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Gao X, Guo J, Pan D, Gu Y. Treatment Strategies for Asymptomatic Carotid Stenosis: A Systematic Review and Bayesian Network Meta-Analysis. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01241. [PMID: 38967441 DOI: 10.1227/ons.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/23/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES To compare the safety and efficacy of carotid endarterectomy (CEA), carotid stenting (CAS), and optimal medical therapy (OMT) in patients with asymptomatic carotid stenosis. METHODS Relevant randomized controlled trials were researched with PubMed, Web of Science, and the Cochrane Library databases. Fixed-effects model and random-effects model were used to estimate the relative risks and the hazard ratios (HRs). The results of the probabilistic analysis were reported as surfaces under the cumulative ranking curve. RESULTS Eight randomized controlled trials were included. Data from 10 348 patients (CEA: n = 4758; CAS: n = 3919; OMT: n = 1673) were evaluated. Compared with the previous OMT, CEA, CAS, and the current OMT (c-OMT) were all effective in reducing the risk of stroke (CEA: HR, 0.52; CI, 0.40-0.66; CAS: HR, 0.58; CI, 0.42-0.81; c-OMT: HR, 0.40; CI, 0.15-0.94); CEA and CAS reduced the risk of ipsilateral stroke (CEA: HR, 0.41; CI, 0.28-0.59; CAS: HR, 0.51; CI, 0.31-0.84), and the risk of fatal or disabling stroke (CEA: HR, 0.59; CI, 0.43-0.81; CAS: HR, 0.57; CI, 0.34-0.95). Regarding reducing the risk of stroke, only CEA was statistically significant in patients with any degree of stenosis compared with the previous medical treatment (<80%: HR, 0.48; CI, 0.33%-0.70%; 80%-99%: HR, 0.53; CI, 0.38-0.73). CONCLUSION In the treatment of asymptomatic carotid stenosis, the perioperative outcomes of CAS were similar to that of CEA; CEA, CAS, and c-OMT shared similar long-term outcomes; and CEA and CAS may be more effective in patients with high levels of asymptomatic stenosis.
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Affiliation(s)
- Xinyi Gao
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Alajaji SA, Amarin R, Masri R, Tavares T, Kumar V, Price JB, Sultan AS. Detection of extracranial and intracranial calcified carotid artery atheromas in cone beam computed tomography using a deep learning convolutional neural network image segmentation approach. Oral Surg Oral Med Oral Pathol Oral Radiol 2024; 138:162-172. [PMID: 37770329 DOI: 10.1016/j.oooo.2023.08.009] [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: 02/24/2023] [Revised: 07/16/2023] [Accepted: 08/04/2023] [Indexed: 09/30/2023]
Abstract
OBJECTIVE We leveraged an artificial intelligence deep-learning convolutional neural network (DL CNN) to detect calcified carotid artery atheromas (CCAAs) on cone beam computed tomography (CBCT) images. STUDY DESIGN We obtained 137 full-volume CBCT scans with previously diagnosed CCAAs. The DL model was trained on 170 single axial CBCT slices, 90 with extracranial CCAAs and 80 with intracranial CCAAs. A board-certified oral and maxillofacial radiologist confirmed the presence of each CCAA. Transfer learning through a U-Net-based CNN architecture was utilized. Data allocation was 60% training, 10% validation, and 30% testing. We determined the accuracy of the DL model in detecting CCAA by calculating the mean training and validation accuracy and the area under the receiver operating characteristic curve (AUC). We reserved 5 randomly selected unseen full CBCT volumes for final testing. RESULTS The mean training and validation accuracy of the model in detecting extracranial CCAAs was 92% and 82%, respectively, and the AUC was 0.84 with 1.0 sensitivity and 0.69 specificity. The mean training and validation accuracy in detecting intracranial CCAAs was 61% and 70%, respectively, and the AUC was 0.5 with 0.93 sensitivity and 0.08 specificity. Testing of full-volume scans yielded an AUC of 0.72 and 0.55 for extracranial and intracranial CCAAs, respectively. CONCLUSION Our DL model showed excellent discrimination in detecting extracranial CCAAs on axial CBCT images and acceptable discrimination on full-volumes but poor discrimination in detecting intracranial CCAAs, for which further research is required.
