency for rupture and can be used to identify high-risk patients. Medical therapy, carotid endarterectomy, and carotid stenting are the mainstays for patient management. With careful selection of patients, all anesthesia techniques (general anesthesia, monitored anesthesia care, and regional anesthesia) can be used safely for these revascularization procedures.

Assessing radiation-induced carotid vasculopathy using ultrasound after unilateral irradiation: a cross-sectional study

Background

Increased head and neck cancer (HNC) survival requires attention to long-term treatment sequelae. Irradiated HNC survivors have a higher ischemic stroke risk. However, the pathophysiology of radiation-induced vasculopathy is unclear. Arterial stiffness could be a biomarker. This study examined alterations in intima-media thickness (IMT) and stiffness-related parameters, shear wave (SWV) and pulse wave velocity (PWV), in irradiated compared to control carotids in unilateral irradiated patients.

Methods

Twenty-six patients, median 40.5 years, 5–15 years after unilateral irradiation for head and neck neoplasms underwent a bilateral carotid ultrasound using an Aixplorer system with SL18-5 and SL10-2 probes. IMT, SWV, and PWV were assessed in the proximal, mid, and distal common (CCA) and internal carotid artery (ICA). Plaques were characterized with magnetic resonance imaging. Measurements were compared between irradiated and control sides, and radiation dose effects were explored.

Results

CCA-IMT was higher in irradiated than control carotids (0.54 [0.50–0.61] vs. 0.50 [0.44–0.54] mm, p = 0.001). For stiffness, only anterior mid-CCA and posterior ICA SWV were significantly higher in the irradiated side. A radiation dose–effect was only (weakly) apparent for PWV (R²: end-systolic = 0.067, begin-systolic = 0.155). Ultrasound measurements had good–excellent intra- and interobserver reproducibility. Plaques had similar characteristics but were more diffuse in the irradiated side.

Conclusions

Increased CCA-IMT and SWV in some segments were seen in irradiated carotids. These alterations, even in young patients, mark the need for surveillance of radiation-induced vasculopathy.

Trial registration: clinicaltrials.gov (https://clinicaltrials.gov/ct2/show/NCT04257968).

The utility of ultrasound and computed tomography in the assessment of carotid artery plaque vulnerability-A mini review

As the burden of cardiovascular and cerebrovascular events continues to increase, emerging evidence supports the concept of plaque vulnerability as a strong marker of plaque rupture, and embolization. Qualitative assessment of the plaque can identify the degree of plaque instability. Ultrasound and computed tomography (CT) have emerged as safe and accurate techniques for the assessment of plaque vulnerability. Plaque features including but not limited to surface ulceration, large lipid core, thin fibrous cap (FC), intraplaque neovascularization and hemorrhage can be assessed and are linked to plaque instability.

Topography of the Anatomical Landmarks of Carotid Bifurcation and Clinical Significance

OBJECTIVE

Carotid bifurcation (CB) and its terminal branches are the most common sites of atherosclerotic plaques. In surgical treatment, these plaques can be reached by an endarterectomy technique. The success of the technique can be achieved with good anatomical knowledge of these arteries and their relationships with surrounding structures.

MATERIALS AND METHODS

The study was performed retrospectively on archived images of patients with computed tomography angiography (CTA). Two hundred forty-seven patients who met the criteria were included in this study. Three-dimensional (3D) reconstructions of two-dimensional CTA images were made automatically using the open-source software Horos v.4.0.0. The distance between the transverse plane passing through the bifurcation point (BP) and the defined planes of the surrounding structures was evaluated.

RESULTS

CB was observed below the mastoid process, gonion point, and hyoid bone. CB was observed above the thyroid cartilage. Carotid bifurcation was seen at 15 levels in total, the lowest in the upper 1/3 of the C6 vertebral body and the highest in the lower 1/3 of the C2 vertebral body. In all cases, the most common level was the C3 lower level.

CONCLUSION

All these values, which emerged as a result of the study, provide general information about the topography of the CB according to the neighboring structures. Estimating the location of the CB according to the gonion and hyoid bone will give a more accurate result. The vertebral level on the right side increased in direct proportion to age; there was no similar relationship on the left side. It is necessary to be aware of these anatomical variations in order to prevent various iatrogenic complications.

Thirty-Day Stroke and Mortality After Carotid Revascularization Among Octogenarians with Symptomatic Carotid Stenosis: Real-World Evidence from a National Surgical Quality Registry

BACKGROUND

The outcomes of carotid revascularization among octogenarians are not well studied. We present analyses of 30-day stroke and mortality of patients aged ≥80 years using real-world data from a national surgical quality registry.

METHODS

The National Surgical Quality Improvement Program targeted data set for carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) was queried for patients aged ≥80 years undergoing CEA and CAS between 2012 and 2019.

RESULTS

A total of 122 and 3013 patients aged ≥80 years with symptomatic carotid stenosis undergoing CAS and CEA, respectively, were identified. Patients with CAS were more likely to be older than 90 years (P = 0.006) and have diabetes (P = 0.036), were more likely to have high-risk anatomy (P < 0.001), but had lower American Society of Anesthesiologists score (P < 0.001). An ipsilateral stroke had been experienced by 43.6% of patients with CAS and 44.7% of patients with CEA. The rate of 30-day composite outcome was 6.4% in the CAS group and 4.5% in the CEA group (P = 0.326). The f 30-day mortality was significantly higher for CAS (5.6% vs. 1.7%, P = 0.001); however, the difference between the cohorts was not significant (CAS, 2.4% vs. CEA, 3.4%, P = 0.555). On multivariable analysis, CEA was associated with significantly lower odds of mortality (odds ratio [OR], 0.32; P = 0.0145). Symptom presentation other than ipsilateral stroke was associated with significantly decreased odds of 30-day outcome (amaurosis fugax/transient monocular blindness, OR, 0.39, P = 0.004; transient ischemic attack, OR, 0.57, P = 0.003), whereas higher age had significantly increased odds (OR, 1.95; P = 0.0172).

