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Pakizer D, Kozel J, Taffé P, Elmers J, Feber J, Michel P, Školoudík D, Sirimarco G. Diagnostic accuracy of carotid plaque instability by noninvasive imaging: a systematic review and meta-analysis. Eur Heart J Cardiovasc Imaging 2024; 25:1325-1335. [PMID: 38953552 DOI: 10.1093/ehjci/jeae144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 05/02/2024] [Accepted: 05/27/2024] [Indexed: 07/04/2024] Open
Abstract
AIMS There is increasing evidence that plaque instability in the extracranial carotid artery may lead to an increased stroke risk independently of the degree of stenosis. We aimed to determine diagnostic accuracy of vulnerable and stable plaque using noninvasive imaging modalities when compared to histology in patients with symptomatic and asymptomatic carotid atherosclerosis. METHODS AND RESULTS Medline Ovid, Embase, Cochrane Library, and Web of Science were searched for diagnostic accuracy of noninvasive imaging modalities (CT, MRI, US) in the detection of 1) vulnerable/stable plaque, and 2) vulnerable/stable plaque characteristics, compared to histology. The quality of included studies was assessed by QUADAS-2 and univariate and bivariate random-effect meta-analyses were performed. We included 36 vulnerable and 5 stable plaque studies in the meta-analysis, and out of 211 plaque characteristics from remaining studies, we classified 169 as vulnerable and 42 as stable characteristics (28 CT, 120 MRI, 104 US characteristics). We found that MRI had high accuracy [90% (95% CI: 82-95%)] in the detection of vulnerable plaque, similar to CT [86% (95% CI: 76-92%); P > 0.05], whereas US showed less accuracy [80% (95% CI: 75-84%); P = 0.013]. CT showed high diagnostic accuracy in visualizing characteristics of vulnerable or stable plaques (89% and 90%) similar to MRI (86% and 89%; P > 0.05); however, US had lower accuracy (77%, P < 0.001 and 82%, P > 0.05). CONCLUSION CT and MRI have a similar, high performance in detecting vulnerable carotid plaques, whereas US showed significantly less diagnostic accuracy. Moreover, MRI visualized all vulnerable plaque characteristics allowing for a better stroke risk assessment. REGISTRATION PROSPERO ID CRD42022329690.
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Affiliation(s)
- David Pakizer
- Centre for Health Research, Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - Jiří Kozel
- Centre for Health Research, Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - Patrick Taffé
- Center for Primary Care and Public Health, Division of Biostatistics, University of Lausanne, Route de la Corniche 10, 1010, Lausanne, Switzerland
| | - Jolanda Elmers
- Medical Library, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Janusz Feber
- Centre for Health Research, Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road, ON K1H8L1 Ottawa, Canada
| | - Patrik Michel
- Stroke Center, Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - David Školoudík
- Centre for Health Research, Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - Gaia Sirimarco
- Stroke Center, Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland
- Neurology Unit, Department of Internal Medicine, Riviera Chablais Hospital, Route du Vieux-Séquoia 20, 1847 Rennaz, Switzerland
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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: 3] [Impact Index Per Article: 3.0] [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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Li Q, Cai M, Wang H, Chen L. Diagnostic Performance of Contrast-Enhanced Ultrasound and High-Resolution Magnetic Resonance Imaging for Carotid Atherosclerotic Plaques: A Systematic Review and Meta-Analysis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:739-749. [PMID: 36321389 DOI: 10.1002/jum.16122] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 08/17/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES The aim of this meta-analysis was to evaluate the diagnostic value of contrast-enhanced ultrasound (CEUS) and high-resolution magnetic resonance imaging (HR-MRI) in patients with carotid vulnerable plaques. METHODS A systematic review was conducted in PubMed, Embase, Cochrane Library, and Web of Science using the search terms carotid artery, atherosclerotic plaque, CEUS, contrast-enhanced ultrasound, HR-MRI, and high-resolution magnetic resonance. Studies published since the establishment of the library until December 2021 were retrieved. The statistical analyses were performed with Meta-DiSc version 1.4. Beyond that, the potential sources of heterogeneity for CEUS and HR-MRI were explored. RESULTS Nine articles were included in this study. For CEUS, the pooled sensitivity and specificity for detecting carotid vulnerable plaques 91% (95% confidence interval [CI]: 84%, 95%) and 67% (95% CI: 54%, 79%), respectively. For HR-MRI, the pooled sensitivity and specificity were 78% (95% CI: 72%, 83%) and 65% (95% CI, 56%, 73%), respectively. The area under the summary receiver operating characteristic curve for CEUS and HR-MRI were 0.9218 and 0.8129, respectively. However, the difference in diagnostic accuracy between CEUS and HR-MRI diagnostic accuracy was not statistically significant. CONCLUSIONS The study shows that the sensitivity of CEUS was higher than that of HR-MRI, and the specificity was similar to HR-MRI. CEUS and HR-MRI provide a similar diagnostic yield in detecting a vulnerable plaque. Thus, CEUS may be a useful tool for the diagnosis of carotid vulnerable plaques.
