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Huang Y, Sun X, Ding X, Tan S, Yu Z, Shi X, Li X, Ge H. Pathological Intraplaque Hemorrhage as the Gold Standard to Assess the Efficacy of Ultrasound in Predicting Vulnerable Carotid Plaque Rupture. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024. [PMID: 38962941 DOI: 10.1002/jum.16518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/27/2024] [Accepted: 06/14/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVE To assess the clinical utility of ultrasound in predicting the risk of carotid vulnerable plaque rupture using pathological intraplaque hemorrhage as the gold standard. METHODS A total of 118 patients who underwent endarterectomy due to symptomatic carotid artery stenosis were enrolled. Conventional ultrasound assessed the plaque thickness, area stenosis rate, echo, and surface morphology. Neovascularization were assessed by contrast-enhanced ultrasound (CEUS) and tracing intraplaque nonenhanced areas. According to neovascularization grade (0-4), plaques were classified as low-, intermediate-, and high risk. Fresh intraplaque hemorrhage within the pathology was adopted as the gold standard for diagnosing plaque rupture risk. Thus, we divided patients into ruptured risk and nonruptured risk groups to assess the value of crucial factors for plaque rupture risk using ultrasound. RESULTS Of the 118 patients, hypertension accounted for 71.2%, hyperlipidemia 68.6%, diabetes 52.5%, and statin history 64.4%. In the rupture risk group, diabetes, smoking, and stenosis rate were significantly higher than the nonrupture risk group (P < .001); plaque thickness ≥4 mm (P > .05); and mainly hypoechoic with irregular surface morphology (P < .001), nonenhanced areas in the plaques (P < .001), and neovascularization >grade 2 (P < .001). Compared with the low-risk group, plaque rupture risk was 7.219 times higher in the medium-risk group and 18.333 times higher in the high-risk group. The kappa value of the interobserver consistency of crucial ultrasound parameters was >0.75, and the intraclass correlation coefficient was 0.919 (P < .01). CONCLUSIONS Both conventional ultrasound and CEUS have significant clinical importance in the prediction of rupture risk in vulnerable carotid plaques, thereby enabling stroke risk stratification and the assessment of plaque rupture risk.
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Affiliation(s)
- Yaping Huang
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- Department of Ultrasound, Chuiyangliu Hospital Affiliated to Tsinghua University, Beijing, China
| | - Xinping Sun
- Department of Ultrasound, Chuiyangliu Hospital Affiliated to Tsinghua University, Beijing, China
| | - Xu Ding
- Department of Vascular Surgery, Chuiyangliu Hospital Affiliated to Tsinghua University, Beijing, China
| | - Shuping Tan
- Department of Vascular Surgery, Beijing Hospital, Beijing, China
| | - Zexing Yu
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xue Shi
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xin Li
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Huiyu Ge
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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2
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Xiao J, Poblete RA, Lerner A, Nguyen PL, Song JW, Sanossian N, Wilcox AG, Song SS, Lyden PD, Saver JL, Wasserman BA, Fan Z. MRI in the Evaluation of Cryptogenic Stroke and Embolic Stroke of Undetermined Source. Radiology 2024; 311:e231934. [PMID: 38652031 PMCID: PMC11070612 DOI: 10.1148/radiol.231934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 12/15/2023] [Accepted: 12/21/2023] [Indexed: 04/25/2024]
Abstract
Cryptogenic stroke refers to a stroke of undetermined etiology. It accounts for approximately one-fifth of ischemic strokes and has a higher prevalence in younger patients. Embolic stroke of undetermined source (ESUS) refers to a subgroup of patients with nonlacunar cryptogenic strokes in whom embolism is the suspected stroke mechanism. Under the classifications of cryptogenic stroke or ESUS, there is wide heterogeneity in possible stroke mechanisms. In the absence of a confirmed stroke etiology, there is no established treatment for secondary prevention of stroke in patients experiencing cryptogenic stroke or ESUS, despite several clinical trials, leaving physicians with a clinical dilemma. Both conventional and advanced MRI techniques are available in clinical practice to identify differentiating features and stroke patterns and to determine or infer the underlying etiologic cause, such as atherosclerotic plaques and cardiogenic or paradoxical embolism due to occult pelvic venous thrombi. The aim of this review is to highlight the diagnostic utility of various MRI techniques in patients with cryptogenic stroke or ESUS. Future trends in technological advancement for promoting the adoption of MRI in such a special clinical application are also discussed.
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Affiliation(s)
- Jiayu Xiao
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Roy A. Poblete
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Alexander Lerner
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Peggy L. Nguyen
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Jae W. Song
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Nerses Sanossian
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Alison G. Wilcox
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Shlee S. Song
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Patrick D. Lyden
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Jeffrey L. Saver
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Bruce A. Wasserman
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Zhaoyang Fan
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
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3
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Khenkina N, Aimo A, Fabiani I, Masci PG, Sagris D, Williams SE, Mavraganis G, Chen HS, Wintermark M, Michel P, Ntaios G, Georgiopoulos G. Magnetic resonance imaging for diagnostic workup of embolic stroke of undetermined source: A systematic review. Int J Stroke 2024; 19:293-304. [PMID: 37435743 DOI: 10.1177/17474930231189946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
BACKGROUND Embolic stroke of undetermined source (ESUS) refers to ischemic stroke where the underlying cause of thromboembolism cannot be found despite the recommended diagnostic workup. Unidentified source of emboli hinders clinical decision-making and patient management with detrimental consequences on long-term prognosis. The rapid development and versatility of magnetic resonance imaging (MRI) make it an appealing addition to the diagnostic routine of patients with ESUS for the assessment of potential vascular and cardiac embolic sources. AIMS To review the use of MRI in the identification of cardiac and vascular embolic sources in ESUS and to assess the reclassification value of MRI examinations added to the conventional workup of ESUS. SUMMARY OF REVIEW We reviewed the use of cardiac and vascular MRI for the identification of a variety of embolic sources associated with ESUS, including atrial cardiomyopathy, left ventricular pathologies, and supracervical atherosclerosis in carotid and intracranial arteries and in distal thoracic aorta. The additional reclassification after MRI examinations added to the workup of patients with ESUS ranged from 6.1% to 82.3% and varied depending on the combination of imaging modalities. CONCLUSION MRI techniques allow us to identify additional cardiac and vascular embolic sources and may further decrease the prevalence of patients with the diagnosis of ESUS.
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Affiliation(s)
- Natallia Khenkina
- Postgraduate School of Diagnostic and Interventional Radiology, University of Milan, Milan, Italy
| | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Iacopo Fabiani
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Pier Giorgio Masci
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Dimitrios Sagris
- Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | | | - George Mavraganis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Max Wintermark
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Georgios Georgiopoulos
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
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4
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Simaan N, Jubeh T, Shalabi F, Jubran H, Metanis I, Parag Y, Schwartzman Y, Magadlla J, Gomori JM, Beiruti KW, Cohen JE, Leker R. Diagnostic Yield of High-Resolution Vessel Wall Magnetic Resonance Imaging in the Evaluation of Young Stroke Patients. J Clin Med 2023; 13:189. [PMID: 38202196 PMCID: PMC10779627 DOI: 10.3390/jcm13010189] [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: 09/27/2023] [Revised: 11/16/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
(1) Background: The mechanism responsible for stroke in patients younger than 50 often remains unknown. This study was designed to assess whether high-resolution intracranial vessel wall MR imaging (icVWI) may be instrumental in determining stroke cause. (2) Methods: Young stroke patients with and without an identified cause of stroke despite an exhaustive investigation were prospectively included. Patients who underwent icVWI were compared to those who did not. We next compared patients with and without intracranial vulnerable plaques on icVWI. (3) Results: Overall, 47 young stroke patients were identified over the span of 2 years and included in this study. Of those, 20 (42%) underwent intracranial icVWI. Cancer prevalence was higher among patients who did not have an icVWI study (19% vs. 0% p = 0.042) but there were no other significant differences between patients who had an icVWI study and those who did not have an icVWI. Among patients who had an icVWI, 11 (55%) had vulnerable plaques and the remaining nine studies were negative. Patients with positive icVWI scans had significantly higher stroke severity at admission (mean ± SD NIHSS score 5.5 ± 3.5 vs. 1.7 ± 2.3, p = 0.012). Patients with positive icVWI scans were more often treated with antiplatelets upon discharge (100% vs. 67%, p = 0.038). (4) Conclusions: icVWI can add significant information relevant to stroke pathogenesis and secondary prevention among young stroke patients with a negative exhaustive diagnostic workup.
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Affiliation(s)
- Naaem Simaan
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem 9112102, Israel; (N.S.); (F.S.); (H.J.); (I.M.); (Y.S.); (J.M.)
- Azrieli Faculty of Medicine, Bar Ilan University, Safed 1311502, Israel
- Department of Neurology, Ziv Medical Center, Safed 1311001, Israel;
| | - Tamer Jubeh
- Department of Neurology, Ziv Medical Center, Safed 1311001, Israel;
| | - Fatma Shalabi
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem 9112102, Israel; (N.S.); (F.S.); (H.J.); (I.M.); (Y.S.); (J.M.)
| | - Hamza Jubran
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem 9112102, Israel; (N.S.); (F.S.); (H.J.); (I.M.); (Y.S.); (J.M.)
| | - Issa Metanis
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem 9112102, Israel; (N.S.); (F.S.); (H.J.); (I.M.); (Y.S.); (J.M.)
| | - Yoav Parag
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem 9112102, Israel; (Y.P.); (J.M.G.)
| | - Yoel Schwartzman
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem 9112102, Israel; (N.S.); (F.S.); (H.J.); (I.M.); (Y.S.); (J.M.)
| | - Jad Magadlla
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem 9112102, Israel; (N.S.); (F.S.); (H.J.); (I.M.); (Y.S.); (J.M.)
| | - John. M. Gomori
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem 9112102, Israel; (Y.P.); (J.M.G.)
| | | | - Jose E. Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem 9112102, Israel;
| | - Ronen Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem 9112102, Israel; (N.S.); (F.S.); (H.J.); (I.M.); (Y.S.); (J.M.)
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5
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Simaan N, Shalabi F, Schwartzmann Y, Jubeh T, Parag Y, Honig A, Metanis I, Joubran H, Magadlla J, Gomori JM, Cohen JE, Leker RR. Impact of high-resolution intracranial vessel wall magnetic resonance imaging on diagnosis in patients with embolic stroke of unknown source. J Neurol Sci 2023; 454:120863. [PMID: 37931444 DOI: 10.1016/j.jns.2023.120863] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/05/2023] [Accepted: 10/27/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND The mechanism responsible for stroke in patients with embolic stroke of unknown source (ESUS) often remains unknown despite extensive investigations. We aimed to test whether high-resolution intracranial vessel wall MR imaging (icVWI) can add to the diagnostic yield in these patients. PATIENTS AND METHODS Patients with ESUS were prospectively included into an ongoing registry. Patients that underwent icVWI as part of their diagnostic workup were compared to those that did not have an icVWI. Patients with icVWI positive for intracranial vulnerable plaques were than compared to those without evidence of plaque vulnerability on VWI. RESULTS A total of 179 patients with ESUS were included and 48 of them (27%) underwent icVWI. Patients that had an icVWI scan were significantly younger, had lower rates of ischemic heart disease and prior disability as well as significantly lower stroke severity. On regression analysis the only factor that remained associated with not obtaining an icVWI scan was increasing age (Odds ratio [OR] 0.97/year, 95% confidence intervals [CI] 0.95-0.97). Among patients that had an icVWI scan 28 (58%) had evidence of plaque enhancement on VWI in the same distribution of the stroke and the remaining 20 studies were negative. The relative proportion of stroke presumed to be secondary to intracranial non-stenotic atheromatous disease increased from 15% in patients without icVWI scans to 58% among patients with icVWI scans (p = 0.001). On regression analysis the only factor that was associated with vulnerable plaques on icVWI was smoking (OR 11.05 95% CI 1.88-65.17). CONCLUSIONS icVWI can add significant information relevant to stroke pathogenesis and treatment in patients with ESUS and a negative initial exhaustive diagnostic workup.
