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Huang Y, Sun X, Ding X, Tan S, Yu Z, Shi X, Li X, Ge H. Pathological Intraplaque Hemorrhage as the Gold Standard to Assess the Efficacy of Ultrasound in Predicting Vulnerable Carotid Plaque Rupture. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024. [PMID: 38962941 DOI: 10.1002/jum.16518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/27/2024] [Accepted: 06/14/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVE To assess the clinical utility of ultrasound in predicting the risk of carotid vulnerable plaque rupture using pathological intraplaque hemorrhage as the gold standard. METHODS A total of 118 patients who underwent endarterectomy due to symptomatic carotid artery stenosis were enrolled. Conventional ultrasound assessed the plaque thickness, area stenosis rate, echo, and surface morphology. Neovascularization were assessed by contrast-enhanced ultrasound (CEUS) and tracing intraplaque nonenhanced areas. According to neovascularization grade (0-4), plaques were classified as low-, intermediate-, and high risk. Fresh intraplaque hemorrhage within the pathology was adopted as the gold standard for diagnosing plaque rupture risk. Thus, we divided patients into ruptured risk and nonruptured risk groups to assess the value of crucial factors for plaque rupture risk using ultrasound. RESULTS Of the 118 patients, hypertension accounted for 71.2%, hyperlipidemia 68.6%, diabetes 52.5%, and statin history 64.4%. In the rupture risk group, diabetes, smoking, and stenosis rate were significantly higher than the nonrupture risk group (P < .001); plaque thickness ≥4 mm (P > .05); and mainly hypoechoic with irregular surface morphology (P < .001), nonenhanced areas in the plaques (P < .001), and neovascularization >grade 2 (P < .001). Compared with the low-risk group, plaque rupture risk was 7.219 times higher in the medium-risk group and 18.333 times higher in the high-risk group. The kappa value of the interobserver consistency of crucial ultrasound parameters was >0.75, and the intraclass correlation coefficient was 0.919 (P < .01). CONCLUSIONS Both conventional ultrasound and CEUS have significant clinical importance in the prediction of rupture risk in vulnerable carotid plaques, thereby enabling stroke risk stratification and the assessment of plaque rupture risk.
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Affiliation(s)
- Yaping Huang
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- Department of Ultrasound, Chuiyangliu Hospital Affiliated to Tsinghua University, Beijing, China
| | - Xinping Sun
- Department of Ultrasound, Chuiyangliu Hospital Affiliated to Tsinghua University, Beijing, China
| | - Xu Ding
- Department of Vascular Surgery, Chuiyangliu Hospital Affiliated to Tsinghua University, Beijing, China
| | - Shuping Tan
- Department of Vascular Surgery, Beijing Hospital, Beijing, China
| | - Zexing Yu
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xue Shi
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xin Li
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Huiyu Ge
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Gencer ES, Yilmaz E, Arsava EM, Gocmen R, Topcuoglu MA. Carotid Artery Perivascular Adipose Tissue Density and Response to Intravenous Tissue Plasminogen Activator in Acute Ischemic Stroke. Angiology 2024; 75:472-479. [PMID: 37163448 DOI: 10.1177/00033197231174654] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
The importance of Carotid Artery Perivascular Adipose Tissue Density (CAPATd), a parameter that can be readily evaluated on emergency computed tomographic angiography (CTA), in acute stroke has not been adequately clarified. We created exploratory logistic regression models to detect the interaction between the effect of CAPATd and intravenous (IV) tissue plasminogen activator (tPA) in 174 patients (mean age 71 ± 14 years, 94 women) with acute ischemic stroke treated with IV-tPA alone. The CAPATd-average mean (-60.6 ± 18.7 vs -89.8 ± 25.3 Hounsfield units (HU), P = .002) and CAPATd-maximum (14.8 ± 68.9 vs -20.5 ± 39.8 HU, P = .020) values were higher on the ipsilateral side of carotid artery stenosis >60%. CAPATd-maximum ipsilateral emerged as an independent predictor for both modified Rankin's Score 0-2 (52%) [exp(β) = .984] and mRS 0-1 outcome (32%) [exp(β) = .828] in addition to admission National Institutes of Health Stroke Scale, age and carotid plaque burden. CAPATd-maximum ipsilateral was acceptably accurate (Area under the Receiver operating characteristic Curve was .607, P = .0109 for mRS 0-2 and .613, P = .0102 for mRS 0-1). Ipsilateral CAPATd ≥ -25 HU predicted both mRS >3 and mRS >2 with usable sensitivity (59.8% and 66.07%) and specificity (63.6% and 59.68%). In conclusion, higher maximum CAPATd measured on emergency CTA indicates poorer functional prognosis in acute stroke patients treated with IV-tPA.
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Affiliation(s)
- Elif Sarionder Gencer
- Hacettepe University, Faculty of Medicine Hospital, Department of Neurology, Ankara, Turkey
- Department of Neurology, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Turkey
| | - Ezgi Yilmaz
- Hacettepe University, Faculty of Medicine Hospital, Department of Neurology, Ankara, Turkey
| | - Ethem Murat Arsava
- Hacettepe University, Faculty of Medicine Hospital, Department of Neurology, Ankara, Turkey
| | - Rahsan Gocmen
- Hacettepe University, Faculty of Medicine Hospital, Department of Radiology, Ankara, Turkey
| | - Mehmet Akif Topcuoglu
- Hacettepe University, Faculty of Medicine Hospital, Department of Neurology, Ankara, Turkey
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Zou X, Li Y, Yang J, Miao J, Li Y, Ling W. Contrast-enhanced ultrasound reveals free-floating thrombus in carotid artery: The cause of stroke is surprisingly plaque rupture. Clin Hemorheol Microcirc 2024; 87:129-136. [PMID: 38277285 DOI: 10.3233/ch-232037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
BACKGROUND Acute stroke poses a serious threat to people's health. The occurrence of a thrombus following the rupture of vulnerable plaques in the carotid artery is a significant contributor to the development of stroke. In previous case reports, it has been challenging to visualize tiny ulcerations within carotid artery plaques using computed tomography angiography (CTA) and digital subtraction angiography (DSA), even when the rupture of the plaque leads to the formation of a free-floating thrombus (FFT). However, in this particular case, contrast-enhanced ultrasound (CEUS) was able to overcome this limitation and provide a more precise assessment, confirming that the FFT formation was indeed a result of plaque rupture rather than any other potential causes. Cases that utilize CEUS to visualize the formation of ulcers and FFT resulting from plaque rupture are even more rare. As such, we present this case to shed light on this infrequent phenomenon. CASE SUMMARY In this case study, we present a 65-year-old male patient who was admitted to the hospital due to headache and abnormal mental behavior for one day. During the routine cervical artery ultrasound examination upon admission, we detected the presence of plaque in the right internal carotid artery of the patient, resulting in luminal stenosis. Additionally, we observed suspected hypoechoic material at the distal end of the plaque. After undergoing CEUS examination, it was definitively determined that an ulcer had formed and a FFT had developed due to the rupture of carotid artery plaque. Subsequent CTA and DSA examinations further confirmed the presence of the FFT. The magnetic resonance imaging (MRI) reveals an acute lacunar infarction in the head of the right caput nuclei caudate, which strengthens the potential link between the patient's neurological and psychiatric symptoms observed during admission. The patient received prompt antiplatelet therapy and underwent cervical artery stenting surgery with the assistance of a distal embolic protection device. Following the procedure, the patient was discharged on the fourth day and experienced a complete recovery. CONCLUSION CEUS is a valuable tool for visualizing FFT resulting from the rupture of vulnerable plaques in the carotid artery.
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Affiliation(s)
- Xiuli Zou
- Department of Medical Ultrasound, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Medical Ultrasound, Zigong Fourth People's Hospital, Zigong, Sichuan, China
| | - Ying Li
- Department of Medical Ultrasound, Zigong Fourth People's Hospital, Zigong, Sichuan, China
| | - Jilan Yang
- Department of Medical Ultrasound, Zigong Fourth People's Hospital, Zigong, Sichuan, China
| | - Juan Miao
- Department of Medical Ultrasound, Zigong Fourth People's Hospital, Zigong, Sichuan, China
| | - Yuan Li
- Department of Medical Ultrasound, Zigong Fourth People's Hospital, Zigong, Sichuan, China
| | - Wenwu Ling
- Department of Medical Ultrasound, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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4
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Kopyto E, Czeczelewski M, Mikos E, Stępniak K, Kopyto M, Matuszek M, Nieoczym K, Czarnecki A, Kuczyńska M, Cheda M, Drelich-Zbroja A, Jargiełło T. Contrast-Enhanced Ultrasound Feasibility in Assessing Carotid Plaque Vulnerability-Narrative Review. J Clin Med 2023; 12:6416. [PMID: 37835061 PMCID: PMC10573420 DOI: 10.3390/jcm12196416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/15/2023] Open
Abstract
The risk assessment for carotid atherosclerotic lesions involves not only determining the degree of stenosis but also plaque morphology and its composition. Recently, carotid contrast-enhanced ultrasound (CEUS) has gained importance for evaluating vulnerable plaques. This review explores CEUS's utility in detecting carotid plaque surface irregularities and ulcerations as well as intraplaque neovascularization and its alignment with histology. Initial indications suggest that CEUS might have the potential to anticipate cerebrovascular incidents. Nevertheless, there is a need for extensive, multicenter prospective studies that explore the relationships between CEUS observations and patient clinical outcomes in cases of carotid atherosclerotic disease.
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Affiliation(s)
- Ewa Kopyto
- Students’ Scientific Society, Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-594 Lublin, Poland; (E.K.); (E.M.); (K.S.); (M.K.); (M.M.); (K.N.); (A.C.)
| | - Marcin Czeczelewski
- Students’ Scientific Society, Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-594 Lublin, Poland; (E.K.); (E.M.); (K.S.); (M.K.); (M.M.); (K.N.); (A.C.)
| | - Eryk Mikos
- Students’ Scientific Society, Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-594 Lublin, Poland; (E.K.); (E.M.); (K.S.); (M.K.); (M.M.); (K.N.); (A.C.)
| | - Karol Stępniak
- Students’ Scientific Society, Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-594 Lublin, Poland; (E.K.); (E.M.); (K.S.); (M.K.); (M.M.); (K.N.); (A.C.)
| | - Maja Kopyto
- Students’ Scientific Society, Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-594 Lublin, Poland; (E.K.); (E.M.); (K.S.); (M.K.); (M.M.); (K.N.); (A.C.)
| | - Małgorzata Matuszek
- Students’ Scientific Society, Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-594 Lublin, Poland; (E.K.); (E.M.); (K.S.); (M.K.); (M.M.); (K.N.); (A.C.)
| | - Karolina Nieoczym
- Students’ Scientific Society, Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-594 Lublin, Poland; (E.K.); (E.M.); (K.S.); (M.K.); (M.M.); (K.N.); (A.C.)
| | - Adam Czarnecki
- Students’ Scientific Society, Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-594 Lublin, Poland; (E.K.); (E.M.); (K.S.); (M.K.); (M.M.); (K.N.); (A.C.)
| | - Maryla Kuczyńska
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-594 Lublin, Poland; (M.K.); (M.C.); (A.D.-Z.); (T.J.)
| | - Mateusz Cheda
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-594 Lublin, Poland; (M.K.); (M.C.); (A.D.-Z.); (T.J.)
| | - Anna Drelich-Zbroja
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-594 Lublin, Poland; (M.K.); (M.C.); (A.D.-Z.); (T.J.)
| | - Tomasz Jargiełło
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-594 Lublin, Poland; (M.K.); (M.C.); (A.D.-Z.); (T.J.)
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Bianchini E, Guala A, Golemati S, Alastruey J, Climie RE, Dalakleidi K, Francesconi M, Fuchs D, Hartman Y, Malik AEF, Makūnaitė M, Nikita KS, Park C, Pugh CJA, Šatrauskienė A, Terentes-Printizios D, Teynor A, Thijssen D, Schmidt-Trucksäss A, Zupkauskienė J, Boutouyrie P, Bruno RM, Reesink KD. The Ultrasound Window Into Vascular Ageing: A Technology Review by the VascAgeNet COST Action. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2183-2213. [PMID: 37148467 DOI: 10.1002/jum.16243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/24/2023] [Accepted: 04/14/2023] [Indexed: 05/08/2023]
Abstract
Non-invasive ultrasound (US) imaging enables the assessment of the properties of superficial blood vessels. Various modes can be used for vascular characteristics analysis, ranging from radiofrequency (RF) data, Doppler- and standard B/M-mode imaging, to more recent ultra-high frequency and ultrafast techniques. The aim of the present work was to provide an overview of the current state-of-the-art non-invasive US technologies and corresponding vascular ageing characteristics from a technological perspective. Following an introduction about the basic concepts of the US technique, the characteristics considered in this review are clustered into: 1) vessel wall structure; 2) dynamic elastic properties, and 3) reactive vessel properties. The overview shows that ultrasound is a versatile, non-invasive, and safe imaging technique that can be adopted for obtaining information about function, structure, and reactivity in superficial arteries. The most suitable setting for a specific application must be selected according to spatial and temporal resolution requirements. The usefulness of standardization in the validation process and performance metric adoption emerges. Computer-based techniques should always be preferred to manual measures, as long as the algorithms and learning procedures are transparent and well described, and the performance leads to better results. Identification of a minimal clinically important difference is a crucial point for drawing conclusions regarding robustness of the techniques and for the translation into practice of any biomarker.