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Affiliation(s)
- Shahd A Alajaji
- Department of Oncology and Diagnostic Sciences, School of Dentistry, University of Maryland Baltimore, MD, USA; Division of Artificial Intelligence Research, University of Maryland School of Dentistry, Baltimore, MD, USA; Department of Oral Medicine and Diagnostic Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
| | - Rula Amarin
- Department of Advanced Oral Sciences and Therapeutics, School of Dentistry, University of Maryland, Baltimore, MD, USA
| | - Radi Masri
- Department of Advanced Oral Sciences and Therapeutics, School of Dentistry, University of Maryland, Baltimore, MD, USA
| | - Tiffany Tavares
- Department of Comprehensive Dentistry, UT Health San Antonio, School of Dentistry, San Antonio, TX, USA
| | - Vandana Kumar
- Department of Oncology and Diagnostic Sciences, School of Dentistry, University of Maryland Baltimore, MD, USA
| | - Jeffery B Price
- Department of Oncology and Diagnostic Sciences, School of Dentistry, University of Maryland Baltimore, MD, USA; Division of Artificial Intelligence Research, University of Maryland School of Dentistry, Baltimore, MD, USA
| | - Ahmed S Sultan
- Department of Oncology and Diagnostic Sciences, School of Dentistry, University of Maryland Baltimore, MD, USA; Division of Artificial Intelligence Research, University of Maryland School of Dentistry, Baltimore, MD, USA; Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD, USA.
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Marks K, Ahn SJ, Rai N, Anfray A, Iadecola C, Anrather J. A minimally invasive thrombotic stroke model to study circadian rhythm in awake mice. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.06.10.598243. [PMID: 38915621 PMCID: PMC11195071 DOI: 10.1101/2024.06.10.598243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
Experimental stroke models in rodents are essential for mechanistic studies and therapeutic development. However, these models have several limitations negatively impacting their translational relevance. Here we aimed to develop a minimally invasive thrombotic stroke model through magnetic particle delivery that does not require craniotomy, is amenable to reperfusion therapy, can be combined with in vivo imaging modalities, and can be performed in awake mice. We found that the model results in reproducible cortical infarcts within the middle cerebral artery (MCA) with cytologic and immune changes similar to that observed with more invasive distal MCA occlusion models. Importantly, the injury produced by the model was ameliorated by tissue plasminogen activator (tPA) administration. We also show that MCA occlusion in awake animals results in bigger ischemic lesions independent of day/night cycle. Magnetic particle delivery had no overt effects on physiologic parameters and systemic immune biomarkers. In conclusion, we developed a novel stroke model in mice that fulfills many requirements for modeling human stroke.
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Gimžauskaitė A, Inčiūra D, Diringytė G, Lukoševičius S, Kaupas R, Pranculis A, Mačiulaitytė A, Basevičius A, Kuprytė M, Stankevičius E, Plisienė J. Assessment of Plaque Characteristics by Contrast-Enhanced Ultrasound and Stent Restenosis following Carotid Artery Stenting: A Retrospective Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:836. [PMID: 38793019 PMCID: PMC11123181 DOI: 10.3390/medicina60050836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/11/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024]
Abstract
Background and objective: carotid artery stenosis contributes significantly to ischemic strokes, with management options including carotid endarterectomy (CEA) and carotid artery stenting (CAS) ischemic stroke risk can be reduced. Controversies persist regarding their efficacy and factors influencing complications, and understanding the relationship between atherosclerotic plaque characteristics and stent restenosis after CAS is crucial. Methods: we conducted a retrospective study involving 221 patients who underwent CAS for symptomatic or asymptomatic carotid artery stenosis. Comprehensive assessments of plaque morphology were performed using contrast-enhanced ultrasound (CEUS) before CAS. Patient demographics, including smoking status and diabetes, were also recorded. Stent restenosis was diagnosed using various imaging modalities, including ultrasound, angiography, and digital subtraction angiography (DSA). Results: plaque analysis using CEUS revealed a significant association between plaque grade and restenosis incidence (p < 0.001), particularly with grade 0 (11.1%) and grade 2 plaques (66.7%). Smoking was notably associated with plaque vascularization and restenosis (p < 0.001), while diabetes did not significantly impact plaque characteristics or restenosis risk (p > 0.05). The mean duration of restenosis was 17.67 months. Stenting was the most frequent treatment modality for restenosis (70.6%). However, no significant relationship was found between restenosis type and plaque morphology (p = 0.268). Furthermore, while no clear relationship was observed between plaque morphology and the type of restenosis, our findings underscored the importance of plaque characterization in predicting post-CAS outcomes. Conclusions: this study highlights the utility of CEUS in predicting stent restenosis following CAS. There was a significant association between stent restenosis within 12-24 months after the carotid stenting procedure and an elevated grade of plaque vascularization. Moreover, one of the main factors possibly determining the grade of plaque vascularization was smoking. Further research is warranted to elucidate the underlying mechanisms and refine risk stratification in this patient population.