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Affiliation(s)
- Naaem Simaan
- Departments of Neurology, Ziv Medical Center, Zefat, Israel
| | - Fatma Shalabi
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yoel Schwartzmann
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Tamer Jubeh
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yoav Parag
- Departments of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Asaf Honig
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Issa Metanis
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Hamza Joubran
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Jad Magadlla
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - John M Gomori
- Departments of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Jose E Cohen
- Departments of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronen R Leker
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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6
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Larson AS, Brinjikji W, Lekah A, Klaas JP, Lanzino G, Huston J, Saba L, Benson JC. Nonstenotic Carotid Plaques and Embolic Stroke of Undetermined Source: A Multimodality Review. AJNR Am J Neuroradiol 2023; 44:118-124. [PMID: 36549844 PMCID: PMC9891333 DOI: 10.3174/ajnr.a7750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/10/2022] [Indexed: 12/24/2022]
Abstract
Symptomatic nonstenotic carotid artery disease has been increasingly recognized as a thromboembolic source in patients who would otherwise be classified as having embolic stroke of undetermined source. Evidence suggests that certain plaque features seen on sonography, CT, and MR imaging in nonstenotic carotid artery disease may predispose to recurrent stroke in patients with embolic stroke of undetermined source. We performed a focused literature review to further study plaque features in the context of embolic stroke of undetermined source and to determine which plaque features may be associated with ipsilateral ischemic events in such patients. Plaque thickness as seen on both ultrasound and CT appears to have a consistent association with ipsilateral stroke in patients with embolic stroke of undetermined source across multiple studies. Intraplaque hemorrhage as seen on MR imaging is now understood to have a strong association with ipsilateral stroke in patients with embolic stroke of undetermined source. Continued study of various plaque features as seen on different modalities is warranted to uncover other potential associations.
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Affiliation(s)
- A S Larson
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
| | - W Brinjikji
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
- Neurosurgery (W.B., G.L.)
| | - A Lekah
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
| | - J P Klaas
- Neurology (J.P.K.), Mayo Clinic, Rochester, Minnesota
| | - G Lanzino
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
- Neurosurgery (W.B., G.L.)
| | - J Huston
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
| | - L Saba
- Department of Medical Sciences (L.S.), University of Cagliari, Cagliari, Italy
| | - J C Benson
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
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7
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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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Han N, Ma Y, Li Y, Zheng Y, Wu C, Gan T, Li M, Ma L, Zhang J. Imaging and Hemodynamic Characteristics of Vulnerable Carotid Plaques and Artificial Intelligence Applications in Plaque Classification and Segmentation. Brain Sci 2023; 13:brainsci13010143. [PMID: 36672124 PMCID: PMC9856903 DOI: 10.3390/brainsci13010143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/24/2022] [Accepted: 01/10/2023] [Indexed: 01/18/2023] Open
Abstract
Stroke is a massive public health problem. The rupture of vulnerable carotid atherosclerotic plaques is the most common cause of acute ischemic stroke (AIS) across the world. Currently, vessel wall high-resolution magnetic resonance imaging (VW-HRMRI) is the most appropriate and cost-effective imaging technique to characterize carotid plaque vulnerability and plays an important role in promoting early diagnosis and guiding aggressive clinical therapy to reduce the risk of plaque rupture and AIS. In recent years, great progress has been made in imaging research on vulnerable carotid plaques. This review summarizes developments in the imaging and hemodynamic characteristics of vulnerable carotid plaques on the basis of VW-HRMRI and four-dimensional (4D) flow MRI, and it discusses the relationship between these characteristics and ischemic stroke. In addition, the applications of artificial intelligence in plaque classification and segmentation are reviewed.
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Affiliation(s)
- Na Han
- Department of Magnetic Resonance, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Province Clinical Research Center for Functional and Molecular Imaging, Lanzhou 730030, China
- Second Clinical School, Lanzhou University, Lanzhou 730030, China
| | - Yurong Ma
- Department of Magnetic Resonance, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Province Clinical Research Center for Functional and Molecular Imaging, Lanzhou 730030, China
| | - Yan Li
- School of Mathematics and Statistics, Lanzhou University, Lanzhou 730030, China
| | - Yu Zheng
- Department of Magnetic Resonance, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Province Clinical Research Center for Functional and Molecular Imaging, Lanzhou 730030, China
- Second Clinical School, Lanzhou University, Lanzhou 730030, China
| | - Chuang Wu
- Department of Magnetic Resonance, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Province Clinical Research Center for Functional and Molecular Imaging, Lanzhou 730030, China
| | - Tiejun Gan
- Department of Magnetic Resonance, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Province Clinical Research Center for Functional and Molecular Imaging, Lanzhou 730030, China
| | - Min Li
- Department of Magnetic Resonance, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Province Clinical Research Center for Functional and Molecular Imaging, Lanzhou 730030, China
| | - Laiyang Ma
- Department of Magnetic Resonance, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Province Clinical Research Center for Functional and Molecular Imaging, Lanzhou 730030, China
- Second Clinical School, Lanzhou University, Lanzhou 730030, China
| | - Jing Zhang
- Department of Magnetic Resonance, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Province Clinical Research Center for Functional and Molecular Imaging, Lanzhou 730030, China
- Correspondence: ; Tel.: +86-139-1999-2479
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Jumah A, Aboul Nour H, Intikhab O, Choudhury O, Gagi K, Fana M, Alhajala H, Alkhoujah M, Alsrouji OK, Eltous L, Schultz L, Latack K, Brady M, Chebl A, Marin H, Miller D. Non-stenosing carotid artery plaques in embolic stroke of undetermined source: a retrospective analysis. Neurol Sci 2023; 44:247-252. [PMID: 36166175 DOI: 10.1007/s10072-022-06425-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/21/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND We aim to identify the association between high-risk carotid plaques and their laterality to stroke in ESUS patient population. We also discuss recurrent stroke events and their laterality to the index stroke. METHODS This was a retrospective study. We reviewed data for patients with ESUS between June 20, 2016, and June 20, 2021. Using computed tomography angiography, we analyzed plaque features that are associated with ESUS, and then, we identified the recurrent stroke events and characterized lateralization to the index stroke. RESULTS Out of 1779 patients with cryptogenic ischemic stroke, we included 152 patients who met the criteria for ESUS. High-risk plaque features were found more often ipsilateral to the stroke side when compared contralaterally: plaque ulceration (19.08% vs 5.26%, p < .0001), plaque thickness > 3 mm (19.08% vs 7.24%, p = 0.001), and plaque length > 1 cm (13.16% vs 5.92%, p = 0.0218). There was also a significant difference in plaque component in which both components (soft and calcified) and only soft plaques were more prevalent ipsilaterally (42.76% vs 23.68% and 17.76% vs 9.21%, respectively, p < .0001). Of the 152 patients, 17 patients were found to have a recurrent stroke event, and 47% (n = 8) had an ipsilateral stroke to the index event. Moreover, stroke was bilateral in 41% of the patients (n = 7), and contralateral in 12% (n = 2). CONCLUSION High-risk plaque features studied here were more prevalent ipsilaterally to the stroke side in ESUS than contralaterally. Multicenter studies are needed to form precise prediction models and scoring systems to help guide treatment, i.e., choice of medical therapy and/or revascularization.
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Affiliation(s)
- Ammar Jumah
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA.
| | - Hassan Aboul Nour
- Department of Vascular Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Osama Intikhab
- Department of Neuroradiology, Henry Ford Hospital, Detroit, MI, USA
| | - Omar Choudhury
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Karam Gagi
- Department of Neurology, Sparrow Hospital, Lansing, MI, USA
| | - Michael Fana
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Hisham Alhajala
- Department of Vascular Neurology, University of Toledo, Toledo, OH, USA
| | | | | | - Lara Eltous
- Jordan University of Science and Technology, Amman, Jordan
| | - Lonni Schultz
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI, USA
| | - Katie Latack
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI, USA
| | - Megan Brady
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Alex Chebl
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Horia Marin
- Department of Neuroradiology, Henry Ford Hospital, Detroit, MI, USA
| | - Daniel Miller
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
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10
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Jumah A, Aboul Nour H, Fana M, Choudhury O, Eltous L, Zoghoul S, Jumah F, Alsrouji OK, Alhajala H, Intikhab O, Marin H, Chebl A, Miller D. The role of non-stenosing carotid artery plaques in embolic stroke of undetermined source, is it a silent offender? A review of literature. Interv Neuroradiol 2022:15910199221143172. [PMID: 36451548 DOI: 10.1177/15910199221143172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
PURPOSE Atherosclerotic cervical internal carotid artery disease is one of the major causes of ischemic stroke and transient ischemic attacks. The risk of stroke from mild to moderate stenoses (i.e. <50% stenosis) might be underestimated. There is increasing evidence that plaque morphological features reflect plaque instability that may harbor high risk for embolization. In this narrative review, we will review the literature on plaque features that predict vulnerability beyond the degree of stenosis, discuss the clinical association with stroke, and evaluate the evidence that these lesions serve as a source for embolic stroke of unknown source (ESUS). METHODS We performed a literature search using PubMed, EMBASE, and Web of Science. The terms "embolic stroke of undetermined source" and "plaque morphology" were used either alone or in combination with "non-flow limiting stenosis," "non-stenosing plaques," "high-risk plaque features" or "internal carotid artery plaque." Data on plaque morphology and ESUS were mainly taken from review articles, observational studies including retrospective cohort and cross-sectional studies, meta-analyses, and systematic reviews. CONCLUSION Nonstenosing carotid artery plaques with high-risk features carry a remarkable risk for stroke occurrence and randomized clinical trials are warranted for further evaluation of using carotid artery stenting or carotid endarterectomy to mitigate the risk of stroke.
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Affiliation(s)
- Ammar Jumah
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Hassan Aboul Nour
- Department of Vascular Neurology, Emory University Hospital, Atlanta, GA, USA
| | - Michael Fana
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Omar Choudhury
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Lara Eltous
- 37251Jordan University of Science and Technology, Irbid, Jordan
| | - Sohaib Zoghoul
- Department of Radiology, 36977Hamad Medical Corporation, Doha, Qatar
| | - Fareed Jumah
- Department of Neurosurgery, University of Missouri Hospital, Columbia, MO, USA
| | - Owais K Alsrouji
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Hisham Alhajala
- Department of Vascular Neurology, University of Toledo, Toledo, OH, USA
| | - Osama Intikhab
- Department of Interventional Neuroradiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Horia Marin
- Department of Neuroradiology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Alex Chebl
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Daniel Miller
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
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11
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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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12
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Baradaran H, Kamel H, Gupta A. The role of cross-sectional imaging of the extracranial and intracranial vasculature in embolic stroke of undetermined source. Front Neurol 2022; 13:982896. [PMID: 36090870 PMCID: PMC9459011 DOI: 10.3389/fneur.2022.982896] [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: 06/30/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
Despite an extensive workup, nearly one third of ischemic strokes are defined as Embolic Stroke of Undetermined Source (ESUS), indicating that no clear etiologic cause has been identified. Since large vessel atherosclerotic disease is a major cause of ischemic stroke, we focus on imaging of large vessel atherosclerosis to identify further sources of potential emboli which may be contributing to ESUS. For a stroke to be considered ESUS, both the extracranial and intracranial vessels must have <50% stenosis. Given the recent paradigm shift in our understanding of the role of plaque vulnerability in ischemic stroke risk, we evaluate the role of imaging specific high-risk extracranial plaque features in non-stenosing plaque and their potential contributions to ESUS. Further, intracranial vessel-wall MR is another potential tool to identify non-stenosing atherosclerotic plaques which may also contribute to ESUS. In this review, we discuss the role of cross-sectional imaging of the extracranial and intracranial arteries and how imaging may potentially uncover high risk plaque features which may be contributing to ischemic strokes.
