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Advances in Multimodality Carotid Plaque Imaging: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 217:16-26. [PMID: 33438455 DOI: 10.2214/ajr.20.24869] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Contemporary imaging methods provide detailed visualization of carotid athero-sclerotic plaque, enabling a major evolution of in vivo carotid plaque imaging evaluation. The degree of luminal stenosis in the carotid artery bifurcation, as assessed by ultrasound, has historically served as the primary imaging feature for determining ischemic stroke risk and the potential need for surgery. However, stroke risk may be more strongly driven by the presence of specific characteristics of vulnerable plaque, as visualized on CT and MRI, than by traditional ultrasound-based assessment of luminal narrowing. This review highlights six promising imaging-based plaque characteristics that harbor unique information regarding plaque vulnerability: maximum plaque thickness and volume, calcification, ulceration, intraplaque hemorrhage, lipid-rich necrotic core, and thin or ruptured fibrous cap. Increasing evidence supports the association of these plaque characteristics with risk of ischemic stroke, although these characteristics have varying suitability for clinical implementation. Key aspects of CT and MRI protocols for carotid plaque imaging are also considered. Practical next steps and hurdles are explored for implementing routine imaging assessment of these plaque characteristics in addition to, or even as replacement for, traditional assessment of the degree of vascular stenosis on ultrasound, in the identification of individuals at high risk of ischemic stroke.
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Yoshida K, Yang T, Yamamoto Y, Kurosaki Y, Funaki T, Kikuchi T, Ishii A, Kataoka H, Miyamoto S. Expansive carotid artery remodeling: possible marker of vulnerable plaque. J Neurosurg 2020; 133:1435-1440. [PMID: 31585432 DOI: 10.3171/2019.7.jns19727] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 07/12/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Accumulated findings in the pathophysiology of atherosclerosis have demonstrated that not only luminal narrowing but also plaque characteristics influence the risk of future ischemic events. The morphology of the carotid artery (CA) changes in response to atherosclerotic development by expansive remodeling (ER), the clinical significance of which remains unclear. This study aimed to define associations between ER and local risk factors, including CA geometry and traditional systemic risk factors for ischemic events, to determine whether ER could serve as a clinical marker of carotid vulnerable plaque. METHODS The authors retrospectively analyzed 66 patients with CA stenosis who were scheduled to undergo carotid endarterectomy or CA stenting. They calculated ER ratios in the internal CA (ICA) from long-axis MR images and as the maximal distance between the lumen and the outer borders of the plaque perpendicular to the axis of the ICA/the maximal luminal diameter of the distal ICA at a region unaffected by atherosclerosis. Relative overall signal intensity (roSI) was calculated to assess intraplaque hemorrhage and defined as the signal intensity of plaque on an axial T1-weighted image with maximal stenosis relative to that of the adjacent sternocleidomastoid muscle. The authors evaluated CA geometry by calculating the angles between the common CA (CCA) and ICA, and between the CCA and external CA (ECA) using digital subtraction angiography. The ER ratios, age, sex, percentage of stenosis, roSI, hypertension, hyperlipidemia, low-density lipoprotein, statin medication, diabetes, smoking habit, and ischemic heart disease were compared between 33 symptomatic and 33 asymptomatic patients. The authors also compared symptomatic status, age, sex, percentage of stenosis, ICA angle, ECA angle, roSI, and other traditional atherosclerotic risk factors between groups with extensive and slight ER. RESULTS The ER ratio was significantly greater in symptomatic than in asymptomatic patients (1.91 ± 0.46 vs 1.68 ± 0.40, p < 0.05). The ICA angle was significantly larger in the group with extensive ER than in those with slight ER (33.9° ± 20.2° vs 21.7° ± 13.8°, p < 0.01). The roSI, ECA angle, percentage stenosis, or any other traditional vascular risk factors were not associated with ER. CONCLUSIONS Carotid ER might be an independent indicator of carotid vulnerable plaque, which should be validated in a longitudinal study of patients with carotid atherosclerosis, including those with nonstenotic to moderate stenosis.
