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Saba L, Loewe C, Weikert T, Williams MC, Galea N, Budde RPJ, Vliegenthart R, Velthuis BK, Francone M, Bremerich J, Natale L, Nikolaou K, Dacher JN, Peebles C, Caobelli F, Redheuil A, Dewey M, Kreitner KF, Salgado R. State-of-the-art CT and MR imaging and assessment of atherosclerotic carotid artery disease: standardization of scanning protocols and measurements-a consensus document by the European Society of Cardiovascular Radiology (ESCR). Eur Radiol 2023; 33:1063-1087. [PMID: 36194267 PMCID: PMC9889495 DOI: 10.1007/s00330-022-09024-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 06/26/2022] [Accepted: 06/30/2022] [Indexed: 02/04/2023]
Abstract
The European Society of Cardiovascular Radiology (ESCR) is the European specialist society of cardiac and vascular imaging. This society's highest priority is the continuous improvement, development, and standardization of education, training, and best medical practice, based on experience and evidence. The present intra-society consensus is based on the existing scientific evidence and on the individual experience of the members of the ESCR writing group on carotid diseases, the members of the ESCR guidelines committee, and the members of the executive committee of the ESCR. The recommendations published herein reflect the evidence-based society opinion of ESCR. We have produced a twin-papers consensus, indicated through the documents as respectively "Part I" and "Part II." The first document (Part I) begins with a discussion of features, role, indications, and evidence for CT and MR imaging-based diagnosis of carotid artery disease for risk stratification and prediction of stroke (Section I). It then provides an extensive overview and insight into imaging-derived biomarkers and their potential use in risk stratification (Section II). Finally, detailed recommendations about optimized imaging technique and imaging strategies are summarized (Section III). The second part of this consensus paper (Part II) is focused on structured reporting of carotid imaging studies with CT/MR. KEY POINTS: • CT and MR imaging-based evaluation of carotid artery disease provides essential information for risk stratification and prediction of stroke. • Imaging-derived biomarkers and their potential use in risk stratification are evolving; their correct interpretation and use in clinical practice must be well-understood. • A correct imaging strategy and scan protocol will produce the best possible results for disease evaluation.
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Affiliation(s)
- Luca Saba
- Department of Radiology, University of Cagliari, Cagliari, Italy
| | - Christian Loewe
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Thomas Weikert
- Department of Radiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB, UK
- Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh, UK
| | - Nicola Galea
- Policlinico Umberto I, Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Ricardo P J Budde
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Rozemarijn Vliegenthart
- Department of Radiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, Utrecht University Medical Center, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marco Francone
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072, Milan, Italy
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Jens Bremerich
- Department of Radiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luigi Natale
- Department of Radiological Sciences - Institute of Radiology, Catholic University of Rome, "A. Gemelli" University Hospital, Rome, Italy
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University of Tuebingen, Tübingen, Germany
| | - Jean-Nicolas Dacher
- Department of Radiology, Normandie University, UNIROUEN, INSERM U1096 - Rouen University Hospital, F 76000, Rouen, France
| | - Charles Peebles
- Department of Cardiothoracic Radiology, University Hospital Southampton, Southampton, UK
| | - Federico Caobelli
- University Clinic of Nuclear Medicine Inselspital Bern, University of Bern, Bern, Switzerland
| | - Alban Redheuil
- Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
- Department of Cardiovascular and Thoracic, Imaging and Interventional Radiology, Institute of Cardiology, APHP, Pitié-Salpêtrière University Hospital, Paris, France
- Laboratoire d'Imagerie Biomédicale, Sorbonne Universités, UPMC Univ Paris 06, INSERM 1146, CNRS 7371, Paris, France
| | - Marc Dewey
- Department of Radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Karl-Friedrich Kreitner
- Department of Diagnostic and Interventional Radiology, University Medical Center, Mainz; Langenbeckstraße 1, 55131, Mainz, Germany
| | - Rodrigo Salgado
- Department of Radiology, Antwerp University Hospital & Antwerp University, Holy Heart Lier, Belgium.