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Affiliation(s)
| | - Andrea Guala
- Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Spyretta Golemati
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Jordi Alastruey
- Department of Biomedical Engineering, King's College London, London, UK
| | - Rachel E Climie
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
- INSERM, U970, Paris Cardiovascular Research Center (PARCC), Université de Paris, Hopital Europeen Georges Pompidou - APHP, Paris, France
| | - Kalliopi Dalakleidi
- Biomedical Simulations and Imaging (BIOSIM) Laboratory, School of Electrical and Computer Engineering, National Technical University of Athens, Athens, Greece
| | - Martina Francesconi
- Institute of Clinical Physiology, CNR, Pisa, Italy
- University of Pisa, Pisa, Italy
| | - Dieter Fuchs
- Fujifilm VisualSonics, Amsterdam, The Netherlands
| | - Yvonne Hartman
- Department of Physiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Afrah E F Malik
- CARIM School for Cardiovascular Diseases and Heart and Vascular Center, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Monika Makūnaitė
- Biomedical Engineering Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Konstantina S Nikita
- Biomedical Simulations and Imaging (BIOSIM) Laboratory, School of Electrical and Computer Engineering, National Technical University of Athens, Athens, Greece
| | - Chloe Park
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Christopher J A Pugh
- Cardiff School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | - Agnė Šatrauskienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Centre of Cardiology and Angiology, Vilnius University Hospital Santaros klinikos, Vilnius, Lithuania
| | - Dimitrios Terentes-Printizios
- First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandra Teynor
- Faculty of Computer Science, Augsburg University of Applied Sciences, Augsburg, Germany
| | - Dick Thijssen
- Department of Physiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arno Schmidt-Trucksäss
- Department of Sport, Exercise and Health, Division Sport and Exercise Medicine, University of Basel, Basel, Switzerland
| | - Jūratė Zupkauskienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Pierre Boutouyrie
- INSERM, U970, Paris Cardiovascular Research Center (PARCC), Université de Paris, Hopital Europeen Georges Pompidou - APHP, Paris, France
| | - Rosa Maria Bruno
- INSERM, U970, Paris Cardiovascular Research Center (PARCC), Université de Paris, Hopital Europeen Georges Pompidou - APHP, Paris, France
| | - Koen D Reesink
- CARIM School for Cardiovascular Diseases and Heart and Vascular Center, Maastricht University Medical Center+, Maastricht, The Netherlands
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Healy J, Searle E, Panta RK, Chernoglazov A, Roake J, Butler P, Butler A, Gieseg SP. Ex-vivo atherosclerotic plaque characterization using spectral photon-counting CT: Comparing material quantification to histology. Atherosclerosis 2023; 378:117160. [PMID: 37495488 DOI: 10.1016/j.atherosclerosis.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND AND AIMS Atherosclerotic plaques are characterized as being vulnerable to rupture based on a series of histologically defined features, including a lipid-rich necrotic core, spotty calcification and ulceration. Existing imaging modalities have limitations in their ability to distinguish between different materials and structural features. We examined whether X-ray spectral photon-counting computer tomography (SPCCT) images were able to distinguish key plaque features in a surgically excised specimen from the carotid artery with comparison to histological images. METHODS An excised carotid plaque was imaged in the diagnostic X-ray energy range of 30-120 keV using a small-bore SPCCT scanner equipped with a Medipix3RX photon-counting spectral X-ray detector with a cadmium telluride (CdTe) sensor. Material identification and quantification (MIQ) images of the carotid plaque were generated using proprietary MIQ software at 0.09 mm volumetric pixels (voxels). The plaque was sectioned, stained and photographed at high resolution for comparison. RESULTS A lipid-rich core with spotty calcification was identified in the MIQ images and confirmed by histology. MIQ showed a core region containing lipid, with a mean concentration of 260 mg lipid/ml corresponding to a mean value of -22HU. MIQ showed calcified regions with mean concentration of 41 mg Ca/ml corresponded to a mean value of 123HU. An ulceration of the carotid wall at the bifurcation was identified to be lipid-lined, with a small calcification identified near the breach of the artery wall. CONCLUSIONS SPCCT derived material identification and quantification images showed hallmarks of vulnerable plaque including a lipid-rich necrotic core, spotty calcifications and ulcerations.
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Affiliation(s)
- Joe Healy
- Free Radical Biochemistry Laboratory, School of Biological Sciences, University of Canterbury, Christchurch, New Zealand; MARS Bioimaging Ltd., Christchurch, New Zealand
| | - Emily Searle
- Free Radical Biochemistry Laboratory, School of Biological Sciences, University of Canterbury, Christchurch, New Zealand; MARS Bioimaging Ltd., Christchurch, New Zealand
| | - Raj Kumar Panta
- Department of Radiology, University of Otago, Christchurch, New Zealand; MARS Bioimaging Ltd., Christchurch, New Zealand; European Organization for Nuclear Research (CERN), Geneva, Switzerland
| | | | - Justin Roake
- Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Phil Butler
- Department of Physics and Astronomy, University of Canterbury, New Zealand; MARS Bioimaging Ltd., Christchurch, New Zealand; European Organization for Nuclear Research (CERN), Geneva, Switzerland
| | - Anthony Butler
- Department of Physics and Astronomy, University of Canterbury, New Zealand; Department of Radiology, University of Otago, Christchurch, New Zealand; MARS Bioimaging Ltd., Christchurch, New Zealand; European Organization for Nuclear Research (CERN), Geneva, Switzerland
| | - Steven P Gieseg
- Free Radical Biochemistry Laboratory, School of Biological Sciences, University of Canterbury, Christchurch, New Zealand; Department of Radiology, University of Otago, Christchurch, New Zealand; European Organization for Nuclear Research (CERN), Geneva, Switzerland.
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7
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Li L, Hu Z, Huang Y, Zhu W, Zhao C, Wang Y, Chen M, Yu J. BP-Net: Boundary and perfusion feature guided dual-modality ultrasound video analysis network for fibrous cap integrity assessment. Comput Med Imaging Graph 2023; 107:102246. [PMID: 37210966 DOI: 10.1016/j.compmedimag.2023.102246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 05/23/2023]
Abstract
Ultrasonography is one of the main imaging methods for monitoring and diagnosing atherosclerosis due to its non-invasiveness and low-cost. Automatic differentiation of carotid plaque fibrous cap integrity by using multi-modal ultrasound videos has significant diagnostic and prognostic value for cardiovascular and cerebrovascular disease patients. However, the task faces several challenges, including high variation in plaque location and shape, the absence of analysis mechanism focusing on fibrous cap, the lack of effective mechanism to capture the relevance among multi-modal data for feature fusion and selection, etc. To overcome these challenges, we propose a new target boundary and perfusion feature guided video analysis network (BP-Net) based on conventional B-mode ultrasound and contrast-enhanced ultrasound videos for assessing the integrity of fibrous cap. Based on our previously proposed plaque auto-tracking network, in our BP-Net, we further introduce the plaque edge attention module and reverse mechanism to focus the dual video analysis on the fiber cap of plaques. Moreover, to fully explore the rich information on the fibrous cap and inside/outside of the plaque, we propose a feature fusion module for B-mode and contrast video to filter out the most valuable features for fibrous cap integrity assessment. Finally, multi-head convolution attention is proposed and embedded into transformer-based network, which captures semantic features and global context information to obtain accurate evaluation of fibrous caps integrity. The experimental results demonstrate that the proposed method has high accuracy and generalizability with an accuracy of 92.35% and an AUC of 0.935, which outperforms than the state-of-the-art deep learning based methods. A series of comprehensive ablation studies suggest the effectiveness of each proposed component and show great potential in clinical application.
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Affiliation(s)
- Leyin Li
- School of Information Science and Technology, Fudan University, Shanghai, China
| | - Zhaoyu Hu
- School of Information Science and Technology, Fudan University, Shanghai, China
| | - Yunqian Huang
- Department of Ultrasound, Tongren Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wenqian Zhu
- Department of Ultrasound, Tongren Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Chengqian Zhao
- School of Information Science and Technology, Fudan University, Shanghai, China
| | - Yuanyuan Wang
- School of Information Science and Technology, Fudan University, Shanghai, China
| | - Man Chen
- Department of Ultrasound, Tongren Hospital, Shanghai Jiao Tong University, Shanghai, China.
| | - Jinhua Yu
- School of Information Science and Technology, Fudan University, Shanghai, China.
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8
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Obaid DR, Okonji I, Cheng SF, Giannopoulos AA, Kamalathevan P, Halcox J, Rodriguez-Justo M, Richards T. Identification of vulnerable carotid plaque with histologically validated CT-derived plaque maps. Br J Radiol 2023:20220982. [PMID: 37183910 DOI: 10.1259/bjr.20220982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
OBJECTIVES Ruptured carotid plaque causes stroke, but differentiating rupture-prone necrotic core from fibrous tissue with CT is limited by overlap of X-ray attenuation. We investigated the ability of CT-derived plaque maps created from ratios of plaque/contrast attenuation to identify histologically proven vulnerable plaques. METHODS Seventy patients underwent carotid CT angiography and carotid endarterectomy. A derivation cohort of 20 patients had CT images matched with histology and carotid plaque components attenuation defined. In a validation cohort of 50 patients, CT-derived plaque maps were compared in 43 symptomatic vs 40 asymptomatic carotid plaques and accuracy detecting vulnerable plaques calculated. RESULTS In 250 plaque areas co-registered with histology, the median attenuation (HU) of necrotic core 43(26-63), fibrous plaque 127(110-162) and calcified plaque 964 (816-1207) created significantly different ratios of plaque/contrast attenuation. CT-derived plaque maps revealed symptomatic plaques had larger necrotic core than asymptomatic (13.5%(5.9-33.3) vs 7.4%(2.3-14.3), p = 0.004) with large necrotic core predicting symptoms (area under ROC curve 0.68, p = 0.004). Twenty-four of 47 carotid plaques were histologically classified as most vulnerable (Starry-Type VI). Plaque maps revealed Type VI plaques had a greater necrotic core volume than Type IV/V plaques and a necrotic core/fibrous plaque ratio >0.5 distinguished Type VI plaques with sensitivity 75.0% (55.1-88.0) and specificity of 39.1% (22.2-59.2). CONCLUSIONS Carotid plaque components can be differentiated by CT using a ratio of plaque/contrast attenuation. CT-derived plaque map volumes of necrotic core help distinguished the most vulnerable plaques. ADVANCES IN KNOWLEDGE CT-derived plaque maps based on plaque/contrast attenuation may provide new markers of carotid plaque vulnerability.
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Affiliation(s)
| | - Ike Okonji
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Suk F Cheng
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | | | | | - Toby Richards
- Department of Surgery, University of Western Australia, Perth, Australia
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9
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David E, Martinelli O, Pacini P, Di Serafino M, Huang P, Dolcetti V, Del Gaudio G, Barr RG, Renda M, Lucarelli GT, Di Marzo L, Clevert DA, Solito C, Di Bella C, Cantisani V. New Technologies in the Assessment of Carotid Stenosis: Beyond the Color-Doppler Ultrasound-High Frame Rate Vector-Flow and 3D Arterial Analysis Ultrasound. Diagnostics (Basel) 2023; 13:diagnostics13081478. [PMID: 37189578 DOI: 10.3390/diagnostics13081478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/27/2023] [Accepted: 04/03/2023] [Indexed: 05/17/2023] Open
Abstract
Atherosclerotic plaque in the carotid artery is the main cause of ischemic stroke, with a high incidence rate among people over 65 years. A timely and precise diagnosis can help to prevent the ischemic event and decide patient management, such as follow up, medical, or surgical treatment. Presently, diagnostic imaging techniques available include color-Doppler ultrasound, as a first evaluation technique, computed tomography angiography, which, however, uses ionizing radiation, magnetic resonance angiography, still not in widespread use, and cerebral angiography, which is an invasively procedure reserved for therapeutically purposes. Contrast-enhanced ultrasound is carving out an important and emerging role which can significantly improve the diagnostic accuracy of an ultrasound. Modern ultrasound technologies, still not universally utilized, are opening new horizons in the arterial pathologies research field. In this paper, the technical development of various carotid artery stenosis diagnostic imaging modalities and their impact on clinical efficacy is thoroughly reviewed.
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Affiliation(s)
- Emanuele David
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia", University Hospital "Policlinico G. Rodolico", University of Catania, 95123 Catania, Italy
- Radiology Unit, Papardo-Hospital, 98158 Messina, Italy
| | - Ombretta Martinelli
- Department of Surgery "Paride Stefanini", Vascular and Endovascular Surgery Division, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Patrizia Pacini
- Department of Radiological Sciences, Oncology and Pathology, Policlinico Umberto I, Sapienza University of Rome, 00161 Rome, Italy
| | - Marco Di Serafino
- Department of General and Emergency Radiology, "Antonio Cardarelli" Hospital, 80131 Naples, Italy
| | - Pintong Huang
- Department of Ultrasound in Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 242332, China
| | - Vincenzo Dolcetti
- Department of Radiological Sciences, Oncology and Pathology, Policlinico Umberto I, Sapienza University of Rome, 00161 Rome, Italy
| | - Giovanni Del Gaudio
- Department of Radiological Sciences, Oncology and Pathology, Policlinico Umberto I, Sapienza University of Rome, 00161 Rome, Italy
| | - Richard G Barr
- Department of Radiology, Northeastern Ohio Medical University, Rootstown, OH 44272, USA
- Southwoods Imaging, Youngstown, OH 44512, USA
| | - Maurizio Renda
- Department of Radiological Sciences, Oncology and Pathology, Policlinico Umberto I, Sapienza University of Rome, 00161 Rome, Italy
| | - Giuseppe T Lucarelli
- Department of Radiological Sciences, Oncology and Pathology, Policlinico Umberto I, Sapienza University of Rome, 00161 Rome, Italy
| | - Luca Di Marzo
- Department of Surgery "Paride Stefanini", Vascular and Endovascular Surgery Division, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Dirk A Clevert
- Interdisciplinary Ultrasound-Center, Department of Radiology, University of Munich, Grosshadern Campus, 81377 Munich, Germany
| | - Carmen Solito
- Department of Radiological Sciences, Oncology and Pathology, Policlinico Umberto I, Sapienza University of Rome, 00161 Rome, Italy
| | - Chiara Di Bella
- Department of Radiological Sciences, Oncology and Pathology, Policlinico Umberto I, Sapienza University of Rome, 00161 Rome, Italy
| | - Vito Cantisani
- Department of Radiological Sciences, Oncology and Pathology, Policlinico Umberto I, Sapienza University of Rome, 00161 Rome, Italy
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Singh A, Nasir U, Segal J, Waheed TA, Ameen M, Hafeez H. The utility of ultrasound and computed tomography in the assessment of carotid artery plaque vulnerability-A mini review. Front Cardiovasc Med 2022; 9:1023562. [PMID: 36465468 PMCID: PMC9709330 DOI: 10.3389/fcvm.2022.1023562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/25/2022] [Indexed: 08/27/2023] Open
Abstract
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.