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Affiliation(s)
- Kazumichi Yoshida
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto; and
| | - Tao Yang
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto; and
| | - Yu Yamamoto
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto; and
| | | | - Takeshi Funaki
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto; and
| | - Takayuki Kikuchi
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto; and
| | - Akira Ishii
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto; and
| | - Hiroharu Kataoka
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto; and
| | - Susumu Miyamoto
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto; and
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Motoyama R, Saito K, Tonomura S, Ishibashi-Ueda H, Yamagami H, Kataoka H, Morita Y, Uchihara Y, Iihara K, Takahashi JC, Sugie K, Toyoda K, Nagatsuka K. Utility of Complementary Magnetic Resonance Plaque Imaging and Contrast-Enhanced Ultrasound to Detect Carotid Vulnerable Plaques. J Am Heart Assoc 2020; 8:e011302. [PMID: 30977413 PMCID: PMC6507198 DOI: 10.1161/jaha.118.011302] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background We aimed to improve the assessment quality of plaque vulnerability with combined use of magnetic resonance imaging and contrast-enhanced ultrasound ( CEUS ). Methods and Results We prospectively enrolled 71 patients with internal carotid artery stenosis who underwent carotid endarterectomy and performed preoperative CEUS and magnetic resonance plaque imaging. We distinguished high-signal-intensity plaques ( HIP s) and non- HIP s based on magnetization-prepared rapid acquisition with gradient echo images. We graded them according to the CEUS contrast effect and compared the CEUS images with the carotid endarterectomy specimens. Among the 70 plaques, except 1 carotid endarterectomy tissue sample failure, 59 were classified as HIP s (43 symptomatic) and 11 were classified as non- HIP s (5 symptomatic). Although the magnetization-prepared rapid acquisition with gradient echo findings alone had no significant correlation with symptoms ( P=0.07), concomitant use of magnetization-prepared rapid acquisition with gradient echo and CEUS findings did show a significant correlation ( P<0.0001). CEUS showed that all 5 symptomatic non- HIP s had a high-contrast effect. These 5 plaques were histopathologically confirmed as vulnerable, with extensive neovascularization but only a small amount of intraplaque hemorrhage. Conclusions Complementary use of magnetic resonance imaging and CEUS to detect intraplaque hemorrhage and neovascularization in plaques can be useful for evaluating plaque vulnerability, consistent with the destabilization process associated with neovessel formation and subsequent intraplaque hemorrhage.
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Affiliation(s)
- Rie Motoyama
- 1 Department of Neurology National Cerebral and Cardiovascular Center Osaka Japan.,8 Department of Neurology Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology Tokyo Japan
| | - Kozue Saito
- 1 Department of Neurology National Cerebral and Cardiovascular Center Osaka Japan.,5 Department of Neurology Nara Medical University Nara Japan
| | - Shuichi Tonomura
- 1 Department of Neurology National Cerebral and Cardiovascular Center Osaka Japan
| | | | - Hiroshi Yamagami
- 1 Department of Neurology National Cerebral and Cardiovascular Center Osaka Japan
| | - Hiroharu Kataoka
- 3 Department of Neurosurgery National Cerebral and Cardiovascular Center Osaka Japan
| | - Yoshiaki Morita
- 4 Department of Radiology National Cerebral and Cardiovascular Center Osaka Japan
| | - Yuto Uchihara
- 5 Department of Neurology Nara Medical University Nara Japan
| | - Koji Iihara
- 3 Department of Neurosurgery National Cerebral and Cardiovascular Center Osaka Japan.,6 Department of Neurosurgery Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Jun C Takahashi
- 3 Department of Neurosurgery National Cerebral and Cardiovascular Center Osaka Japan
| | - Kazuma Sugie
- 5 Department of Neurology Nara Medical University Nara Japan
| | - Kazunori Toyoda
- 7 Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan
| | - Kazuyuki Nagatsuka
- 1 Department of Neurology National Cerebral and Cardiovascular Center Osaka Japan
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Luo X, Du L, Li Z. Ultrasound assessment of tensile stress in carotid arteries of healthy human subjects with varying age. BMC Med Imaging 2019; 19:93. [PMID: 31783804 PMCID: PMC6884773 DOI: 10.1186/s12880-019-0394-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 11/08/2019] [Indexed: 12/03/2022] Open
Abstract