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Aarli SJ, Thomassen L, Waje-Andreassen U, Logallo N, Kvistad CE, Næss H, Fromm A. The Course of Carotid Plaque Vulnerability Assessed by Advanced Neurosonology. Front Neurol 2021; 12:702657. [PMID: 34489850 PMCID: PMC8417551 DOI: 10.3389/fneur.2021.702657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/28/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Carotid artery atherosclerosis is a major risk factor for ischemic stroke. This risk is related to plaque vulnerability and is characterized by plaque morphology, intraplaque neovascularization, and cerebral microembolization. Advanced neurosonology can identify vulnerable plaques and aid in preventing subsequent stroke. We aimed to assess the time course of cerebral microembolization and intraplaque neovascularization during 6 months of follow-up and to explore the utility of advanced neurosonology in patients with acute cerebral ischemia. Methods: Fifteen patients with acute cerebral ischemia and carotid artery plaques underwent comprehensive extra- and intracranial ultrasound examinations, including microemboli detection and contrast-enhanced ultrasound. The examinations were repeated after 3 and 6 months. Results: We examined 28 plaques in 15 patients. The ultrasonographic features of plaque vulnerability were frequent in symptomatic and asymptomatic plaques. There were no significant differences in stenosis degree, plaque composition, plaque surface, neovascularization, or cerebral microembolization between symptomatic and asymptomatic plaques, but symptomatic plaques had a higher number of vulnerable features. None of the patients had recurrent clinical stroke or transient ischemic attack during the follow-up period. We observed a decrease in cerebral microembolization at 6 months, but no significant change in intraplaque neovascularization. Conclusions: In patients with acute cerebral ischemia and carotid artery plaques, cerebral microembolization decreased during 6 months of follow-up, indicating plaque stabilization. Clinical Trial Registration:ClinicalTrial.gov, identifier NCT02759653.
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Affiliation(s)
- Sander Johan Aarli
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Thomassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ulrike Waje-Andreassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway
| | - Nicola Logallo
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Christopher Elnan Kvistad
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Halvor Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,SESAM - Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Annette Fromm
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Vessel Wall–Imaging Biomarkers of Carotid Plaque Vulnerability in Stroke Prevention Trials. JACC Cardiovasc Imaging 2020; 13:2445-2456. [DOI: 10.1016/j.jcmg.2020.07.046] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/27/2020] [Accepted: 07/31/2020] [Indexed: 02/06/2023]
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Mofidi R, Thomas M, Wong PF, Bergin A, Young G. Do Integrated Systems of Stroke Care Improve Symptom to Surgery Times in Patients with Symptomatic Carotid Stenosis? A Single Centre Decision Tree Analysis. Eur J Vasc Endovasc Surg 2018; 56:784-792. [PMID: 30174270 DOI: 10.1016/j.ejvs.2018.07.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/20/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of this study was to examine the impact of an integrated system of stroke care on symptom to surgery times, cost-effectiveness, and quality of life measures in patients with symptomatic carotid stenosis. METHODS Patients who underwent carotid endarterectomy (CEA) in a regional vascular centre between April 1, 2011, and March 31, 2016, were identified from the National Vascular Registry (NVR). Risk of stroke on medical therapy for each patient was calculated using the Oxford stroke risk calculator. Symptom to surgery times were compared among patients referred from a stroke service providing an integrated stroke care and the stroke service in an adjacent NHS trust which provides standard urgent referral pathway. A decision analytic Markov process model was constructed to determine the cost-effectiveness of CEA versus medical treatment in patients who followed the standard and integrated pathways. This model examined the lifetime costs and health benefits of CEA through each pathway. RESULTS A total of 376 patients underwent CEA, of whom 243 were managed through the integrated stroke pathway and 133 through the standard urgent referral pathway. Median symptom to surgery time was 11 (0-66) days for the former and 15 (3-90) days for the latter (p < .001). There was no significant difference in peri-operative stroke death rate between integrated (2.1%) and standard (1.5%) pathways (chi-square = 0.14, p = .73). CEA through the integrated pathway improved quality adjusted life expectancy by an additional 0.13 (0.64 QALYs [integrated pathway] to 0.51 QALYs [standard pathway]) and was associated with an incremental lifetime cost benefit of £2203.4. CONCLUSIONS An integrated stroke system of care is cost-effective and associated with significant improvements in quality adjusted life years.