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Affiliation(s)
- Qiuping Li
- Department of Ultrasonography, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Miaomiao Cai
- Department of Ultrasonography, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Hui Wang
- Department of Ultrasonography, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Libo Chen
- Department of Ultrasonography, China-Japan Union Hospital of Jilin University, Changchun, Jilin, 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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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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Sultan SR, Bashmail FT, Alzahrani NA, Alharbi SI, Anbar R, Alkharaiji M. Contrast-enhanced ultrasound for the evaluation of symptomatic and asymptomatic carotid plaques: A systematic review and meta-analysis. Echocardiography 2022; 39:1032-1043. [PMID: 35768892 DOI: 10.1111/echo.15407] [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: 02/14/2022] [Revised: 04/22/2022] [Accepted: 06/09/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Contrast-enhanced ultrasound (CEUS) is a promising imaging modality for the assessment of plaque vulnerability. We aimed to systematically review and meta-analyze the ability of CEUS parameters to differentiate between symptomatic and asymptomatic carotid plaques and to assess its reproducibility. METHODS PubMed, EMBASE, and Cochrane Library databases were searched for studies that potentially evaluated carotid plaques using CEUS. From the initial 2870 searches, 11 relevant publications comprising a total of 821 carotid plaques were reviewed. Data on CEUS parameters including quantitative and semi-quantitative parameters were extracted and analyzed. RESULTS The overall analysis showed significantly higher CEUS parameters in symptomatic carotid plaques compared to asymptomatic carotid plaques (standardised mean difference (SMD) .95, 95% confidence interval (CI) .56-1.27, p < .01). Intra and inter-observer reproducibility of quantitative CEUS parameters were excellent (intra-observer, r = .95, 95% CI .87-1; inter-observer, r = .93, 95% CI .80-.1). Semi-quantitative CEUS parameters showed good intra-observer reliability and moderate inter-observer reliability (intra-observer, r = .77, 95% CI .64-.89; inter-observer, r = .75, 95% CI .61-.89). Heterogeneity among studies compared CEUS parameters in symptomatic and asymptomatic plaques and studies assessed inter-observer reproducibility, and significant biases in studies assessing CEUS reproducibility were present. CONCLUSION CEUS is a useful vascular imaging method to differentiate between symptomatic and asymptomatic carotid plaques with moderate to excellent reproducibility. Quantitative CEUS analysis appeared to be more sensitive and reliable in assessing carotid plaques than semi-quantitative parameters. Further longitudinal prospective trials evaluating carotid plaque in asymptomatic population using CEUS to determine plaque characteristics that can become symptomatic are required.
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Affiliation(s)
- Salahaden R Sultan
- Department of Radiologic Sciences, College of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Fatima T Bashmail
- Department of Radiologic Sciences, College of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Nouf A Alzahrani
- Department of Radiologic Sciences, College of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Shahd I Alharbi
- Department of Radiologic Sciences, College of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Rayan Anbar
- Department of Radiologic Sciences, College of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammed Alkharaiji
- Department of Public Health, College of Health Sciences, Saudi Electronic University, Riyadh, Saudi Arabia
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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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Aulivola B. A view through the looking glass at chronic total occlusions. J Vasc Surg 2021; 74:615. [PMID: 34303478 DOI: 10.1016/j.jvs.2021.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/26/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Bernadette Aulivola
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Chicago, Stritch School of Medicine, Maywood, Ill
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Boswell-Patterson CA, Hétu MF, Kearney A, Pang SC, Tse MY, Herr JE, Spence M, Zhou J, Johri AM. Vascularized Carotid Atherosclerotic Plaque Models for the Validation of Novel Methods of Quantifying Intraplaque Neovascularization. J Am Soc Echocardiogr 2021; 34:1184-1194. [PMID: 34129920 DOI: 10.1016/j.echo.2021.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/04/2021] [Accepted: 06/04/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Intraplaque neovascularization (IPN) in advanced lesions of the carotid artery has been linked to plaque progression and risk of rupture. Quantitative measurement of IPN may provide a more powerful tool for the detection of such "vulnerable" plaque than the current visual scoring method. The aim of this study was to develop a phantom platform of a neovascularized atherosclerotic plaque within a carotid artery to assess new methods of quantifying IPN. METHODS Ninety-two synthetic plaque models with various IPN architectures representing different ranges of IPN scoring were created and assessed using contrast-enhanced ultrasound. Intraplaque neovascularization volume was calculated from contrast infiltration in B mode. The plaque models were used to develop a testing platform for IPN quantification. A neovascularized enhancement ratio (NER) was calculated using commercially available software. The plaque model NERs were then compared to human plaque NERs (n = 42) to assess score relationship. Parametric mapping of dynamic intensity over time was used to differentiate IPN from calcified plaque regions. RESULTS A positive correlation between NER and IPN volume (rho = 0.45; P < .0001) was found in the plaque models. Enhancement of certain plaque model types showed that they resembled human plaques, with visual grade scores of 0 (NER mean difference = 1.05 ± SE 2.45; P = .67), 1 (NER mean difference = 0.22 ± SE 3.26; P = .95), and 2 (NER mean difference = -0.84 ± SE 3.33; P = .80). An optimal cutoff for NER (0.355) identified grade 2 human plaques with a sensitivity of 95% and specificity of 91%. CONCLUSIONS We developed a carotid artery model of neovascularized plaque and established a quantitative method for IPN using commercially available technology. We also developed an analysis method to quantify IPN in calcified plaques. This novel tool has the potential to improve clinical identification of vulnerable plaques, providing objective measures of IPN for cardiovascular risk assessment.
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Affiliation(s)
| | - Marie-France Hétu
- Department of Medicine, Cardiovascular Imaging Network at Queen's, Queen's University, Kingston, Ontario, Canada
| | - Abigail Kearney
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Stephen C Pang
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - M Yat Tse
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Julia E Herr
- Department of Medicine, Cardiovascular Imaging Network at Queen's, Queen's University, Kingston, Ontario, Canada
| | - Michaela Spence
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Jianhua Zhou
- School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Amer M Johri
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada; Department of Medicine, Cardiovascular Imaging Network at Queen's, Queen's University, Kingston, Ontario, Canada.