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Affiliation(s)
- Aniruddha Singh
- College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Usama Nasir
- Tower Health, West Reading, PA, United States
| | - Jared Segal
- Tower Health, West Reading, PA, United States
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Shen X, Zou S, Jin J, Liu Y, Wu J, Qu L. Dengzhan Shengmai capsule versus Aspirin in the treatment of carotid atherosclerotic plaque: A single-centre, non-inferiority, prospective, randomised controlled trial. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2022; 106:154408. [PMID: 36029646 DOI: 10.1016/j.phymed.2022.154408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/30/2022] [Accepted: 08/17/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Aspirin is an effective antiplatelet agent for the treatment of carotid atherosclerosis. However, the high risk of bleeding events associated with the drug makes it necessary to seek a safer alternative, with similar or more efficacy than aspirin. Dengzhan Shengmai (DZSM) capsules have been widely used to treat carotid atherosclerosis, and if proven to be non-inferior to aspirin, it may be preferable over the latter for carotid atherosclerosis treatment due to its numerous advantages. We conducted a randomised trial to test the non-inferiority of DZSM to aspirin for the treatment of carotid atherosclerotic plaques. METHODS We performed a single-centre, prospective, open-label, randomised non-inferiority trial. Patients with carotid atherosclerotic plaques were enrolled and randomly assigned (1:1) to receive either DZSM capsules or aspirin. The follow-up period was 12 months. The primary outcome was the mean change in carotid intima-media thickness (IMT). Secondary outcomes included ischaemic events, rate of lumen stenosis, lipid levels, and plaque scores, length, counts, and vulnerability. Adverse events and laboratory test results were recorded as safety outcomes. The non-inferiority of DZSM was demonstrated when the lower limit of the one-sided 97.5% confidence interval (CI) of the difference in IMT between groups was more than -0.06 mm (margin of non-inferiority). This trial has been registered at ClinicalTrials.gov (CHiCTR1900021365). RESULTS From 1 April 2019 to 30 September 2019, 150 patients were enrolled, and there was no statistical difference in demographics between the groups. Intention-to-treat analysis showed that the decrease in IMT(∆IMT) was 0.216 ± 0.160 and 0.225 ± 0.149 mm in the DZSM and aspirin groups, respectively. The one-sided 97.5% CI for the difference between ∆IMTs was (-0.0593, +∞). The non-inferiority of DZSM was demonstrated (Pnon-inferiority = 0.0234). There was no significant difference in the incidence of ischaemic events between the groups (P = 1.0). The DZSM group had significantly reduced plaque scores (P < 0.0001), length (P < 0.0001), and counts (P < 0.0001), and improved plaque vulnerability (P < 0.0001). The DZSM group also had reduced levels of low-density lipoprotein cholesterol (LDL-C) (P < 0.0001). Finally, the DZSM group had a lower incidence of total adverse events (14.7% vs. 28%, P = 0.046), especially gastrointestinal discomfort (5.3% vs. 16%, P = 0.034). Although there was no significant difference in bleeding events (0 vs. 5.3%, P = 0.120), the DZSM group tended to have a lower incidence. CONCLUSION This trial demonstrated that DZSM was not inferior, in efficacy, to aspirin in treating carotid atherosclerotic plaques, and was found to be superior to aspirin in terms of safety. This study provides a new approach for treating carotid plaques, especially in aspirin-intolerant patients.
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Affiliation(s)
- Xu Shen
- Department of Vascular and Endovascular Surgery, Second Affiliated Hospital of Naval Medical University, District of Huangpu, Fengyang Road 415, Shanghai 200003, China
| | - Sili Zou
- Department of Vascular and Endovascular Surgery, Second Affiliated Hospital of Naval Medical University, District of Huangpu, Fengyang Road 415, Shanghai 200003, China
| | - Jie Jin
- Department of Vascular and Endovascular Surgery, Second Affiliated Hospital of Naval Medical University, District of Huangpu, Fengyang Road 415, Shanghai 200003, China
| | - Yandong Liu
- Department of Vascular and Endovascular Surgery, Second Affiliated Hospital of Naval Medical University, District of Huangpu, Fengyang Road 415, Shanghai 200003, China
| | - Jianjin Wu
- Department of Vascular and Endovascular Surgery, Second Affiliated Hospital of Naval Medical University, District of Huangpu, Fengyang Road 415, Shanghai 200003, China
| | - Lefeng Qu
- Department of Vascular and Endovascular Surgery, Second Affiliated Hospital of Naval Medical University, District of Huangpu, Fengyang Road 415, Shanghai 200003, China.
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Advances in Noninvasive Carotid Wall Imaging with Ultrasound: A Narrative Review. J Clin Med 2022; 11:jcm11206196. [PMID: 36294515 PMCID: PMC9604731 DOI: 10.3390/jcm11206196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/12/2022] [Indexed: 11/17/2022] Open
Abstract
Carotid atherosclerosis is a major cause for stroke, with significant associated disease burden morbidity and mortality in Western societies. Diagnosis, grading and follow-up of carotid atherosclerotic disease relies on imaging, specifically ultrasound (US) as the initial modality of choice. Traditionally, the degree of carotid lumen stenosis was considered the sole risk factor to predict brain ischemia. However, modern research has shown that a variety of other imaging biomarkers, such as plaque echogenicity, surface morphology, intraplaque neovascularization and vasa vasorum contribute to the risk for rupture of carotid atheromas with subsequent cerebrovascular events. Furthermore, the majority of embolic strokes of undetermined origin are probably arteriogenic and are associated with nonstenosing atheromas. Therefore, a state-of-the-art US scan of the carotid arteries should take advantage of recent technical developments and should provide detailed information about potential thrombogenic (/) and emboligenic arterial wall features. This manuscript reviews recent advances in ultrasonographic assessment of vulnerable carotid atherosclerotic plaques and highlights the fields of future development in multiparametric arterial wall imaging, in an attempt to convey the most important take-home messages for clinicians performing carotid ultrasound.
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Jain N, Singh G, Muralidharan C, Gupta A, Chatterjee S, Rajesh U. Assessment of plaque vulnerability in carotid atherosclerotic plaques using contrast-enhanced ultrasound. Med J Armed Forces India 2022; 78:422-429. [PMID: 36267515 PMCID: PMC9577269 DOI: 10.1016/j.mjafi.2020.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 09/29/2020] [Indexed: 01/10/2023] Open
Abstract
Background Atherosclerotic carotid plaques are one of the most important causes of stroke. Apart from the severity of stenosis, there are certain plaque characteristics such as neovascularization and, surface ulceration which makes a plaque vulnerable. This study was performed to study the plaque characteristics using contrast-enhanced ultrasound (CEUS) and evaluate their association with presence of ischemic cerebrovascular symptoms in these patients. Methods This study included patients presenting at a tertiary care center, having carotid plaques causing >60% stenosis. CEUS was performed for assessment of intraplaque neovascularity and plaque surface characteristics. These plaque features were then evaluated for their association with presence of ischemic cerebrovascular symptoms in patients. Results Sixty plaques were studied in 50 patients. Thirty-two plaques were associated with ischemic cerebrovascular symptoms. On CEUS, intraplaque neovascularization was seen in 38 of the 60 plaques studied (63.3%). There was statistically significant association of intraplaque neovascularity and plaque surface characteristics with presence of ischemic cerebrovascular symptoms. Conclusion CEUS allows better characterization of plaque surface characteristics and also depicts plaque neovascularization, which helps in determining the plaque vulnerability. It should be used as an adjunct to ultrasound and doppler assessment of carotid plaques.
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Affiliation(s)
- N.K. Jain
- Senior Adviser (Radiology) Command Hospital (WC), Chandimandir, India
| | - Giriraj Singh
- Consultant & HOD (Radiology), Army Hospital (R&R), Delhi Cantt, India
| | | | - Aditya Gupta
- Senior Adviser (Medicine & Neurology), INHS, Kalyani, India
| | | | - U. Rajesh
- Associate Professor, Department of Radiology, Armed Forces Medical College, Pune, India
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Fresilli D, Di Leo N, Martinelli O, Di Marzo L, Pacini P, Dolcetti V, Del Gaudio G, Canni F, Ricci LI, De Vito C, Caiazzo C, Carletti R, Di Gioia C, Carbone I, Feinstein SB, Catalano C, Cantisani V. 3D-Arterial analysis software and CEUS in the assessment of severity and vulnerability of carotid atherosclerotic plaque: a comparison with CTA and histopathology. Radiol Med 2022; 127:1254-1269. [PMID: 36114929 PMCID: PMC9587943 DOI: 10.1007/s11547-022-01551-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 08/26/2022] [Indexed: 11/30/2022]
Abstract
Purpose Our purpose is to assess Multiparametric Ultrasound (MPUS) efficacy for evaluation of carotid plaque vulnerability and carotid stenosis degree in comparison with Computed Tomography angiography (CTA) and histology. Material and methods 3D-Arterial Analysis is a 3D ultrasound software that automatically provides the degree of carotid stenosis and a colorimetric map of carotid plaque vulnerability. We enrolled 106 patients who were candidates for carotid endarterectomy. Prior to undergoing surgery, all carotid artery plaques were evaluated with Color-Doppler-US (CDUS), Contrast-Enhanced Ultrasound (CEUS), and 3D Arterial analysis (3DAA) US along with Computerized Tomographic Angiography (CTA) to assess the carotid artery stenosis degree. Post-surgery, the carotid specimens were fixed with 10% neutral buffered formalin solution, embedded in paraffin and used for light microscopic examination to assess plaque vulnerability morphological features.
Results The results of the CTA examinations revealed 91 patients with severe carotid stenoses with a resultant diagnostic accuracy of 82.3% for CDUS, 94.5% for CEUS, 98.4% for 3DAA, respectively. The histopathological examination showed 71 vulnerable plaques with diagnostic accuracy values of 85.8% for CDUS, 93.4% for CEUS, 90.3% for 3DAA, 92% for CTA, respectively.
Conclusions The combination of CEUS and 3D Arterial Analysis may provide a powerful new clinical tool to identify and stratify “at-risk” patients with atherosclerotic carotid artery disease, identifying vulnerable plaques. These applications may also help in the postoperative assessment of treatment options to manage cardiovascular risks.
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Affiliation(s)
- Daniele Fresilli
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
| | - Nicola Di Leo
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Ombretta Martinelli
- Department of Surgery "Paride Stefanini'', Vascular and Endovascular Surgery Division, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Luca Di Marzo
- Department of Surgery "Paride Stefanini'', Vascular and Endovascular Surgery Division, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Patrizia Pacini
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Vincenzo Dolcetti
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Giovanni Del Gaudio
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Fabrizio Canni
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Ludovica Isabella Ricci
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185, Rome, Italy
| | - Corrado De Vito
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185, Rome, Italy
| | - Corrado Caiazzo
- Breast Service, Local Health Agency of Naples ASL NA1, Naples, Italy
| | - Raffaella Carletti
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Cira Di Gioia
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Iacopo Carbone
- Department of Radiological, Oncological and Pathological Sciences, Diagnostic Imaging Unit, ICOT Hospital, Sapienza University of Rome, Via Franco Faggiana1668, 04100, Latina, Italy
| | - Steven B Feinstein
- Department of Internal Medicine, Section of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Carlo Catalano
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Vito Cantisani
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
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Identification Markers of Carotid Vulnerable Plaques: An Update. Biomolecules 2022; 12:biom12091192. [PMID: 36139031 PMCID: PMC9496377 DOI: 10.3390/biom12091192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 12/02/2022] Open
Abstract
Vulnerable plaques have been a hot topic in the field of stroke and carotid atherosclerosis. Currently, risk stratification and intervention of carotid plaques are guided by the degree of luminal stenosis. Recently, it has been recognized that the vulnerability of plaques may contribute to the risk of stroke. Some classical interventions, such as carotid endarterectomy, significantly reduce the risk of stroke in symptomatic patients with severe carotid stenosis, while for asymptomatic patients, clinically silent plaques with rupture tendency may expose them to the risk of cerebrovascular events. Early identification of vulnerable plaques contributes to lowering the risk of cerebrovascular events. Previously, the identification of vulnerable plaques was commonly based on imaging technologies at the macroscopic level. Recently, some microscopic molecules pertaining to vulnerable plaques have emerged, and could be potential biomarkers or therapeutic targets. This review aimed to update the previous summarization of vulnerable plaques and identify vulnerable plaques at the microscopic and macroscopic levels.
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Ge Z, Wang Y, Wang Y, Fang S, Wang H, Li J. Diagnostic value of contrast-enhanced ultrasound in intravenous leiomyomatosis: a single-center experiences. Front Oncol 2022; 12:963675. [PMID: 36033528 PMCID: PMC9403056 DOI: 10.3389/fonc.2022.963675] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Intravenous leiomyomatosis (IVL) is a rare disease, and few studies have focused on the diagnostic value of contrast-enhanced ultrasound (CEUS) in this condition. This study aimed to investigate the diagnostic value of CEUS in IVL and summarize the specific CEUS characteristics of IVL. Materials and Method From December 2016 to March 2021, 93 patients admitted to our hospital with inferior vena cava (IVC) occupying lesions were prospectively enrolled and underwent detailed ultrasound multi-modality examinations, including conventional and contrast-enhanced ultrasound scans. The diagnostic value of CEUS and conventional ultrasound (CU) in IVL was compared, and the specific IVL signs were summarized. Results Among the 93 patients with inferior vena cava mass, 67 were IVL while 26 were non-IVL. The inter-observer agreement of the two senior doctors was good, with Kappa coefficient = 0.71 (95% CI: 0.572–0.885). The area under the ROC curve of CU for IVL diagnosis was 0.652 (95% CI: 0.528–0.776), and its sensitivity, specificity, accuracy, positive predictive value, negative predictive value, missed diagnosis rate, and misdiagnosis rate were 61.1%, 69.2%, 63.4%, 83.7%, 40.9%, 38.8%, and 30.8%, respectively. The area under curve (AUC) for IVL diagnosis by CEUS was 0.807 (95% CI: 0.701–0.911), and the sensitivity, specificity, accuracy, positive predictive value, negative predictive value, missed diagnosis rate, and misdiagnosis rate were 82.0%, 84.6%, 82.8%, 93.2%, 64.7%, 15.4%, and 17.9%, respectively. In CEUS mode, “sieve hole sign” and “multi-track sign” were detected in 57 lesions, and the detected rate was higher than that of CU (https://loop.frontiersin.org/people/1014187 < 0.01). Conclusion CEUS can better show the fine blood flow inside the IVL, which is important for IVL differential diagnosis. Moreover, CEUS can obtain more information about IVL diagnosis than CU, compensating for the shortcomings of CU in detecting more blood flow within the lesion. Thus, this technique has great significance for IVL diagnosis.