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Affiliation(s)
- Reza Mofidi
- Department of Vascular Surgery, James Cook University Hospital, Marton Road, Middlesbrough, UK.
| | - Matthew Thomas
- Department of Vascular Surgery, James Cook University Hospital, Marton Road, Middlesbrough, UK
| | - Peng F Wong
- Department of Vascular Surgery, James Cook University Hospital, Marton Road, Middlesbrough, UK
| | - Adrian Bergin
- Department of Stroke Care, James Cook University Hospital, Marton Road, Middlesbrough, UK
| | - Gavin Young
- Department of Neurology, James Cook University Hospital, Marton Road, Middlesbrough, UK
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Munteanu AI, Raica M, Zota EG. [Immunohistochemical study of the role of mast cells and macrophages in the process of angiogenesis in the atherosclerotic plaques in patients with metabolic syndrome]. Arkh Patol 2016; 78:19-28. [PMID: 27070771 DOI: 10.17116/patol201678219-28] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE to analyze the histotopographic distribution of neogenic vessels, the degree of mast cell degranulation, the expression of markers of macrophages in different types of plaques in different stages and in different arterial vessels in patients with atherosclerosis and in those with metabolic syndrome associated with atherosclerosis and to establish the role of mast cells and macrophages in the development of stages of atherosclerosis along with their diagnostic and prognostic value. MATERIAL AND METHODS Fragments of the thoracic and abdominal aorta, middle cerebral, carotid, renal, and iliac, and vertebral arteries from 34 persons who had died from atherosclerosis (n=17) and atherosclerotic complications due to metabolic syndrome (n=17) were examined. The investigators employed standard techniques, such as hematoxylin-eosin or orcein staining; silver impregnation. They used immunohistochemical staining with anti-mast cell tryptase (anti-MCT) for the determination of mast cells, the specific markers CD68 for macrophages, and CD105 (endoglin) for neogenic vessels. RESULTS The immunohistochemical technique is effective in identifying mast cells, macrophages, and neogenic vessels in atherosclerotic plaques. They were found in many types of atherosclerotic plaques, advantium, and subendothelial layers in the immediate vicinity of the plaques. There was a statistical correlation between the types of plaques and clinical data, which is of importance in elucidating the specific features of the pathogenesis of atherosclerosis in patients with metabolic syndrome. CONCLUSION CD105 is a sensitive marker for neogenic endothelial cells, an effective indicator of microvascular activation and proliferation in the atherosclerotic plaques. Neovascularization in the plaques frequently begins in the intima, progresses, and gives rise to their further destabilization. Anti-MCT staining used to reveal mast cells and CD68 for macrophages can elucidate the important patterns of development of atherosclerosis and its complications in patients with metabolic disturbances.
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Affiliation(s)
- A I Munteanu
- Pathological Anatomy Department, Nicolae N. Testemiţanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova
| | - M Raica
- Angiogenesis Research Center, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - E G Zota
- Pathological Anatomy Department, Nicolae N. Testemiţanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova
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Arbustini E, Kodama T, Favalli V. Radiation Therapy for Head and Neck Cancer and Angioneogenesis: Good for Cancer, Bad for Carotids? JACC Cardiovasc Imaging 2016; 9:676-9. [PMID: 27209104 DOI: 10.1016/j.jcmg.2015.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 07/23/2015] [Indexed: 02/04/2023]
Affiliation(s)
- Eloisa Arbustini
- Center for Inherited Cardiovascular Diseases, IRCCS Foundation Policlinico San Matteo, Pavia, Italy.