Background Arterial remodeling is thought to reflect the adaptation of the vessel wall to mechanical and hemodynamic stimuli and contributes to the progression of cardiovascular and cerebrovascular diseases. Tensile stress (TS) is one of the mechanical properties of the artery wall. The purpose of this study was to investigate the tensile stress change (TS) of carotid artery with varying viscoelasticity in healthy subjects within two groups of different ages. Methods Forty-five subjects were recruited and randomly assigned into the group at the age above 50 years and below 50 years. The carotid arteries were examined by ultrasonography, using the techniques of shear wave elastography (SWE), shear wave dispersion (SWD) and radiofrequency (RF) -based ultrasound. The following values, including elastic modulus (SWER) and viscous index (SWDR), as well as the peak and mean TS of the left and right carotid arteries (L-PTS, R-PTS, L-MTS and R-MTS) were measured. The correlations between SWER, SWDR and tensile stress were evaluated. Results The SWER and SWDR of carotid arteries are lower in the subjects ≥50 years old than the subjects younger than 50 years (SWER, 10.29 ± 9.57 kPa VS 17.24 ± 14.07 kPa; SWDR, 11.99 ± 3.51 (m/s)/kHz VS 13.97 ± 3.71 (m/s)/kHz, P < 0.05). The R-PTS was lower in the group with younger age (P < 0.05). Pearson correlation analysis showed that SWER of carotid artery was positively correlated with the parameters of tensile stress, R-PTS, R-MTS, L-PTS and L-MTS(r = 0.218, r = 0.359, r = 0.209 and r = 0.369, respectively, P < 0.05). However, SWDR of carotid arteries was not significantly associated with TS. Conclusion Ultrasonic shear wave imaging could be used to quantitatively assess carotid viscoelasticity. The carotid TS was related to its elasticity while little related to its viscosity, suggesting that mechanical properties of the arterial wall might be better revealed. Trial registration Date of our trial registration: 2018-06-11. Registered with the official website of China Clinical Trial Registration Center (ChiCTR1800016590)
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Affiliation(s)
- Xianghong Luo
- Department of Echocardiography, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Lianfang Du
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 100 Haining Road, Hongkou District, Shanghai, 200080, China
| | - Zhaojun Li
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 100 Haining Road, Hongkou District, Shanghai, 200080, China.
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Rots ML, Meershoek AJ, Bonati LH, den Ruijter HM, de Borst GJ. Editor's Choice – Predictors of New Ischaemic Brain Lesions on Diffusion Weighted Imaging After Carotid Stenting and Endarterectomy: A Systematic Review. Eur J Vasc Endovasc Surg 2019; 58:163-174. [DOI: 10.1016/j.ejvs.2019.04.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/09/2019] [Accepted: 04/14/2019] [Indexed: 12/16/2022]
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Traenka C, Engelter ST, Brown MM, Dobson J, Frost C, Bonati LH. Silent brain infarcts on diffusion-weighted imaging after carotid revascularisation: A surrogate outcome measure for procedural stroke? A systematic review and meta-analysis. Eur Stroke J 2019; 4:127-143. [PMID: 31259261 DOI: 10.1177/2396987318824491] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 12/20/2018] [Indexed: 12/13/2022] Open
Abstract
Aim To investigate whether lesions on diffusion-weighted imaging (DWI+) after carotid artery stenting (CAS) or endarterectomy (CEA) might provide a surrogate outcome measure for procedural stroke. Materials and Methods Systematic MedLine® database search with selection of all studies published up to the end of 2016 in which DWI scans were obtained before and within seven days after CAS or CEA. The correlation between the underlying log odds of stroke and of DWI+ across all treatment groups (i.e. CAS or CEA groups) from included studies was estimated using a bivariate random effects logistic regression model. Relative risks of DWI+ and stroke in studies comparing CAS vs. CEA were estimated using fixed-effect Mantel-Haenszel models. Results We included data of 4871 CAS and 2099 CEA procedures (85 studies). Across all treatment groups (CAS and CEA), the log odds for DWI+ was significantly associated with the log odds for clinically manifest stroke (correlation coefficient 0.61 (95% CI 0.27 to 0.87), p = 0.0012). Across all carotid artery stenting groups, the correlation coefficient was 0.19 (p = 0.074). There were too few CEA groups to reliably estimate a correlation coefficient in this subset alone. In 19 studies comparing CAS vs. CEA, the relative risks (95% confidence intervals) of DWI+ and stroke were 3.83 (3.17-4.63, p < 0.00001) and 2.38 (1.44-3.94, p = 0.0007), respectively. Discussion This systematic meta-analysis demonstrates a correlation between the occurrence of silent brain infarcts on diffusion-weighted imaging and the risk of clinically manifest stroke in carotid revascularisation procedures. Conclusion Our findings strengthen the evidence base for the use of DWI as a surrogate outcome measure for procedural stroke in carotid revascularisation procedures. Further randomised studies comparing treatment effects on DWI lesions and clinical stroke are needed to fully establish surrogacy.