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Li X, Cokkinos D, Gadani S, Rafailidis V, Aschwanden M, Levitin A, Szaflarski D, Kirksey L, Staub D, Partovi S. Advanced ultrasound techniques in arterial diseases. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2022; 38:1711-1721. [PMID: 35195805 DOI: 10.1007/s10554-022-02558-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/08/2022] [Indexed: 12/24/2022]
Abstract
Ultrasound (US) remains a valuable modality for the assessment of vascular diseases, with conventional sonographic techniques such as grayscale and Doppler US used extensively to assess carotid atherosclerosis and abdominal aortic aneurysms. However, conventional US techniques are inherently limited by factors such as operator dependency and limited field of view. There is an increasing interest in the use of advanced sonographic techniques such as contrast-enhanced US (CEUS) and 3-dimensional (3D) US to mitigate some of these limitations. Clinical applications of advanced sonographic techniques include surveillance of abdominal aortic aneurysm, post-endovascular aortic repair, and carotid atherosclerotic plaques. Recently published studies have demonstrated that CEUS and 3D US are superior to conventional US and comparable to computed tomography for certain vascular applications. Further research is required to fully validate the application of advanced sonographic techniques in evaluating various atherosclerotic diseases.
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Affiliation(s)
- Xin Li
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Sameer Gadani
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Vasileios Rafailidis
- Department of Radiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Markus Aschwanden
- Department of Vascular Medicine/Angiology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Abraham Levitin
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Diane Szaflarski
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Levester Kirksey
- Department of Vascular Surgery, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Daniel Staub
- Department of Vascular Medicine/Angiology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sasan Partovi
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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Dong S, Hou J, Zhang C, Lu G, Qin W, Huang L, Zhou G. Diagnostic Performance of Atherosclerotic Carotid Plaque Neovascularization with Contrast-Enhanced Ultrasound: A Meta-Analysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:7531624. [PMID: 35295205 PMCID: PMC8920645 DOI: 10.1155/2022/7531624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/12/2022] [Accepted: 01/15/2022] [Indexed: 11/18/2022]
Abstract
Objectives To evaluate the diagnostic performance of contrast-enhanced ultrasound (CEUS) for atherosclerotic carotid plaque neovascularization. Methods The electronic databases like PubMed, Embase, OVID, and Web of Science were used to search for the relevant studies, which are involved in the evaluation of the diagnostic parameters of QUS for atherosclerotic carotid plaque neovascularization. Review Manager 5.4 and Stata 14.0 were used to estimate the pooled diagnostic value of CEUS. Forest plots, sensitivity analysis, and Deeks' funnel plots were performed on the included studies. Results Ten studies eventually met the final inclusion criteria. For diagnostic performance, CUES showed that the pooled values of sensitivity, specificity, positive likelihood odds ratios, negative likelihood odds ratios, and diagnostic odds ratios were 0.83 (95% CI 0.78-0.86), 0.77 (95% CI 0.68-0.84), 3.61 (95% CI 2.59-5.03), 0.23 (95% CI 0.18-0.28), and 16.02 (95% CI 10.02-25.60), respectively. The estimate of the area under curve (AUC) was 0.85 (95% CI 0.82-0.88). Conclusion Our research supported that CEUS had high sensitivity and specificity in the diagnosis of atherosclerotic carotid plaque neovascularization. More high-quality prospective multicenter studies focusing on the accuracy of CEUS for carotid atherosclerotic plaque should be performed to verify our conclusions.
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Affiliation(s)
- Shanshan Dong
- Department of Function, First Affiliated Hospital, School of Medical, Shihezi University, Shihezi, Xinjiang 832000, China
| | - Jianzhong Hou
- Department of General Surgery, First Affiliated Hospital, School of Medical, Shihezi University, Shihezi, Xinjiang 832000, China
| | - Caiyun Zhang
- Department of Function, First Affiliated Hospital, School of Medical, Shihezi University, Shihezi, Xinjiang 832000, China
| | - Guilin Lu
- Department of Function, First Affiliated Hospital, School of Medical, Shihezi University, Shihezi, Xinjiang 832000, China
| | - Wenjuan Qin
- Department of Function, First Affiliated Hospital, School of Medical, Shihezi University, Shihezi, Xinjiang 832000, China
| | - Lei Huang
- Department of Function, First Affiliated Hospital, School of Medical, Shihezi University, Shihezi, Xinjiang 832000, China
| | - Guangqin Zhou
- Department of Function, First Affiliated Hospital, School of Medical, Shihezi University, Shihezi, Xinjiang 832000, China
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Bonati LH, Brown MM. Carotid Artery Disease. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00022-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Cantisani V, Di Leo N, David E, Clevert DA. Role of CEUS in Vascular Pathology. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:348-366. [PMID: 33915577 DOI: 10.1055/a-1403-2400] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
In recent years, the implementation of contrast-enhanced ultrasound (CEUS) in clinical practice has opened new horizons in the arterial pathologies research field, since this technique is able to supply new sets of data that can be crucial in patient management. The main applications of CEUS in the arterial system are the detection, characterization, and follow-up of carotid plaques and endoleaks after EVAR. Other situations in which CEUS was demonstrated to be a useful tool are large vessel vasculitis, dissections, and untreated aneurysms. In carotid atherosclerosis CEUS is not only able to acquire quantitative data about stenosis but also to perform a qualitative assessment of the plaque. The most important plaque features that CEUS is able to depict are ulceration, neovascularization, and the presence of inflammatory infiltrates. All of these factors contribute to plaque vulnerability. Thus, CEUS is crucial in order to allow better risk stratification and management of patients. In follow-up after EVAR, CEUS shows sensitivity and specificity values similar to CTA while ensuring several advantages, such as lower cost and the absence of ionizing radiation and nephrotoxic agents. Moreover, CEUS is able to offer real-time evaluation of endoleaks and thus is a useful tool in cases that are ambiguous on CTA. Most limitations are patient-related and are the same as in all other ultrasound techniques, such as high BMI and meteorism.
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Affiliation(s)
- Vito Cantisani
- Department of Radiological, Oncological and Anatomopathological Sciences-Radiology, "Sapienza" University of Rome, Rome, Italy, Universita degli Studi di Roma La Sapienza, Roma, Italy
| | - Nicola Di Leo
- Department of Radiological, Oncological and Anatomopathological Sciences-Radiology, "Sapienza" University of Rome, Rome, Italy, Universita degli Studi di Roma La Sapienza, Roma, Italy
| | - Emanuele David
- Radiological Sciences, Radiology Unit, Papardo-Hospital, Messina, Italy, Messina, Italy
| | - Dirk-André Clevert
- Department of Clinical Radiology, University of Munich-Großhadern Campus, Munich, Germany
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21
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Iannuzzi A, Rubba P, Gentile M, Mallardo V, Calcaterra I, Bresciani A, Covetti G, Cuomo G, Merone P, Di Lorenzo A, Alfieri R, Aliberti E, Giallauria F, Di Minno MND, Iannuzzo G. Carotid Atherosclerosis, Ultrasound and Lipoproteins. Biomedicines 2021; 9:biomedicines9050521. [PMID: 34066616 PMCID: PMC8148516 DOI: 10.3390/biomedicines9050521] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 12/13/2022] Open
Abstract
Carotid artery plaques are considered a measure of atherosclerosis and are associated with an increased risk of atherosclerotic cardiovascular disease, particularly ischemic strokes. Monitoring of patients with an elevated risk of stroke is critical in developing better prevention strategies. Non-invasive imaging allows us to directly see atherosclerosis in vessels and many features that are related to plaque vulnerability. A large body of evidence has demonstrated a strong correlation between some lipid parameters and carotid atherosclerosis. In this article, we review the relationship between lipids and atherosclerosis with a focus on carotid ultrasound, the most common method to estimate atherosclerotic load.
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Affiliation(s)
- Arcangelo Iannuzzi
- Department of Medicine and Medical Specialties, A. Cardarelli Hospital, 80131 Naples, Italy; (A.B.); (G.C.)
- Correspondence:
| | - Paolo Rubba
- Department of Clinical Medicine, Surgery Federico II University, 80131 Naples, Italy; (P.R.); (M.G.); (V.M.); (I.C.); (M.N.D.D.M.); (G.I.)
| | - Marco Gentile
- Department of Clinical Medicine, Surgery Federico II University, 80131 Naples, Italy; (P.R.); (M.G.); (V.M.); (I.C.); (M.N.D.D.M.); (G.I.)
| | - Vania Mallardo
- Department of Clinical Medicine, Surgery Federico II University, 80131 Naples, Italy; (P.R.); (M.G.); (V.M.); (I.C.); (M.N.D.D.M.); (G.I.)
| | - Ilenia Calcaterra
- Department of Clinical Medicine, Surgery Federico II University, 80131 Naples, Italy; (P.R.); (M.G.); (V.M.); (I.C.); (M.N.D.D.M.); (G.I.)
| | - Alessandro Bresciani
- Department of Medicine and Medical Specialties, A. Cardarelli Hospital, 80131 Naples, Italy; (A.B.); (G.C.)
| | - Giuseppe Covetti
- Department of Medicine and Medical Specialties, A. Cardarelli Hospital, 80131 Naples, Italy; (A.B.); (G.C.)
| | - Gianluigi Cuomo
- Department of Translational Medical Sciences, Federico II University of Naples, 80131 Naples, Italy; (G.C.); (P.M.); (A.D.L.); (R.A.); (F.G.)
| | - Pasquale Merone
- Department of Translational Medical Sciences, Federico II University of Naples, 80131 Naples, Italy; (G.C.); (P.M.); (A.D.L.); (R.A.); (F.G.)
| | - Anna Di Lorenzo
- Department of Translational Medical Sciences, Federico II University of Naples, 80131 Naples, Italy; (G.C.); (P.M.); (A.D.L.); (R.A.); (F.G.)
| | - Roberta Alfieri
- Department of Translational Medical Sciences, Federico II University of Naples, 80131 Naples, Italy; (G.C.); (P.M.); (A.D.L.); (R.A.); (F.G.)
| | - Emilio Aliberti
- North Tees University Hospital, Stockton-on Tees TS19 8PE, UK;
| | - Francesco Giallauria
- Department of Translational Medical Sciences, Federico II University of Naples, 80131 Naples, Italy; (G.C.); (P.M.); (A.D.L.); (R.A.); (F.G.)
| | - Matteo Nicola Dario Di Minno
- Department of Clinical Medicine, Surgery Federico II University, 80131 Naples, Italy; (P.R.); (M.G.); (V.M.); (I.C.); (M.N.D.D.M.); (G.I.)
| | - Gabriella Iannuzzo
- Department of Clinical Medicine, Surgery Federico II University, 80131 Naples, Italy; (P.R.); (M.G.); (V.M.); (I.C.); (M.N.D.D.M.); (G.I.)
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22
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Simonetto M, Dharmadhikari S, Bennett A, Campo N, Asdaghi N, Romano J, Koch S. Do Carotid Plaque Ulcers Heal? Potential Detection of Carotid Artery Plaque Healing by Carotid Ultrasound Imaging. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:973-980. [PMID: 32888371 DOI: 10.1002/jum.15472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 07/02/2020] [Accepted: 07/08/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Carotid plaque ulcers confer an increased risk for stroke/ transient ischemic attacks in both symptomatic and asymptomatic carotid artery stenosis. Little is known about the healing rates of ulcers or the development of new ulcers. Carotid Duplex studies are noninvasive and easily repeatable tests to monitor progression of carotid stenosis and plaque morphology. Our aim was to determine the prevalence and healing rates of ultrasound-detected carotid plaque ulcers. METHODS We retrospectively reviewed 5837 carotid Duplex studies performed in an outpatient ultrasound laboratory affiliated with the neurological department of an academic center. A total of 3215 patients underwent a first carotid ultrasound Duplex study, and 2622 follow-up studies were done. Carotid ulcer was defined as a 2 mm deep surface indentation in a carotid plaque with a well-defined back wall, as determined by multimodal ultrasound imaging techniques. RESULTS The prevalence of carotid plaque ulcers among the 3215 patients with a first ultrasound study was 3% (82/3215). The mean follow-up was 42 ± 30 months, and the median number of follow-up studies was 6. Among patients with ulcers, follow-up studies were available in 65/82 patients. During the follow-up period, 28/65 (43%) ulcers healed. Among all 2622 follow-up studies, 45 patients developed a new ulcer. CONCLUSIONS Duplex-detected carotid plaque ulcer prevalence is low. The carotid ulcers healed in approximately half of patients during follow-up. Factors associated with ulcer healing and development remain poorly understood.
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Affiliation(s)
- Marialaura Simonetto
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Sushrut Dharmadhikari
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Ari Bennett
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Nelly Campo
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Negar Asdaghi
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Jose Romano
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Sebastian Koch
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, Florida
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23
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Shimonaga K, Matsushige T, Takahashi H, Hashimoto Y, Yoshiyama M, Ono C, Sakamoto S. Peptidylarginine Deiminase 4 as a Possible Biomarker of Plaque Instability in Carotid Artery Stenosis. J Stroke Cerebrovasc Dis 2021; 30:105816. [PMID: 33906071 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105816] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/04/2021] [Accepted: 04/05/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND AND PURPOSE Neutrophil extracellular traps (NETs) exhibit pro-inflammatory and pro-thrombotic properties. However, they have only been reported as important regulators in atherosclerosis, especially in atherothrombosis. We investigated the presence of NETs and plaque instability in patients with carotid artery stenosis. MATERIAL AND METHODS A total of 39 consecutive patients with carotid artery stenosis were evaluated. All patients underwent carotid artery stenting (CAS) with dual protection (simultaneous flow reversal + distal filter) and blood aspiration as a method of distal embolism prevention. Local arterial blood was aspirated at the stent site and peptidylarginine deiminase 4 (PAD4), which is essential for the formation of NETs, was measured. The relationships between PAD4 and the patient profile, blood examination and plaque data were investigated. RESULTS The mean value of PAD4 in local arterial blood in CAS was 0.5 ng/ml. Bivariate analysis demonstrated that PAD4 was associated with the neutrophil to lymphocyte ratio (p = 0.007), high-density lipoprotein (p = 0.02), triglycerides to high-density lipoprotein ratio (p = 0.007), ulceration (p = 0.02) and plaque contrast enhancement on T1 black blood imaging (p = 0.03). In multiple linear regression analyses, PAD4 was correlated with the neutrophil to lymphocyte ratio (p = 0.01) and ulceration (p = 0.01, cut-off value: 0.49 odds ratio: 19.3). CONCLUSIONS PAD4, representative of the presence of NETs, was high in carotid plaques with unstable features. The neutrophil to lymphocyte ratio in peripheral blood was suggested to be a biomarker of vulnerable plaques. Elucidating the role of NETs may aid in clarifying factors that promote the instability of carotid plaques.