CONCLUSIONS

Real-world analyses from a surgical quality registry show that CEA may be associated with lower odds of mortality compared with CAS among octogenarians.

Cerebrospinal Fluid CSF Flow Artifacts are Associated with Brain Pulsation in Patients with Severe Carotid Artery Stenoses

OBJECTIVE

We investigated the factors associated with cerebrospinal fluid (CSF) flow artifacts on fluid-attenuated inversion recovery imaging in patients with carotid artery (CA) stenosis.

METHODS

Each CSF artifact grade was defined by comparing the highest intensity in a given region of interest (ROI) to those in reference ROIs, as follows: higher than the intensity of normal white matter in the centrum semiovale = 2 points; equal to or less than the white matter, and higher than CSF = 1 point; and equal to CSF = 0. CSF flow scores in eight sites were measured and added to the total score (0 -16). The prevalences of each finding, specifically white matter lesions, CA stenoses and brain atrophy, were compared using multivariate logistic regression models.

RESULTS

We evaluated the findings in 54 patients with CA stenosis treated by CA stenting (CAS) and 200 adults with no history of neurological disorders (control group). Adjusted by stroke risk factors, a CSF flow score ≤ 11 was positively associated with CA stenosis, heart rate > 70 / min, and brain atrophy, and negatively with the female gender. The score was 12.8 ± 1.8 in the control group and 12.0 ± 2.0 in CA stenosis group after CAS, which was significantly higher than before CAS (10.4 ± 2.8, p<0.001).

CONCLUSION

The CSF flow score was associated with female gender, brain atrophy, heart rate, and severe CA stenosis, and was found to be elevated after revascularization.

Retinal microvasculature and cerebral hemodynamics in patients with internal carotid artery stenosis

Purpose

To investigate the relationship between retinal microvasculature and cerebral hemodynamics in patients with internal carotid artery (ICA) stenosis.

Methods

Patients with unilateral moderate or severe ICA stenosis(≥50%) from West China hospital, Sichuan university were consecutively and prospectively recruited enrolled in the current study. En face angiograms of the superficial vascular complex (SVC), deep vascular complex (DVC), superficial vascular plexus (SVP), intermediate capillary plexus (ICP), and deep capillary plexus (DCP) were generated by automatic segmentation using swept-source optical coherence tomography angiography (SS-OCTA) to assess the retinal microvascular perfusion. The cerebral blood flow perfusion on bilateral middle cerebral artery territories measured at the basal ganglia level was assessed by brain computed tomography perfusion (CTP). CTP data were postprocessed to generate maps of different perfusion parameters including cerebral blood flow (CBF), cerebral blood volume (CBV), time to peak (TTP), mean transit time (MTT) and permeability surface(PS). Relative perfusion parameters (rPS, rCBF, etc.) were calculated as the ratio of the value on the contralateral side to that on the ipsilateral side.

Results

In the final analysis, 31 patients were included, of whom 11 patients had a moderate ICA stenosis (50–69%) and 20 with a severe ICA stenosis(≥70%). A total of 55 eyes were analyzed in the study, 27 eyes from the ipsilateral side (ie, side with stenosis) and 28 eyes from the contralateral side. In the patients with ICA stenosis, there was a strong correlation between the retinal microvascular perfusion of SVC with rCBV(B = 0.45, p = 0.03), rCBF(B = 0.26, p = 0.02) and rPS(B = 0.45, p < 0.001) after adjustment for age, sex and vascular risk factors. Similar correlations were also found between microvasculature in SVP and cerebral perfusion changes. There were no any significant associations of microvascular perfusion in both DVC and DCP with CTP parameters(all p > 0.05).

Conclusions

Retinal perfusion changes in superficial vascular layer (SVC and SVP) were correlated with brain hemodynamic compromise in patients with unilateral moderate or severe ICA stenosis(≥50%). Given the limited size of our study, future studies with larger sample size are needed to confirm our findings.

A novel integrated angioscope-laser system for atherosclerotic carotid artery occlusion: Feasibility and techniques

Introduction

Atherosclerotic extracranial carotid artery stenosis accounts for about 20%-30% of all strokes, which is one of the leading causes of adult morbidity and mortality. Although carotid endarterectomy (CEA) is still the mainly operational manner for atherosclerotic carotid artery stenosis/occlusion (ACAS/ACAO), and carotid angioplasty and stenting (CAS) have been used as an alternative, both CEA and CAS have limitations of their own, such as extensive invasiveness and in-stent restenosis.

Methods

In this study we established a novel interventional system in vitro to take advantage of both CEA and CAS. Twenty consecutive carotid atherosclerotic plaques were harvested from the patients who underwent CEA. The plaques were randomized into two groups and inserted into the pruned and sutured descending aortas of the swine in vitro. The ZebraScope™ was modified with a protective device on its flexible tip, so that the plaque could be dissected from the wall of parent carotid artery and ablated completely without damage to the carotid artery. The holmium:YAG (Ho:YAG) and thulium fiber laser (TFL) generators were alternately used when needed.

Results

All the carotid atherosclerotic plaques were completely ablated by Ho:YAG laser and/or TFL. The Ho:YAG laser was more effective for the atherosclerotic plaques with severe calcification, while the TFL was more suitable for those with moderate calcification. There were still some thermal injury spots on the inner wall of the parent carotid artery caused by the laser in the non-protected group B. In the protected group A, on the contrary, there was no even a thermal injury spot was found on the relevant location except for one sample. The difference of ablating duration was statistically significant between group A (36.5 ± 4.79 min) and group B (63.4 ± 6.55 min) (P < 0.01).

Conclusion

According to our knowledge, this is the first attempt to ablate carotid atherosclerotic plaques assisted by the ZebraScope™ in vitro. The protective and dissecting device on the tip of the angioscope makes it safe and visible when the ablation is performed to carotid atherosclerotic plaques. The Ho:YAG laser and TFL are effective and safe for ablating the plaque in vitro.