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Affiliation(s)
- Christopher Traenka
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland
| | - Stefan T Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland
| | - Martin M Brown
- Stroke Research Group, Department of Brain Repair & Rehabilitation, UCL Institute of Neurology, London, UK
| | - Joanna Dobson
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Chris Frost
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Leo H Bonati
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Stroke Research Group, Department of Brain Repair & Rehabilitation, UCL Institute of Neurology, London, UK
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Wu WJ, Jiang CJ, Zhang ZY, Xu K, Li W. Diffusion-weighted magnetic resonance imaging reflects activation of signal transducer and activator of transcription 3 during focal cerebral ischemia/reperfusion. Neural Regen Res 2017; 12:1124-1130. [PMID: 28852395 PMCID: PMC5558492 DOI: 10.4103/1673-5374.211192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Signal transducer and activator of transcription (STAT) is a unique protein family that binds to DNA, coupled with tyrosine phosphorylation signaling pathways, acting as a transcriptional regulator to mediate a variety of biological effects. Cerebral ischemia and reperfusion can activate STATs signaling pathway, but no studies have confirmed whether STAT activation can be verified by diffusion-weighted magnetic resonance imaging (DWI) in rats after cerebral ischemia/reperfusion. Here, we established a rat model of focal cerebral ischemia injury using the modified Longa method. DWI revealed hyperintensity in parts of the left hemisphere before reperfusion and a low apparent diffusion coefficient. STAT3 protein expression showed no significant change after reperfusion, but phosphorylated STAT3 expression began to increase after 30 minutes of reperfusion and peaked at 24 hours. Pearson correlation analysis showed that STAT3 activation was correlated positively with the relative apparent diffusion coefficient and negatively with the DWI abnormal signal area. These results indicate that DWI is a reliable representation of the infarct area and reflects STAT phosphorylation in rat brain following focal cerebral ischemia/reperfusion.
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Affiliation(s)
- Wen-Juan Wu
- Department of Radiology, Nanjing Medical Unversity Affiliated Wuxi Second People's Hospital, Wuxi, Jiangsu Province, China.,Department of Radiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Chun-Juan Jiang
- Department of Radiology, Nanjing Medical Unversity Affiliated Wuxi Second People's Hospital, Wuxi, Jiangsu Province, China
| | - Zhui-Yang Zhang
- Department of Radiology, Nanjing Medical Unversity Affiliated Wuxi Second People's Hospital, Wuxi, Jiangsu Province, China
| | - Kai Xu
- Department of Radiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Wei Li
- Department of Radiology, Nanjing Medical Unversity Affiliated Wuxi Second People's Hospital, Wuxi, Jiangsu Province, China
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Brinjikji W, Lehman VT, Huston J, Murad MH, Lanzino G, Cloft HJ, Kallmes DF. The association between carotid intraplaque hemorrhage and outcomes of carotid stenting: a systematic review and meta-analysis. J Neurointerv Surg 2016; 9:837-842. [PMID: 27540090 DOI: 10.1136/neurintsurg-2016-012593] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this systematic review and meta-analysis was to determine whether carotid stenting patients with intraplaque hemorrhage (IPH) identified on preoperative MRI were more likely to suffer perioperative ischemic complications compared with patients without IPH. METHODS We conducted a comprehensive literature search of studies published between January 1, 2005 and December 31, 2015 reporting perioperative outcomes of carotid stenting among patients with and without IPH on hemorrhage sensitive carotid MRI sequences. Clinical outcomes included perioperative (≤30 days post-stenting) minor stroke, major stroke, death, and a composite outcome combining stroke, death, and myocardial infarction (MI). We also compared the rate of silent ischemia on diffusion weighted imaging (DWI) between groups. Statistical analysis was performed using a random effects meta-analysis. RESULTS 9 studies with 491 unique patients (198 in the IPH group and 293 in the non-IPH group) were included. The rate of the composite outcome of any stroke, death, or MI within 30 days was 8.1% (13/160) in the IPH group and 2.1% (5/239) in the non-IPH group (OR=4.45, 95% CI 1.61 to 12.30, p<0.01). There were no significant differences between groups in the rates of minor stroke, major stroke, or death when considered individually. The rate of postoperative infarct on DWI was 49.7% (75/161) for the IPH group and 33.6% (81/241) for the non-IPH group (OR=2.01, 95% CI 1.31 to 3.09, p<0.01). CONCLUSIONS Our systematic review and meta-analysis demonstrated that patients with IPH on pre-carotid stenting MRI had higher rates of silent ischemia as well as of a composite outcome of perioperative stroke, death, and MI compared with those without IPH.
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Affiliation(s)
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - John Huston
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - M Hassan Murad
- Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Harry J Cloft
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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