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Affiliation(s)
- Koji Shimonaga
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabeminami, Asakitaku, 731 0293 Hiroshima, Japan.
| | - Toshinori Matsushige
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabeminami, Asakitaku, 731 0293 Hiroshima, Japan; Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Hiroki Takahashi
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabeminami, Asakitaku, 731 0293 Hiroshima, Japan.
| | - Yukishige Hashimoto
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabeminami, Asakitaku, 731 0293 Hiroshima, Japan.
| | - Michitsura Yoshiyama
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabeminami, Asakitaku, 731 0293 Hiroshima, Japan.
| | - Chiaki Ono
- Department of Radiology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan.
| | - Shigeyuki Sakamoto
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
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Stress Echocardiography and Carotid Ultrasound: Combined Use for the Assessment of Coronary Artery Disease? J Am Soc Echocardiogr 2021; 34:625-628. [PMID: 33831514 DOI: 10.1016/j.echo.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/01/2021] [Indexed: 11/21/2022]
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25
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Song Y, Dang Y, Li H, Feng J, Ruan L. Relationship between carotid intraplaque neovascularization and haemoglobin A1c in diabetic patients. Clin Neurol Neurosurg 2021; 203:106515. [PMID: 33601236 DOI: 10.1016/j.clineuro.2021.106515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 01/19/2021] [Accepted: 01/19/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION We aimed to evaluate the characteristics of carotid artery plaques and the relationship between intraplaque neovascularization (IPN) and hemoglobin A1c (HbA1c) in patients of <60 years old with diabetes mellitus (DM) by comparison with diabetes ≥60 years of age. METHODS One-hundred-and-one patients with DM were studied into two groups: those <60 and those ≥60 years of age. All the patients underwent standard carotid ultrasonography and contrast-enhanced ultrasonography, which we used to evaluate IPN. RESULTS Diabetic complications were present in 41 of 50 patients (82 %) in the <60-year-old group, of whom 17 (34 %) had diabetes-related vascular complications. Of the 47 plaques in the <60-year-old group, six (13 %) had IPN Grade 0, 16 (34 %) had IPN Grade 1, and 25 (53 %) had IPN Grade 2. The AUC and RAUC of the plaque in the <60-year-old group were significantly higher than those of the ≥60-year-old group (P = 0.012 and 0.031, respectively). There were also differences in the AUC, RAUC and semi-quantitative grades between patients with and without diabetic macrovasculopathy and diabetic peripheral artery disease (all P < 0.05). The AUC, RAUC and semi-quantitative grading of IPN positively correlated with blood glucose and HbA1c (P < 0.05). CONCLUSION IPN is more common in DM patients who are younger, and have higher blood glucose and HbA1c concentrations, and these plaques are more vulnerable.
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Affiliation(s)
- Yan Song
- Department of Ultrasound, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Ying Dang
- Department of Ultrasound, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Hao Li
- Department of Critical Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Jun Feng
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
| | - Litao Ruan
- Department of Ultrasound, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
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26
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Advances in Multimodality Carotid Plaque Imaging: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 217:16-26. [PMID: 33438455 DOI: 10.2214/ajr.20.24869] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Contemporary imaging methods provide detailed visualization of carotid athero-sclerotic plaque, enabling a major evolution of in vivo carotid plaque imaging evaluation. The degree of luminal stenosis in the carotid artery bifurcation, as assessed by ultrasound, has historically served as the primary imaging feature for determining ischemic stroke risk and the potential need for surgery. However, stroke risk may be more strongly driven by the presence of specific characteristics of vulnerable plaque, as visualized on CT and MRI, than by traditional ultrasound-based assessment of luminal narrowing. This review highlights six promising imaging-based plaque characteristics that harbor unique information regarding plaque vulnerability: maximum plaque thickness and volume, calcification, ulceration, intraplaque hemorrhage, lipid-rich necrotic core, and thin or ruptured fibrous cap. Increasing evidence supports the association of these plaque characteristics with risk of ischemic stroke, although these characteristics have varying suitability for clinical implementation. Key aspects of CT and MRI protocols for carotid plaque imaging are also considered. Practical next steps and hurdles are explored for implementing routine imaging assessment of these plaque characteristics in addition to, or even as replacement for, traditional assessment of the degree of vascular stenosis on ultrasound, in the identification of individuals at high risk of ischemic stroke.
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27
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Baun J. Contrast-Enhanced Ultrasound: Identification of Neovascularization Permits Characterization of Vulnerable Carotid Plaques. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2020. [DOI: 10.1177/8756479320929017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Carotid atherosclerotic vascular disease (ASVD) represents an ongoing health problem and is responsible for a significant proportion of all cerebral ischemic events (CIEs). Method: A review of the literature was performed on the application of contrast-enhanced ultrasound (CEUS) to enhance the diagnosis of ASVD and further avoid CIEs. Results: Cerebral ischemic events are those resulting from reduction or cessation of perfusion to localized regions of the brain made manifest by neurological, typically stroke-like, symptoms. Traditional triplex ultrasound evaluation is a reliable and widely established method of identifying carotid ASVD lesions and grading the accompanying degree of focal stenoses and their hemodynamic impact. While this information plays an integral role in determining management of patients with significant carotid ASVD, it is less useful in classifying individual lesions as “vulnerable” or not. Vulnerable lesions are those that, based on their histological and morphological features, predispose a patient to an increased risk of a CIE due to plaque or thrombus embolization. Conclusions: The addition of CEUS to carotid artery diagnostic studies offers new potential in identifying vulnerable plaques and predicting which patients will progress to sequelae associated with a cerebral ischemic event.
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Affiliation(s)
- Jim Baun
- University of Findlay, Toledo, OH, USA
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28
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Nezu T, Hosomi N. Usefulness of Carotid Ultrasonography for Risk Stratification of Cerebral and Cardiovascular Disease. J Atheroscler Thromb 2020; 27:1023-1035. [PMID: 32863299 PMCID: PMC7585913 DOI: 10.5551/jat.rv17044] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Carotid ultrasonography is useful for the assessments of the risk stratification for stroke or coronary artery disease, because it is a simple, repeatable, and noninvasive procedure. The carotid intima-media thickness (IMT), which is assessed using carotid ultrasonography, is a widely used surrogate marker for the severity of atherosclerosis. Several large clinical studies showed that increased carotid IMT is associated with the future stroke or cardiovascular events. In addition, in many clinical trials, it has been adopted for surrogate markers of clinical endpoints of medical intervention. Moreover, carotid ultrasonography allows the measurement of the presence and characteristics of plaques and the severity of carotid artery stenosis. The unstable morphology of plaque, such as hypoechoic, ulcer, and mobility, is associated with future ischemic stroke events. The screening tool of asymptomatic carotid artery stenosis is also important, although whether routine carotid ultrasonography assessment is recommended in the general population remains controversial. The screening of carotid artery stenosis using ultrasonography is essential for not only daily clinical settings but also management of patients with acute ischemic stroke. The patients with atherothrombotic stroke with severe internal carotid artery stenosis should be considered to surgical intervention, and duplex ultrasound approach is important to estimate for the severity of carotid stenosis. Physicians should keep in mind the usefulness of carotid ultrasonography for risk stratification of cerebral and cardiovascular disease based on various aspects. In addition, visual assessment or dynamic changes using carotid ultrasonography could provide the various and valuable insights in clinical settings.
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Affiliation(s)
- Tomohisa Nezu
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Naohisa Hosomi
- Department of Neurology, Chikamori Hospital.,Department of Disease Model, Research Institute of Radiation Biology and Medicine, Hiroshima University
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29
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Grubic N, Colledanchise KN, Liblik K, Johri AM. The Role of Carotid and Femoral Plaque Burden in the Diagnosis of Coronary Artery Disease. Curr Cardiol Rep 2020; 22:121. [PMID: 32778953 DOI: 10.1007/s11886-020-01375-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW With limitations of cardiovascular disease risk stratification by traditional risk factors, the role of noninvasive imaging techniques, such as vascular ultrasound, has emerged as a prominent utility for decision-making in coronary artery disease. A review of current guidelines and contemporary approaches for carotid and femoral plaque assessment is needed to better inform the diagnosis, management, and treatment of atherosclerosis in clinical practice. RECENT FINDINGS The recent consensus-based guidelines for carotid plaque assessment in coronary artery disease have been established, supported by some outcomes-based research. Currently, there is a gap of evidence on the use of femoral ultrasound to detect atherosclerosis, as well as predict adverse cardiovascular outcomes. The quantification and characterization of individualized plaque burden are important to stratify risk in asymptomatic or symptomatic atherosclerosis patients. Standardized quantification guidelines, supported by further outcomes-based research, are required to assess disease severity and progression.
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Affiliation(s)
- Nicholas Grubic
- Department of Medicine, Division of Cardiology, CINQ, Queen's University, 76 Stuart Street, FAPC 3, Kingston, ON, K7L 2V7, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Kayla N Colledanchise
- Department of Medicine, Division of Cardiology, CINQ, Queen's University, 76 Stuart Street, FAPC 3, Kingston, ON, K7L 2V7, Canada
| | - Kiera Liblik
- Department of Medicine, Division of Cardiology, CINQ, Queen's University, 76 Stuart Street, FAPC 3, Kingston, ON, K7L 2V7, Canada
| | - Amer M Johri
- Department of Medicine, Division of Cardiology, CINQ, Queen's University, 76 Stuart Street, FAPC 3, Kingston, ON, K7L 2V7, Canada.
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30
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Johri AM, Nambi V, Naqvi TZ, Feinstein SB, Kim ESH, Park MM, Becher H, Sillesen H. Recommendations for the Assessment of Carotid Arterial Plaque by Ultrasound for the Characterization of Atherosclerosis and Evaluation of Cardiovascular Risk: From the American Society of Echocardiography. J Am Soc Echocardiogr 2020; 33:917-933. [PMID: 32600741 DOI: 10.1016/j.echo.2020.04.021] [Citation(s) in RCA: 135] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Atherosclerotic plaque detection by carotid ultrasound provides cardiovascular disease risk stratification. The advantages and disadvantages of two-dimensional (2D) and three-dimensional (3D) ultrasound methods for carotid arterial plaque quantification are reviewed. Advanced and emerging methods of carotid arterial plaque activity and composition analysis by ultrasound are considered. Recommendations for the standardization of focused 2D and 3D carotid arterial plaque ultrasound image acquisition and measurement for the purpose of cardiovascular disease stratification are formulated. Potential clinical application towards cardiovascular risk stratification of recommended focused carotid arterial plaque quantification approaches are summarized.
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Affiliation(s)
| | | | | | | | - Esther S H Kim
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Margaret M Park
- Cleveland Clinic Heart and Vascular Institute, Cleveland, Ohio
| | - Harald Becher
- University of Alberta Hospital, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Henrik Sillesen
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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31
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Rafailidis V, Li X, Sidhu PS, Partovi S, Staub D. Contrast imaging ultrasound for the detection and characterization of carotid vulnerable plaque. Cardiovasc Diagn Ther 2020; 10:965-981. [PMID: 32968654 DOI: 10.21037/cdt.2020.01.08] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Not only the degree of luminal narrowing but also the plaque morphology and composition play an important role in risk stratification of carotid atherosclerotic lesions. During the last few years, carotid contrast-enhanced ultrasound (CEUS) has emerged as a valuable imaging tool to assess such vulnerable carotid plaques. This review article discussed the use of CEUS for the detection of carotid plaque irregularities and ulcerations as well as the quantification of intraplaque neovascularization and its correlation with histology and inflammatory biomarkers. Apart from evaluating for markers of vulnerable carotid plaques, CEUS enhancement is directly associated with past cerebrovascular events. More importantly, preliminary evidence has shown that CEUS could be used to predict future cerebrovascular and cardiovascular events. Despite the progress in CEUS imaging for carotid atherosclerotic disease, past studies still suffer from the retrospective nature, small sample size, and a lack of matched, well controlled prospective studies. In the future, large multi-center prospective studies addressing the relationship between CEUS findings and patient clinical outcomes in carotid atherosclerotic disease are warranted.