| | - Takahide Kodama
- Center for Inherited Cardiovascular Diseases, IRCCS Foundation Policlinico San Matteo, Pavia, Italy; Cardiovascular Center, Toranomon Hospital, Tokyo, Japan
| | - Valentina Favalli
- Center for Inherited Cardiovascular Diseases, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
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Saito K, Nagatsuka K, Ishibashi-Ueda H, Watanabe A, Kannki H, Iihara K. Contrast-Enhanced Ultrasound for the Evaluation of Neovascularization in Atherosclerotic Carotid Artery Plaques. Stroke 2014; 45:3073-5. [DOI: 10.1161/strokeaha.114.006483] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background and Purpose—
Neovascularization associated with plaque vulnerability, particularly in the plaque shoulder, is susceptible to rupture, causing ischemic events. We aimed to use contrast-enhanced ultrasound to evaluate neovessels in carotid plaques quantitatively, focusing on plaque shoulders.
Methods—
Using contrast-enhanced ultrasound with perflubutane, we analyzed 50 consecutive patients who underwent carotid endarterectomy. We measured enhanced intensity and assessed the correlation between contrast effect and histopathology, comparing symptomatic and asymptomatic plaques.
Results—
Enhanced intensity of the plaque shoulder was associated with neovessel density (
P
<0.01; ρ=0.43). Enhanced intensity of the plaque shoulder was higher in plaques with rupture than in those without (
P
<0.05), and in symptomatic plaques (n=31) than in asymptomatic ones (n=19;
P
<0.01).
Conclusions—
Quantitative evaluation of the contrast effect using contrast-enhanced ultrasound enabled the assessment of neovascularization of plaque shoulders in vivo real time, which may help stratify plaque vulnerability.
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Affiliation(s)
- Kozue Saito
- From the Departments of Neurology (K.S., K.N., A.W., H.K.), Pathology (H.I.-U.), Neurosurgery (K.I.), National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazuyuki Nagatsuka
- From the Departments of Neurology (K.S., K.N., A.W., H.K.), Pathology (H.I.-U.), Neurosurgery (K.I.), National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hatsue Ishibashi-Ueda
- From the Departments of Neurology (K.S., K.N., A.W., H.K.), Pathology (H.I.-U.), Neurosurgery (K.I.), National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Akihiro Watanabe
- From the Departments of Neurology (K.S., K.N., A.W., H.K.), Pathology (H.I.-U.), Neurosurgery (K.I.), National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hideaki Kannki
- From the Departments of Neurology (K.S., K.N., A.W., H.K.), Pathology (H.I.-U.), Neurosurgery (K.I.), National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Koji Iihara
- From the Departments of Neurology (K.S., K.N., A.W., H.K.), Pathology (H.I.-U.), Neurosurgery (K.I.), National Cerebral and Cardiovascular Center, Osaka, Japan
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El-Sayyad HI, Al-Haggar MS, El-Ghawet HA, Bakr IH. Cardiomyopathy and angiogenesis defects of Wistar rat fetuses of diabetic and hypercholesterolemic mothers. Nutrition 2012; 28:e33-43. [DOI: 10.1016/j.nut.2011.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 12/22/2011] [Accepted: 12/22/2011] [Indexed: 10/28/2022]
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Kacprzak M, Liebert A, Staszkiewicz W, Gabrusiewicz A, Sawosz P, Madycki G, Maniewski R. Application of a time-resolved optical brain imager for monitoring cerebral oxygenation during carotid surgery. JOURNAL OF BIOMEDICAL OPTICS 2012; 17:016002. [PMID: 22352652 DOI: 10.1117/1.jbo.17.1.016002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Recent studies have shown that time-resolved optical measurements of the head can estimate changes in the absorption coefficient with depth discrimination. Thus, changes in tissue oxygenation, which are specific to intracranial tissues, can be assessed using this advanced technique, and this method allows us to avoid the influence of changes to extracerebral tissue oxygenation on the measured signals. We report the results of time-resolved optical imaging that was carried out during carotid endarterectomy. This surgery remains the "gold standard" treatment for carotid stenosis, and intraoperative brain oxygenation monitoring may improve the safety of this procedure. A time-resolved optical imager was utilized within the operating theater. This instrument allows for the simultaneous acquisition of 32 distributions of the time-of-flight of photons at two wavelengths on both hemispheres. Analysis of the statistical moments of the measured distributions of the time-of-flight of photons was applied for estimating changes in the absorption coefficient as a function of depth. Time courses of changes in oxy- and deoxyhemoglobin of the extra- and intracerebral compartments during cross-clamping of the carotid arteries were obtained. A decrease in the oxyhemoglobin concentration and an increase in the deoxyhemoglobin concentrations were observed in a large area of the head. Large changes were observed in the hemisphere ipsilateral to the site of clamped carotid arteries. Smaller amplitude changes were noted at the contralateral site. We also found that changes in the hemoglobin signals, as estimated from intracerebral tissue, are very sensitive to clamping of the internal carotid artery, whereas its sensitivity to clamping of the external carotid artery is limited. We concluded that intraoperative multichannel measurements allow for imaging of brain tissue hemodynamics. However, when monitoring the brain during carotid surgery, a single-channel measurement may be sufficient.