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Affiliation(s)
- Hediyeh Baradaran
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, United States
- *Correspondence: Hediyeh Baradaran
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, NY, United States
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, United States
| | - Ajay Gupta
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, United States
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
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13
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Sakai Y, Lehman VT, Eisenmenger LB, Obusez EC, Kharal GA, Xiao J, Wang GJ, Fan Z, Cucchiara BL, Song JW. Vessel wall MR imaging of aortic arch, cervical carotid and intracranial arteries in patients with embolic stroke of undetermined source: A narrative review. Front Neurol 2022; 13:968390. [PMID: 35968273 PMCID: PMC9366886 DOI: 10.3389/fneur.2022.968390] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/01/2022] [Indexed: 11/13/2022] Open
Abstract
Despite advancements in multi-modal imaging techniques, a substantial portion of ischemic stroke patients today remain without a diagnosed etiology after conventional workup. Based on existing diagnostic criteria, these ischemic stroke patients are subcategorized into having cryptogenic stroke (CS) or embolic stroke of undetermined source (ESUS). There is growing evidence that in these patients, non-cardiogenic embolic sources, in particular non-stenosing atherosclerotic plaque, may have significant contributory roles in their ischemic strokes. Recent advancements in vessel wall MRI (VW-MRI) have enabled imaging of vessel walls beyond the degree of luminal stenosis, and allows further characterization of atherosclerotic plaque components. Using this imaging technique, we are able to identify potential imaging biomarkers of vulnerable atherosclerotic plaques such as intraplaque hemorrhage, lipid rich necrotic core, and thin or ruptured fibrous caps. This review focuses on the existing evidence on the advantages of utilizing VW-MRI in ischemic stroke patients to identify culprit plaques in key anatomical areas, namely the cervical carotid arteries, intracranial arteries, and the aortic arch. For each anatomical area, the literature on potential imaging biomarkers of vulnerable plaques on VW-MRI as well as the VW-MRI literature in ESUS and CS patients are reviewed. Future directions on further elucidating ESUS and CS by the use of VW-MRI as well as exciting emerging techniques are reviewed.
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Affiliation(s)
- Yu Sakai
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Vance T. Lehman
- Department of Radiology, The Mayo Clinic, Rochester, MN, United States
| | - Laura B. Eisenmenger
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States
| | | | - G. Abbas Kharal
- Department of Neurology, Cerebrovascular Center, Neurological Institute, Cleveland, OH, United States
| | - Jiayu Xiao
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Grace J. Wang
- Department of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Zhaoyang Fan
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Brett L. Cucchiara
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Jae W. Song
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
- *Correspondence: Jae W. Song
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14
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Saba L, Antignani PL, Gupta A, Cau R, Paraskevas KI, Poredos P, Wasserman B, Kamel H, Avgerinos ED, Salgado R, Caobelli F, Aluigi L, Savastano L, Brown M, Hatsukami T, Hussein E, Suri JS, Mansilha A, Wintermark M, Staub D, Montequin JF, Rodriguez RTT, Balu N, Pitha J, Kooi ME, Lal BK, Spence JD, Lanzino G, Marcus HS, Mancini M, Chaturvedi S, Blinc A. International Union of Angiology (IUA) consensus paper on imaging strategies in atherosclerotic carotid artery imaging: From basic strategies to advanced approaches. Atherosclerosis 2022; 354:23-40. [DOI: 10.1016/j.atherosclerosis.2022.06.1014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/10/2022] [Accepted: 06/14/2022] [Indexed: 12/24/2022]
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15
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Diener HC, Easton JD, Hart RG, Kasner S, Kamel H, Ntaios G. Review and update of the concept of embolic stroke of undetermined source. Nat Rev Neurol 2022; 18:455-465. [PMID: 35538232 DOI: 10.1038/s41582-022-00663-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 12/28/2022]
Abstract
Ischaemic strokes have traditionally been classified according to the TOAST criteria, in which strokes with unclear aetiology are classified as cryptogenic strokes. However, the definition of cryptogenic stroke did not meet the operational criteria necessary to define patient populations for randomized treatment trials. To address this problem, the concept of embolic stroke of undetermined source (ESUS) was developed and published in 2014. A hypothesis that underpinned this concept was that most strokes in patients with ESUS are caused by embolic events, perhaps many cardioembolic, and that anticoagulation would prevent secondary ischaemic events. On this basis, two large randomized trials were conducted to compare the non-vitamin K antagonist oral anticoagulants (NOACs) dabigatran and rivaroxaban with aspirin. Neither NOAC was superior to aspirin in these trials, although subgroups of patients with ESUS seemed to benefit specifically from anticoagulation or antiplatelet therapy. The neutral results of the trials of anticoagulation and insights into ESUS from research conducted since the concept was introduced warrant reassessment of the ESUS construct as a research concept and a treatment target. In this Review, we discuss the evidence produced since the concept of ESUS was introduced, and propose updates to the criteria and diagnostic algorithm in light of the latest knowledge.
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Affiliation(s)
- Hans-Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE) Medical Faculty of the University Duisburg-Essen, Essen, Germany.
| | - J Donald Easton
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Robert G Hart
- Population Health Research Institute/McMaster University, David Braley Cardiac, Vascular and Stroke Research Institute (DBCVSRI), Hamilton, Ontario, Canada
| | - Scott Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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16
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Holmes DR, Alkhouli MA, Klaas JP, Brinjikji W, Savastano LE, Lanzino G, Benson JC. Change of Heart: The Underexplored Role of Plaque Hemorrhage in the Evaluation of Stroke of Undetermined Etiology. J Am Heart Assoc 2022; 11:e025323. [PMID: 35475334 PMCID: PMC9238607 DOI: 10.1161/jaha.122.025323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In the evaluation of embolic strokes of undetermined source, great emphasis is often placed on cardiovascular disease, namely on atrial fibrillation. Other pathophysiologic mechanisms, however, may also be involved. Carotid artery intraplaque hemorrhage (IPH)—the presence of blood components within an atheromatous plaque—has become increasingly recognized as a possible etiologic mechanism in some cryptogenic strokes. IPH is a marker of plaque instability and is associated with ipsilateral neurologic ischemic events, even in nonstenotic carotid plaques. As recognition of carotid IPH as an etiology of embolic strokes has grown, so too has the complexity with which such patients are evaluated and treated, particularly because overlaps exist in the risk factors for atrial fibrillation and IPH. In this article, we review what is currently known about carotid IPH and how this clinical entity should be approached in the context of the evaluation of embolic strokes of undetermined source.
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Affiliation(s)
- David R Holmes
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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17
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Larson A, Nardi V, Brinjikji W, Benson JC, Lanzino G, Savastano L. Endarterectomy for symptomatic non-stenotic carotids: a systematic review and descriptive analysis. Stroke Vasc Neurol 2022; 7:6-12. [PMID: 34244446 PMCID: PMC8899633 DOI: 10.1136/svn-2021-001122] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/22/2021] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To systematically analyse prior reports of carotid endarterectomy (CEA) performed in cases of ≤50% carotid stenosis in order to understand patient tolerance and potential benefit. METHODS A systematic review and descriptive analysis was performed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An English-language search was performed of online databases using librarian-selected search terms. Abstracts were reviewed for relevance which included mention of carotid endarterectomy and stenosis. Prospective or retrospective observational cohort studies that reported series of patients who underwent endarterectomy for minimal (≤50%) luminal stenosis with reported outcomes were included. RESULTS Six studies (which included our institutional series) with a total of 143 patients met the inclusion criteria. The weighted mean age at the time of CEA was 72.3 years; 113 (79.0%) were male. 55.8% of patients with available data had recurrent ipsilateral ischaemic events despite medical therapy. Two patients out of 129 with available perioperative data (1.6%) had perioperative MRI findings of acute ischaemic stroke, both within the hemisphere contralateral to the side of CEA. Of the 138 patients with available follow-up (mean, 36 months), none had recurrent ipsilateral ischaemic events. CONCLUSIONS Endarterectomy for symptomatic carotid disease causing ≤50% stenosis may be a potentially beneficial strategy to prevent stroke recurrence. Studies with robust methodology are needed to draw more definitive conclusions in terms of the safety and efficacy of endarterectomy for minimal stenosis with vulnerable features relative to intensive medical therapy.
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Affiliation(s)
- Anthony Larson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Valentina Nardi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
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18
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Larson AS, Brinjikji W, Kroll NJ, Savastano L, Huston J, Benson JC. Normalized intraplaque hemorrhage signal on MP-RAGE as a marker for acute ischemic neurological events. Neuroradiol J 2022; 35:112-118. [PMID: 34224247 PMCID: PMC8826295 DOI: 10.1177/19714009211029263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE This study sought to validate whether the signal intensity ratio (SIR) of carotid intraplaque hemorrhage (IPH) was associated with acute ischemic neurologic events. METHODS A retrospective review was completed of consecutive patients that underwent neck magnetic resonance angiography using magnetization prepared-rapid gradient echo (MP-RAGE) and T1-CUBE sequences between 2017 and 2020. Patients with magnetic resonance evidence of IPH were included. SIRs were measured by comparing the maximum IPH signal with the mean intramuscular signal from the adjacent sternocleidomastoid. Patients were stratified into ischemic or non-ischemic groups based on the presence of acute ipsilateral ischemic events (stroke, retinal artery occlusion). Logistic regression analysis was performed to determine if increasing IPH SIR was associated with an increased risk of ipsilateral ischemic events. RESULTS Of 85 included patients (85 arteries), 66 were male (77.6%). Mean age was 71.0 (SD ± 11.1). There were 70 arteries with IPH that were ipsilateral to an ischemic event, and 15 that belonged to patients without an ischemic event. No association was found between increasing IPH SIR seen on MP-RAGE (odds ratio (OR): 0.82; 95% confidence interval (CI): 0.58-1.4; P = 0.43) or T1-CUBE sequences (OR: 0.85; 95% CI: 0.53-1.5; P = 0.56). CONCLUSIONS There was no association between the SIR of IPH and acute ischemia on either MP-RAGE or T1-CUBE sequences. Further investigation is required prior to widespread acceptance of SIR as a predictive imaging marker of symptomatic carotid plaque.
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Affiliation(s)
- Anthony S Larson
- Department of Radiology, Mayo
Clinic, USA,Department of Neurosurgery, Mayo
Clinic, USA,Anthony S Larson, Department of Radiology,
Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Waleed Brinjikji
- Department of Radiology, Mayo
Clinic, USA,Department of Neurosurgery, Mayo
Clinic, USA
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19
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Nardi V, Benson J, Bois MC, Saba L, Larson AS, Özcan I, Ahmad A, Morse DW, Meyer FB, Brinjikji W, Lanzino G, Lerman LO, Savastano LE, Lerman A. Carotid Plaques From Symptomatic Patients With Mild Stenosis Is Associated With Intraplaque Hemorrhage. Hypertension 2022; 79:271-282. [PMID: 34878895 DOI: 10.1161/hypertensionaha.121.18128] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Carotid plaque vulnerability features beyond the degree of stenosis may play a key role in the pathogenesis and recurrence of ischemic cerebrovascular events. This study sought to compare intraplaque hemorrhage (IPH) as a marker of plaque vulnerability in symptomatic patients with mild (<50%), moderate (50%-69%), and severe (≥70%) carotid artery stenosis. We included patients who experienced ischemic cerebrovascular events with no other identifiable sources and underwent carotid endarterectomy for mild (n=32), moderate (n=47), and severe (n=58) carotid artery stenosis. The degree of stenosis and imaging hallmarks were assessed by computed tomography angiography or magnetic resonance angiography. Plaque specimens were stained with hematoxylin and eosin and Movat pentachrome staining. Carotid plaques of patients with mild stenosis had a higher extent of IPH (%) on tissue analysis compared with patients with moderate (mild, 15.7% [interquartile range, 7.8%-26.7%]; moderate, 3.9% [0.0%-9.2%]; P<0.001) and severe carotid artery stenosis (mild, 15.7% [interquartile range, 7.8%-26.7%]; severe, 2.5% [interquartile range, 0.0%-11.2%]; P<0.001). When considering the degree of carotid artery stenosis as a continuous variable, a lower lumen narrowing was associated with higher extent of IPH (P<0.001; R, -0.329). Our major finding is the association of IPH with mild carotid artery stenosis based on histological analysis. The current study may suggest that IPH potentially plays a role in the mechanism of stroke in patients with nonobstructive carotid stenosis.