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Affiliation(s)
| | - Xin Li
- Department of Internal Medicine, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Paul S Sidhu
- Department of Radiology, King's College Hospital, London, UK
| | - Sasan Partovi
- Interventional Radiology Section, Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Daniel Staub
- Department of Angiology, University Hospital Basel, University of Basel, Basel, Switzerland
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32
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Lyu Q, Tian X, Ding Y, Yan Y, Huang Y, Zhou P, Hui P. Evaluation of Carotid Plaque Rupture and Neovascularization by Contrast-Enhanced Ultrasound Imaging: an Exploratory Study Based on Histopathology. Transl Stroke Res 2020; 12:49-56. [PMID: 32601933 DOI: 10.1007/s12975-020-00825-w] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/27/2020] [Accepted: 06/01/2020] [Indexed: 12/22/2022]
Abstract
A significant portion of ischemic stroke is on account of emboli caused by fibrous cap rupture of vulnerable plaque with intraplaque neovascularization as a significant triggering factor to plaque vulnerability. Contrast-enhanced ultrasound (CEUS) could offer detailed information on plaque surface and intraplaque microvascular. This study aims to comprehensively assess the value of CEUS for the detection of plaque rupture and neovascularization in histologically verified plaques that had been removed from the patients who had undergone carotid endarterectomy (CEA). Fifty-one consecutive subjects (mean age, 67.0 ± 6.5 years; 43 [84.3%] men) scheduled for CEA were recruited. Standard ultrasound and CEUS were performed prior to surgery. Based on the direction of the contrast agents that diffuse within the plaques, plaques were divided as "inside-out" direction (contrast agents diffuse from the artery lumen towards the inside of the plaque) and non-inside-out direction. Plaque enhancement was assessed by using a semi-quantitative grading scale (grade 1: no enhancement; grade 2: moderate enhancement; grade 3: extensive enhancement). Plaques were evaluated for histopathologic characteristics according to Oxford Plaque Study (OPS) standard postoperative. Intraplaque neovascularization as manifested by the appearance of CD34-positive microvessels was characterized in terms of microvessel density (MVD), microvessel area (MVA), and microvessel shape (MVS). In 51 plaques, the sensitivity, specificity, positive, and negative predictive values of contrast agent inside-out direction diffusion for the detection of plaque fibrous cap rupture were 87.5%, 92.6%, 91.3%, and 89.3%, respectively. The incidence of cap rupture was significantly higher in contrast agent inside-out direction diffusion than non-inside-out direction diffusion (73.9% vs 25.0%, p < 0.001), and inside-out direction diffusion did exhibit higher frequency of vulnerable plaques (OPS grades 3-4) (95.7% vs 53.6%, p = 0.001). Multivariate logistic regression analysis revealed the contrast agent inside-out direction diffusion as an independent correlate to plaque rupture (OR 8.5, 95% CI 2.4-30.1, p = 0.001). With increasing plaque enhancement, plaque MVD (p < 0.001), plaque MVA (p = 0.012), and percentage of highly irregular-shaped microvessels increased (p < 0.001). Contrast agent inside-out direction diffusion could indicate plaque rupture. The increase in plaque enhancement paralleled increased, larger, and more irregular-shaped microvessels, which may suggest an increased risk of plaque vulnerability.
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Affiliation(s)
- Qi Lyu
- Department of Stroke Center, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, China
| | - Xiaojie Tian
- Department of Stroke Center, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, China
| | - Yafang Ding
- Department of Stroke Center, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, China
| | - Yanhong Yan
- Department of Stroke Center, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, China
| | - Yabo Huang
- Department of Stroke Center, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, China
| | - Peng Zhou
- Department of Stroke Center, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, China
| | - Pinjing Hui
- Department of Stroke Center, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, China.
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Fabiani I, Palombo C, Caramella D, Nilsson J, De Caterina R. Imaging of the vulnerable carotid plaque: Role of imaging techniques and a research agenda. Neurology 2020; 94:922-932. [PMID: 32393647 DOI: 10.1212/wnl.0000000000009480] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 03/18/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Atherothrombosis in the carotid arteries is a main cause of ischemic stroke and may depend on plaque propensity to complicate with rupture or erosion, in turn related to vulnerability features amenable to in vivo imaging. This would provide an opportunity for risk stratification and-potentially-local treatment of more vulnerable plaques. We here review current information on this topic. METHODS We systematically reviewed the literature for concepts derived from pathophysiologic, histopathologic, and clinical studies on imaging techniques attempting at identifying vulnerable carotid lesions. RESULTS Ultrasound, MRI, CT, and nuclear medicine-based techniques, alone or with multimodality approaches, all have a link to pathophysiology and describe different-potentially complementary-aspects of lesions prone to complications. There is also, however, a true paucity of head-to-head comparisons of such techniques for practical implementation of a thorough and cost-effective diagnostic strategy based on evaluation of outcomes. Especially in asymptomatic patients, major international societies leave wide margins of indecision in the advice to techniques guiding interventions to prevent atherothrombotic stroke. CONCLUSIONS To improve practical management of such patients-in addition to the patient's vulnerability for systemic reasons-a more precise identification of the vulnerable plaque is needed. A better definition of the diagnostic yield of each imaging approach in comparison with the others should be pursued for a cost-effective translation of the single techniques. Practical translation to guide future clinical practice should be based on improved knowledge of the specific pathophysiologic correlates and on a comparative modality approach, linked to subsequent stroke outcomes.
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Affiliation(s)
- Iacopo Fabiani
- From the University Cardiology (I.F., C.P., R.D.C.) and Radiology Divisions (D.C.), Pisa University Hospital; Dipartimento di Patologia Chirurgica (I.F., D.C., C.P., R.D.C.), Medica, Molecolare e dell'Area Critica, University of Pisa Medical School, Italy; Department of Clinical Sciences (J.N.), Malmö University Hospital, University of Lund, Sweden; and Fondazione VillaSerena per la Ricerca (R.D.C.), Città Sant' Angelo, Pescara, Italy
| | - Carlo Palombo
- From the University Cardiology (I.F., C.P., R.D.C.) and Radiology Divisions (D.C.), Pisa University Hospital; Dipartimento di Patologia Chirurgica (I.F., D.C., C.P., R.D.C.), Medica, Molecolare e dell'Area Critica, University of Pisa Medical School, Italy; Department of Clinical Sciences (J.N.), Malmö University Hospital, University of Lund, Sweden; and Fondazione VillaSerena per la Ricerca (R.D.C.), Città Sant' Angelo, Pescara, Italy
| | - Davide Caramella
- From the University Cardiology (I.F., C.P., R.D.C.) and Radiology Divisions (D.C.), Pisa University Hospital; Dipartimento di Patologia Chirurgica (I.F., D.C., C.P., R.D.C.), Medica, Molecolare e dell'Area Critica, University of Pisa Medical School, Italy; Department of Clinical Sciences (J.N.), Malmö University Hospital, University of Lund, Sweden; and Fondazione VillaSerena per la Ricerca (R.D.C.), Città Sant' Angelo, Pescara, Italy
| | - Jan Nilsson
- From the University Cardiology (I.F., C.P., R.D.C.) and Radiology Divisions (D.C.), Pisa University Hospital; Dipartimento di Patologia Chirurgica (I.F., D.C., C.P., R.D.C.), Medica, Molecolare e dell'Area Critica, University of Pisa Medical School, Italy; Department of Clinical Sciences (J.N.), Malmö University Hospital, University of Lund, Sweden; and Fondazione VillaSerena per la Ricerca (R.D.C.), Città Sant' Angelo, Pescara, Italy
| | - Raffaele De Caterina
- From the University Cardiology (I.F., C.P., R.D.C.) and Radiology Divisions (D.C.), Pisa University Hospital; Dipartimento di Patologia Chirurgica (I.F., D.C., C.P., R.D.C.), Medica, Molecolare e dell'Area Critica, University of Pisa Medical School, Italy; Department of Clinical Sciences (J.N.), Malmö University Hospital, University of Lund, Sweden; and Fondazione VillaSerena per la Ricerca (R.D.C.), Città Sant' Angelo, Pescara, Italy.
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Schinkel AFL, Bosch JG, Staub D, Adam D, Feinstein SB. Contrast-Enhanced Ultrasound to Assess Carotid Intraplaque Neovascularization. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:466-478. [PMID: 31791553 DOI: 10.1016/j.ultrasmedbio.2019.10.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/25/2019] [Accepted: 10/28/2019] [Indexed: 06/10/2023]
Abstract
Contrast-enhanced ultrasound (CEUS) is increasingly being used to identify patients with carotid plaques that are vulnerable to rupture, so-called vulnerable atherosclerotic plaques, by assessment of intraplaque neovascularization. A complete overview of the strengths and limitations of carotid CEUS is currently not available. The aim of this systematic review was to provide a complete overview of existing publications on the role of CEUS in assessment of carotid intraplaque neovascularization. The systematic review of the literature yielded 52 studies including a total of 4660 patients (mean age: 66 y, 71% male) who underwent CEUS for the assessment of intraplaque neovascularization. The majority of the patients (76%) were asymptomatic and had no history of transient ischemic attack (TIA) or stroke. The assessment of intraplaque neovascularization was mostly performed using a visual scoring system; several studies used time-intensity curves or dedicated quantification software to optimize analysis. In 17 studies CEUS was performed in patients before carotid surgery (endarterectomy), allowing a comparison of pre-operative CEUS findings with histologic analysis of the tissue sample that is removed from the carotid artery. In a total of 576 patients, the CEUS findings were compared with histopathological analysis of the plaque after surgery. In 16 of the 17 studies, contrast enhancement was found to correlate with the presence and degree of intraplaque neovascularization on histology. Plaques with a larger amount of contrast enhancement had significantly increased density of microvessels in the corresponding region on histology. In conclusion, CEUS is a readily available imaging modality for the assessment of patients with carotid atherosclerosis, providing information on atherosclerotic plaques, such as ulceration and intraplaque neovascularization, which may be clinically relevant. The ultimate clinical goal is the early identification of carotid atherosclerosis to start early preventive therapy and prevent clinical complications such as TIA and stroke.
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Affiliation(s)
- Arend F L Schinkel
- Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands.
| | - Johan G Bosch
- Department of Biomedical Engineering, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Daniel Staub
- Division of Angiology, Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Dan Adam
- Biomedical Engineering, Israel Institute of Technology, Haifa, Israel
| | - Steven B Feinstein
- Section of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
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Rafailidis V, Chryssogonidis I, Grisan E, Xerras C, Cheimariotis GA, Tegos T, Rafailidis D, Sidhu PS, Charitanti-Kouridou A. Does Quantification of Carotid Plaque Surface Irregularities Better Detect Symptomatic Plaques Compared to the Subjective Classification? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:3163-3171. [PMID: 31066924 DOI: 10.1002/jum.15017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/22/2019] [Accepted: 04/17/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To evaluate the interobserver agreement of color Doppler ultrasound (CDUS) and contrast-enhanced ultrasound (CEUS) for quantification of carotid plaque surface irregularities and to correlate objective and subjective measures with stroke occurrence. METHODS This work was an observational study involving 54 patients with 62 internal carotid artery or carotid bulb plaques (31 symptomatic) undergoing CDUS and CEUS between February 2016 and February 2018, with retrospective interpretation of prospectively acquired data. Plaques were included if causing moderate (50%-69%) or severe (70%-99%) stenosis based on velocity criteria, and their surface was classified as smooth, irregular, or ulcerated based on CEUS. The surface irregularities were quantified in the form of a surface irregularity index by 2 observers, based on CDUS and CEUS. The surface irregularity index was evaluated for interobserver agreement with CDUS and CEUS and correlated with the occurrence of stroke, as was the subjective characterization of the plaque surface. RESULTS Color Doppler ultrasound and CEUS showed good interobserver agreement (intraclass correlation coefficients, 0.979 and 0.952, respectively). Plaques were characterized as smooth in 30.6% of cases, irregular in 50%, and ulcerated in 19.4%. The subjective classification of the plaque surface did not correlate with stroke occurrence (P > .05, χ2 ). Surface irregularity index values were significantly higher for symptomatic plaques with both CDUS and CEUS (P < .05). CONCLUSIONS Color Doppler ultrasound and CEUS can quantify carotid plaque surface irregularities with good interobserver agreement. The resulting quantitative measure was significantly higher in symptomatic plaques, whereas the subjective characterization of plaque surface failed to differ between symptomatic and asymptomatic plaques.
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Affiliation(s)
- Vasileios Rafailidis
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Chryssogonidis
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Enrico Grisan
- Department of Information Engineering, University of Padova, Padova, Italy
- School of Imaging Sciences and Biomedical Engineering, King's College London, London, England
| | - Chrysostomos Xerras
- First Neurological Department, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Grigorios-Aris Cheimariotis
- Laboratory of Computing, Medical Informatics, and Biomedical Imaging Technologies, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Thomas Tegos
- First Neurological Department, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Rafailidis
- Department of Radiology, G. Gennimatas General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Paul S Sidhu
- Department of Radiology, King's College Hospital, London, England
| | - Afroditi Charitanti-Kouridou
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Rafailidis V, Huang DY, Yusuf GT, Sidhu PS. General principles and overview of vascular contrast-enhanced ultrasonography. Ultrasonography 2019; 39:22-42. [PMID: 31671927 PMCID: PMC6920620 DOI: 10.14366/usg.19022] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 06/25/2019] [Indexed: 12/18/2022] Open
Abstract
Ultrasonography (US) is the first-line modality for the evaluation of vascular pathology. Although well-established for many diseases, US has inherent limitations that can occasionally hinder an accurate diagnosis. The value of US was improved by the introduction of microbubbles as ultrasonographic contrast agents (UCAs) and the emergence of contrast-enhanced ultrasonography (CEUS), following the introduction of second-generation UCAs and the emergence of modern contrast-specific techniques. CEUS offers valuable information about vascular disease, both on a macrovascular and a microvascular level, with well-established applications for carotid disease, post-interventional follow-up of abdominal aortic aneurysms, and the assessment of portal vein thrombosis. The purpose of this review is to discuss the principles of CEUS and to present an overview of its vascular applications.
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Affiliation(s)
- Vasileios Rafailidis
- Department of Radiology, King's College London, King's College Hospital, London, UK
| | - Dean Y Huang
- Department of Radiology, King's College London, King's College Hospital, London, UK
| | - Gibran Timothy Yusuf
- Department of Radiology, King's College London, King's College Hospital, London, UK
| | - Paul S Sidhu
- Department of Radiology, King's College London, King's College Hospital, London, UK
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Zhang T, Yin H, Xue H. Evaluation of ultrasonography on carotid arteries and left ventricular function in patients with subclinical atherosclerosis. Exp Ther Med 2019; 17:4465-4470. [PMID: 31105784 PMCID: PMC6507511 DOI: 10.3892/etm.2019.7517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 04/12/2019] [Indexed: 11/23/2022] Open
Abstract
Ultrasonography in the evaluation and diagnosis of carotid arteries and left ventricular function in patients with subclinical atherosclerosis (SA) was explored. In total, 152 patients with no obvious clinical symptoms of atherosclerosis confirmed by carotid ultrasonography in Tengzhou Central People's Hospital from September 2015 to March 2016 were enrolled as the experimental group, and further 45 patients with normal physical examination at the same time were collected as the control group. Patients in the experimental group were divided into three groups according to Framingham risk assessment: low, middle and high risk. The carotid arteries and left ventricular function of all patients were detected by Doppler ultrasound. There were differences in the systolic pressure, TG and TC between the control group and the experimental group (P<0.05). The expression levels of β, cIMT, Ep and PWVβ increased with the risk degree in the low, middle and high risk groups (P<0.05). The expression levels of LVEDV, LVESV, and LVEF in the experimental group were significantly decreased compared with those in the control group (P<0.05), while the expression levels of LAV, E/e, GLS and GCS were significantly increased compared with those in the control group (P<0.05). There was a difference of left ventricular function parameters in the low, medium and high risk groups (P<0.05). The expression levels of LVEDV, LVESV, LAV and E/e increased with the risk degree in the low, middle and high risk groups (P<0.05). The detection rate of plaque was lower in the low risk group than those in the middle and high risk group (P<0.05). By observing the parameters of carotid arteries and left ventricular function, it was found that ultrasonography has important clinical value in the early diagnosis of SA, and can be promoted in clinic.