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Affiliation(s)
- Agnė Gimžauskaitė
- Department of Cardiac, Thoracic and Vascular Surgery, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (D.I.); (A.M.)
| | - Donatas Inčiūra
- Department of Cardiac, Thoracic and Vascular Surgery, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (D.I.); (A.M.)
| | - Gintautė Diringytė
- Faculty of Medicine, Medical Academy, Lithuanian University of Health Sciences, LT-44307 Kaunas, Lithuania;
| | - Saulius Lukoševičius
- Department of Radiology, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (S.L.); (R.K.); (A.P.); (A.B.)
| | - Rytis Kaupas
- Department of Radiology, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (S.L.); (R.K.); (A.P.); (A.B.)
| | - Andrius Pranculis
- Department of Radiology, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (S.L.); (R.K.); (A.P.); (A.B.)
| | - Aistė Mačiulaitytė
- Department of Cardiac, Thoracic and Vascular Surgery, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (D.I.); (A.M.)
| | - Algidas Basevičius
- Department of Radiology, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (S.L.); (R.K.); (A.P.); (A.B.)
| | - Milda Kuprytė
- Department of Pathological Anatomy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania;
| | - Edgaras Stankevičius
- Institute of Physiology and Pharmacology, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania;
| | - Jurgita Plisienė
- Department of Cardiology Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania;
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Yu F, Zhang Y, Sun H, Li X, Shan Y, Zheng C, Cui B, Li J, Yang Y, Yang B, Ma Y, Wang Y, Jiao L, Li X, Lu J. In Vivo Classification and Characterization of Carotid Atherosclerotic Lesions with Integrated 18F-FDG PET/MRI. Diagnostics (Basel) 2024; 14:1006. [PMID: 38786304 PMCID: PMC11120206 DOI: 10.3390/diagnostics14101006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/26/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND The aim of this study was to exploit integrated PET/MRI to simultaneously evaluate the morphological, component, and metabolic features of advanced atherosclerotic plaques and explore their incremental value. METHODS In this observational prospective cohort study, patients with advanced plaque in the carotid artery underwent 18F-FDG PET/MRI. Plaque morphological features were measured, and plaque component features were determined via MRI according to AHA lesion-types. Maximum standardized uptake values (SUVmax) and tissue to background ratio (TBR) on PET were calculated. Area under the receiver-operating characteristic curve (AUC) and net reclassification improvement (NRI) were used to compare the incremental contribution of FDG uptake when added to AHA lesion-types for symptomatic plaque classification. RESULTS A total of 280 patients with advanced plaque in the carotid artery were recruited. A total of 402 plaques were confirmed, and 87 of 402 (21.6%) were symptomatic plaques. 18F-FDG PET/MRI was performed a mean of 38 days (range 1-90) after the symptom. Increased stenosis degree (61.5% vs. 50.0%, p < 0.001) and TBR (2.96 vs. 2.32, p < 0.001) were observed in symptomatic plaques compared with asymptomatic plaques. The performance of the combined model (AHA lesion type VI + stenosis degree + TBR) for predicting symptomatic plaques was the best among all models (AUC = 0.789). The improvement of the combined model (AHA lesion type VII + stenosis degree + TBR) over AHA lesion type VII model for predicting symptomatic plaques was the highest (AUC = 0.757/0.454, combined model/AHA lesion type VII model), and the NRI was 50.7%. CONCLUSIONS Integrated PET/MRI could simultaneously evaluate the morphological component and inflammation features of advanced atherosclerotic plaques and provide supplementary optimization information over AHA lesion-types for identifying vulnerable plaques in atherosclerosis subjects to achieve further stratification of stroke risk.
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Affiliation(s)
- Fan Yu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
| | - Yue Zhang
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
| | - Heyu Sun
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
| | - Xiaoran Li
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
| | - Yi Shan
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
| | - Chong Zheng
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
| | - Bixiao Cui
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
| | - Jing Li
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
| | - Yang Yang
- Beijing United Imaging Research Institute of Intelligent Imaging, Beijing 100094, China;
| | - Bin Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (B.Y.); (Y.M.); (Y.W.); (L.J.)