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Affiliation(s)
- Valentina Nardi
- Department of Cardiovascular Medicine (V.N., I.Ö., A.A., D.W.M., A.L.), Mayo Clinic, Rochester, MN
| | - John Benson
- Department of Radiology (J.C.B., A.S.L., W.B.), Mayo Clinic, Rochester, MN
| | - Melanie C Bois
- Department of Laboratory Medicine and Pathology (M.C.B.), Mayo Clinic, Rochester, MN
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria, Cagliari, Italy (L.S.)
| | - Anthony S Larson
- Department of Radiology (J.C.B., A.S.L., W.B.), Mayo Clinic, Rochester, MN
| | - Ilke Özcan
- Department of Cardiovascular Medicine (V.N., I.Ö., A.A., D.W.M., A.L.), Mayo Clinic, Rochester, MN
| | - Ali Ahmad
- Department of Cardiovascular Medicine (V.N., I.Ö., A.A., D.W.M., A.L.), Mayo Clinic, Rochester, MN
| | - David W Morse
- Department of Cardiovascular Medicine (V.N., I.Ö., A.A., D.W.M., A.L.), Mayo Clinic, Rochester, MN
| | - Fredric B Meyer
- Department of Neurologic Surgery (F.B.M., G.L., L.E.S.), Mayo Clinic, Rochester, MN
| | - Waleed Brinjikji
- Department of Radiology (J.C.B., A.S.L., W.B.), Mayo Clinic, Rochester, MN
| | - Giuseppe Lanzino
- Department of Neurologic Surgery (F.B.M., G.L., L.E.S.), Mayo Clinic, Rochester, MN
| | - Lilach O Lerman
- Department of Nephrology and Hypertension (L.O.L.), Mayo Clinic, Rochester, MN
| | - Luis E Savastano
- Department of Neurologic Surgery (F.B.M., G.L., L.E.S.), Mayo Clinic, Rochester, MN
| | - Amir Lerman
- Department of Cardiovascular Medicine (V.N., I.Ö., A.A., D.W.M., A.L.), Mayo Clinic, Rochester, MN
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20
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Aplin M, Andersen A, Brandes A, Dominguez H, Dahl JS, Damgaard D, Iversen HK, Iversen KK, Nielsen E, Risum N, Schmidt MR, Andersen NH. Assessment of patients with a suspected cardioembolic ischemic stroke. A national consensus statement. SCAND CARDIOVASC J 2021; 55:315-325. [PMID: 34470566 DOI: 10.1080/14017431.2021.1973085] [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] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Several cardiovascular, structural, and functional abnormalities have been considered as potential causes of cardioembolic ischemic strokes. Beyond atrial fibrillation, other sources of embolism clearly exist and may warrant urgent action, but they are only a minor part of the many stroke mechanisms and strokes that seem to be of embolic origin remain without a determined source. The associations between stroke and findings like atrial fibrillation, valve calcification, or heart failure are confounded by co-existing risk factors for atherosclerosis and vascular disease. In addition, a patent foramen ovale which is a common abnormality in the general population is mostly an innocent bystander in patients with ischemic stroke. For these reasons, experts from the national Danish societies of cardiology, neurology, stroke, and neuroradiology sought to develop a consensus document to provide national recommendations on how to manage patients with a suspected cardioembolic stroke. Design: Comprehensive literature search and analyses were done by a panel of experts and presented at a consensus meeting. Evidence supporting each subject was vetted by open discussion and statements were adjusted thereafter. Results: The most common sources of embolic stroke were identified, and the statement provides advise on how neurologist can identify cases that need referral, and what is expected by the cardiologist. Conclusions: A primary neurological and neuroradiological assessment is mandatory and neurovascular specialists should manage the initiation of secondary prophylactic treatment. If a cardioembolic stroke is suspected, a dedicated cardiologist experienced in the management of cardioembolism should provide a tailored clinical and echocardiographic assessment.
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Affiliation(s)
- Mark Aplin
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Axel Brandes
- Department of Cardiology, Odense University Hospital, Odense, Denmark.,Department of Internal Medicine - Cardiology, University Hospital of Southern Denmark - Esbjerg, Esbjerg, Denmark
| | - Helena Dominguez
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Jordi S Dahl
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Dorte Damgaard
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark
| | - Helle K Iversen
- Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kasper K Iversen
- Department of Cardiology, Herlev-Gentofte Hospital, Herlev, Denmark
| | - Edith Nielsen
- Department of Neuroradiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Niels Risum
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Michael R Schmidt
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Niels H Andersen
- Department of Cardiology, Odense University Hospital, Odense, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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21
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Siniscalchi A, Murphy S, Gray C, De Sarro G, Gallelli L. Biomarkers in unstable carotid plaque: Physiopathology and Prediction. Cardiovasc Hematol Agents Med Chem 2021; 20:13-19. [PMID: 34468303 DOI: 10.2174/1871525719666210901131509] [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: 05/26/2021] [Revised: 06/17/2021] [Accepted: 07/14/2021] [Indexed: 11/22/2022]
Abstract
AIMS To study the role of cytokines and vascular inflammatory biomarkers in unstable carotid plaque. BACKGROUND Clinical studies showed that not only the degree of stenosis but also the type of carotid plaque can be responsible for ipsilateral ischemic stroke. OBJECTIVE The objective of this study is to suggest a role for vulnerable carotid atherosclerotic disease in the occurrence of ischemic stroke. METHODS PubMed, Embase, Cochrane library, and reference lists have been used to evaluate articles published until February 15, 2021. RESULTS Several factors may be involved in unstable plaque. Clinical studies support the involvement of brain inflammatory biomarkers as well as cytokines in the unstable carotid plaque. CONCLUSIONS Biomarkers could help to stratify patients with a vulnerable carotid plaque and to personalize the drug treatment. In this review, we briefly discuss the characteristics of vulnerable plaque and the role of biomarkers in the vulnerable carotid plaque.
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Affiliation(s)
- Antonio Siniscalchi
- Department of Neurology and Stroke Unit, Annunziata Hospital of Cosenza, Cosenza, Italy
| | - Sean Murphy
- General Medicine, Stroke Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Cleona Gray
- Vascular and Endovascular Surgery Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Giovambattista De Sarro
- Chair of Pharmacology, Department of Health Science, School of Medicine, University of Catanzaro, Clinical Pharmacology Unit, Mater Domini University Hospital, Catanzaro, Italy
| | - Luca Gallelli
- Department of Health Science, School of Medicine, University of Catanzaro, Catanzaro, Italy
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22
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Singh N, Ospel J, Mayank A, Marko M, Zaidat OO, Mueller-Kronast NH, Liebeskind DS, Goyal M. Nonstenotic Carotid Plaques in Ischemic Stroke: Analysis of the STRATIS Registry. AJNR Am J Neuroradiol 2021; 42:1645-1652. [PMID: 34326103 DOI: 10.3174/ajnr.a7218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/27/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Few studies assess nonstenotic carotid plaques on CTA, and the causative role of these plaques in stroke is not entirely clear. We used CTA to determine the prevalence of nonstenotic carotid plaques (<50%), plaque features, and their association with ipsilateral strokes in patients with cardioembolic and cryptogenic strokes. MATERIALS AND METHODS Data were from the Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke (STRATIS) registry, a prospective, nonrandomized registry of patients undergoing thrombectomy with the Solitaire device. The prevalence of nonstenotic carotid plaques ipsilateral and contralateral to the stroke was compared in patients with cryptogenic and cardioembolic strokes. Plaque features were further compared within both subgroups between patients with and without ipsilateral stroke. Adjusted associations among nonstenotic carotid plaque, plaque characteristics, and ipsilateral stroke in both subgroups were determined with logistic regression. RESULTS Of the 946 patients in the data base, 226 patients with cardioembolic stroke (median age, 72 years) and 141 patients with cryptogenic stroke (median age, 69 years) were included in the analysis. The prevalence of nonstenotic carotid plaque in the cardioembolic and cryptogenic subgroups was 33/226 (14.6%) and 32/141 (22.7%), respectively. Bilateral nonstenotic carotid plaques were seen in 10/226 (4.4%) patients with cardioembolic and 13/141 (9.2%) with cryptogenic strokes. Nonstenotic carotid plaques were significantly associated with ipsilateral strokes in the cardioembolic stroke (adjusted OR = 1.91; 95% CI, 1.15-3.18) and the cryptogenic stroke (adjusted OR = 1.69; 95% CI, 1.05-2.73) groups. Plaque irregularity, hypodensity, and per-millimeter increase in plaque thickness were significantly associated with ipsilateral stroke in the cryptogenic subgroup. CONCLUSIONS Nonstenotic carotid plaques were significantly associated with ipsilateral stroke in cardioembolic and cryptogenic stroke groups, and there was an association of plaque irregularity and hypodense plaque with ipsilateral stroke in the cryptogenic group, suggesting these plaques could be a potential cause of stroke in these patient subgroups.
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Affiliation(s)
- N Singh
- From the Departments of Clinical Neurosciences (N.S., A.M., M.G.)
| | - J Ospel
- Department of Radiology (J.O.), University Hospital of Basel, Basel, Switzerland
| | - A Mayank
- From the Departments of Clinical Neurosciences (N.S., A.M., M.G.)
| | - M Marko
- Department of Neurology (M.M.), Medical University of Vienna, Vienna, Austria
| | - O O Zaidat
- Neuroscience Institute (O.O.Z.), Mercy Health St. Vincent Medical Center, Toledo, Ohio
| | - N H Mueller-Kronast
- Department of Neurology (N.H.M.-K.), Delray Medical Center, Delray Beach, Florida
| | - D S Liebeskind
- UCLA Comprehensive Stroke Center (D.S.L.), Los Angeles, California
| | - M Goyal
- From the Departments of Clinical Neurosciences (N.S., A.M., M.G.) .,Diagnostic Imaging (M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
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23
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Yang X, Jing J, Meng X, Li Z, Pan Y, Jiang Y, Xiang X, Liu H, Chen Y, Liu L, Zhao X, Wang Y, Li H, Wang Y. Characteristics and prognosis of patients with embolic stroke of undetermined source in China. Int J Stroke 2021; 17:526-535. [PMID: 34125633 DOI: 10.1177/17474930211028040] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to explore the frequencies, risk factors, and natural history of embolic stroke of undetermined source (ESUS) through a national prospective registry in China. METHODS Between August 2015 and March 2018, the Third China National Stroke Registry recruited consecutive patients with ischemic stroke or transient ischemic attack in China. The baseline characteristics, risks of stroke, and prognosis in patients with embolic stroke of undetermined source were described and compared with that in patients with other causative subtypes. RESULTS A total of 15,166 transient ischemic attack and ischemic stroke patients were enrolled in the Third China National Stroke Registry. Among 8528 ischemic stroke with standard diagnostic work-up, 2415 (28.3%) patients were diagnosed with embolic stroke of undetermined source. The mean age was 61 years and 70% of them were male. Compared to patients with cardioembolic strokes and small vessel disease, patients with embolic stroke of undetermined source had higher prevalence of nonstenosing large artery atherosclerosis (37.93% vs. 31.26%, P = 0.008 and 37.93% vs. 34.40%, P = 0.044 respectively). The cumulative probability of stroke recurrence in patients with embolic stroke of undetermined source at three months and one year was 5.59% and 8.74%. Compared with embolic stroke of undetermined source patients (0.70% and 1.99%), patients with the large artery atherosclerosis and cardioembolic strokes had higher cumulative probability of death at three months (1.94% and 3.22%) and one year (4.17% and 7.39%). CONCLUSIONS Embolic stroke of undetermined source is a common cause of ischemic stroke in Chinese population with a higher stroke recurrence than previously reported. It was more likely to have nonstenosing large artery atherosclerosis in patients with embolic stroke of undetermined source than with cardioembolic strokes and small vessel disease.