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10
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Fedak A, Chrzan R, Chukwu O, Urbanik A. Ultrasound methods of imaging atherosclerotic plaque in carotid arteries: examinations using contrast agents. J Ultrason 2020; 20:e191-e200. [PMID: 33365156 PMCID: PMC7705485 DOI: 10.15557/jou.2020.0032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/11/2020] [Indexed: 11/22/2022] Open
Abstract
The primary technique for detecting the presence and monitoring the development of carotid atherosclerotic plaque is ultrasound. The development of ultrasound techniques has made it possible to precisely visualise not only blood flow, but also vessel walls, including atherosclerotic plaque. Contrast-enhanced ultrasound examination enables one to make an objective observation of atherosclerotic plaque neovascularisation, clearly indicating active inflammation, which is an inherent feature of vulnerable (unstable) plaque. Depending on the examination method used, it is possible to precisely visualise different components of the plaque and its behaviour during blood flow through the vessel lumen or through the neovessels of the plaque, and, consequently, determine the possible presence of inflammation, which is a defining feature of plaque stability. The full utilisation of physical phenomena that underlie contrast-enhanced ultrasound will bring further enormous progress of diagnostic and probably also therapeutic methods for carotid atherosclerosis. The selection of the right examination method significantly accelerates diagnosis and adequate classification of plaque, and makes it possible to monitor the progression of atherosclerosis. However, one needs to bear in mind that ultrasound remains a very subjective method. The success of contrast-enhanced ultrasound also depends on the skills and experience of the examiner. Current attempts at increasing the objectivity of contrast-enhanced ultrasound examination using artificial intelligence will make it possible in the future to make a definitive evaluation of atherosclerotic plaque stability. This will allow one to assess the risk of ischaemic stroke adequately.
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Affiliation(s)
- Andrzej Fedak
- Department of Radiology, Jagiellonian University Medical College, Kraków, Poland
| | - Robert Chrzan
- Department of Radiology, Jagiellonian University Medical College, Kraków, Poland
| | - Ositadima Chukwu
- Student Science Club, Department of Radiology, Jagiellonian University Medical College, Kraków, Poland
| | - Andrzej Urbanik
- Department of Radiology, Jagiellonian University Medical College, Kraków, Poland
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11
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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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12
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Baud JM, Stanciu D, Yeung J, Maurizot A, Chabay S, de Malherbe M, Chadenat ML, Bachelet D, Pico F. Contrast enhanced ultrasound of carotid plaque in acute ischemic stroke (CUSCAS study). Rev Neurol (Paris) 2020; 177:115-123. [PMID: 32653212 DOI: 10.1016/j.neurol.2020.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Carotid atherosclerosis represents 8 to 15% of ischemic strokes in relation to the concept of "vulnerable" plaque. Contrast enhanced ultrasound (CEUS) can detect moving microbubbles within the plaque corresponding to neovessels that constitute "precursors" of vulnerable plaque and intraplaque hemorrhage. CEUS was not studied specifically in acute ischemic strokes. The aim of this study is to analyse the prevalence of CEUS carotid plaque ipsilateral at the ischemic stroke as well as the main characteristics of contrast-plaques. METHOD A single-centre prospective pilot study involving 33 consecutive patients with a stroke ≤10 days, diagnosed by an MRI with positive diffusion sequence and having a carotid plaque thickness ≥2.5mm with low or heterogeneous echogenicity, located in the ipsilateral carotid territory at the stroke. Plaque echogenicity was done by visual analysis and by measurement of the gray scale median (GSM). A transcranial Doppler monitoring was carried out in search of HITS. The contrast ultrasound was performed after 2.5 cc IV injection of SonoVue®. A video clip was recorded after injection which was used for interpretation by visual analysis in 3 grades, provided by two independent expert readers. RESULTS The population consisted of 10 women and 23 men aged 73 on average. The topography of strokes in the carotid territory was located on the right in 11 (33%) cases and on the left in 22 (67%) cases. Seventeen patients had carotid stenosis between 0 and 49% according to the Nascet method and 16 patients had stenosis of 50 to 99%. The visual characterisation of the plaques had echolucent dominance (Type 1-2) in 18 cases and echogenic dominance (Type 3-4a) in 15 cases. Cardiovascular risk factors were common with no difference by sex. The inter-observer agreement of plaque enhancement was moderate in first reading (k=0.48) and excellent at consensus (k=0.91). Only one disagreement was found. Contrast agent enhancement of carotid plaque was observed in 11/32 patients, representing a prevalence of 34.4% - CI95% [17.9-50.9]. Variables associated with contrast plaque included the absence of antiplatelet drug (63.6% vs. 23.8%, P=0.05) and the presence of a regular edge on the plaque (91% vs. 48%, P=0.04). There was no difference in contrast enhancement for stenosis>or<50% in diameter and neither for the type of plaque. CONCLUSION In a consecutive cohort of 33 patients, the prevalence of CEUS from an ipsilateral carotid plaque to a recent acute ischemic stroke was 34.4%. There was a statistically significant association between the contrast enhancement of the plaque and the absence of antiplatelet drug (P=0.05) and also the presence of a regular edge on the plaque (P=0.04). There was no correlation between plaque contrast and clinical and biological characteristics of patients or the presence of HITS.