- China International Neuroscience Institute (China-INI), Beijing 100053, China
- Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (B.Y.); (Y.M.); (Y.W.); (L.J.)
- China International Neuroscience Institute (China-INI), Beijing 100053, China
- Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China
| | - Yabing Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (B.Y.); (Y.M.); (Y.W.); (L.J.)
- China International Neuroscience Institute (China-INI), Beijing 100053, China
- Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (B.Y.); (Y.M.); (Y.W.); (L.J.)
- China International Neuroscience Institute (China-INI), Beijing 100053, China
- Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China
| | - Xiang Li
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Vienna General Hospital, Medical University of Vienna, 1090 Vienna, Austria
- Department of Nuclear Medicine, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing 101149, China
| | - Jie Lu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
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Chen Y, Xu Y, Pan D, Li H, Cai J, Li Y, Shen Q, Tang Y. Progression rate of radiation-induced carotid stenosis in head and neck cancer survivors after statin treatment: a retrospective cohort study. J Neurol 2024; 271:2573-2581. [PMID: 38332351 DOI: 10.1007/s00415-024-12197-4] [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] [Received: 10/16/2023] [Revised: 01/03/2024] [Accepted: 01/11/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND AND AIMS Whether statin treatment is effective in retarding the progression of radiation-induced carotid stenosis (RICS) in head and neck cancer (HNC) survivors has not been well studied. The purpose of this study was to assess the association of statin treatment with RICS progression rate in HNC survivors after radiotherapy. METHODS We conducted a retrospective cohort study at Sun Yat-sen Memorial Hospital, Sun Yat-sen University in Guangzhou, China. Between January 2010 and December 2021, we screened HNC survivors whose carotid ultrasound scans had shown stenosis of the common and/or internal carotid arteries. The primary outcome was the RICS progression rate. We compared eligible patients treated with statins with those who did not in multivariable Cox regression models. RESULTS A total of 200 patients were included in this study, of whom 108 received statin treatment and 92 did not. Over a mean follow-up time of 1.5 years, 56 (28.0%) patients showed RICS progression, 24 (42.9%) and 32 (57.1%) in the statin and control groups, respectively. The statin group showed less RICS progression than the control group (adjusted-HR 0.49, 95% CI 0.30-0.80, P = 0.005). In the subgroup analysis, there was no significant interaction in the effect of statins on lowering RICS progression rate in the subgroups stratified by baseline low-density lipoprotein cholesterol (LDL-C) levels (P for interaction = 0.53) or baseline degrees of stenosis (P for interaction = 0.50). CONCLUSIONS Statin treatment was associated with a lower risk of RICS progression in patients with HNC after radiotherapy, regardless of baseline LDL-C level and baseline stenosis degrees.
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Affiliation(s)
- Yanting Chen
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Yongteng Xu
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Dong Pan
- Department of Neurology, The Eighth Affiliated Hospital, SunYat-Sen University, Shenzhen, 528406, China
| | - Honghong Li
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Jinhua Cai
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Yi Li
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China.
| | - Qingyu Shen
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China.
| | - Yamei Tang
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China.
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China.
- Guangdong Province Key Laboratory of Brain Function and Disease, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, 510120, China.