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Affiliation(s)
- Michal Kacprzak
- Nalecz Institute of Biocybernetics and Biomedical Engineering PAS, Trojdena 4, 02-109 Warsaw, Poland.
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Olson FJ, Strömberg S, Hjelmgren O, Kjelldahl J, Fagerberg B, Bergström GML. Increased vascularization of shoulder regions of carotid atherosclerotic plaques from patients with diabetes. J Vasc Surg 2011; 54:1324-1331.e5. [PMID: 21764240 DOI: 10.1016/j.jvs.2011.04.061] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 04/27/2011] [Accepted: 04/30/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Increased vascularization is considered an important contributing factor for plaque vulnerability. Microvascular proliferative disease in patients with diabetes results in renal damage and visual loss. We assessed the hypothesis that vascularization in carotid atherosclerotic tissue is increased in diabetic patients, especially in the critical shoulder regions of the plaque. METHODS Carotid endarterectomy specimens, clinical data, and blood samples were collected from patients with symptomatic carotid artery stenosis (median 85 days after clinical event) and pharmacologic treatment for diabetes (n = 26) or no diabetes (n = 85). Plaques were fixed in formalin and transverse tissue sections prepared. Histopathology and immunohistochemistry were performed for detection of endothelial cells (anti-CD34), macrophages (anti-CD68), vascular endothelial growth factor (VEGF), and its receptor (VEGFR-2). Neovascularization was assessed as CD34(+) neovessel density in the entire section area and by the presence or absence of CD34(+) vessels in the shoulder and cap regions of the plaques. RESULTS The patient groups did not differ significantly in neovascularization in the entire transverse sections (2.0 vs 2.1 vessels/mm(2); P = .61) or in the fibrous cap (52% of the patients in both groups; P = .95). Neovascularization of the plaque shoulder regions was observed in 52% of the diabetic patients and in 26% of the nondiabetic patients (P = .028). VEGF-stained areas were similar in the two patient groups (0.4% and 0.2% of shoulder area; P = .61). Patients with diabetes had more VEGFR-2 (1.0% vs 0.2% of shoulder area; P < .016) and less CD68 staining (0.4% vs 3.6% of shoulder area; P < .008). Time from clinical event to surgery was positively associated with neovascularization of the plaque shoulder regions (≤90 days, 18% of patients; >90 days, 50% of patients; P = .002), independently of diabetes status. CONCLUSIONS Diabetes was associated with increased vascularization of the shoulder regions in patients with symptomatic carotid atherosclerotic plaques. This was accompanied by increased expression of VEGFR-2. The increased vascularization of the plaque shoulder regions may help explain why patients with diabetes are at increased risk of atherosclerotic complications.