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Affiliation(s)
- J M Baud
- Vascular Medicine Unit, centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France.
| | - D Stanciu
- Department of Neurology and stroke centre, centre hospitalier de Versailles, 78150 Le Chesnay, France
| | - J Yeung
- Department of Neurology and stroke centre, centre hospitalier de Versailles, 78150 Le Chesnay, France
| | - A Maurizot
- Vascular Medicine Unit, centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France
| | - S Chabay
- Vascular Medicine Unit, centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France
| | - M de Malherbe
- Department of Radiology, centre hospitalier de Versailles, 78150 Le Chesnay, France
| | - M-L Chadenat
- Department of Neurology and stroke centre, centre hospitalier de Versailles, 78150 Le Chesnay, France
| | - D Bachelet
- Direction of clinical research and innovation, centre hospitalier de Versailles, 78150 Le Chesnay, France
| | - F Pico
- Department of Neurology and stroke centre, centre hospitalier de Versailles, 78150 Le Chesnay, France; Versailles Saint-Quentin-en Yvelines university, 78000 Versailles, France
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13
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Chen X, Wang H, Jiang Y, Li J, Li N, Kong J, Zhang X, Ye W, Zhao D, Cai S. Neovascularization in carotid atherosclerotic plaques can be effectively evaluated by superb microvascular imaging (SMI): Initial experience. Vasc Med 2020; 25:328-333. [PMID: 32303154 DOI: 10.1177/1358863x20909992] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objective of this study was to investigate the correlation between the amount of blood flow in the area of neovascularization within a carotid atherosclerotic plaque by superb microvascular imaging (SMI) and the microvessel density (MVD) determined by histopathological staining. Twenty-eight carotid atherosclerotic plaques were detected by SMI in 28 patients who underwent carotid endarterectomy. SMI was graded according to the visual methods as follows: grade I: no appearance of neovascularization within the plaque; grade II: punctate neovascularization; grade III: one or two linear neovascularizations within the plaque; and grade IV: multiple (> 2) linear neovascularizations throughout the plaque. The neovascularization density was determined by the CD31 complex staining method. There was a significant correlation between the density of neovascularization in histopathologic plaques and the blood flow grade found by SMI (r = 0.788, p < 0.001). A significant difference was observed in SMI blood flow grade between the symptomatic and asymptomatic groups (χ2 = 2.634, p = 0.036). The MVD of plaques in the symptomatic group was significantly higher than that in the asymptomatic group (t = 2.530, p = 0.018). The SMI-based classification was positively correlated with plaque thickness. SMI, which is a new nonultrasound contrast-enhanced imaging method, can effectively evaluate neovascularization in carotid atherosclerotic plaques and can be used as a novel method for the clinical prediction of stroke risk.
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Affiliation(s)
- Xuanjia Chen
- Department of Medical Ultrasound, Peking Union Medical College Hospital, Beijing, China.,Department of Medical Ultrasound, Maternal and Child Health Care Hospital of Tongzhou District, Beijing, China
| | - Hongyan Wang
- Department of Medical Ultrasound, Peking Union Medical College Hospital, Beijing, China
| | - Yuxin Jiang
- Department of Medical Ultrasound, Peking Union Medical College Hospital, Beijing, China
| | - Jianchu Li
- Department of Medical Ultrasound, Peking Union Medical College Hospital, Beijing, China
| | - Na Li
- Department of Medical Ultrasound, Peking Union Medical College Hospital, Beijing, China
| | - Jing Kong
- Department of Medical Ultrasound, Peking Union Medical College Hospital, Beijing, China
| | - Xiaoyan Zhang
- Department of Medical Ultrasound, Peking Union Medical College Hospital, Beijing, China
| | - Wei Ye
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Dachun Zhao
- Department of Pathology, Peking Union Medical College Hospital, Beijing, China
| | - Siman Cai
- Department of Medical Ultrasound, Peking Union Medical College Hospital, Beijing, China
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14
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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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15
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Song Y, Dang Y, Dang LL, Zhao C, Zheng J, Feng J, Ruan LT. Association between intraplaque neovascularization assessed by contrast-enhanced ultrasound and the risk of stroke. Clin Radiol 2019; 75:70-75. [PMID: 31629485 DOI: 10.1016/j.crad.2019.08.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 08/21/2019] [Indexed: 11/16/2022]
Abstract
AIM To determine the cut-off value of the area ratio under the curve (ARUC) for predicting symptoms of stroke. MATERIALS AND METHODS Contrast-enhanced ultrasound was used to analyse intraplaque neovascularization (IPN). The correlations between the ARUC and risk factors of stroke were examined. A receiver operating characteristic curve was used to determine the cut-off value of the ARUC. RESULTS Using a quantitative analysis method for IPN, the ARUC was significantly higher in the symptomatic group than in the asymptomatic group (p=0.017). The ARUC was positively associated with the homocysteine level (r=0.429, p=0.002) and high-sensitivity C-reactive protein level (r=0.424, p=0.003). Regression analysis showed that the ARUC was a risk factor for symptoms of stroke. The receiver operating characteristic curve showed that the cut-off value for symptoms was 0.24; the sensitivity was 77%, and the specificity was 70%; the positive predictive value was 68%, and the negative predictive value was 78%. CONCLUSION IPN was a risk factor for the occurrence of the clinical symptoms of stroke. Patients with an ARUC of >0.24 had a higher risk of stroke.