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Pagliariccio G, Di Sario I, Capoccia L, D'Elia M, Bafile G, Leopardi M, Fiore F, Palmieri A, Antico L, Antico A. Carotid Near-Occlusion: Surgical or Conservative Management? Retrospective Multicenter Study. Ann Vasc Surg 2024; 102:133-139. [PMID: 38408393 DOI: 10.1016/j.avsg.2023.11.047] [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: 10/04/2023] [Revised: 11/14/2023] [Accepted: 11/26/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Carotid near-occlusion (CNO) represents an anatomical-functional condition characterized by severe (more than 90%) internal carotid artery stenosis which can lead to a distal lumen diameter greater or less than 2 mm. CNO can be divided into a less severe subgroup (without lumen full collapse: diameter >2 mm) and a more severe subgroup (with lumen full collapse: diameter <2 mm). The decision for revascularization is still highly debated in Literature. The aim of the present multicenter retrospective study is to analyze the incidence of perioperative (30 days) and follow-up complications in 2 groups of patients with or without distal internal carotid lumen full collapse. METHODS Between January 2011 and March 2023, in 5 Vascular Surgery Units, 67 patients (49 male, 73% and 18 females, 27%) with CNO underwent carotid endarterectomy: 28 (41.7%) with lumen diameter <2 mm and 39 (58.3%) with diameter >2 mm. 19 patients were symptomatic and 48 asymptomatic. The outcomes considered for comparative analysis were: perioperative neurological and cardiac complications, carotid restenosis or occlusion at follow-up. Both groups were homogeneous in terms of risk factors, morphological features and pharmacological treatments. RESULTS In the group with lumen <2 mm, 3 perioperative major events (10.7%) occurred (1 ischemic stroke, 1 hemorrhagic stroke, 1 myocardial infarction) and 2 (7.1%) at follow-up (average 11 ± 14.5 months; 1 asymptomatic carotid occlusion, 1 hemodynamic restenosis treated with stenting). No event was recorded in the group with lumen >2 mm. CONCLUSIONS According to our results CNO patients show different complication risk according to the presence or not of distal lumen collapse. The later seems to play a significant role in perioperative and follow-up complication rate. These results therefore support a surgical treatment only in patients with CNO without lumen full collapse.
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Affiliation(s)
| | | | - Laura Capoccia
- Vascular Surgery Department, Avezzano Hospital, Avezzano, Italy
| | - Marcello D'Elia
- Vascular Surgery Department, Avezzano Hospital, Avezzano, Italy
| | - Gennaro Bafile
- Vascular Surgery Department, L'Aquila Hospital, L'Aquila, Italy
| | - Marco Leopardi
- Vascular Surgery Department, L'Aquila Hospital, L'Aquila, Italy
| | - Franco Fiore
- Vascular Surgery Department, Chieti Hospital, Chieti, Italy
| | | | - Lorenzo Antico
- Vascular Surgery Department, Pescara Hospital, Pescara, Italy
| | - Antonio Antico
- Vascular Surgery Department, Pescara Hospital, Pescara, Italy
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Wang L, Guo T, Wang L, Yang W, Wang J, Nie J, Cui J, Jiang P, Li J, Zhang H. Improving radiomic modeling for the identification of symptomatic carotid atherosclerotic plaques using deep learning-based 3D super-resolution CT angiography. Heliyon 2024; 10:e29331. [PMID: 38644848 PMCID: PMC11033096 DOI: 10.1016/j.heliyon.2024.e29331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 04/23/2024] Open
Abstract
Rationale and objectives Radiomic models based on normal-resolution (NR) computed tomography angiography (CTA) images can fail to distinguish between symptomatic and asymptomatic carotid atherosclerotic plaques. This study aimed to explore the effectiveness of a deep learning-based three-dimensional super-resolution (SR) CTA radiomic model for improved identification of symptomatic carotid atherosclerotic plaques. Materials and methods A total of 193 patients with carotid atherosclerotic plaques were retrospectively enrolled and allocated into either a symptomatic (n = 123) or an asymptomatic (n = 70) groups. SR CTA images were derived from NR CTA images using deep learning-based three-dimensional SR technology. Handcrafted radiomic features were extracted from both the SR and NR CTA images and three risk models were developed based on manually measured quantitative CTA characteristics and NR and SR radiomic features. Model performances were assessed via receiver operating characteristic, calibration, and decision curve analyses. Results The SR model exhibited the optimal performance (area under the curve [AUC] 0.820, accuracy 0.802, sensitivity 0.854, F1 score 0.847) in the testing cohort, outperforming the other two models. The calibration curve analyses and Hosmer-Lemeshow test demonstrated that the SR model exhibited the best goodness of fit, and decision curve analysis revealed that SR model had the highest clinical value and potential patient benefits. Conclusions Deep learning-based three-dimensional SR technology could improve the CTA-based radiomic models in identifying symptomatic carotid plaques, potentially providing more accurate and valuable information to guide clinical decision-making to reduce the risk of ischemic stroke.