Identification of Metabolomics Biomarkers in Extracranial Carotid Artery Stenosis

The biochemical identification of carotid artery stenosis (CAS) is still a challenge. Hence, 349 male subjects (176 normal controls and 173 stroke patients with extracranial CAS ≥ 50% diameter stenosis) were recruited. Blood samples were collected 14 days after stroke onset with no acute illness. Carotid plaque score (≥2, ≥5 and ≥8) was used to define CAS severity. Serum metabolites were analyzed using a targeted Absolute IDQ®p180 kit. Results showed hypertension, diabetes, smoking, and alcohol consumption were more common, but levels of diastolic blood pressure, HDL-C, LDL-C, and cholesterol were lower in CAS patients than controls (p < 0.05), suggesting intensive medical treatment for CAS. PCA and PLS-DA did not demonstrate clear separation between controls and CAS patients. Decision tree and random forest showed that acylcarnitine species (C4, C14:1, C18), amino acids and biogenic amines (SDMA), and glycerophospholipids (PC aa C36:6, PC ae C34:3) contributed to the prediction of CAS. Metabolite panel analysis showed high specificity (0.923 ± 0.081, 0.906 ± 0.086 and 0.881 ± 0.109) but low sensitivity (0.230 ± 0.166, 0.240 ± 0.176 and 0.271 ± 0.169) in the detection of CAS (≥2, ≥5 and ≥8, respectively). The present study suggests that metabolomics profiles could help in differentiating between controls and CAS patients and in monitoring the progression of CAS.

Effect of Chronic Antiplatelet and Anticoagulant Medication in Neck Haematoma and Perioperative Outomes After Carotid Endarterectomy

OBJECTIVES

A retrospective analysis of neck haematoma, stroke and mortality after symptomatic and asymptomatic carotid endarterectomy (CEA) was conducted, in order to determine the most appropriate perioperative medication for these patients. Thirty-day outcomes of moderate and severe neck bleeding were also investigated.

METHODS

Patients undergoing CEA in a Vascular Surgery department were analysed (2015-2019). Pre-procedure antithrombotic medication (from the 5-days prior to surgery) was identified. End point predictors were identified by univariate and multivariable analyses and adjusted for confounders.

RESULTS

A total of 304 CEA were included. Almost half of the included patients (49.67%) were under low-dose aspirin, 17.55% other single antiplatelet agent, 12.59% dual antiplatelet therapy, 8.61% anticoagulation and 10.92% no antithrombotic therapy. There was 8.22% rate of important haematoma, including 4.93% severe (requiring surgical exploration) hematomas and a 30-day all-stroke incidence of 2.94% in symptomatic and 1.79% asymptomatic patients (p=.51). When compared to aspirin, severe haematoma was more prevalent with single clopidogrel or triflusal (RR 4.25, p=.11), dual antiplatelet group (RR 11.84, p=.002) and anticoagulation (RR 8.604, p=.02). Dual antiaggregation and anticoagulation did not confer post-operative stroke protection compared to single aspirin in either symptomatic or asymptomatic patients. Non-significant higher intra-hospital mortality was noted in no medication, dual antiplatelet and anticoagulation groups in contrast to aspirin. Severe neck bleeding was associated with increased congestive heart failure (9.26-fold, p=.03) and longer hospital stay (11.20±24.69 days versus 3.18±4.79 with no bleeding, p<.001), with a tendency for higher hospital readmission at 30-days (4.66-fold, p=.13). Mortality and stroke rates were similar.

CONCLUSIONS

Double antiaggregation and anticoagulation did not confer better perioperative outcomes after elective CEA in our study. These regimens were associated with increased risk of neck haematoma, especially severe bleeding, with similar rates of neurologic events in both symptomatic and asymptomatic patients and no mortality benefit. Monotherapy with aspirin appears to be the safest perioperative antithrombotic regimen for elective CEA.

Sex Difference in the Impact of Dual Antiplatelet Therapy using Cilostazol for Secondary Stroke Prevention: A Sub-Analysis of CSPS.com

AIM

Although some sex differences in stroke have been reported, differences in the effects of antiplatelet therapy for secondary stroke prevention have not been clarified.

METHODS

In the Cilostazol Stroke Prevention Study combination trial, patients with high-risk, non-cardioembolic ischemic stroke between 8 and 180 days after onset treated with aspirin or clopidogrel alone were recruited and randomly assigned to receive either monotherapy or dual antiplatelet therapy (DAPT) using cilostazol and followed up for 0.5-3.5 years. The primary efficacy outcome was recurrence of ischemic stroke. The safety outcome was severe or life-threatening hemorrhage. Outcomes were analyzed by sex.

RESULTS

A total of 1,320 male patients and 558 female patients were included. The male patients had more risk factors than the female patients. In male patients, the primary endpoint occurred at a rate of 2.0 per 100-patient years in the DAPT group and 5.1 per 100 patient-years in the monotherapy group (hazard ratio (HR), 0.40; 95% confidence interval (CI), 0.23-0.68). In male patients, DAPT prolonged the time to recurrent stroke by 4.02-fold (95% CI, 1.63-9.96) compared with monotherapy. In female patients, the average annual event rates were 2.7 per 100 patient-years in the DAPT group and 3.3 per 100 patient-years in the monotherapy group (HR, 0.82; 95% CI, 0.37-1.84). Safety outcomes did not differ significantly in both male and female patients.

CONCLUSIONS

Long-term DAPT using cilostazol reduced the recurrence of ischemic stroke and prolonged the recurrence-free time in male patients, but not in female patients.

Intraoperative Transcranial Doppler Monitoring Predicts the Risk of Cerebral Hyperperfusion Syndrome After Carotid Endarterectomy

OBJECTIVE

Cerebral hyperperfusion syndrome (CHS) is a rare but serious complication following carotid endarterectomy (CEA). The aim of this study was to identify intraoperative transcranial Doppler (TCD) hemodynamic predictors of CHS after CEA.