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Affiliation(s)
- Y Song
- Department of Ultrasound, The First Affiliated Hospital of Xi'an Jiaotong University, No.277 Yanta West Road, Xi'an, Shaanxi 710061, China
| | - Y Dang
- Department of Ultrasound, The First Affiliated Hospital of Xi'an Jiaotong University, No.277 Yanta West Road, Xi'an, Shaanxi 710061, China
| | - L L Dang
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, No.277 Yanta West Road, Xi'an, Shaanxi 710061, China
| | - C Zhao
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, No.277 Yanta West Road, Xi'an, Shaanxi 710061, China
| | - J Zheng
- The Clinical Research Center, The First Affiliated Hospital of Xi'an Jiaotong University, No.277 Yanta West Road, Xi'an, Shaanxi 710061, China
| | - J Feng
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, No.277 Yanta West Road, Xi'an, Shaanxi 710061, China.
| | - L T Ruan
- Department of Ultrasound, The First Affiliated Hospital of Xi'an Jiaotong University, No.277 Yanta West Road, Xi'an, Shaanxi 710061, China.
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16
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Evdokimenko A, Chechetkin A, Druina L, Tanashyan M. Contrast-enhanced ultrasonography for assessing neovascularization of carotid atherosclerotic plaque. BULLETIN OF RUSSIAN STATE MEDICAL UNIVERSITY 2019. [DOI: 10.24075/brsmu.2019.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Neovascularization of a carotid atherosclerotic plaque (AP) is associated with an increased risk of stroke. Contrast-enhanced ultrasonography (CEUS) is a widely used method for imaging intraplaque neovascularization in vivo. Unfortunately, there are no standardized guidelines for CEUS interpretation. The aim of this study was to identify the most reliable method for CEUS-based assessment of AP neovascularization. Seventy-eight AP were removed during carotid endarterectomy in 73 patients, of whom 5 had AP on both sides, and examined morphologically. All patients underwent preoperative duplex scanning and CEUS; Sonovue was used as a contrast agent. AP neovascularization was assessed on a 4-grade visual scale and with 3 different quantitative methods using QLAB software. On the visual scale (method 1), poorly (37%) and moderately (51%) vascularized plaques were the most common. Quantitative analysis (data were presented as Me (Q1; Q3)) revealed that the number of blood vessels per 1 cm2 of the plaque (method 2) was 16 (10; 26), the ratio of the total vessel area to the plaque area (method 3) was 6% (3; 9), and AP ROI (method 4) was 2.6 dB (1.8; 4.1). Significant correlations were demonstrated between the results produced by method 2 and method 3 (р < 0.0001), method 3 and method 2 (p = 0.0006), and between pathomorphological findings and the results produced by methods 1–3, especially method 2 (p < 0.004). AP ROI brightness did not correlate with other results. The presence of hyperechoic components (calcifications) in AP dramatically reduced the reliability of US-based intraplaque neovascularization assessment. The most accurate CEUS-based quantitative method for assessing intraplaque neovascularization is estimation of blood vessel number per 1 cm2 of the plaque.
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Affiliation(s)
| | | | - L.D. Druina
- Research Center of Neurology, Moscow, Russia
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17
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Di Leo N, Venturini L, de Soccio V, Forte V, Lucchetti P, Cerone G, Alagna G, Caratozzolo M, Messineo D, Di Gioia C, Di Marzo L, Fresilli D, De Vito C, Pugliese G, Cantisani V, D'Ambrosio F. Multiparametric ultrasound evaluation with CEUS and shear wave elastography for carotid plaque risk stratification. J Ultrasound 2018; 21:293-300. [PMID: 30378007 PMCID: PMC6237715 DOI: 10.1007/s40477-018-0320-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 09/10/2018] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To assess the diagnostic effectiveness of Multiparametric ultrasound (MPUS), which includes color Doppler ultrasound (CDUS), CEUS and Shear wave elastography (SWE), for evaluating carotid plaque as compared with CT-angiography (CTA) and histology. MATERIALS AND METHODS Forty-three consecutive patients scheduled to undergo carotid endarterectomy underwent MPUS. Then, after periods ranging from 2 days to 2 weeks, all underwent CTA. Each plaque was classified by means of dedicated scores for CEUS and SWE as compared with CTA features. At surgery, each plaque was removed in a single fragment to facilitate histological analysis, which evaluated 4 features: extension of the lipid core, thickness of the fibrous cap, inflammatory infiltrate (CD68 + and CD3 + markers) and the presence of intraplaque microvessels. For the CEUS, SWE and CTA, the following values for identifying plaque vulnerability were evaluated: sensitivity, specificity, accuracy, negative predictive value (NPV), positive predictive value (PPV) and Area under the curve (AUC). Cohen's kappa was used to evaluate the concordance between measurements in the different imaging methods. A p < 0.05 was considered statistically significant. RESULTS At histology, 31 out of 43 plaques were identified as vulnerable because of the presence of at least one of the following criteria: fibrous cap < 200 μm, lipid core, intraplaque hemorrhage, inflammatory infiltrate or intraplaque neovascularization. CTA showed a sensitivity of 87.1%, a specificity of 100%, a PPV of 100%, an NPV of 75% and an AUC of 93.5%. SWE showed a sensitivity of 87.1%, a specificity of 66.7%, a PPV of 87.1%, an NPV of 66.7% and an AUC of 76.9%. CEUS showed a sensitivity of 87.1%, a specificity of 58.3%, a PPV of 84.4%, an NPV of 63.6% and an AUC of 72.7%. CONCLUSIONS Multiparametric ultrasound is an effective modality to obtain comprehensive information on carotid plaques. Further studies are needed to determine whether it can be considered a diagnostic standard.