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Affiliation(s)
- Fredrik J Olson
- Sahlgrenska Center for Cardiovascular and Metabolic Research, Institute of Medicine, the Sahlgrenska Academy at the University of Gothenburg and Wallenberg Laboratory, Gothenburg, Sweden
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Identification of carotid 'vulnerable plaque' by contrast-enhanced ultrasonography: correlation with plaque histology, symptoms and cerebral computed tomography. Eur J Vasc Endovasc Surg 2010; 41:238-48. [PMID: 21145266 DOI: 10.1016/j.ejvs.2010.11.002] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 11/01/2010] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Indication to carotid revascularisation is commonly determined by percent of stenosis as well as neurological symptoms and clinical conditions. High plaque embolic potential is defined as 'vulnerability'; however, its characterisation is not universally used for carotid revascularisation. We investigated the role of contrast-enhanced ultrasonography (CEUS) to identify carotid vulnerable plaque. METHODS Patients undergoing carotid endarterectomy were preoperatively evaluated by cerebral computed tomography (CT) scan and CEUS. Contrast microbubbles detected within the plaque indicated neovascularisation and were quantified by decibel enhancement (dB-E). Plaques were histologically evaluated for five features: (microvessel density, fibrous cap thickness, extension of calcification, inflammatory infiltrate and lipid core) and blindly scored 1-5 to assess plaque vulnerability. Analysis of variance (ANOVA), Fisher's and Student's t-test were used to correlate patients' characteristics, histological features and dB-E. RESULTS In 22 patients, dB-E (range 2-7.8, mean 4.85 ± 1.9 SD) was significantly greater in symptomatic (7.40 ± 0.5) vs. asymptomatic (3.5 ± 1.4) patients (p = 0.002). A higher dB-E was significantly associated with thinner fibrous cap (<200 μm, 5.96 ± 1.5 vs. 3 ± 1, p = 0.01) and greater inflammatory infiltrate (3.2 ± 0.9 vs. 6.4 ± 1.2, p = 0.03). Plaques with vulnerability score of 5 had significantly higher dB-E compared with those with vulnerability score of 1 (7.6 ± 0.2 vs. 2.5 ± 0.6, respectively, p = 0.001). Preoperative ipsilateral embolic lesions at CT were correlated with higher dB-E (5.96 ± 1.5 vs. 3.0 ± 1.0, p = 0.01). CONCLUSION CEUS with dB-E is indicative of the extent of plaque neovascularisation. It can be used therefore as a marker for vulnerable plaque.
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Gadofosveset-enhanced magnetic resonance imaging of human carotid atherosclerotic plaques: a proof-of-concept study. Invest Radiol 2010; 45:275-81. [PMID: 20351652 DOI: 10.1097/rli.0b013e3181d5466b] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the potential of gadofosveset-enhanced MR imaging for the characterization of human carotid atherosclerotic plaques. MATERIALS AND METHODS Sixteen (9 symptomatic, 7 asymptomatic) patients with 70% to 99% carotid stenosis (according to NASCET criteria) were included (13 men, 3 women, mean age 67.6 years). All patients underwent baseline precontrast MR imaging of the carotid plaque. Immediately after completion of the baseline examination, 0.03 mmol/kg gadofosveset was administered. At 24 hours postinjection, the acquisition was repeated. Twelve patients were scheduled for carotid endarterectomy. Carotid endarterectomy specimens were HE-, CD31-, CD68-, and albumin-stained to correlate signal enhancement with plaque composition, intraplaque microvessel density, and macrophage and albumin content. A random intercept model was used to compare signal enhancement between symptomatic and asymptomatic patients, adjusting for size of various plaque components. This study was approved by the institutional medical ethics committee. All participants gave written informed consent. RESULTS Signal enhancement (SE) of the plaque was significantly higher in symptomatic patients compared with asymptomatic patients (median log SE 0.182 vs. -0.109, respectively, P < 0.001). A positive association (as expressed by a regression coefficient beta = 0.0035) was found between signal enhancement on the log scale and intraplaque albumin content (P = 0.038). There was no association between signal enhancement and various other plaque components. CONCLUSION In this study, the potential of gadofosveset-enhanced human carotid plaque MR imaging for identification of high-risk plaques was demonstrated. Signal enhancement of the plaque after administration of gadofosveset was associated with differences in intraplaque albumin content. Although promising, we emphasize that these results are based on a small patient population. Larger prospective studies are warranted.