METHODS

Between January 2013 and December 2018, intraoperative TCD monitoring was performed for 969 patients who underwent CEA. The percentage increase in the mean velocity of the middle cerebral artery (MCAV%) at 3 postdeclamping time points (immediately after declamping, 5 minutes after declamping, and after suturing the skin) over baseline was compared between CHS and non-CHS patients.

RESULTS

CHS was diagnosed in 31 patients (3.2%), including 11 with intracranial hemorrhage. The MCAV% values at the 3 postdeclamping time points over baseline were 177% (81%-275%), 90% (41%-175%), and 107% (55%-191%) in the CHS group, significantly higher than those in the non-CHS group (40% [14%-75%], 15% [1%-36%], and 18% [3%-41%], respectively, all P < 0.001). Receiver operating characteristic curve analysis showed that the 3 intraoperative MCAV% parameters all had excellent accuracy in identifying CHS (areas under the curve: 0.854, 0.839, and 0.858, respectively, all P < 0.001). The predictive value of the model consisting only of preoperative parameters was significantly increased by adding the intraoperative TCD hemodynamic parameters (area under the curve: 0.747 vs. 0.858, P = 0.006). Multivariate analyses identified the intraoperative MCAV% immediately after declamping (odds ratio: 9.840, 95% confidence interval: 2.638-36.696, P < 0.001) as an independent predictor of CHS.

CONCLUSIONS

Our results indicate that intraoperative TCD monitoring helps predict CHS after CEA at an early stage.

Interventional compared with medical management of symptomatic carotid web: A systematic review

BACKGROUND

Carotid web (CaW) is non-atheromatous, shelf-like intraluminal projection, generally affecting the posterolateral wall of the proximal internal carotid artery, and associated with embolic stroke, particularly in younger patients without traditional stroke risk factors. Treatment options for symptomatic CaWs include interventional therapy with carotid endarterectomy or carotid stenting versus medical therapy with antiplatelet or anticoagulants. As safety and efficacy of these approaches have been incompletely delineated in small-to-moderate case series, we performed a systematic review of outcomes with interventional and medical management.

METHODS

Systematic literature search was conducted and data analyzed per PRISMA guidelines (Preferred Reporting Items for Systemic Reviews and Meta-Analyses) from January 2000 to October 2021 using the search strategy: "Carotid web" OR "Carotid shelf" OR "Web vessels" OR "Intraluminal web". Patient-level demographics, stroke risk factors, technical procedure details, medical and interventional management strategies were abstracted across 15 series. All data were analyzed using descriptive statistics.

RESULTS

Among a total of symptomatic 282 CaW patients across 14 series, age was 49.5 (44-55.7) years, 61.7% were women, and 76.6% were black. Traditional stroke risk factors were less frequent than the other stroke causes, including hypertension in 28.6%, hyperlipidemia 14.6%, DM 7.0%, and smoking 19.8%. Thrombus adherent to CaW was detected on initial imaging in 16.2%. Among 289 symptomatic CaWs across 15 series, interventional management was pursued in 151 (52.2%), carotid artery stenting in 87, and carotid endarterectomy in 64; medical management was pursued in 138 (47.8%), including antiplatelet therapy in 80.4% and anticoagulants in 11.6%. Interventional and medical patients were similar in baseline characteristics. The reported time from index stroke to carotid revascularization was median 14 days (IQR 9.5-44). In the interventional group, no periprocedural mortality was noted, major periprocedural complications occurred in 1/151 (0.5%), and no recurrent ischemic events were observed over follow-up range of 3-60 months. In the medical group, over a follow-up of 2-55 months, the recurrence cerebral ischemia rate was 26.8%.

CONCLUSION

Cumulative evidence from multiple series suggests that carotid revascularization is a safe and effective option for preventing recurrent ischemic events in patients with symptomatic carotid webs.

Relationship between annular calcification of plaques in the carotid sinus and perioperative hemodynamic disorder in carotid angioplasty and stenting

OBJECTIVE

To investigate the correlation between annular plaque calcification in the carotid sinus and perioperative hemodynamic disorder (HD) in carotid angioplasty and stenting (CAS).

METHODS

The clinical data of 49 patients undergoing CAS due to narrowing of the carotid sinus were retrospectively analyzed. All patients had preoperative carotid computed tomography angiography (CTA) and were divided into HD and non-HD groups based on the occurrence of HD in the perioperative period of CAS. HD was defined as persistent bradycardia (heart rate < 60 beats per min) or persistent hypotension (systolic blood pressure < 90 mmHg) in the perioperative period and lasting for at least 1 h. The baseline data, including the degree of carotid artery stenosis, plaque length, plaque thickness, calcified plaque morphologies (i.e., plaque circumferential angle: < 90° defined as dotted calcification; 90°-180° defined as arcuate calcification; > 180° defined as annular calcification), contralateral carotid artery conditions, balloon diameter, and stent types, were compared between the two groups. Binary logistic regression was used to analyze the risk factors for the occurrence of HD.

RESULTS

Among the 49 patients undergoing CAS, 14 (28.57%) developed perioperative HD, and 35 did not. Annular calcification was more common in the patients in the HD group than in the non-HD group. No significant differences in the probabilities of dotted and arcuate calcifications were found between the two groups (p > 0.05). The duration of continuous dopamine consumption in the HD group was 9-71 h. The average hospital stay of the HD group (10.14 ± 4.17 days) was significantly longer than that of the non-HD group (6.57 ± 1.9 days; p < 0.001). Patients in the HD group had significantly more pronounced lumen stenosis (p = 0.033) and longer plaque length (p = 0.034) than those in the non-HD group. After adjusting for age and sex, multivariate regression analysis showed that the presence of annular plaque calcification was an independent predictor of HD (odds ratio: 7.68, 95% confidence interval: 1.46-40.37, p = 0.016).

CONCLUSIONS

The occurrence of annular plaque calcification in the carotid sinus was an independent risk factor for perioperative HD in CAS. Preoperative carotid CTA assists with the early identification of high-risk patients who may develop HD.