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Affiliation(s)
- N Di Leo
- Dipartimento di Scienze Radiologiche, Oncologiche e Anatomopatologiche, Policlinico Umberto I Roma, Viale del Policlinico 155, 00161, Rome, RM, Italy.
| | - L Venturini
- Department of Surgery "Pietro Valdoni", Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - V de Soccio
- Dipartimento di Scienze Radiologiche, Oncologiche e Anatomopatologiche, Policlinico Umberto I Roma, Viale del Policlinico 155, 00161, Rome, RM, Italy
| | - V Forte
- Dipartimento di Scienze Radiologiche, Oncologiche e Anatomopatologiche, Policlinico Umberto I Roma, Viale del Policlinico 155, 00161, Rome, RM, Italy
| | - P Lucchetti
- Department of Public Health and Infectious Diseases, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - G Cerone
- Biomedicine and Prevention Department, University Tor Vergata of Rome, Rome, Italy
| | - G Alagna
- Dipartimento di Scienze Radiologiche, Oncologiche e Anatomopatologiche, Policlinico Umberto I Roma, Viale del Policlinico 155, 00161, Rome, RM, Italy
| | - M Caratozzolo
- Dipartimento di Scienze Radiologiche, Oncologiche e Anatomopatologiche, Policlinico Umberto I Roma, Viale del Policlinico 155, 00161, Rome, RM, Italy
| | - D Messineo
- Dipartimento di Scienze Radiologiche, Oncologiche e Anatomopatologiche, Policlinico Umberto I Roma, Viale del Policlinico 155, 00161, Rome, RM, Italy
| | - C Di Gioia
- Dipartimento di Scienze Radiologiche, Oncologiche e Anatomopatologiche, Policlinico Umberto I Roma, Viale del Policlinico 155, 00161, Rome, RM, Italy
| | - L Di Marzo
- Department of Surgery "Pietro Valdoni", Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - D Fresilli
- Dipartimento di Scienze Radiologiche, Oncologiche e Anatomopatologiche, Policlinico Umberto I Roma, Viale del Policlinico 155, 00161, Rome, RM, Italy
| | - C De Vito
- Department of Public Health and Infectious Diseases, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - G Pugliese
- Dipartimento di Scienze Radiologiche, Oncologiche e Anatomopatologiche, Policlinico Umberto I Roma, Viale del Policlinico 155, 00161, Rome, RM, Italy
| | - V Cantisani
- Dipartimento di Scienze Radiologiche, Oncologiche e Anatomopatologiche, Policlinico Umberto I Roma, Viale del Policlinico 155, 00161, Rome, RM, Italy
| | - F D'Ambrosio
- Dipartimento di Scienze Radiologiche, Oncologiche e Anatomopatologiche, Policlinico Umberto I Roma, Viale del Policlinico 155, 00161, Rome, RM, Italy
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18
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D'Oria M, Chiarandini S, Pipitone MD, Fisicaro M, Calvagna C, Bussani R, Rotelli A, Ziani B. Contrast Enhanced Ultrasound (CEUS) Is Not Able to Identify Vulnerable Plaques in Asymptomatic Carotid Atherosclerotic Disease. Eur J Vasc Endovasc Surg 2018; 56:632-642. [PMID: 30193730 DOI: 10.1016/j.ejvs.2018.07.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 07/13/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Contrast enhanced ultrasound (CEUS) has been suggested as an imaging tool for detection of asymptomatic carotid atherosclerotic disease (ACAD) at high risk of cerebral embolisation. The objective of this study was to evaluate CEUS and immunohistochemical (IHC) patterns in ACAD (i.e., without any neurologic symptoms in the last 6 months) and their correlations with histology. METHODS CEUS analysis was classified on a semiquantitative basis using a three-point classification scale. Plaque morphology was assessed using the American Heart Association (AHA) classification of atherosclerotic plaques, then accordingly assigned as non-vulnerable (AHA Type IV/V) or vulnerable (AHA Type VI). IHC analysis for intra-plaque neo-angiogenesis (IPN) was identified by CD34/VEGF immunostaining and classified on a semiquantitative basis using a four-point classification scale. Both CEUS and IHC analyses were performed and scored by single observers. RESULTS Fifty-eight consecutive asymptomatic patients (mean age 73 years, 33 males) undergoing carotid endarterectomy were included in the final analysis. Nineteen had AHA Class IV/V plaques, and the remaining 39 had AHA Class VI plaques. There were two main findings of the study: (a) histologically proven vulnerable plaques compared with histologically proven non-vulnerable plaques had denser IPN (p = .004), but did not show more pronounced contrast enhancement; (b) the correlation between IHC analysis and CEUS analysis was significant for both vulnerable and non-vulnerable plaques (p = .04 and p = .01, respectively), but it was direct for AHA Type IV/V plaques and inverse for AHA Type VI plaques. CONCLUSIONS The main findings of the study were that histologically proven vulnerable plaques (i.e., AHA Class VI) as compared with histologically proven non-vulnerable plaques (i.e., AHA Class IV/V) had denser neo-vascularisation, but not more pronounced contrast enhancement.
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Affiliation(s)
- Mario D'Oria
- Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara Hospital ASUITs, Trieste, Italy.