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Affiliation(s)
- Xiaomeng Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Neuroimaging Center of Excellence, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Project Management, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- Department of Research Methodology and Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Department of Research Methodology and Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xianglong Xiang
- Department of Research Methodology and Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Huan Liu
- Department of Research Methodology and Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yu Chen
- Neuroimaging Center of Excellence, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- Department of Research Methodology and Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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24
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Ntaios G, Wintermark M, Michel P. Supracardiac atherosclerosis in embolic stroke of undetermined source: the underestimated source. Eur Heart J 2021; 42:1789-1796. [PMID: 32300781 DOI: 10.1093/eurheartj/ehaa218] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/16/2019] [Accepted: 03/12/2020] [Indexed: 01/17/2023] Open
Abstract
The term 'embolic stroke of undetermined source' (ESUS) is used to describe patients with a non-lacunar ischaemic stroke without any identified embolic source from the heart or the arteries supplying the ischaemic territory, or any other apparent cause. When the ESUS concept was introduced, covert atrial fibrillation was conceived to be the main underlying cause in the majority of ESUS patients. Another important embolic source in ESUS is the atherosclerotic plaque in the carotid, vertebrobasilar, and intracranial arteries, or the aortic arch-collectively described as supracardiac atherosclerosis. There is emerging evidence showing that the role of supracardiac atherosclerosis is larger than it was initially perceived. Advanced imaging methods are available to identify plaques which high embolic risk. The role of novel antithrombotic strategies in these patients needs to be assessed in randomized controlled trials. This review presents the evidence which points towards a major aetiological association between atherosclerotic plaques and ESUS, summarizes the imaging features which may aid to identify plaques more likely to be associated with ESUS, discusses strategies to reduce the associated stroke risk, and highlights the rationale for future research in this field.
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Affiliation(s)
- George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, 41110 Larissa, Greece
| | - Max Wintermark
- Department of Radiology, Neuroradiology Section, Stanford University and Medical Center, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Rue du Bugnon 46, Lausanne CH-1011, Switzerland
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25
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Tonetti DA, Desai SM, Nayar G, Jankowitz BT, Jovin TG, Jadhav AP. Symptomatic nonstenotic carotid disease: Evaluation of a proposed classification scheme in a prospective cohort. J Clin Neurosci 2021; 90:21-25. [PMID: 34275551 DOI: 10.1016/j.jocn.2021.04.039] [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: 01/18/2021] [Revised: 04/21/2021] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Unraveling symptomatic nonstenotic carotid disease (SyNC) as a stroke etiology from other cryptogenic stroke may have important implications for defining natural history and for tailoring secondary prevention strategies. We aim to describe the characteristics of the plaques in a prospectively-collected cohort of patients with non-invasive imaging suggesting symptomatic carotid stenosis but whose DSA demonstrated nonstenotic atheromatous disease, and to evaluate the recurrence rate depending on the type of SyNC. METHODS We reviewed prospectively-collected data for patients presenting with new neurologic events and non-invasive imaging suggestive of moderate or severe (≥50%) carotid stenosis between July 2016 and October 2018. Patients were included in the present study if the degree of stenosis on DSA was < 50%. We assigned these patients into groups based on a previously-proposed working definition of SyNC, and analyzed the rate of recurrent stroke in the following 6 months. RESULTS 28 patients had DSA-confirmed < 50% stenosis and constituted the study cohort. The median age was 73 years and 64% were male; median presenting NIHSS was 1 (IQR 0-3). The great majority (86%) of carotid plaques had high-risk features including ulcerated plaque (n = 21, 75%) and plaque > 3 mm thick (n = 18, 64%). 17 of 28 patients (61%) met classification criteria for "definite" or "probable" SyNC. Three of five patients in the "definite SyNC" group experienced recurrent neurologic events. CONCLUSION The majority of patients with non-invasive imaging suggesting carotid stenosis harbor symptomatic carotid disease per current classifications despite DSA stenosis < 50%. Current classification schema may allow for risk stratification of SyNC patients and these findings warrant further study.
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Affiliation(s)
- Daniel A Tonetti
- The Departments of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; The Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | | | - Gautam Nayar
- The Departments of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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26
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Kitsiou A, Zuhorn F, Wachter R, Israel CW, Schäbitz WR, Rogalewski A. [Embolic stroke of undetermined source (ESUS) - Classification of a new stroke entity]. Dtsch Med Wochenschr 2021; 146:403-409. [PMID: 33735920 DOI: 10.1055/a-1309-8701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Embolic stroke of undetermined source (ESUS) represents a subpopulation of cryptogenic strokes defined by its embolic stroke pattern on imaging and if after a carefully performed diagnostic evaluation, a specific, well recognized cause of stroke has not been identified. This review article analyses the basics of the ESUS concept and provides an overview of the evidence from recent cohort studies. The definition, aetiology and diagnosis of ESUS are reassessed. Targeted diagnostics in ESUS patients can reduce the number of cryptogenic strokes by making a specific diagnosis.
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Affiliation(s)
- Alkisti Kitsiou
- Evangelisches Klinikum Bethel, Klinik für Neurologie, Bielefeld, Deutschland
| | - Frédéric Zuhorn
- Evangelisches Klinikum Bethel, Klinik für Neurologie, Bielefeld, Deutschland
| | - Rolf Wachter
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | | | | | - Andreas Rogalewski
- Evangelisches Klinikum Bethel, Klinik für Neurologie, Bielefeld, Deutschland
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27
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Larson AS, Benson JC, Brinjikji W, Savastano L, Lanzino G, Huston J, Nasr D. Variations in the Presence of Carotid Intraplaque Hemorrhage Across Age Categories: What Age Groups Are Most Likely to Benefit From Plaque Imaging? Front Neurol 2021; 11:603055. [PMID: 33381079 PMCID: PMC7768076 DOI: 10.3389/fneur.2020.603055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/25/2020] [Indexed: 11/13/2022] Open
Abstract
Although carotid artery intraplaque hemorrhage (IPH) is a known risk-factor for cerebral ischemic events in patients of advanced age, its prevalence in younger cohorts is less certain. The purpose of this study was to assess the prevalence of carotid artery IPH across the age spectrum. A retrospective review was completed of all adult patients from our institution who underwent neck MRA with high-resolution carotid plaque imaging between 2017 and 2020. The mean ages of patients with and without IPH were calculated. The prevalence of IPH was compared between patients that were categorized into age groups. Patients with and without a cerebral ischemic event (e.g., stroke, retinal ischemia) were included. Unilateral anterior circulation ischemic events in patients without atrial fibrillation were presumed to be likely related to ipsilateral carotid artery disease. Multiple regression analysis was performed to determine independent associations with IPH. 634 patients were included (1,268 carotid arteries). Increasing age (OR: 1.04; 95% CI: 1.02-1.06; P = 0.001) was independently associated with IPH. 211 patients had unilateral anterior circulation ischemic events. The mean age of patients with carotid IPH was 71.4 years (SD = 9.9), compared to 62.8 years (SD = 15.8) of those without (P ≤ 0.0001). The prevalence of IPH increased with age in all patients (P = 0.0002). Among patients with ipsilateral anterior circulation ischemic events, each age category above 50 years had a significantly higher prevalence of IPH when compared to patients 18-50 years (P ≤ 0.05 for all comparisons). The prevalence of carotid IPH increases with age and is rare in patients under 50 years. The approximate threshold age for IPH development is likely around 50 years.
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Affiliation(s)
- Anthony S Larson
- Department of Radiology, Mayo Clinic, Rochester, MN, United States.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, United States.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Luis Savastano
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Giuseppe Lanzino
- Department of Radiology, Mayo Clinic, Rochester, MN, United States.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - John Huston
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Deena Nasr
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
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28
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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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29
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Complicated Carotid Artery Plaques as a Cause of Cryptogenic Stroke. J Am Coll Cardiol 2020; 76:2212-2222. [DOI: 10.1016/j.jacc.2020.09.532] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/25/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
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30
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Ntaios G, Sagris D, Strambo D, Perlepe K, Sirimarco G, Georgiopoulos G, Nannoni S, Korompoki E, Manios E, Makaritsis K, Vemmos K, Michel P. Carotid Atherosclerosis and Patent Foramen Ovale in Embolic Stroke of Undetermined Source. J Stroke Cerebrovasc Dis 2020; 30:105409. [PMID: 33137616 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105409] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/07/2020] [Accepted: 10/12/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Carotid atherosclerosis and likely pathogenic patent foramen ovale (PFO) are two potential embolic sources in patients with embolic stroke of undetermined source (ESUS). The relationship between these two mechanisms among ESUS patients remains unclear. AIM To investigate the relation between carotid atherosclerosis and likely pathogenic PFO in patients with ESUS. We hypothesized that ipsilateral carotid atherosclerotic plaques are less prevalent in ESUS with likely pathogenic PFO compared to patients with likely incidental PFO or without PFO. METHODS The presence of PFO was assessed with transthoracic echocardiography with microbubble test and, when deemed necessary, through trans-oesophageal echocardiography. The presence of PFO was considered as likely incidental if the RoPE (Risk of Paradoxical Embolism) score was 0-6 and likely pathogenic if 7-10. RESULTS Among 374 ESUS patients (median age: 61years, 40.4% women), there were 63 (49.6%) with likely incidental PFO, 64 (50.4%) with likely pathogenic PFO and 165 (44.1%) with ipsilateral carotid atherosclerosis. The prevalence of ipsilateral carotid atherosclerosis was lower in patients with likely pathogenic PFO (7.8%) compared to patients with likely incidental PFO (46.0%) or patients without PFO (53.0%) (p<0.001). After adjustment for multiple confounders, the prevalence of ipsilateral carotid atherosclerosis remained lower in patients with likely pathogenic PFO compared to patients with likely incidental PFO or without PFO (adjusted OR=0.32, 95%CI:0.104-0.994, p=0.049). CONCLUSIONS The presence of carotid atherosclerosis is inversely related to the presence of likely pathogenic PFO in patients with ESUS.
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Affiliation(s)
- George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Dimitrios Sagris
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Davide Strambo
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Kalliopi Perlepe
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Gaia Sirimarco
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Georgios Georgiopoulos
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom
| | - Stefania Nannoni
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Eleni Korompoki
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, National and Kapodistrian University of Athens, Greece; Division of Brain Sciences, Department of Stroke Medicine, Imperial College, London, United Kingdom
| | - Efstathios Manios
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, National and Kapodistrian University of Athens, Greece
| | - Konstantinos Makaritsis
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Vemmos
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, National and Kapodistrian University of Athens, Greece
| | - Patrik Michel
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
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31
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Ntaios G, Weng SF, Perlepe K, Akyea R, Condon L, Lambrou D, Sirimarco G, Strambo D, Eskandari A, Karagkiozi E, Vemmou A, Korompoki E, Manios E, Makaritsis K, Vemmos K, Michel P. Data-driven machine-learning analysis of potential embolic sources in embolic stroke of undetermined source. Eur J Neurol 2020; 28:192-201. [PMID: 32918305 DOI: 10.1111/ene.14524] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/31/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE Hierarchical clustering, a common 'unsupervised' machine-learning algorithm, is advantageous for exploring potential underlying aetiology in particularly heterogeneous diseases. We investigated potential embolic sources in embolic stroke of undetermined source (ESUS) using a data-driven machine-learning method, and explored variation in stroke recurrence between clusters. METHODS We used a hierarchical k-means clustering algorithm on patients' baseline data, which assigned each individual into a unique clustering group, using a minimum-variance method to calculate the similarity between ESUS patients based on all baseline features. Potential embolic sources were categorised into atrial cardiopathy, atrial fibrillation, arterial disease, left ventricular disease, cardiac valvulopathy, patent foramen ovale (PFO) and cancer. RESULTS Among 800 consecutive ESUS patients (43.3% women, median age 67 years), the optimal number of clusters was four. Left ventricular disease was most prevalent in cluster 1 (present in all patients) and perfectly associated with cluster 1. PFO was most prevalent in cluster 2 (38.9% of patients) and associated significantly with increased likelihood of cluster 2 [adjusted odds ratio: 2.69, 95% confidence interval (CI): 1.64-4.41]. Arterial disease was most prevalent in cluster 3 (57.7%) and associated with increased likelihood of cluster 3 (adjusted odds ratio: 2.21, 95% CI: 1.43-3.13). Atrial cardiopathy was most prevalent in cluster 4 (100%) and perfectly associated with cluster 4. Cluster 3 was the largest cluster involving 53.7% of patients. Atrial fibrillation was not significantly associated with any cluster. CONCLUSIONS This data-driven machine-learning analysis identified four clusters of ESUS that were strongly associated with arterial disease, atrial cardiopathy, PFO and left ventricular disease, respectively. More than half of the patients were assigned to the cluster associated with arterial disease.