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Affiliation(s)
- Tao Zhang
- Department of Ultrasonography, Tengzhou Central People's Hospital, Tengzhou, Shandong 277599, P.R. China
| | - Haiwei Yin
- Department of Ultrasonography, Tengzhou Central People's Hospital, Tengzhou, Shandong 277599, P.R. China
| | - Hanwen Xue
- Department of Ultrasonography, Tengzhou Central People's Hospital, Tengzhou, Shandong 277599, P.R. China
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Saba L, Saam T, Jäger HR, Yuan C, Hatsukami TS, Saloner D, Wasserman BA, Bonati LH, Wintermark M. Imaging biomarkers of vulnerable carotid plaques for stroke risk prediction and their potential clinical implications. Lancet Neurol 2019; 18:559-572. [PMID: 30954372 DOI: 10.1016/s1474-4422(19)30035-3] [Citation(s) in RCA: 263] [Impact Index Per Article: 52.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 01/15/2023]
Abstract
Stroke represents a massive public health problem. Carotid atherosclerosis plays a fundamental part in the occurence of ischaemic stroke. European and US guidelines for prevention of stroke in patients with carotid plaques are based on quantification of the percentage reduction in luminal diameter due to the atherosclerotic process to select the best therapeutic approach. However, better strategies for prevention of stroke are needed because some subtypes of carotid plaques (eg, vulnerable plaques) can predict the occurrence of stroke independent of the degree of stenosis. Advances in imaging techniques have enabled routine characterisation and detection of the features of carotid plaque vulnerability. Intraplaque haemorrhage is accepted by neurologists and radiologists as one of the features of vulnerable plaques, but other characteristics-eg, plaque volume, neovascularisation, and inflammation-are promising as biomarkers of carotid plaque vulnerability. These biomarkers could change current management strategies based merely on the degree of stenosis.
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Affiliation(s)
- Luca Saba
- Department of Medical Sciences, University of Cagliari, Cagliari, Italy.
| | - Tobias Saam
- Department of Radiology, University Hospital Munich, Ludwig-Maximilians-University Munich, Munich, Germany; Radiologisches Zentrum Rosenheim, Rosenheim, Germany
| | - H Rolf Jäger
- Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, University College London Institute of Neurology, London, UK
| | - Chun Yuan
- Department of Radiology, University of Washington, Seattle, WA, USA
| | | | - David Saloner
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Bruce A Wasserman
- The Russell H Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Leo H Bonati
- Department of Neurology and Stroke Center, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Max Wintermark
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
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Ramanathan R, Dey D, Nørgaard BL, Goeller M, Bjerrum IS, Antulov R, Diederichsen ACP, Sidelmann JJ, Gram JB, Sand NPR. Carotid plaque composition by CT angiography in asymptomatic subjects: a head-to-head comparison to ultrasound. Eur Radiol 2019; 29:5920-5931. [PMID: 30915562 DOI: 10.1007/s00330-019-06086-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 01/27/2019] [Accepted: 02/08/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To describe carotid plaque composition by computed tomography angiography (CTA) in asymptomatic subjects and to compare this to carotid plaque assessment by ultrasound, coronary plaques by coronary CTA, and inflammatory biomarkers in plasma. METHODS Middle-aged asymptomatic men, n = 43, without known cardiovascular disease and diabetes were included. Plaques in coronary and carotid arteries were evaluated using CTA. Total plaque volumes and plaque composition were assessed by a validated plaque analysis software. The 60% centile cut point was used to divide the population into low or high carotid total plaque volumes. The occurrence of carotid plaques and intima-media thickness (IMT) was estimated by ultrasound. RESULTS Carotid plaque by ultrasound was undiagnosed in 13 of 28 participants (46%) compared to CTA. Participants having carotid plaques by ultrasound had significantly higher absolute volumes of all CTA-defined carotid plaque subtypes and a higher fraction of calcified plaque. A high carotid total plaque volume was independently associated with age (adjusted odds ratio (OR) 1.41 [95% confidence interval (CI) 1.14-1.74], p = 0.001), IMT (adjusted OR 2.26 [95% CI 1.10-4.65], p = 0.03), and D-dimer (adjusted OR 8.86 [95% CI 1.26-62.37], p = 0.03). All coronary plaque features were significantly higher in participants with a high carotid total plaque volume. CONCLUSION The occurrence of carotid plaques in asymptomatic individuals is underestimated by ultrasound compared to plaque assessment by CTA. Carotid plaque composition by CTA is different in individuals with and without carotid plaques by ultrasound. KEY POINTS • The occurrence of carotid plaques by ultrasound was underestimated in 46% of participants who had plaques by carotid CTA. • Participants with carotid plaques by ultrasound had higher volumes of all plaque subtypes and a higher calcified plaque component as determined by carotid CTA compared to participants without carotid plaques by ultrasound. • A high carotid total plaque volume was independently associated with age, intima-media thickness, and D-dimer.
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Affiliation(s)
- Ramshanker Ramanathan
- Department of Cardiology, University Hospital of Southern Denmark, Esbjerg, Denmark.
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
- Department of Clinical Biochemistry, University Hospital of Southern Denmark, Esbjerg, Denmark.
- Unit for Thrombosis Research, Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark.
| | - Damini Dey
- Cedars-Sinai Medical Center, Biomedical Imaging Research Institute, Los Angeles, CA, 90048, USA
| | - Bjarne L Nørgaard
- Department of Cardiology, Skejby University Hospital, Aarhus, Denmark
| | - Markus Goeller
- Cedars-Sinai Medical Center, Biomedical Imaging Research Institute, Los Angeles, CA, 90048, USA
| | - Ida S Bjerrum
- Department of Cardiology, University Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Ronald Antulov
- Department of Radiology, University Hospital of Southern Denmark, Esbjerg, Denmark
| | | | - Johannes J Sidelmann
- Department of Clinical Biochemistry, University Hospital of Southern Denmark, Esbjerg, Denmark
- Unit for Thrombosis Research, Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
| | - Jørgen B Gram
- Department of Clinical Biochemistry, University Hospital of Southern Denmark, Esbjerg, Denmark
- Unit for Thrombosis Research, Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
| | - Niels Peter R Sand
- Department of Cardiology, University Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Carotid artery plaque characterization with a wide-detector computed tomography using a dedicated post-processing 3D analysis: comparison with histology. Radiol Med 2019; 124:795-803. [PMID: 30903605 DOI: 10.1007/s11547-019-01026-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 03/11/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE The characterization of atherosclerotic carotid plaque plays a key role in the identification of patients at risk. The aim of our work was to evaluate the potentialities of carotid computed tomography angiography (CCTA) in assessing composition of atherosclerotic plaque. MATERIALS AND METHODS We retrospectively evaluated 29 patients (7 women and 22 men, age range 54-81; mean age 69) who underwent carotid endarterectomy. All patients underwent pre-surgical CCTA using a 320-slice scanner. Post-processing reconstructions and analysis were performed using a specific software. Percentage of three different components of the atherosclerotic plaque (adipose, fibrotic and calcific) were classified based on Hounsfield unit values. Post-processing results were compared with histological analysis. Vessel and plaque parameters were compared using the Pearson correlation coefficient (r). Bland-Altman plots with 95% confidence intervals were calculated for correlation. McNemar's test was used for comparison of dichotomous variables. RESULTS A significant correlation between histology and CCTA was found with respect to the areas corresponding to adipose, fibrotic and calcified plaques. The existence of proportional bias was observed between the two quantifying methods with lower discrepancies found for the adipose and fibrotic plaque areas. The Bland-Altman analyses showed a mean bias of 3.2%, 2.5% and 0.6% between histology and CCTA, for adipose, fibrotic and calcified plaque areas, respectively. CONCLUSIONS Multi-detector CT angiography represents a valuable technique to assess quantitatively the composition of atherosclerotic plaques, with particular reference to the prevalence of fibrotic tissue, and is a useful diagnostic tool to improve risk stratification of patients for cerebral stroke.
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Rafailidis V, Chryssogonidis I, Xerras C, Nikolaou I, Tegos T, Kouskouras K, Rafailidis D, Charitanti-Kouridou A. A comparative study of color Doppler imaging and contrast-enhanced ultrasound for the detection of ulceration in patients with carotid atherosclerotic disease. Eur Radiol 2018; 29:2137-2145. [PMID: 30350162 DOI: 10.1007/s00330-018-5773-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/14/2018] [Accepted: 09/18/2018] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To evaluate the diagnostic accuracy of color Doppler imaging (CDI) and contrast-enhanced ultrasound (CEUS) for diagnosing carotid ulceration, having multi-detector computed tomography angiography (MDCTA) as the reference method. METHODS Patients with carotid disease referred for ultrasound (US), either due to the occurrence of neurovascular symptoms or for screening purposes, were included in this study if at least one plaque causing moderate (50-69%) or severe (70-99%) internal carotid artery stenosis was detected. Carotid US with CDI technique, CEUS, and MDCTA were performed in all patients, investigating the presence of ulceration. The agreement between modalities was evaluated using kappa statistics. RESULTS The study population included 54 patients (median age 62 years, inter-quartile range 16.2) and 66 carotid arteries. The mean degree of stenosis was 68.5% (SD 12.2%) while 47.1% of plaques were symptomatic. MDCTA characterized 28.8% of plaques as smooth, 45.5% irregular, and 24.3% ulcerated. Flow reversal was detected with CDI in 65.5% of ulcerations, while swirling of the microbubbles and neovessels adjacent to the ulcer were detected with CEUS in 17.64%. The agreement for ulceration diagnosis was moderate between CDI and CEUS (kappa 0.473) and between CDI and MDCTA (kappa 0.473) and very good between CEUS and MDCTA (kappa 0.921). The sensitivity, specificity, and positive and negative predictive values of CDI for the diagnosis of ulceration were 41.2%, 97.95%, 87.5%, 82.8% respectively, while CEUS respective measures were 94.1%, 97.95%, 94.1%, and 97.95%. CONCLUSION CEUS outperformed CDI in terms of agreement with MDCTA and diagnostic accuracy for the diagnosis of ulcerated carotid plaque. KEY POINTS • Superficial ulceration is a significant feature of carotid plaque vulnerability. • Color Doppler imaging has the potential to demonstrate carotid plaque ulceration but is characterized by limited sensitivity and moderate agreement with the reference method of multi-detector computed tomography angiography. • Contrast-enhanced ultrasound outperforms color Doppler imaging in terms of sensitivity for the detection of carotid plaque ulceration and in agreement with the reference method of multi-detector computed tomography angiography.
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Affiliation(s)
- Vasileios Rafailidis
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Ioannis Chryssogonidis
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Chrysostomos Xerras
- 1st Neurological Department, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Irini Nikolaou
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Thomas Tegos
- 1st Neurological Department, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Kouskouras
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Rafailidis
- Department of Radiology, "G. Gennimatas" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Afroditi Charitanti-Kouridou
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Rafailidis V, Sidhu PS. Vascular ultrasound, the potential of integration of multiparametric ultrasound into routine clinical practice. ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2018; 26:136-144. [PMID: 30147737 DOI: 10.1177/1742271x18762250] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 02/06/2018] [Indexed: 01/12/2023]
Abstract
Introduction Ultrasound has traditionally been regarded as the first-line imaging modality for screening, diagnostic evaluation and monitoring treatment and disease progression of vascular pathology, including both the arterial and the venous branch of the vascular system. Albeit of its well-tolerated nature, wide availability and low cost, ultrasound above all, has the advantage of providing the clinician with clinically significant information related to both intraluminal irregularities and extravascular disease. Ultrasound has the potential not only to anatomically describe tissues but also to assess physiology by evaluating blood flow characteristics in real time. Discussion The already fundamental role of ultrasound has been even more expanded with the introduction of newer techniques like contrast-enhanced ultrasound, tissue-elastography and 3D ultrasound and the incorporation of research advances into clinical practice. The purpose of this review is to present and discuss some of the latest advances in the field of vascular ultrasound in attempt to illustrate how the adoption of multiparametric ultrasound into everyday clinical practice could address the patient's needs. Pathology and applications discussed include carotid and aortic disease, portal and peripheral venous abnormalities. Conclusion Widespread availability of modern technology in ultrasound devices has made the application of contrast-enhanced ultrasound, tissue elastography and 3D ultrasound feasible options, ready to contribute to the diagnostic performance of the ultrasonographic technique.
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Affiliation(s)
- Vasileios Rafailidis
- Department of Radiology, King's College London, King's College Hospital, London, England, UK
| | - Paul S Sidhu
- Department of Radiology, King's College London, King's College Hospital, London, England, UK
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Bredahl K, Mestre XM, Coll RV, Ghulam QM, Sillesen H, Eiberg J. Contrast-Enhanced Ultrasound in Vascular Surgery: Review and Update. Ann Vasc Surg 2017; 45:287-293. [DOI: 10.1016/j.avsg.2017.05.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/19/2017] [Accepted: 05/26/2017] [Indexed: 01/24/2023]
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Baud JM, Luong S, Rouyer O, Maurizot A, Gautier C. [Contribution of contrast enhanced ultrasonography in the characterization of carotid lesions]. JOURNAL DE MEDECINE VASCULAIRE 2017; 42:301-314. [PMID: 28964389 DOI: 10.1016/j.jdmv.2017.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 05/19/2017] [Indexed: 06/07/2023]
Abstract
Harmonic mode ultrasound with injection of a contrast enhancement agent allows visualization of mobile microbubbles in the carotid plaque corresponding to neovessels secondary to an inflammation or hypoxia. These neovessels could be considered "precursor" markers of the vulnerable plaque. The aim of this work was to give an update on ultrasound contrast imaging acquisition in the exploration of carotid artery both for atheromatous lesions and for large vessel vasculitis. A precise description of the material to be used, the image acquisition methodology and the environmental conditions is discussed, emphasizing the pitfalls to be avoided as well as proper image interpretation. Microbubbles in a plaque are significantly associated with an increase in cardiovascular events (infarction and acute coronary syndrome) and ipsilateral cerebral ischemic events. Wall irregularities, microfissures and ulcer plaque detection are facilitated by the use of contrast compared to the CT scan. No studies have yet validated contrast enhanced ultrasound in the exploration of asymptomatic carotid stenosis. Contrast enhanced ultrasound also allows to detect vasculitis of the large vessels active phases by the presence of microbubbles in the carotid wall thickening and to monitor the regression under appropriate medical treatment. Future validation studies or even registries are needed to allow better use of this tool in everyday clinical practice.