| | - Stefano Chiarandini
- Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara Hospital ASUITs, Trieste, Italy
| | - Marco D Pipitone
- Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara Hospital ASUITs, Trieste, Italy
| | - Maurizio Fisicaro
- Cardiovascular Health Services Centre, Cardiovascular Department, Maggiore Hospital ASUITs, Trieste, Italy
| | - Cristiano Calvagna
- Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara Hospital ASUITs, Trieste, Italy
| | - Rossana Bussani
- Surgical Pathology, Surgical, Medical and Health Sciences Department, Cattinara Hospital ASUITs, Trieste, Italy
| | - Alice Rotelli
- Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara Hospital ASUITs, Trieste, Italy
| | - Barbara Ziani
- Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara Hospital ASUITs, Trieste, Italy
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19
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Shang J, Wang W, Feng J, Luo GG, Dang Y, Sun J, Yang YQ, Ruan LT. Carotid Plaque Stiffness Measured with Supersonic Shear Imaging and Its Correlation with Serum Homocysteine Level in Ischemic Stroke Patients. Korean J Radiol 2018; 19:15-22. [PMID: 29353995 PMCID: PMC5768496 DOI: 10.3348/kjr.2018.19.1.15] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 12/24/2016] [Indexed: 11/15/2022] Open
Abstract
Objective To ascertain the feasibility of using shear wave velocity (SWV) in assessing the stiffness of carotid plaque by supersonic shear imaging (SSI) and explore preliminary clinical value for such evaluation. Materials and Methods Supersonic shear imaging was performed in 142 patients with ischemic stroke, including 76 males and 66 females with mean age of 66 years (range, 45-80 years). The maximum, minimum, and mean values of SWV were measured for 129 carotid plaques. SWVs were compared between echolucent and echogenic plaques. Correlations between SWVs and serum homocysteine levels were investigated. Based on neurological symptom, the surrogate marker of vulnerable plaque (VP), binary logistic regression was performed and area under curve (AUC) of homocysteine only and homocysteine combing SWVmean was calculated respectively. Results Echogenic plaques (n = 51) had higher SWVs than echolucent ones (n = 78) (SWVmin 3.91 [3.24-4.17] m/s vs. 1.51 [1.04-1.94] m/s; SWVmean, 4.29 [3.98-4.57] m/s vs. 2.09 [1.69-2.41] m/s; SWVmax, 4.67 [4.33-4.86] m/s vs. 2.62 [2.32-3.31] m/s all p values < 0.01). Pearson correlation analysis showed that stiffness of plaques was negatively correlated with homocysteine level. R values for SWVmin, SWVmean, and SWVmax were -0.205, -0.213, and -0.199, respectively. Binary logistic regression analysis showed that sex (p = 0.008), low-density lipoprotein (p = 0.015), triglycerides (p = 0.011), SWVmean (p = 0.004), and hyper-homocysteinemia (p = 0.010) were significantly associated with symptomatic ischemic stroke. Receiver operating characteristic curves revealed that SWVmean combing serum homocysteine level (AUC = 0.67) presented better diagnostic value than serum homocysteine only (AUC = 0.60) for symptomatic ischemic stroke. Conclusion Supersonic shear imaging could be used to quantitatively evaluate stiffness of both echolucent and echogenic carotid plaques. More importantly, SWVs of plaques were not only correlated to serum homocysteine level, but also associated with symptomatic ischemic stroke, suggesting that SSI might be useful for understanding more about VP.
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Affiliation(s)
- Jing Shang
- Department of Ultrasound Medicine, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an 710061, China
| | - Wen Wang
- Department of Radiology, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Jun Feng
- Department of Neurology, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an 710061, China
| | - Guo-Gang Luo
- Department of Neurology, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an 710061, China
| | - Ying Dang
- Department of Ultrasound Medicine, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an 710061, China
| | - Jian Sun
- Department of Ultrasound Medicine, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an 710061, China
| | - Yan-Qiu Yang
- Department of Ultrasound Medicine, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an 710061, China
| | - Li-Tao Ruan
- Department of Ultrasound Medicine, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an 710061, China
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Fumagalli S, Perego C, Zangari R, De Blasio D, Oggioni M, De Nigris F, Snider F, Garred P, Ferrante AMR, De Simoni MG. Lectin Pathway of Complement Activation Is Associated with Vulnerability of Atherosclerotic Plaques. Front Immunol 2017; 8:288. [PMID: 28360913 PMCID: PMC5352714 DOI: 10.3389/fimmu.2017.00288] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 02/28/2017] [Indexed: 12/20/2022] Open
Abstract
Inflammatory mechanisms may be involved in atherosclerotic plaque rupture. By using a novel histology-based method to quantify plaque instability here, we assess whether lectin pathway (LP) of complement activation, a major inflammation arm, could represent an index of plaque instability. Plaques from 42 consecutive patients undergoing carotid endarterectomy were stained with hematoxylin-eosin and the lipid core, cholesterol clefts, hemorrhagic content, thickness of tunica media, and intima, including or not infiltration of cellular debris and cholesterol, were determined. The presence of ficolin-1, -2, and -3 and mannose-binding lectin (MBL), LP initiators, was assessed in the plaques by immunofluorescence and in plasma by ELISA. LP activation was assessed in plasma by functional in vitro assays. Patients presenting low stenosis (≤75%) had higher hemorrhagic content than those with high stenosis (>75%), indicating increased erosion. Increased hemorrhagic content and tunica media thickness, as well as decreased lipid core and infiltrated content were associated with vulnerable plaques and therefore used to establish a plaque vulnerability score that allowed to classify patients according to plaque vulnerability. Ficolins and MBL were found both in plaques’ necrotic core and tunica media. Patients with vulnerable plaques showed decreased plasma levels and intraplaque deposition of ficolin-2. Symptomatic patients experiencing a transient ischemic attack had lower plasma levels of ficolin-1. We show that the LP initiators are present within the plaques and their circulating levels change in atherosclerotic patients. In particular, we show that decreased ficolin-2 levels are associated with rupture-prone vulnerable plaques, indicating its potential use as marker for cardiovascular risk assessment in atherosclerotic patients.