Absence of the Anterior Communicating Artery on Selective MRA is Associated with New Ischemic Lesions on MRI after Carotid Revascularization

BACKGROUND AND PURPOSE

ICA-selective MRA using a pencil beam presaturation pulse can accurately visualize anterior communicating artery flow. We evaluated the impact of anterior communicating artery flow on the perioperative hemodynamic status and new ischemic lesions after carotid revascularization.

MATERIALS AND METHODS

Eighty-three patients with carotid artery stenosis were included. We assessed anterior communicating artery flow using ICA-selective MRA. The preoperative hemodynamic status was measured using SPECT. We also measured the change in regional cerebral oxygen saturation after temporary ICA occlusion. New ischemic lesions were evaluated by DWI on the day after treatment.

RESULTS

Anterior communicating artery flow was detected in 61 patients, but it was not detected in 22 patients. Preoperative cerebrovascular reactivity was significantly higher in patients with (versus without) anterior communicating artery flow with a mean peak systolic velocity of ≥200 cm/s (39.6% [SD, 23.8%] versus 25.2% [SD, 16.4%]; P = .030). The decrease in mean regional cerebral oxygen saturation was significantly greater in patients without (versus with) anterior communicating artery flow (8.5% [SD, 5.6%] versus 3.7% [SD, 3.8%]; P = .002). New ischemic lesions after the procedure were observed in 23 patients. The multivariate logistic regression analysis revealed that anterior communicating artery flow (OR, 0.07; 95% CI, 0.012-0.45; P = .005) was associated with new ischemic lesions.

CONCLUSIONS

The absence of anterior communicating artery flow influenced the perioperative hemodynamic status in patients with carotid stenosis and was associated with an increased incidence of new ischemic lesions after carotid revascularization.

Perioperative functional imaging after extracranial carotid endarterectomy for the detection of cerebral hyperperfusion syndrome

INTRODUCTION

SyngoDynaPBVNeuro® is a tool to perform cerebral blood volume (CBV) measurements intraoperatively by functional imaging producing CT-like images. Aim of this prospective study was to analyze the clinical relevance and benefit of CBV measurement with regard to neurological complications like cerebral hyperfusion syndrome (CHS).

METHODS

Forty-five patients undergoing endarterectomy (CEA) of the internal carotid artery were included; functional imaging with CBV measurement was performed before and after CEA. To evaluate and analyze CBV, six regions of interest (ROI) were identified for all patients with an additional ROI in patients with symptomatic ICA stenosis and previous stroke. The primary endpoint of the study was a perioperative change in CBV measurements. Secondary outcomes were incidence of stroke, TIA, CHS, and perioperative morbidity and mortality.

RESULTS

Thirty-day stroke incidence and thirty-day mortality were 0%. Thirty-day morbidity was 6.7%. Two patients from the asymptomatic group suffered from transient neurological symptoms without signs of intracerebral infarction in CT or MR scan, meeting diagnostic criteria for CHS. In 83.3% of ROIs in these patients, an increase of blood volume was detected. Overall, 26.7% patients suffered from unilateral headache as expression of potential CHS. A total of 69.4% of ROIs in patients with postoperative unilateral headache showed an increase when comparing pre- and postoperative CBV measurements.

CONCLUSION

The results show that increased CBV measured by functional imaging is a possible surrogate marker of neurological complications like CHS after CEA. By using intraoperative CBV measurement, the risk of CHS can be estimated early and appropriate therapeutic measures can be applied.

Vessel wall MR imaging of aortic arch, cervical carotid and intracranial arteries in patients with embolic stroke of undetermined source: A narrative review

Despite advancements in multi-modal imaging techniques, a substantial portion of ischemic stroke patients today remain without a diagnosed etiology after conventional workup. Based on existing diagnostic criteria, these ischemic stroke patients are subcategorized into having cryptogenic stroke (CS) or embolic stroke of undetermined source (ESUS). There is growing evidence that in these patients, non-cardiogenic embolic sources, in particular non-stenosing atherosclerotic plaque, may have significant contributory roles in their ischemic strokes. Recent advancements in vessel wall MRI (VW-MRI) have enabled imaging of vessel walls beyond the degree of luminal stenosis, and allows further characterization of atherosclerotic plaque components. Using this imaging technique, we are able to identify potential imaging biomarkers of vulnerable atherosclerotic plaques such as intraplaque hemorrhage, lipid rich necrotic core, and thin or ruptured fibrous caps. This review focuses on the existing evidence on the advantages of utilizing VW-MRI in ischemic stroke patients to identify culprit plaques in key anatomical areas, namely the cervical carotid arteries, intracranial arteries, and the aortic arch. For each anatomical area, the literature on potential imaging biomarkers of vulnerable plaques on VW-MRI as well as the VW-MRI literature in ESUS and CS patients are reviewed. Future directions on further elucidating ESUS and CS by the use of VW-MRI as well as exciting emerging techniques are reviewed.

The 2nd European Carotid Surgery Trial (ECST-2): rationale and protocol for a randomised clinical trial comparing immediate revascularisation versus optimised medical therapy alone in patients with symptomatic and asymptomatic carotid stenosis at low to intermediate risk of stroke

Background

Carotid endarterectomy is currently recommended for patients with recently symptomatic carotid stenosis ≥50%, based on randomised trials conducted 30 years ago. Several factors such as carotid plaque ulceration, age and associated comorbidities might influence the risk-benefit ratio of carotid revascularisation. A model developed in previous trials that calculates the future risk of stroke based on these features can be used to stratify patients into low, intermediate or high risk. Since the original trials, medical treatment has improved significantly. Our hypothesis is that patients with carotid stenosis ≥50% associated with a low to intermediate risk of stroke will not benefit from additional carotid revascularisation when treated with optimised medical therapy. We also hypothesise that prediction of future risk of stroke in individual patients with carotid stenosis can be improved using the results of magnetic resonance imaging (MRI) of the carotid plaque.