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Affiliation(s)
- J M Baud
- Unité de médecine vasculaire, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France.
| | - S Luong
- Département d'imagerie diagnostique et thérapeutique, hôpital Louis-Pradel, hospices Civils de Lyon, 28, avenue Doyen-Lépine, 69500 Bron, France
| | - O Rouyer
- Unité neurovasculaire, hôpital de Hautepierre, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - A Maurizot
- Unité de médecine vasculaire, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France
| | - C Gautier
- Unité fonctionnelle de neurosonologie de l'hôpital Roger-Salengro, service des explorations fonctionnelles cardiovasculaires de l'hôpital cardiologique, CHRU de Lille, rue du Professeur Emile-Laine, 59037 Lille cedex, France
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Zhang H, Du J, Wang H, Wang H, Jiang J, Zhao J, Lu H. Comparison of diagnostic values of ultrasound micro-flow imaging and contrast-enhanced ultrasound for neovascularization in carotid plaques. Exp Ther Med 2017; 14:680-688. [PMID: 28672985 PMCID: PMC5488622 DOI: 10.3892/etm.2017.4525] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 05/17/2017] [Indexed: 12/12/2022] Open
Abstract
The aim of the present study was to compare the diagnostic values of ultrasound micro-flow imaging (SMI) and contrast-enhanced ultrasound (CEUS) for neovascularization in carotid plaques, and to investigate their capacities for predicting the risks of cerebral stroke. A total of 39 patients (64 carotid plaques) with severe carotid artery stenosis undergoing carotid endarterectomy were selected between February 2015 and February 2016, and SMI and CEUS were used to detect neovascularization in plaques. According to the CEUS dynamic graph of plaques, the enhanced intensity visual scales and contrast parameters were obtained. Carotid atherosclerotic plaques were divided into 4 groups. The differences in the enhanced intensity visual scales, contrast parameters, and gray-scale median (GSM) values among the 4 groups were analyzed. Carotid plaque tissue samples from patients were stained for CD34, and the consistency of the methods for the diagnosis of neovascularization in plaques was analyzed. The differences in GSM values, enhanced intensities, and enhanced densities among the 4 groups of plaques were statistically significant (F=29.365, χ2=29.025, χ2=30.871, P<0.001); the differences in enhanced intensities of carotid atherosclerotic plaques with different echo types were statistically significant (χ2=17.951, P<0.001). The enhanced intensity of plaques was negatively correlated with the GSM value (r=−0.376, P<0.01), and the enhanced density of plaques was negatively correlated with the GSM value (r=−0.252, P<0.01). SMI and CEUS grading had good consistency (κ=0.860>0), there were statistically significant differences in new vessel densities with different SMI gradings (P<0.001), and the clinical symptoms and severity were positively correlated with SMI grading (rs=0.592>0). In conclusion, SMI and CEUS have good consistency for evaluating neovascularization in carotid plaques, and have good clinical value for evaluating neovascularization in carotid plaques.
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Affiliation(s)
- Hongxue Zhang
- Department of UItrasonic Diagnosis, The Second Clinic, Institute of the Chengde Medical College, Chengde, Hebei 067000, P.R. China
| | - Jianwen Du
- Department of UItrasonic Diagnosis, The Second Clinic, Institute of the Chengde Medical College, Chengde, Hebei 067000, P.R. China
| | - Hong Wang
- Department of UItrasonic Diagnosis, The Second Clinic, Institute of the Chengde Medical College, Chengde, Hebei 067000, P.R. China
| | - Haili Wang
- Department of UItrasonic Diagnosis, The Second Clinic, Institute of the Chengde Medical College, Chengde, Hebei 067000, P.R. China
| | - Jianhui Jiang
- Department of UItrasonic Diagnosis, The Second Clinic, Institute of the Chengde Medical College, Chengde, Hebei 067000, P.R. China
| | - Jingjie Zhao
- Department of Pathology, The Second Clinic, Institute of the Chengde Medical College, Chengde, Hebei 067000, P.R. China
| | - Huan Lu
- Department of UItrasonic Diagnosis, The Second Clinic, Institute of the Chengde Medical College, Chengde, Hebei 067000, P.R. China
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Cires-Drouet RS, Mozafarian M, Ali A, Sikdar S, Lal BK. Imaging of high-risk carotid plaques: ultrasound. Semin Vasc Surg 2017; 30:44-53. [PMID: 28818258 DOI: 10.1053/j.semvascsurg.2017.04.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Duplex ultrasonography has a well-established role in the assessment of the degree of stenosis caused by carotid atherosclerosis. This assessment is derived from Doppler velocity changes induced by the narrowing lumen of the artery. New research into the mechanisms for plaque rupture and atheroembolic stroke indicates that the degree of narrowing is an imperfect predictor of stroke risk, and that other factors, such as plaque composition and remodeling and biomechanical forces acting on the plaque, can play a role. New advances in ultrasound imaging technology have made it possible to investigate these measures of plaque vulnerability to identify pre-embolic unstable carotid plaques. Efforts have been made to quantify the morphologic appearance of the plaque in B-mode images and to correlate them with histology. Additional research has resulted in the first generation of clinically available 3-dimensional ultrasound transducers that reduce operator-dependence and variability. Finally, ultrasonography provides real-time imaging and physiologic information that can be utilized to measure disruptive forces acting on carotid plaques. We review some of these exciting developments in ultrasonography and discuss how these may impact clinical practice.
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Affiliation(s)
- Rafael S Cires-Drouet
- Center for Vascular Diagnostics, Division of Vascular Surgery, University of Maryland School of Medicine, 22 South Greene Street, S10-B00, Baltimore, MD 21201
| | - Mahvash Mozafarian
- Center for Vascular Diagnostics, Division of Vascular Surgery, University of Maryland School of Medicine, 22 South Greene Street, S10-B00, Baltimore, MD 21201
| | - Amir Ali
- Center for Vascular Diagnostics, Division of Vascular Surgery, University of Maryland School of Medicine, 22 South Greene Street, S10-B00, Baltimore, MD 21201; Department of Bioengineering, George Mason University, Fairfax, VA
| | | | - Brajesh K Lal
- Center for Vascular Diagnostics, Division of Vascular Surgery, University of Maryland School of Medicine, 22 South Greene Street, S10-B00, Baltimore, MD 21201; Vascular Service, Veterans Affairs Medical Center, Baltimore, MD.
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Rafailidis V, Charitanti A, Tegos T, Rafailidis D, Chryssogonidis I. Swirling of microbubbles: Demonstration of a new finding of carotid plaque ulceration on contrast-enhanced ultrasound explaining the arterio-arterial embolism mechanism. Clin Hemorheol Microcirc 2017; 64:245-250. [PMID: 27814285 DOI: 10.3233/ch-16200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Carotid plaque ulceration is a well-established feature of vulnerability, associated with high risk for neurological symptoms. From a pathogenetic point of view, the mechanism responsible for occurrence of symptomatology relies on the aggregation of platelets within the ulcer cavity, activation of coagulation mechanism, formation of thrombus and arterio-arterial embolization of thrombotic material in the central nervous system. Many imaging modalities including unenhanced ultrasound, computed tomographic angiography and magnetic resonance angiography have been used to image and diagnose carotid plaque ulceration with varying success. Contrast-enhanced ultrasound has been recently introduced in the study of carotid disease offering improved flow visualization and better plaque surface delineation. We present a case where contrast-enhanced ultrasound visualized the swirling pattern of movement of the microbubbles within the ulcer cavity. These findings illustrate the underlying hemodynamic mechanism of arterio-arterial embolization and can be proposed as a new finding of plaque ulcerations on contrast-enhanced ultrasound.
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Rafailidis V, Charitanti A, Tegos T, Destanis E, Chryssogonidis I. Contrast-enhanced ultrasound of the carotid system: a review of the current literature. J Ultrasound 2017; 20:97-109. [PMID: 28592999 DOI: 10.1007/s40477-017-0239-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 09/01/2016] [Indexed: 12/11/2022] Open
Abstract
Carotid disease is a major current health problem accounting for a significant part of stroke patients. Ultrasound with colour Doppler and spectral analysis is the primary imaging technique used for screening and diagnostic evaluation of the extracranial part of carotid arteries offering identification and grading of carotid disease. However, inherent limitations of this technique include flow-related artefacts like Doppler angle dependence and aliasing artefact which may sometimes hinder complete assessment of a stenotic part of the vessel, potentially failing to address clinically significant differential diagnosis issues. The intravenous use of microbubbles as an US contrast agent has been introduced for the supplementation of conventional technique. The value of contrast-enhanced ultrasound (CEUS) has been investigated in the evaluation of carotid disease leading to promising results. CEUS provides improved flow visualization free of artefacts and detailed plaque surface delineation, thus being able to accurately grade stenosis, identify carotid plaque ulcerations, differentiate occlusion from highly stenotic plaques and identify carotid dissection. Furthermore, microbubbles can be used to identify and grade intraplaque neovascularization, carotid wall inflammation in patients with arteritis, follow-up patients after carotid intervention and assist interventional procedures reducing the need for nephrotoxic contrast agents. The purpose of this review is to present and discuss the current literature regarding the various uses of CEUS in carotid arteries.
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Affiliation(s)
- Vasileios Rafailidis
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloníki, Greece
| | - Afroditi Charitanti
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloníki, Greece
| | - Thomas Tegos
- 1st Neurological Department, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Evangelos Destanis
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloníki, Greece
| | - Ioannis Chryssogonidis
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloníki, Greece
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Rafailidis V, Chryssogonidis I, Tegos T, Kouskouras K, Charitanti-Kouridou A. Imaging of the ulcerated carotid atherosclerotic plaque: a review of the literature. Insights Imaging 2017; 8:213-225. [PMID: 28160261 PMCID: PMC5359146 DOI: 10.1007/s13244-017-0543-8] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 01/02/2017] [Accepted: 01/09/2017] [Indexed: 02/01/2023] Open
Abstract
Abstract Carotid atherosclerotic disease constitutes a major modern health problem whose diagnosis primarily relies on imaging. Grading of stenosis has been long used as the main factor for risk stratification and guiding of management. Nevertheless, increasing evidence has shown that additional plaque characteristics such as plaque composition and surface morphology play an important role in the occurrence of symptoms, justifying the term “vulnerable plaque”. Carotid plaque surface characteristics either in the form of surface irregularities or ulceration represent an important factor of vulnerability and are associated with the occurrence of neurologic symptoms. The delineation of the carotid plaque surface can be performed with virtually all imaging modalities including ultrasound, contrast-enhanced ultrasound, multi-detector computed tomography angiography, magnetic resonance angiography and the traditional reference method of angiography. These techniques have shown varying levels of diagnostic accuracy for the identification of ulcerated carotid plaques or plaque surface irregularities. As a consequence and given its high clinical significance, radiologists should be familiar with the various aspects of this entity, including its definition, classification, imaging findings on different imaging modalities and associations. The purpose of this review is to present the current literature regarding carotid plaque ulcerations and present illustrative images of ulcerated carotid plaques. Teaching Points • Plaque surface and ulceration represent risk factors for stroke in carotid disease. • Characterisation of the plaque surface and ulcerations can be performed with every modality. • US is the first-line modality for carotid disease and identification of ulcerations. • The administration of microbubbles increases US accuracy for diagnosis of carotid ulceration. • MDCTA and MRA are valuable for diagnosing ulceration and evaluating plaque composition.
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Affiliation(s)
- Vasileios Rafailidis
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Ioannis Chryssogonidis
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Thomas Tegos
- 1st Neurological Department, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Kouskouras
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Afroditi Charitanti-Kouridou
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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50
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Yuan J, Usman A, Das T, Patterson AJ, Gillard JH, Graves MJ. Imaging Carotid Atherosclerosis Plaque Ulceration: Comparison of Advanced Imaging Modalities and Recent Developments. AJNR Am J Neuroradiol 2016; 38:664-671. [PMID: 28007772 DOI: 10.3174/ajnr.a5026] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Atherosclerosis remains the leading cause of long-term mortality and morbidity worldwide, despite remarkable advancement in its management. Vulnerable atherosclerotic plaques are principally responsible for thromboembolic events in various arterial territories such as carotid, coronary, and lower limb vessels. Carotid plaque ulceration is one of the key features associated with plaque vulnerability and is considered a notable indicator of previous plaque rupture and possible future cerebrovascular events. Multiple imaging modalities have been used to assess the degree of carotid plaque ulceration for diagnostic and research purposes. Early diagnosis and management of carotid artery disease could prevent further cerebrovascular events. In this review, we highlight the merits and limitations of various imaging techniques for identifying plaque ulceration.
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Affiliation(s)
- J Yuan
- From the Department of Radiology (J.Y., A.U., J.H.G., M.J.G.), University of Cambridge, Cambridge, UK
| | - A Usman
- From the Department of Radiology (J.Y., A.U., J.H.G., M.J.G.), University of Cambridge, Cambridge, UK
| | - T Das
- Department of Radiology (T.D., A.J.P., M.J.G.), Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
| | - A J Patterson
- Department of Radiology (T.D., A.J.P., M.J.G.), Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
| | - J H Gillard
- From the Department of Radiology (J.Y., A.U., J.H.G., M.J.G.), University of Cambridge, Cambridge, UK
| | - M J Graves
- From the Department of Radiology (J.Y., A.U., J.H.G., M.J.G.), University of Cambridge, Cambridge, UK.,Department of Radiology (T.D., A.J.P., M.J.G.), Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
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