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Affiliation(s)
- G Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - S F Weng
- National Institute for Health Research School for Primary Care Research, University of Nottingham, Nottingham, UK.,Primary Care Stratified Medicine, Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - K Perlepe
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - R Akyea
- Primary Care Stratified Medicine, Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - L Condon
- Primary Care Stratified Medicine, Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - D Lambrou
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - G Sirimarco
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - D Strambo
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - A Eskandari
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - E Karagkiozi
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - A Vemmou
- Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece
| | - E Korompoki
- Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece.,Division of Brain Sciences, Department of Stroke Medicine, Imperial College, London, UK
| | - E Manios
- Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece
| | - K Makaritsis
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - K Vemmos
- Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece
| | - P Michel
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
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32
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Kassem M, Florea A, Mottaghy FM, van Oostenbrugge R, Kooi ME. Magnetic resonance imaging of carotid plaques: current status and clinical perspectives. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1266. [PMID: 33178798 PMCID: PMC7607136 DOI: 10.21037/atm-2020-cass-16] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Rupture of a vulnerable carotid plaque is one of the leading causes of stroke. Carotid magnetic resonance imaging (MRI) is able to visualize all the main hallmarks of plaque vulnerability. Various MRI sequences have been developed in the last two decades to quantify carotid plaque burden and composition. Often, a combination of multiple sequences is used. These MRI techniques have been extensively validated with histological analysis of carotid endarterectomy specimens. High agreement between the MRI and histological measures of plaque burden, intraplaque hemorrhage (IPH), lipid-rich necrotic core (LRNC), fibrous cap (FC) status, inflammation and neovascularization has been demonstrated. Novel MRI sequences allow to generate three-dimensional isotropic images with a large longitudinal coverage. Other new sequences can acquire multiple contrasts using a single sequence leading to a tremendous reduction in scan time. IPH can be easily identified as a hyperintense signal in the bulk of the plaque on strongly T1-weighted images, such as magnetization-prepared rapid acquisition gradient echo images, acquired within a few minutes with a standard neurovascular coil. Carotid MRI can also be used to evaluate treatment effects. Several meta-analyses have demonstrated a strong predictive value of IPH, LRNC, thinning or rupture of the FC for ischemic cerebrovascular events. Recently, in a large meta-analysis based on individual patient data of asymptomatic and symptomatic individuals with carotid artery stenosis, it was shown that IPH on MRI is an independent risk predictor for stroke, stronger than any known clinical risk parameter. Expert recommendations on carotid plaque MRI protocols have recently been described in a white paper. The present review provides an overview of the current status and applications of carotid plaque MR imaging and its future potential in daily clinical practice.
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Affiliation(s)
- Mohamed Kassem
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Alexandru Florea
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.,Department of Nuclear Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Felix M Mottaghy
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.,Department of Nuclear Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Robert van Oostenbrugge
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Neurology, MUMC+, Maastricht, The Netherlands
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
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33
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Murgia A, Erta M, Suri JS, Gupta A, Wintermark M, Saba L. CT imaging features of carotid artery plaque vulnerability. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1261. [PMID: 33178793 PMCID: PMC7607080 DOI: 10.21037/atm-2020-cass-13] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Despite steady advances in medical care, cardiovascular disease remains one of the main causes of death and long-term morbidity worldwide. Up to 30% of strokes are associated with the presence of carotid atherosclerotic plaques. While the degree of stenosis has long been recognized as the main guiding factor in risk stratification and therapeutical decisions, recent evidence suggests that features of unstable, or ‘vulnerable’, plaques offer better prognostication capabilities. This paradigmatic shift has motivated researchers to explore the potentialities of non-invasive diagnostic tools to image not only the lumen, but also the vascular wall and the structural characteristics of the plaque. The present review will offer a panoramic on the imaging modalities currently available to characterize carotid atherosclerotic plaques and, in particular, it will focus on the increasingly important role covered by multidetector computed tomographic angiography.
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Affiliation(s)
- Alessandro Murgia
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato, s.s. 554 Monserrato (Cagliari), Italy
| | - Marco Erta
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato, s.s. 554 Monserrato (Cagliari), Italy
| | - Jasjit S Suri
- Stroke Monitoring and Diagnosis Division, AtheroPoint(tm), Roseville, CA, USA
| | - Ajay Gupta
- Department of Radiology, Weill Cornell University, New York, NY, USA
| | - Max Wintermark
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato, s.s. 554 Monserrato (Cagliari), Italy
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34
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Mark IT, Nasr DM, Huston J, de Maria L, de Sanctis P, Lehman VT, Rabinstein AA, Saba L, Brinjikji W. Embolic Stroke of Undetermined Source and Carotid Intraplaque Hemorrhage on MRI : A Systemic Review and Meta-Analysis. Clin Neuroradiol 2020; 31:307-313. [PMID: 32647922 DOI: 10.1007/s00062-020-00921-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 05/27/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Embolic stroke of undetermined source (ESUS) has traditionally discounted the significance of internal carotid artery stenosis of <50%; however, recent studies have examined the role of carotid artery intraplaque hemorrhage (IPH) as an etiology in nonstenotic carotid arteries. We performed a systemic review of the literature to determine the prevalence of carotid artery IPH on magnetic resonance imaging (MRI) of the vessel wall in patients with ESUS. METHODS We used PubMed, Epub ahead of print, Ovid MEDLINE in-process and other non-indexed citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane central register of controlled trials, Ovid Cochrane database of systematic reviews and Scopus. Our study consisted of all case series with >10 patients with IPH and ESUS published through October 2018. Additionally, we included 123 patients from an institutional database from 2015-2019. Random effects meta-analysis was used for pooling across studies. Meta-analysis results were expressed as odds ratio (OR) with respective 95% confidence intervals (CI). RESULTS A total of 7 studies with 354 patients were included. The mean age was 67.5 years old. The overall prevalence estimate for prevalence of IPH ipsilateral to the ischemic lesion was 25.8% (95% CI 13.1-38.5). The odds of having IPH on the ipsilateral side versus the contralateral side was 6.92 (95% CI 3.04-15.79). CONCLUSION Patients with ESUS have IPH in the carotid artery ipsilateral to the ischemic stroke in 25.8% of cases. Carotid artery vessel wall MRI should be considered as part of the standard work-up in patients with ESUS.
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Affiliation(s)
- Ian T Mark
- Department of Radiology, Mayo Clinic, 200 1st St. SW, 55905, Rochester, MN, USA
| | - Deena M Nasr
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - John Huston
- Department of Radiology, Mayo Clinic, 200 1st St. SW, 55905, Rochester, MN, USA
| | - Lucio de Maria
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | | | - Vance T Lehman
- Department of Radiology, Mayo Clinic, 200 1st St. SW, 55905, Rochester, MN, USA
| | | | - Luca Saba
- Department of Radiology, University of Cagliari, Cagliari, Italy
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, 200 1st St. SW, 55905, Rochester, MN, USA.
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35
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Singh N, Marko M, Ospel JM, Goyal M, Almekhlafi M. The Risk of Stroke and TIA in Nonstenotic Carotid Plaques: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2020; 41:1453-1459. [PMID: 32646945 DOI: 10.3174/ajnr.a6613] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 04/29/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Severe carotid stenosis carries a high risk of stroke. However, the risk of stroke with nonstenotic carotid plaques (<50%) is increasingly recognized. PURPOSE We aimed to summarize the risk of TIA or stroke in patients with nonstenotic carotid plaques. DATA SOURCES We performed a comprehensive systematic review and meta-analysis in patients with acute ischemic stroke in whom carotid imaging was performed using MEDLINE and the Cochrane Database, including studies published up to December 2019. STUDY SELECTION Included studies had >10 patients with <50% carotid plaques on any imaging technique and reported the incidence or recurrence of ischemic stroke/TIA. High-risk plaque features and the risk of progression to stenosis >50% were extracted if reported. DATA SYNTHESIS We identified 31 studies reporting on the risk of ipsilateral stroke/TIA in patients with nonstenotic carotid plaques. Twenty-five studies (n = 13,428 participants) reported on first-ever stroke/TIA and 6 studies (n = 122 participants) reported on the recurrence of stroke/TIA. DATA ANALYSIS The incidence of first-ever ipsilateral stroke/TIA was 0.5/100 person-years. The risk of recurrent stroke/TIA was 2.6/100 person-years and increased to 4.9/100 person-years if intraplaque hemorrhage was present. The risk of progression to severe stenosis (>50%) was 2.9/100 person-years (8 studies, n = 448 participants). LIMITATIONS Included studies showed heterogeneity in reporting stroke etiology, the extent of stroke work-up, imaging modalities, and classification systems used for characterizing carotid stenosis. CONCLUSIONS The risk of recurrent stroke/TIA in nonstenotic carotid plaques is not negligible, especially in the presence of high-risk plaque features. Further research is needed to better define the significance of nonstenotic carotid plaques for stroke etiology.
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Affiliation(s)
- N Singh
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - M Marko
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada.,Department of Neurology (M.M.), Medical University of Vienna, Vienna, Austria
| | - J M Ospel
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology (J.M.O.), University Hospital of Basel, Basel, Switzerland
| | - M Goyal
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - M Almekhlafi
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
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36
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Schäbitz WR, Köhrmann M, Schellinger PD, Minnerup J, Fisher M. Embolic Stroke of Undetermined Source: Gateway to a New Stroke Entity? Am J Med 2020; 133:795-801. [PMID: 32247819 DOI: 10.1016/j.amjmed.2020.03.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/10/2020] [Accepted: 03/10/2020] [Indexed: 12/20/2022]
Abstract
Embolic stroke of unknown source (ESUS) is currently thought to represent a subpopulation of cryptogenic strokes defined by its embolic stroke pattern on imaging, and if after a carefully performed diagnostic evaluation, a specific, well-recognized cause of stroke has not been identified. The concept was primarily established to justify and enable the conduct of the ESUS trials, such as Randomized, Double-Blind, Evaluation in Secondary Stroke Prevention Comparing the Efficacy and Safety of the Oral Thrombin Inhibitor Dabigatran Etexilate versus Acetylsalicylic Acid in Patients with Embolic Stroke of Undetermined Source (RESPECT-ESUS) and New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial versus aspirin to Prevent Embolism in Embolic Stroke of Undetermined Source (NAVIGATE-ESUS). With both studies having neutral results, the question arises if the ESUS concept is misleading or rather a gateway for a modern understanding of stroke etiology. This review will analyze the background of the ESUS concept, overview the results and the impact of the recent multicenter trials and cohort studies, and discuss the definition, etiology, and diagnosis of ESUS.