Methods

Patients are randomised between immediate revascularisation plus OMT versus OMT alone. Suitable patients are those with asymptomatic or symptomatic carotid stenosis ≥50% with an estimated 5-year risk of stroke of <20%, as calculated using the Carotid Artery Risk score. MRI of the brain at baseline and during follow-up will be used as a blinded measure to assess the incidence of silent infarction and haemorrhage, while carotid plaque MRI at baseline will be used to investigate the hypotheses that plaque characteristics determine future stroke risk and help identify a subgroup of patients that will benefit from revascularisation. An initial analysis will be conducted after recruitment of 320 patients with baseline MRI and a minimum of 2 years of follow-up, to provide data to inform the design and sample size for a continuation or re-launch of the study. The primary outcome measure of this initial analysis is the combined 2-year rate of any clinically manifest stroke, new cerebral infarct on MRI, myocardial infarction or periprocedural death.

Discussion

ECST-2 will provide new data on the efficacy of modern optimal medical therapy alone versus added carotid revascularisation in patients with carotid stenosis at low to intermediate risk of future stroke selected by individualised risk assessment. We anticipate that the results of baseline brain and carotid plaque MRI will provide data to improve the prediction of the risk of stroke and the effect of treatment in patients with carotid stenosis.

Trial registration

ISRCTN registry ISRCTN97744893. Registered on 05 July 2012

The Problem of Restrictive Thrombectomy Trial Eligibility Criteria

Since 2015, a series of endovascular trials transformed the management of patients with large vessel occlusion stroke. Most thrombectomy trials used restrictive eligibility criteria to optimize the chances of showing that thrombectomy could work. The problem arises when generalizing trial results into evidence-based recommendations. Many organizations, oblivious of this problem, translated verbatim restrictive trial eligibility criteria into authoritative guidelines, which limit the use of thrombectomy to highly selected patients. The clinical problem becomes as follows: what to do for all other stroke patients equally in need of care? The cycle of restrictive trial eligibility criteria, corresponding restrictive guidelines, observational studies of unvalidated practices showing other patients benefit, a new trial is needed, has been repeated often. Thrombectomy trials ought to have included all patients that could potentially benefit. If the signal that was looked for by restricting eligibility is at risk of being lost in the noise generated by the heterogeneity of patients, D. Sackett proposed a solution: to use the same criteria, not to select some patients and exclude others but to prespecify the subgroup of patients most likely to benefit. In this commentary, we propose a tiered approach, where the boundaries of treatment beneficiaries can be more rigorously tested and confirmed. Identification of these patients before the development of guidelines, which would have otherwise neglected these individuals, may open innumerable treatment opportunities to those who will instead be denied of them.

Quantitative assessment of retinal vessel density and thickness changes in internal carotid artery stenosis patients using optical coherence tomography angiography

OBJECTIVE

To quantitatively assess the retinal features of patients with different degrees of internal carotid artery stenosis (ICAS), particularly mild ICAS patients, utilizing optical coherence tomography angiography (OCTA).

METHODS

Thirty-two mild ICAS patients (mild ICAS group), 34 moderate to severe ICAS patients (nonmild ICAS group), and 40 controls were enrolled in this study. Retinal vessel density was quantitatively measured by OCTA, including radial peripapillary capillary vessel density (RPC-VD), superficial and deep capillary plexus vessel density (SCP/DCP-VD). Structural parameters were collected from optical coherence tomography (OCT), including retinal thickness and subfoveal choroidal thickness (SFCT). Furthermore, LASSO-penalized logistic regression was used to construct the diagnostic model based on retinal parameters. ROC curves and nomogram plots were used to assess the diagnostic ability of this model for ICAS.

RESULTS

The macular SCP-VD of mild ICAS patients was significantly lower than that of controls and lower than that of nonmild ICAS patients (all p < 0.05). However, there was no difference among the three groups in terms of DCP-VD (p > 0.05). RPC-VD could effectively discriminate between the mild ICAS group and the nonmild ICAS group (p = 0.005). For structural OCT, only the SFCT decreased as the ICAS degree increased (p < 0.05). Diagnostic scores based on retinal parameters showed a strong diagnostic capability for mild ICAS (AUC = 0.8656).

CONCLUSION

Mild ICAS patients exhibited distinct retinal features compared to nonmild ICAS patients and control subjects. OCTA potentially represents a promising method for the early detection of ICAS patients and the noninvasive surveillance of haemodynamic changes in those patients.

Quantitative comparison between carotid plaque hardness and histopathological findings: an observational study

Background

Plaque hardness in carotid artery stenosis correlates with cerebral infarction. This study aimed to quantitatively compare plaque hardness with histopathological findings and identify the pathological factors involved in plaque hardness.

Methods

This study included 84 patients (89 lesions) undergoing carotid endarterectomy (CEA) at our institution. Plaque hardness was quantitatively measured immediately after excision using a hardness meter. Collagen and calcification were evaluated as the pathological factors. Collagen was stained with Elastica van Gieson stain, converted to a gray-scale image, and displayed in a 256-step histogram. The median gray-scale median (GSM) was used as the collagen content. The degree of calcification was defined by the hematoxylin–eosin stain as follows: "0:" no calcification, "1:" scattered microcalcification, or "2:" calcification greater than 1 mm or more than 2% of the total calcification. Carotid echocardiographic findings, specifically echoluminance or the brightness of the narrowest lesion of the plaque, classified as hypo-, iso-, or hyper-echoic by comparison with the intima-media complex surrounding the plaque, and clinical data were reviewed.

Results

Plaque hardness was significantly negatively correlated with GSM [Spearman's correlation coefficient: -0.7137 (p < 0.0001)]: the harder the plaque, the higher the collagen content. There were significant differences between plaque hardness and degree of calcification between "0" and "2" (p = 0.0206). For plaque hardness and echoluminance (hypo-iso-hyper), significant differences were found between hypo-iso (p = 0.0220), hypo-hyper (p = 0.0006), and iso-hyper (p = 0.0015): the harder the plaque, the higher the luminance. In single regression analysis, GSM, sex, and diabetes mellitus were significant variables, and in multiple regression analysis, only GSM was extracted as a significant variable.