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Affiliation(s)
- Lingjie Wang
- Department of Medical Imaging, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, 030001, China
| | - Tiedan Guo
- Department of Medical Imaging, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, 030001, China
| | - Li Wang
- Department of Medical Imaging, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, 030001, China
| | - Wentao Yang
- Basic Medical College, Shanxi Medical University, Taiyuan, Shanxi Province, 030001, China
| | - Jingying Wang
- Department of Endemic Disease Prevention and Control, Shanxi Province Disease Prevention and Control Center, Shanxi Province, 030001, China
| | - Jianlong Nie
- Shanghai United Imaging Intelligence, Co., Ltd., Shanghai City, 200030, China
| | - Jingjing Cui
- Shanghai United Imaging Intelligence, Co., Ltd., Shanghai City, 200030, China
| | - Pengbo Jiang
- Shanghai United Imaging Intelligence, Co., Ltd., Shanghai City, 200030, China
| | - Junlin Li
- Department of Imaging Medicine, Inner Mongolia Autonomous Region People's Hospital, Hohhot, 010017, China
| | - Hua Zhang
- Department of Medical Imaging, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, 030001, China
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9
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Evans NR, Bhakta S, Chowdhury MM, Markus H, Warburton E. Management of carotid atherosclerosis in stroke. Pract Neurol 2024:pn-2023-003918. [PMID: 38589215 DOI: 10.1136/pn-2023-003918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/10/2024]
Abstract
Internal carotid artery atherosclerosis is a major risk factor for stroke, accounting for 15-20% of ischaemic strokes. Revascularisation procedures-either carotid endarterectomy or carotid artery stenting-can reduce the risk of stroke for those with significant (>50%) luminal stenosis but particularly for those with more severe (70-99%) stenosis. However, advances in medical pharmacotherapy have implications for the relative benefit from surgery for symptomatic carotid atherosclerosis, as well as our approach to asymptomatic disease. This review considers the evidence underpinning the current medical and surgical management of symptomatic carotid atherosclerosis, the importance of factors beyond the degree of luminal stenosis, and developments in therapeutic strategies. We also discuss the importance of non-stenotic but high-risk carotid atherosclerotic plaques on the cause of stroke, and their implications for clinical practice.
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Affiliation(s)
| | - Shiv Bhakta
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - Hugh Markus
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Elizabeth Warburton
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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10
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Lun R, Zitikyte G, Yogendrakumar V, Bereznyakova O, Dewar B, Dowlatshahi D, Fahed R, Shamy M. Network meta-analysis can inform the ethical evaluation of trials that randomise away from standard of care: The case of symptomatic carotid stenosis. J Eval Clin Pract 2024; 30:376-384. [PMID: 38059277 DOI: 10.1111/jep.13951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/27/2023] [Accepted: 10/19/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVE Little guidance exists on the conduct of randomised clinical trials (RCT) that seek to randomise patients away from standard of care. We sought to test the technique of network meta-analysis (NMA) to ascertain best available evidence for the purposes of informing the ethical evaluation of RCTs under these circumstances. We used the example of RCTs for patients with symptomatic, moderate to severe carotid stenosis that seek to compare surgical intervention plus medical therapy (standard of care) versus medical therapy (less than standard of care). STUDY DESIGN AND SETTING Network meta-analysis of RCTs of adults with symptomatic carotid artery stenosis of 50%-99% who were treated with carotid endarterectomy (CEA), carotid artery stenting (CAS), or medical therapy (MT). The primary outcome was any stroke or death until end of follow-up, and secondary outcome was 30-day risk of ipsilateral stroke/death. RESULTS We analysed eight studies, with 7187 subjects with symptomatic moderate/severe stenosis (50%-99%). CEA was more efficacious than MT (HR = 0.82, 95% credible intervals [95% CrI] = 0.73-0.92) and CAS (HR 0.73, 95% CrI = 0.62-0.85) for the prevention of any stroke/death. At 30 days, the odds of experiencing an ipsilateral stroke/death were significantly lower in the CEA group compared to both MT (OR = 0.58, 95% CrI = 0.47-0.72) and CAS (OR = 0.68, 95% CrI = 0.55-0.83). CONCLUSION Our results support the feasibility of using NMA to assess best available evidence to inform the ethical evaluation of RCTs seeking to randomise patients away from standard of care. Our results suggest that a strong argument is required to ethically justify the conduct of RCTs that seek to randomise patients away from standard of care in the setting of symptomatic moderate to severe carotid stenosis.