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Luque A, Slevin M, Turu MM, Juan-Babot O, Badimon L, Krupinski J. CD105 positive neovessels are prevalent in early stage carotid lesions, and correlate with the grade in more advanced carotid and coronary plaques. JOURNAL OF ANGIOGENESIS RESEARCH 2009; 1:6. [PMID: 19946414 PMCID: PMC2776238 DOI: 10.1186/2040-2384-1-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Accepted: 09/21/2009] [Indexed: 11/16/2022]
Abstract
Background Previous studies have demonstrated that expression of CD105 is a sensitive marker and indicator of endothelial cell/microvessel activation and proliferation in aggressive solid tumour growth and atherosclerotic plaque lesions. Since intimal neovascularization contributes significantly to subsequent plaque instability, haemorrhage and rupture. Methods We have used immunohistochemical analysis to investigate the expression of CD105-positive vessels in both large (carotid) and medium calibre (coronary and middle cerebral artery, MCAs) diseased vessels in an attempt to identify any correlation with plaque growth, stage and complication/type. Results Here we show, that carotid arteries expressed intimal neovascularization associated with CD105-positive endothelial cells, concomitant with increased inflammation in early stage lesions, preatheroma (I-III) whilst they were not present in coronary plaques of the same grade. Some of these CD105-positive neovessels were immature, thin walled and without smooth muscle cell coverage making them more prone to haemorrhage and rupture. In high-grade lesions, neovessel proliferation was similar in both arterial types and significantly higher numbers of CD105-positive vasa vasorum were associated with plaque regions in coronary arteries. In contrast, although the MCAs exhibited expanded intimas and established plaques, there were very few CD105 positive neovessels. Conclusion Our results show that CD105 is a useful marker of angiogenesis within adventitial and intimal vessels and suggest the existence of significant differences in the pathological development of atherosclerosis in separate vascular beds which may have important consequences when considering management and treatment of this disease.
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Affiliation(s)
- Ana Luque
- Department of Neurology, Stroke Unit, Hospital Universitari Mutua Terrassa, Terrassa, Barcelona, Spain.
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Slevin M, Krupinski J, Badimon L. Controlling the angiogenic switch in developing atherosclerotic plaques: possible targets for therapeutic intervention. JOURNAL OF ANGIOGENESIS RESEARCH 2009; 1:4. [PMID: 19946412 PMCID: PMC2776234 DOI: 10.1186/2040-2384-1-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Accepted: 09/21/2009] [Indexed: 11/10/2022]
Abstract
Plaque angiogenesis may have an important role in the development of atherosclerosis. Vasa vasorum angiogenesis and medial infiltration provides nutrients to the developing and expanding intima and therefore, may prevent cellular death and contribute to plaque growth and stabilization in early lesions. However in more advanced plaques, inflammatory cell infiltration, and concomitant production of numerous pro-angiogenic cytokines may be responsible for induction of uncontrolled neointimal microvessel proliferation resulting in production of immature and fragile neovessels similar to that seen in tumour development. These could contribute to development of an unstable haemorrhagic rupture-prone environment. Increasing evidence has suggested that the expression of intimal neovessels is directly related to the stage of plaque development, the risk of plaque rupture, and subsequently, the presence of symptomatic disease, the timing of ischemic neurological events and myocardial/cerebral infarction. Despite this, there is conflicting evidence regarding the causal relationship between neovessel expression and plaque thrombosis with some in vivo experimental models suggesting the contrary and as yet, few direct mediators of angiogenesis have been identified and associated with plaque instability in vivo.In recent years, an increasing number of angiogenic therapeutic targets have been proposed in order to facilitate modulation of neovascularization and its consequences in diseases such as cancer and macular degeneration. A complete knowledge of the mechanisms responsible for initiation of adventitial vessel proliferation, their extension into the intimal regions and possible de-novo synthesis of neovessels following differentiation of bone-marrow-derived stem cells is required in order to contemplate potential single or combinational anti-angiogenic therapies. In this review, we will examine the importance of angiogenesis in complicated plaque development, describe the current knowledge of molecular mechanisms of its initiation and maintenance, and discuss possible future anti-angiogenic therapies to control plaque stability.
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Affiliation(s)
- Mark Slevin
- Centro de Investigación Cardiovascular, CSIC-ICCC, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
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