Conclusions

Plaque hardness was associated with a higher amount of collagen, which is the main component of the fibrous cap. Greater plaque hardness was associated with increased plaque stability. The degree of calcification may also be associated with plaque hardness.

The Effect of Severe Contralateral Carotid Stenosis or Occlusion on Early Outcomes after Carotid Endarterectomy

BACKGROUND: Stenosis of the carotid arteries, as a consequence of atherosclerosis is the most common cause of cerebrovascular insult (CVI). Severe (>70%) contralateral stenosis or occlusion (SCSO) of the carotid artery may represent an additional pre-operative risk factor  for neurologic incidents.             AIM: The aim of this study was to confirm and compare early perioperative results (0-30 days) of carotid endarterectomy (CEA) in patients with and without SCSO.                 PATIENT AND METHODS: In our retrospective-prospective study, we analysed the results of 273 CEA, divided into two groups based on the presence of significant contralateral stenosis or occlusion (non-SCSO and SCSO groups)             RESULTS: 273 CEA’s were performed, divided into two groups: SCSO groups 40 (14.7%) and non-SCSO group 233 (85.3%). Between the two groups, a statistically significant difference between patients was found (54.1% compared to 87.5%; p<0.0005), CEA with patch angioplasty (25.3% compared to 52.5%; p=0.001),  and CEA with the use of a shunt (3.9% compared to 35%; p<0.0005) in favour of the SCSO group. There was no statistically significant difference (SCSO was not identified as a risk factor) for any type of stroke or mortality. Logistically regression confirmed SCSO to be an independent predictor of 30-day mortality (OR 21.58; 95% CI  1.27-36.3; p= 0.033) and any type of stroke or mortality (OR 9.27; 95% CI  1.61-53.22; p= 0.012). SCSO was not a predictor of any type of stroke within 30 days. Predictors of any type of stroke was dyslipidemia (OR 0.12, 95% CI  0.02-0.76; p= 0.024).             CONCLUSIONS: There was no statistically significant difference in the incidence of early (30 day) perioperative complications between the analysed groups. The percentage of perioperative complications remains within the accepted parameters, and thus, SCSO should not be qualified as a significant risk factor for CEA. We are of the opinion that CEA remains a safe and acceptable options for patients with SCSO, and SCSO should not be a reason for preferential use of carotid stenting.

Detecting the vulnerable carotid plaque: the Carotid Artery Multimodality imaging Prognostic study design

BACKGROUND

Carotid artery disease is highly prevalent and a main cause of ischemic stroke and vascular dementia. There is a paucity of information on predictors of serious vascular events. Besides percentage diameter stenosis, international guidelines also recommend the evaluation of qualitative characteristics of carotid artery disease as a guide to treatment, but with no agreement on which qualitative features to assess. This inadequate knowledge leads to a poor ability to identify patients at risk, dispersion of medical resources, and unproven use of expensive and resource-consuming techniques, such as magnetic resonance imaging, positron emission tomography, and computed tomography.

OBJECTIVES

The Carotid Artery Multimodality imaging Prognostic (CAMP) study will: prospectively determine the best predictors of silent and overt ischemic stroke and vascular dementia in patients with asymptomatic subcritical carotid artery disease by identifying the noninvasive diagnostic features of the 'vulnerable carotid plaque'; assess whether 'smart' use of low-cost diagnostic methods such as ultrasound-based evaluations may yield at least the same level of prospective information as more expensive techniques.

STUDY DESIGN

We will compare the prognostic/predictive value of all proposed techniques with regard to silent or clinically manifest ischemic stroke and vascular dementia. The study will include ≥300 patients with asymptomatic, unilateral, intermediate degree (40-60% diameter) common or internal carotid artery stenosis detected at carotid ultrasound, with a 2-year follow-up. The study design has been registered on Clinicaltrial.gov on December 17, 2020 (ID number NCT04679727).

Extra-Cranial Carotid Artery Stenosis: An Objective Analysis of the Available Evidence

Background and Purpose

Carotid stenosis is arterial disease narrowing of the origin of the internal carotid artery (main brain artery). Knowing how to best manage this is imperative because it is common in older people and an important cause of stroke. Inappropriately high expectations have grown regarding the value of carotid artery procedures, such as surgery (endarterectomy) and stenting, for lowering the stroke risk associated with carotid stenosis. Meanwhile, the improving and predominant value of medical intervention (lifestyle coaching and medication) continues to be underappreciated.

Methods and Results

This article aims to be an objective presentation and discussion of the scientific literature critical for decision making when the primary goal is to optimize patient outcome. This compilation follows from many years of author scrutiny to separate fact from fiction. Common sense conclusions are drawn from factual statements backed by original citations. Detailed research methodology is given in cited papers. This article has been written in plain language given the importance of the general public understanding this topic. Issues covered include key terminology and the economic impact of carotid stenosis. There is a summary of the evidence-base regarding the efficacy and safety of procedural and medical (non-invasive) interventions for both asymptomatic and symptomatic patients. Conclusions are drawn with respect to current best management and research priorities. Several "furphies" (misconceptions) are exposed that are commonly used to make carotid stenting and endarterectomy outcomes appear similar. Ongoing randomized trials are mentioned and why they are unlikely to identify a routine practice indication for carotid artery procedures. There is a discussion of relevant worldwide guidelines regarding carotid artery procedures, including how they should be improved. There is an outline of systematic changes that are resulting in better application of the evidence-base.

Conclusion

The cornerstone of stroke prevention is medical intervention given it is non-invasive and protects against all arterial disease complications in all at risk. The "big" question is, does a carotid artery procedure add patient benefit in the modern era and, if so, for whom?

Predicting Transcarotid Artery Revascularization adverse outcomes by Imaging Characteristics

OBJECTIVES

Approximately 20-30% of ischemic strokes are caused by internal carotid artery stenosis. Stroke is the leading cause of disability and the second leading cause of death in the United States. Second generation Trans Carotid Arterial Revascularization (TCAR) stenting, using the ENROUTE flow reversal technology to prevent embolic stroke during the stenting process, has demonstrated stroke and death outcomes equivalent to CEA with reduced cranial nerve injury. However, at present, it is not known whether imaging characteristics obtained pre-operatively can predict outcomes of TCAR procedures.