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Affiliation(s)
- Stefano Fumagalli
- Department of Neuroscience, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri , Milan , Italy
| | - Carlo Perego
- Department of Neuroscience, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri , Milan , Italy
| | - Rosalia Zangari
- Department of Neuroscience, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri , Milan , Italy
| | - Daiana De Blasio
- Department of Neuroscience, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri , Milan , Italy
| | - Marco Oggioni
- Department of Neuroscience, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri , Milan , Italy
| | - Francesca De Nigris
- Vascular Surgery Unit, Catholic University of Sacred Heart Medical School "A. Gemelli University Hospital" Foundation , Rome , Italy
| | - Francesco Snider
- Vascular Surgery Unit, Catholic University of Sacred Heart Medical School "A. Gemelli University Hospital" Foundation , Rome , Italy
| | - Peter Garred
- Laboratory of Molecular Medicine, Department of Clinical Immunology, Section 7631, Rigshospitalet, Faculty of Medical and Health Sciences, University of Copenhagen , Copenhagen , Denmark
| | - Angela M R Ferrante
- Vascular Surgery Unit, Catholic University of Sacred Heart Medical School "A. Gemelli University Hospital" Foundation , Rome , Italy
| | - Maria-Grazia De Simoni
- Department of Neuroscience, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri , Milan , Italy
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21
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Huang R, Abdelmoneim SS, Ball CA, Nhola LF, Farrell AM, Feinstein S, Mulvagh SL. Detection of Carotid Atherosclerotic Plaque Neovascularization Using Contrast Enhanced Ultrasound: A Systematic Review and Meta-Analysis of Diagnostic Accuracy Studies. J Am Soc Echocardiogr 2016; 29:491-502. [PMID: 27038513 DOI: 10.1016/j.echo.2016.02.012] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Intraplaque neovascularization is considered an important indicator of plaque vulnerability. Contrast-enhanced ultrasound (CEUS) of carotid arteries improves imaging of carotid intima-media thickness and permits real-time visualization of neovascularization of the atherosclerotic plaque. The authors conducted a systematic review and meta-analysis to evaluate the accuracy of CEUS-detected carotid atherosclerotic plaque. METHODS A systematic search was performed to identify studies published in the MEDLINE, Embase, Scopus, and Web of Science databases from 2004 to June 2015. Studies evaluating the accuracy of quantitative analysis and qualitative analysis (visual interpretation) for the diagnosis of intraplaque neovascularization compared with histologic specimens and/or clinical diagnosis of symptomatic plaque were included. Parameters evaluated were plaque quantitative CEUS intensity and the visual grading of plaque CEUS. A random-effects meta-analysis was used to pool the likelihood ratios (LRs), diagnostic odds ratios, and summary receiver operating characteristic curves. Corresponding areas under the curves were calculated. RESULTS The literature search identified 203 studies, 20 of which were selected for systematic review; the final meta-analysis included seven studies. For qualitative CEUS, pooled sensitivity was 0.80 (95% CI, 0.72-0.87), pooled specificity was 0.83 (95% CI, 0.76-0.89), the pooled positive LR was 3.22 (95% CI, 1.67-6.18), the pooled negative LR was 0.24 (95% CI, 0.09-0.64), the pooled diagnostic odds ratio was 15.57 (95% CI, 4.94-49.03), and area under the curve was 0.894. For quantitative CEUS, pooled sensitivity was 0.77 (95% CI, 0.71-0.83), pooled specificity was 0.68 (95% CI, 0.62-0.73), the pooled positive LR was 2.34 (95% CI, 1.69-3.23), the pooled negative LR was 0.34 (95% CI, 0.25-0.47), the pooled diagnostic odds ratio was 7.06 (95% CI, 3.6-13.82), and area under the curve was 0.888. CONCLUSIONS CEUS is a promising noninvasive diagnostic modality for detecting intraplaque neovascularization. Standardization of quantitative analysis and visual grading classification is needed to increase reliability and reduce technical heterogeneity.
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Affiliation(s)
- Runqing Huang
- Division of Cardiovascular Diseases, Mayo Clinic Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Mayo Clinic, Rochester, Minnesota; Division of Ultrasound, Tongji Hospital, Tongji Medical College, HuaZhong University of Science and Technology, Wuhan, China
| | - Sahar S Abdelmoneim
- Division of Cardiovascular Diseases, Mayo Clinic Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Caroline A Ball
- Internal Medicine, Mayo Clinic Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Lara F Nhola
- Division of Cardiovascular Diseases, Mayo Clinic Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Ann M Farrell
- Mayo Clinic Libraries, Mayo Clinic Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Mayo Clinic, Rochester, Minnesota
| | | | - Sharon L Mulvagh
- Division of Cardiovascular Diseases, Mayo Clinic Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Mayo Clinic, Rochester, Minnesota.
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22
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Saha SA, Gourineni V, Feinstein SB. The Use of Contrast-enhanced Ultrasonography for Imaging of Carotid Atherosclerotic Plaques: Current Evidence, Future Directions. Neuroimaging Clin N Am 2015; 26:81-96. [PMID: 26610662 DOI: 10.1016/j.nic.2015.09.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Contrast-enhanced ultrasonography (CEUS) is a rapidly evolving modality for imaging carotid artery disease and systemic atherosclerosis. CEUS coupled with diagnostic ultrasonography predicts the degree of carotid artery stenosis and is comparable with computed tomography and magnetic resonance angiography. This article reviews the literature on the evolving role of CEUS for the identification and characterization of carotid plaques with an emphasis on detection of intra-plaque neovascularization and related high-risk morphologic features notably present in symptomatic patients. CEUS carotid imaging may play a prominent additive role in risk stratifying patients and serve as a powerful tool for monitoring therapeutic interventions.
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Affiliation(s)
- Sandeep A Saha
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Venu Gourineni
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Steven B Feinstein
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
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