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Affiliation(s)
| | - Martin Köhrmann
- Department of Neurology, University of Essen, Essen, Germany
| | - Peter D Schellinger
- Department of Neurology and Neurogeriatry, Joohn Wesling Medical Center Minden-UK RUB, Germany
| | - Jens Minnerup
- Department of Neurology, University of Münster, Münster, Germany
| | - Marc Fisher
- Department of Neurology, Harvard Medical School, Boston, Mass
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37
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Tsai LK, Lee IH, Chen YL, Chao TF, Chen YW, Po HL, Lien LM, Chu PH, Huang WC, Lin TH, Lin MT, Jeng JS, Hwang JJ. Diagnosis and Treatment for embolic stroke of undetermined source: Consensus statement from the Taiwan stroke society and Taiwan society of cardiology. J Formos Med Assoc 2020; 120:93-106. [PMID: 32534996 DOI: 10.1016/j.jfma.2020.05.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 04/22/2020] [Accepted: 05/18/2020] [Indexed: 01/10/2023] Open
Abstract
Cryptogenic stroke comprises about one-quarter of ischemic strokes with high recurrence rate; however, studies specifically investigating the features and treatment of this stroke subtype are rare. The concept of 'embolic stroke of undetermined source' (ESUS) may facilitate the development of a standardized approach to diagnose cryptogenic stroke and improve clinical trials. Since recent large randomized control trials failed to demonstrate a reduction in stroke recurrence with anticoagulants, anti-platelet agents remain the first-line treatment for ESUS patients. Nevertheless, patients with high risk of stroke recurrence (e.g., those with repeated embolic infarcts despite aspirin treatment) require a more extensive survey of stroke etiology, including cardiac imaging and prolonged cardiac rhythm monitoring. Anticoagulant treatments may still benefit some subgroups of high-risk ESUS patients, such as those with multiple infarcts at different arterial territories without aortic atheroma, the elderly, or patients with high CHA2D2-VASc or HOVAC scores, atrial cardiopathy or patent foramen ovale. Several important ESUS clinical trials are ongoing, and the results are anticipated. With rapid progress in our understanding of ESUS pathophysiology, new subcategorizations of ESUS and assignment of optimal treatments for each ESUS subgroup are expected in the near future.
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Affiliation(s)
- Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - I-Hui Lee
- Department of Neurology, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Yung-Lung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Wei Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan; Department of Neurology, Landseed International Hospital, Taoyuan, Taiwan
| | - Helen L Po
- Stroke Center and Department of Neurology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Li-Ming Lien
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ming-Tai Lin
- Division of Pediatric Cardiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.
| | - Juey-Jen Hwang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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Goyal M, Singh N, Marko M, Hill MD, Menon BK, Demchuk A, Coutts SB, Almekhlafi MA, Ospel JM. Embolic Stroke of Undetermined Source and Symptomatic Nonstenotic Carotid Disease. Stroke 2020; 51:1321-1325. [DOI: 10.1161/strokeaha.119.028853] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mayank Goyal
- From the Department of Clinical Neurosciences (M.G., N.S., M.M., M.D.H., B.K.M., A.D., S.B.C., M.A.A., J.M.O.), University of Calgary, Canada
- Department of Radiology (M.G., M.D.H., B.K.M., A.D., M.A.A.), University of Calgary, Canada
| | - Nishita Singh
- From the Department of Clinical Neurosciences (M.G., N.S., M.M., M.D.H., B.K.M., A.D., S.B.C., M.A.A., J.M.O.), University of Calgary, Canada
| | - Martha Marko
- From the Department of Clinical Neurosciences (M.G., N.S., M.M., M.D.H., B.K.M., A.D., S.B.C., M.A.A., J.M.O.), University of Calgary, Canada
| | - Michael D. Hill
- From the Department of Clinical Neurosciences (M.G., N.S., M.M., M.D.H., B.K.M., A.D., S.B.C., M.A.A., J.M.O.), University of Calgary, Canada
- Department of Radiology (M.G., M.D.H., B.K.M., A.D., M.A.A.), University of Calgary, Canada
| | - Bijoy K. Menon
- From the Department of Clinical Neurosciences (M.G., N.S., M.M., M.D.H., B.K.M., A.D., S.B.C., M.A.A., J.M.O.), University of Calgary, Canada
- Department of Radiology (M.G., M.D.H., B.K.M., A.D., M.A.A.), University of Calgary, Canada
| | - Andrew Demchuk
- From the Department of Clinical Neurosciences (M.G., N.S., M.M., M.D.H., B.K.M., A.D., S.B.C., M.A.A., J.M.O.), University of Calgary, Canada
- Department of Radiology (M.G., M.D.H., B.K.M., A.D., M.A.A.), University of Calgary, Canada
| | - Shelagh B. Coutts
- From the Department of Clinical Neurosciences (M.G., N.S., M.M., M.D.H., B.K.M., A.D., S.B.C., M.A.A., J.M.O.), University of Calgary, Canada
| | - Mohammed A. Almekhlafi
- From the Department of Clinical Neurosciences (M.G., N.S., M.M., M.D.H., B.K.M., A.D., S.B.C., M.A.A., J.M.O.), University of Calgary, Canada
- Department of Radiology (M.G., M.D.H., B.K.M., A.D., M.A.A.), University of Calgary, Canada
| | - Johanna M. Ospel
- From the Department of Clinical Neurosciences (M.G., N.S., M.M., M.D.H., B.K.M., A.D., S.B.C., M.A.A., J.M.O.), University of Calgary, Canada
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Kamtchum-Tatuene J, Wilman A, Saqqur M, Shuaib A, Jickling GC. Carotid Plaque With High-Risk Features in Embolic Stroke of Undetermined Source: Systematic Review and Meta-Analysis. Stroke 2020; 51:311-314. [PMID: 31752616 PMCID: PMC6993880 DOI: 10.1161/strokeaha.119.027272] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 10/16/2019] [Indexed: 11/16/2022]
Abstract
Background and Purpose- An ipsilateral mild carotid stenosis, defined as plaque with <50% luminal narrowing, is identified in nearly 40% of patients with embolic stroke of undetermined source and could represent an unrecognized source of atheroembolism. We aimed to summarize data about the frequency of mild carotid stenosis with high-risk features in embolic stroke of undetermined source. Methods- We searched Pubmed and Ovid-Embase for studies reporting carotid plaque imaging features in embolic stroke of undetermined source. The prevalence of ipsilateral and contralateral mild carotid stenosis with high-risk features was pooled using random-effect meta-analysis. Results- Eight studies enrolling 323 participants were included. The prevalence of mild carotid stenosis with high-risk features in the ipsilateral carotid was 32.5% (95% CI, 25.3-40.2) compared with 4.6% (95% CI, 0.1-13.1) in the contralateral carotid. The odds ratio of finding a plaque with high-risk features in the ipsilateral versus the contralateral carotid was 5.5 (95% CI, 2.5-12.0). Conclusions- Plaques with high-risk features are 5 times more prevalent in the ipsilateral compared with the contralateral carotid in embolic stroke of undetermined source, suggesting a relationship to stroke risk.
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Affiliation(s)
- Joseph Kamtchum-Tatuene
- From the Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry (J.K.-T.), University of Alberta, Edmonton, Canada
| | - Alan Wilman
- Department of Biomedical Engineering (A.W.), University of Alberta, Edmonton, Canada
| | - Maher Saqqur
- Division of Neurology, Department of Medicine (M.S., A.S., G.C.J.), University of Alberta, Edmonton, Canada
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine (M.S., A.S., G.C.J.), University of Alberta, Edmonton, Canada
| | - Glen C Jickling
- Division of Neurology, Department of Medicine (M.S., A.S., G.C.J.), University of Alberta, Edmonton, Canada
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Kamel H, Navi BB, Merkler AE, Baradaran H, Díaz I, Parikh NS, Kasner SE, Gladstone DJ, Iadecola C, Gupta A. Reclassification of Ischemic Stroke Etiological Subtypes on the Basis of High-Risk Nonstenosing Carotid Plaque. Stroke 2019; 51:504-510. [PMID: 31847749 DOI: 10.1161/strokeaha.119.027970] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Carotid artery plaque with <50% luminal stenosis may be an underappreciated stroke mechanism. We assessed how many stroke causes might be reclassified after accounting for nonstenosing plaques with high-risk features. Methods- We included patients enrolled in the Cornell Acute Stroke Academic Registry from 2011 to 2015 who had anterior circulation infarction, magnetic resonance imaging of the brain, and magnetic resonance angiography of the neck. High-risk plaque was identified by intraplaque hemorrhage ascertained from routine neck magnetic resonance angiography studies using validated methods. Infarct location was determined from diffusion-weighted imaging. Intraplaque hemorrhage and infarct location were assessed separately in a blinded fashion by a neuroradiologist. We used the McNemar test for matched data to compare the prevalence of intraplaque hemorrhage ipsilateral versus contralateral to brain infarction. We reclassified stroke subtypes by including large-artery atherosclerosis as a cause if there was intraplaque hemorrhage ipsilateral to brain infarction, regardless of the degree of stenosis. Results- Among the 1721 acute ischemic stroke patients registered in the Cornell Acute Stroke Academic Registry from 2011 to 2015, 579 were eligible for this analysis. High-risk plaque was more common ipsilateral versus contralateral to brain infarction in large-artery atherosclerotic (risk ratio [RR], 3.7 [95% CI, 2.2-6.1]), cryptogenic (RR, 2.1 [95% CI, 1.4-3.1]), and cardioembolic strokes (RR, 1.7 [95% CI, 1.1-2.4]). There were nonsignificant ipsilateral-contralateral differences in high-risk plaque among lacunar strokes (RR, 1.2 [95% CI, 0.4-3.5]) and strokes of other determined cause (RR, 1.5 [95% CI, 0.7-3.3]). After accounting for ipsilateral high-risk plaque, 88 (15.2%) patients were reclassified: 38 (22.6%) cardioembolic to multiple potential etiologies, 6 (8.5%) lacunar to multiple, 3 (15.8%) other determined cause to multiple, and 41 (20.8%) cryptogenic to large-artery atherosclerosis. Conclusions- High-risk carotid plaque was more prevalent ipsilateral to brain infarction across several ischemic stroke subtypes. Accounting for such plaques may reclassify the etiologies of up to 15% of cases in our sample.
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Affiliation(s)
- Hooman Kamel
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., B.B.N., A.E.M., N.S.P., C.I., A.G.), Weill Cornell Medicine, New York, NY
| | - Babak B Navi
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., B.B.N., A.E.M., N.S.P., C.I., A.G.), Weill Cornell Medicine, New York, NY
| | - Alexander E Merkler
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., B.B.N., A.E.M., N.S.P., C.I., A.G.), Weill Cornell Medicine, New York, NY
| | | | - Iván Díaz
- Division of Biostatistics and Epidemiology (I.D.), Weill Cornell Medicine, New York, NY
| | - Neal S Parikh
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., B.B.N., A.E.M., N.S.P., C.I., A.G.), Weill Cornell Medicine, New York, NY
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia (S.E.K.)
| | - David J Gladstone
- Division of Neurology and Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, University of Toronto, ON, Canada (D.J.G.)
| | - Costantino Iadecola
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., B.B.N., A.E.M., N.S.P., C.I., A.G.), Weill Cornell Medicine, New York, NY
| | - Ajay Gupta
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., B.B.N., A.E.M., N.S.P., C.I., A.G.), Weill Cornell Medicine, New York, NY.,Department of Radiology (A.G.), Weill Cornell Medicine, New York, NY
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Knight-Greenfield A, Quitlong Nario JJ, Vora A, Baradaran H, Merkler A, Navi BB, Kamel H, Gupta A. Associations Between Features of Nonstenosing Carotid Plaque on Computed Tomographic Angiography and Ischemic Stroke Subtypes. J Am Heart Assoc 2019; 8:e014818. [PMID: 31818209 PMCID: PMC6951053 DOI: 10.1161/jaha.119.014818] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Thromboembolism from nonstenosing carotid plaques may be an underrecognized cause of embolic strokes of undetermined source (ESUS). We evaluated the association between features of nonstenosing atherosclerotic plaque on computed tomographic angiography and ESUS. Methods and Results We identified consecutive acute ischemic stroke patients from 2011 to 2015 who had unilateral anterior territory infarction on brain magnetic resonance imaging and a neck computed tomographic angiography. We included ESUS cases and as controls, cardioembolic strokes. Patients with ≥50% internal carotid artery atherosclerotic stenosis ipsilateral to the stroke were excluded from this analysis. Reviewers blinded to infarct location and stroke cause retrospectively evaluated computed tomographic angiography studies for specific plaque features including thickness of the total, soft, and calcified plaque; presence of ulceration; and perivascular fat attenuation. Paired t tests and McNemar's test for paired data were used to compare plaque features ipsilateral versus contralateral to the side of infarction. Ninety‐one patients with ESUS or cardioembolic stroke were included in this study. Total plaque thickness was greater on the infarcted side (2.1±2.0 mm) than the contralateral side (1.2±1.5 mm) (P=0.006) among ESUS cases, but not among cardioembolic cases (1.9±1.6 mm versus 1.8±1.6 mm) (P=0.32). Conclusions Among ESUS cases, total plaque thickness was greater ipsilateral to the side of infarction than on the contralateral, stroke‐free side. No such side‐to‐side differences were apparent in cardioembolic strokes. Our findings suggest that nonstenosing large‐artery atherosclerotic plaques represent one underlying mechanism of ESUS.