METHODS

This retrospective cohort study included patients who underwent TCAR with flow reversal at 3 hospitals within a single hospital network who had CT angiography, MRI angiography or pre-operative diagnostic angiogram to determine whether carotid and lesion characteristics could predict patients who experienced Major Adverse Critical Events (MACE) versus those who did not. MACE was defined as myocardial infarction at 30 days, restenosis/persistent stenosis (peak systolic velocity within the stent >230cm/sec by post-operative ultrasound), stroke within any time of follow up or death within 1 year of TCAR. Student's t-tests and chi-squared tests were used to compare imaging characteristics, such as presence of pinpoint stenosis, calcification within the common carotid artery (CCA) at the take-off from the aorta, and plaque length in millimeters. Binomial logistic regression was used to examine the likelihood that imaging characteristics were associated with MACE.

RESULTS

Of 220 patients who underwent TCAR in our network, 7 were excluded because flow reversal was not used or appropriate imaging had not been performed prior to TCAR. Of the 213 patients that were included in analysis, the median length of follow up was 10.8 months (IQR: 3.4-33.1 months). Twelve percent (26/213) experienced a MACE, and a model based on imaging characteristics was statistically significant in predicting MACE with 68% accuracy (P=0.005). The presence of pinpoint stenosis was highly predictive of MACE (HR: 3.34, CI: 1.2 to 9.3, P=0.021). A shorter clavicle to carotid bifurcation distance was associated with an increased likelihood of experiencing a MACE (P=0.009), but it was weakly predictive (HR 1.03, CI: 1.01 to 1.05).

CONCLUSIONS

Pre-operative imaging characteristics, such as pinpoint stenosis and clavicle to carotid bifurcation distance, can be used to predict adverse outcomes in TCAR placement.

Early and late outcomes of type A acute aortic dissection with common carotid artery involvement

Objective

The relationship between common carotid artery (CCA) involvement in acute type A aortic dissection (ATAAD) and postoperative outcomes remains unclear. We investigated outcomes and described our current advanced strategy.

Methods

Of 492 patients who underwent surgical repair for ATAAD between September 1999 and February 2021, CCA involvement was identified in 114. Eighty of these 114 patients (70.2%) were classified as having a thrombosed CCA and 34 (29.8%) were classified as nonthrombosed. To prevent postoperative cerebral malperfusion, we initiated a strategy of early reperfusion and direct reconstruction of dissected and thrombosed CCAs regardless of neurologic symptoms.

Results

Fifty-five patients (48.2%) showed preoperative neurologic symptoms. No significant differences between the thrombosed and nonthrombosed groups were seen in postoperative mortality (20.0% vs 11.8%; P = .421) or frequency of postoperative modified Rankin scale (mRS) score ≥5 (30.0% vs 17.6%; P = .245). The rate of postoperative neurologic deficit was significantly higher (48.8% vs 23.5%; P = .013) and long-term survival rate was significantly lower (5 years; 59.1 ± 6.3% vs 77.9 ± 7.4%; 10 years: 50.0 ± 7.9% vs 72.3 ± 8.7%; P = .041) in the thrombosed group. Risk factors for mRS ≥5 from multivariable analysis included occluded thrombosed CCA, preoperative coma, preoperative shock, and prolonged operation time. Fifteen patients were treated with the early reperfusion and direct reconstruction strategy; postoperative mortality 13.3% (2 patients). No patients showed cerebral reperfusion syndrome.

Conclusions

In patients with CCA involvement, a thrombosed false lumen, especially an occluded CCA, resulted in worse outcomes regardless of preoperative neurologic symptoms. Further study is needed to evaluate the efficacy of the current strategy.

Short-term outcomes of transfemoral carotid artery stenting and carotid endarterectomy in symptomatic patients: data from a multicentric prospective registry in Brazil

BACKGROUND

Transfemoral carotid artery stenting (TF-CAS) and carotid endarterectomy (CEA) are alternative strategies for stroke prevention in patients with atherosclerotic carotid disease. Since their main objective is to prevent future ischemic events, regular reassessment of the outcomes is mandatory for providing the best therapy.

OBJECTIVE

The purpose of this study was to describe the practice and the outcomes of TF-CAS and CEA in symptomatic patients in public university hospitals in Brazil, using data from a prospective multicentric registry.

METHODS

Prospective 8-year observational study of patients with symptomatic carotid artery atherosclerotic disease that underwent TF-CAS and CEA in five public university hospitals affiliated with the RHEUNI (Registry Project of Vascular Disease in the Public University Hospitals of São Paulo). All consecutive procedures were included. The indications for the procedures were determined by each surgeon's individual discretion, in accordance with a preoperative risk evaluation. The outcome measures were any 30-day follow-up death, stroke, myocardial infarction (MI), and their combined outcome (major adverse cardiovascular events - MACE). The registration of the study was made at clinicaltrials.gov NCT02538276.

RESULTS

From January 2012 through December 2019, 376 consecutive and symptomatic patients were included in the study records. There were 152 TF-CAS procedures (40.4%) and 224 CEA procedures (59.5%). All completed the 30-day follow-up period. Occurrence of death (TR-CAS: 0.66% x CEA: 0.66%, P=0.99), stroke (TF-CAS: 4.61% x CEA: 4.46%, P=0.99), and MI (TF-CAS: 0.66% x CEA: 0%, P=0.403) was similar in both groups, without statistically significant differences. MACE rate did not differ in both groups (TF-CAS: 5.92% x CEA: 4.46%, P=0.633).

CONCLUSIONS

Data from a prospective registry of five Brazilian university hospitals showed that transfemoral carotid artery stenting and carotid endarterectomy in symptomatic patients had similar 30-day perioperative rates of death, stroke, and myocardial infarction and their combination.