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Affiliation(s)
| | | | - Amar Vora
- Department of Radiology Weill Cornell Medicine New York NY
| | | | - Alex Merkler
- Department of Radiology Weill Cornell Medicine New York NY.,Feil Family Brain and Mind Research Institute New York NY
| | - Babak B Navi
- Department of Radiology Weill Cornell Medicine New York NY.,Feil Family Brain and Mind Research Institute New York NY
| | - Hooman Kamel
- Department of Radiology Weill Cornell Medicine New York NY.,Feil Family Brain and Mind Research Institute New York NY
| | - Ajay Gupta
- Department of Radiology Weill Cornell Medicine New York NY.,Feil Family Brain and Mind Research Institute New York NY
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Seyedsaadat SM, Rizvi A, Alzuabi M, Dugani SB, Murad MH, Huston J, Saba L, Brinjikji W. Correlation of MRI-detected vulnerable carotid plaques with clinical presentation: a systematic review and meta-analysis. J Neurosurg Sci 2019; 64:263-271. [PMID: 31738030 DOI: 10.23736/s0390-5616.19.04820-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION To determine the association between magnetic resonance imaging (MRI)-detected vulnerable Carotid Plaques and clinical presentation related to ipsilateral carotid artery territory. EVIDENCE ACQUISITION We searched three databases including Ovid MEDLINE, Ovid EMBASE, and Scopus from 2000 to 2018 for studies that evaluated vulnerable carotid plaques by MRI defined as intraplaque hemorrhage (IPH), lipid-rich necrotic core (LRNC), or thinning/rupture of the fibrous cap (TRFC). Data on study characteristics, clinical presentation, and MRI findings were extracted. Publication bias, methodologic quality, and study heterogeneity were assessed. Random-effects meta-analysis model was used to estimate incidence rate ratio (IRR) and 95% confidence intervals (CI) of MRI-detected vulnerable carotid plaque between symptomatic and asymptomatic arteries. EVIDENCE SYNTHESIS Of 2855 studies, 33 studies containing 6210 participants with 8401 assessed arteries were included. Overall, the risk of bias was moderate in 13, and low in 20 studies. The prevalence of MRI-positive IPH, TRFC, and LRNC were higher in symptomatic groups compared with the asymptomatic groups. In 11 studies that compared vulnerable carotid plaques between symptomatic and asymptomatic groups, symptomatic presentation was correlated with increased risk of IPH (IRR=1.57; 95% CI: 1.24-1.99), TRFC (IRR=2.26; 95% CI: 1.83 to 3.76), and LRNC (IRR=1.95; 95% CI: 1.28 to 2.97), respectively. CONCLUSIONS The presence of MRI-positive vulnerable carotid plaques including IPH, LRNC, and TRFC is positively associated with symptomatic clinical presentation. Therefore, carotid plaque MRI might be a useful risk stratification tool in determining the risk of ischemic stroke.
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Affiliation(s)
| | - Asim Rizvi
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.,University of Texas Medical Branch, Galveston, TX, USA
| | - Muayad Alzuabi
- Evidence-based Practice Center, Mayo Clinic, Rochester, MN, USA
| | - Sagar B Dugani
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - M Hassan Murad
- Evidence-based Practice Center, Mayo Clinic, Rochester, MN, USA
| | - John Huston
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Luca Saba
- Department of Radiology, University of Cagliari, Cagliari, Italy
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA - .,Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, ON, Canada
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Arauz A, Serrano F, Pearce LA, Kasner SE, Ameriso SF, Toni D, Bereczki D, Siegler J, Ruiz-Franco A, Cantú-Brito C, Czlonkowska A, Lang W, Berkowitz SD, Mundl H, Hart RG. Regional, sex, and age differences in diagnostic testing among participants in the NAVIGATE-ESUS trial. Int J Stroke 2019; 16:55-62. [PMID: 31631796 DOI: 10.1177/1747493019884523] [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] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIM The diagnosis of embolic stroke of undetermined source (ESUS) is based on excluding other more likely stroke etiologies, and therefore diagnostic testing plays an especially crucial role. Our objective was to compare the diagnostic testing by region, sex, and age among the participants of NAVIGATE-ESUS trial. METHODS Participants were grouped according to five global regions (North America, Latin America, Western Europe, Eastern Europe and East Asia), age (<60, 60-74, and >75 years), and sex. Frequencies of each diagnostic test within areas of echocardiography, cardiac rhythm monitoring, and arterial imaging were described and compared across groups. A multivariable logistic regression model for each diagnostic test was fit to assess the independent influence of each of region, age, and sex and likelihood of testing. RESULTS We included 6985 patients in the analysis (918 from North America; 746 from Latin America; 2853 from Western Europe; 1118 from Eastern Europe; 1350 from East Asia). Average age (highest in Western Europe (69 years), lowest in Eastern Europe (65 years)), % females (highest in Latin America (44%) and lowest in East Asia (31%)), and use of each diagnostic test varied significantly across regions. Region, but not sex, was independently associated with use of each diagnostic test examined. Transesophageal echocardiography and either CT or MR angiogram were more often used in younger patients. CONCLUSION Diagnostic testing differed by region, and less frequently by age, but not by sex. Our findings reflect the existing variations in global practice in diagnostic testing in ESUS patients.
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Affiliation(s)
- Antonio Arauz
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez, México City, México
| | - Fabiola Serrano
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez, México City, México
| | | | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, PA, USA
| | | | - Danilo Toni
- Department of Human Neurosciences, 9311Sapienza University of Rome, Rome, Italy
| | - Daniel Bereczki
- Department of Neurology, 37637Semmelweis University, Budapest, Hungary
| | - James Siegler
- Department of Neurology, University of Pennsylvania, PA, USA
| | | | - Carlos Cantú-Brito
- Department of Neurology. Instituto Nacional de Ciencias Medicas y Nutrición Salvador Zubiran, Mexico City, Mexico
| | - Anna Czlonkowska
- Department of Neurology, Institute Psychiatry and Neurology, Warsaw, Poland
| | - Wilfried Lang
- Department of Neurology, Sigmund Freud University Vienna, Medical Faculty and Hospital St. John of God, Beaconsfield, Australia
| | | | | | - Robert G Hart
- Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Canada
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Tsivgoulis G, Katsanos AH, Köhrmann M, Caso V, Lemmens R, Tsioufis K, Paraskevas GP, Bornstein NM, Schellinger PD, Alexandrov AV, Krogias C. Embolic strokes of undetermined source: theoretical construct or useful clinical tool? Ther Adv Neurol Disord 2019; 12:1756286419851381. [PMID: 31205494 PMCID: PMC6535711 DOI: 10.1177/1756286419851381] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 04/28/2019] [Indexed: 11/30/2022] Open
Abstract
In 2014, the definition of embolic strokes of undetermined source (ESUS) emerged as a new clinical construct to characterize cryptogenic stroke (CS) patients with complete vascular workup to determine nonlacunar, nonatherosclerotic strokes of presumable embolic origin. NAVIGATE ESUS, the first phase III randomized-controlled, clinical trial (RCT) comparing rivaroxaban (15 mg daily) with aspirin (100 mg daily), was prematurely terminated for lack of efficacy after enrollment of 7213 patients. Except for the lack of efficacy in the primary outcome, rivaroxaban was associated with increased risk of major bleeding and hemorrhagic stroke compared with aspirin. RE-SPECT ESUS was the second phase III RCT that compared the efficacy and safety of dabigatran (110 or 150 mg, twice daily) to aspirin (100 mg daily). The results of this trial have been recently presented and showed similar efficacy and safety outcomes between dabigatran and aspirin. Indirect analyses of these trials suggest similar efficacy on the risk of ischemic stroke (IS) prevention, but higher intracranial hemorrhage risk in ESUS patients receiving rivaroxaban compared to those receiving dabigatran (indirect HR = 6.63, 95% CI: 1.38-31.76). ESUS constitute a heterogeneous group of patients with embolic cerebral infarction. Occult AF represents the underlying mechanism of cerebral ischemia in the minority of ESUS patients. Other embolic mechanisms (paradoxical embolism via patent foramen ovale, aortic plaque, nonstenosing unstable carotid plaque, etc.) may represent alternative mechanisms of cerebral embolism in ESUS, and may mandate different management than oral anticoagulation. The potential clinical utility of ESUS may be challenged since the concept failed to identify patients who would benefit from anticoagulation therapy. Compared with the former diagnosis of CS, ESUS patients required thorough investigations; more comprehensive diagnostic work-up than is requested in current ESUS diagnostic criteria may assist clinicians in uncovering the source of brain embolism in CS patients and individualize treatment approaches.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, USA
| | - Aristeidis H. Katsanos
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
- Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany
| | - Martin Köhrmann
- Department of Neurology, Universitätsklinikum Essen, Germany
| | - Valeria Caso
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
| | - Robin Lemmens
- Division of Experimental Neurology, Department of Neurosciences, Catholic University (KU) Leuven-University, Belgium, Flemish Institute for Biotechnology (VIB), Center for Brain and Disease Research, Laboratory of Neurobiology, Leuven, Belgium, and Department of Neurology, University Hospitals Leuven, Belgium
| | - Konstantinos Tsioufis
- First Cardiology Clinic, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Greece
| | - George P. Paraskevas
- First Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| | - Natan M. Bornstein
- Shaare Zedek Medical Center, Jerusalem, and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Peter D. Schellinger
- Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Germany
| | - Andrei V. Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, USA
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Gudrunstr.56, Bochum, 44791, Germany
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Saba L, Saam T, Jäger HR, Yuan C, Hatsukami TS, Saloner D, Wasserman BA, Bonati LH, Wintermark M. Imaging biomarkers of vulnerable carotid plaques for stroke risk prediction and their potential clinical implications. Lancet Neurol 2019; 18:559-572. [PMID: 30954372 DOI: 10.1016/s1474-4422(19)30035-3] [Citation(s) in RCA: 263] [Impact Index Per Article: 52.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 01/15/2023]
Abstract
Stroke represents a massive public health problem. Carotid atherosclerosis plays a fundamental part in the occurence of ischaemic stroke. European and US guidelines for prevention of stroke in patients with carotid plaques are based on quantification of the percentage reduction in luminal diameter due to the atherosclerotic process to select the best therapeutic approach. However, better strategies for prevention of stroke are needed because some subtypes of carotid plaques (eg, vulnerable plaques) can predict the occurrence of stroke independent of the degree of stenosis. Advances in imaging techniques have enabled routine characterisation and detection of the features of carotid plaque vulnerability. Intraplaque haemorrhage is accepted by neurologists and radiologists as one of the features of vulnerable plaques, but other characteristics-eg, plaque volume, neovascularisation, and inflammation-are promising as biomarkers of carotid plaque vulnerability. These biomarkers could change current management strategies based merely on the degree of stenosis.
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Affiliation(s)
- Luca Saba
- Department of Medical Sciences, University of Cagliari, Cagliari, Italy.
| | - Tobias Saam
- Department of Radiology, University Hospital Munich, Ludwig-Maximilians-University Munich, Munich, Germany; Radiologisches Zentrum Rosenheim, Rosenheim, Germany
| | - H Rolf Jäger
- Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, University College London Institute of Neurology, London, UK
| | - Chun Yuan
- Department of Radiology, University of Washington, Seattle, WA, USA
| | | | - David Saloner
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Bruce A Wasserman
- The Russell H Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Leo H Bonati
- Department of Neurology and Stroke Center, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Max Wintermark
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
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