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Affiliation(s)
- Ronda Lun
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Canada
| | - Gabriele Zitikyte
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Vignan Yogendrakumar
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Canada
- Department of Medicine and Neurology, The Royal Melbourne Hospital, Parkville, Australia
| | - Olena Bereznyakova
- Department of Neurosciences, Centre Hospitalier de l'Universite de Montreal, Montreal, Canada
| | - Brian Dewar
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Canada
| | - Dar Dowlatshahi
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Canada
| | - Robert Fahed
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Canada
| | - Michel Shamy
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Canada
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11
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Tsutsui T, Yamada K, Ikedo T, Morita Y, Hamano E, Imamura H, Mori H, Iihara K, Kataoka H. Risk factors for recurrent ischemic events in symptomatic carotid artery stenosis on CT angiography. Vasc Med 2024; 29:211-212. [PMID: 38334056 DOI: 10.1177/1358863x231225463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Affiliation(s)
- Takeyoshi Tsutsui
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kiyofumi Yamada
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Taichi Ikedo
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshiaki Morita
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Eika Hamano
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hisae Mori
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Koji Iihara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
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12
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Oliveira TF, Centellas CDR, Dalio MB, Joviliano EE. Short term outcomes of carotid surgery: the real-world experience of a single teaching center. J Vasc Bras 2024; 23:e20230033. [PMID: 38433985 PMCID: PMC10903515 DOI: 10.1590/1677-5449.202300332] [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: 04/03/2023] [Accepted: 11/27/2023] [Indexed: 03/05/2024] Open
Abstract
Background Surgical treatment of symptomatic extracranial carotid stenosis is well established for preventing neurological events and should adhere to optimal quality standards. However, there is growing concern as to whether results of controlled trials are replicable in real-world settings. Objectives To assess a symptomatic carotid stenosis population that underwent surgery and its short-term outcomes in a real-world context at a professional training center. Methods Observational study using data collected from medical records from January 2012 to January 2023. Patients undergoing operations for other carotid diseases and with concomitant heart surgery were excluded. Results A total of 70 patients undergoing angioplasty or carotid endarterectomy were included. Population subsets undergoing angioplasty or endarterectomy were similar. Differences in anesthetic modality and a longer operative time in the carotid endarterectomy subgroup were statistically significant. There were 4 cases of stroke, only 3 of which (2 minor and 1 major) were related to the index lesion. Thus, the rate of major operation-related stroke was 1.43% and the rate of any lesion-related stroke was 4.29%. There was 1 case of AMI in the angioplasty group and there were no deaths in the sample. The overall rate of major adverse cardiovascular events was 5.71%. There were no statistical differences between the endarterectomy and angioplasty groups regarding the main outcomes. Conclusions The rates of outcomes of ischemic stroke, acute myocardial infarction, death, and major adverse cardiovascular events at this center are in line with the rates reported by randomized controlled trials, demonstrating the feasibility of carotid surgery in centers with teaching programs.
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Affiliation(s)
- Tércio Ferreira Oliveira
- Universidade de São Paulo - USP, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brasil.
| | | | - Marcelo Bellini Dalio
- Universidade de São Paulo - USP, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brasil.
| | - Edwaldo Edner Joviliano
- Universidade de São Paulo - USP, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brasil.
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13
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von Oiste GG, Sangwon KL, Chung C, Narayan V, Raz E, Shapiro M, Rutledge C, Nelson PK, Ishida K, Torres JL, Rostanski SK, Zhang C, Yaghi S, Riina H, Oermann EK, Nossek E. Use of Carotid Web Angioarchitecture for Stroke Risk Assessment. World Neurosurg 2024; 182:e245-e252. [PMID: 38006939 DOI: 10.1016/j.wneu.2023.11.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 11/19/2023] [Indexed: 11/27/2023]
Abstract
OBJECTIVE To examine the usefulness of carotid web (CW), carotid bifurcation and their combined angioarchitectural measurements in assessing stroke risk. METHODS Anatomic data on the internal carotid artery (ICA), common carotid artery (CCA), and the CW were gathered as part of a retrospective study from symptomatic (stroke) and asymptomatic (nonstroke) patients with CW. We built a model of stroke risk using principal-component analysis, Firth regression trained with 5-fold cross-validation, and heuristic binary cutoffs based on the Minimal Description Length principle. RESULTS The study included 22 patients, with a mean age of 55.9 ± 12.8 years; 72.9% were female. Eleven patients experienced an ischemic stroke. The first 2 principal components distinguished between patients with stroke and patients without stroke. The model showed that ICA-pouch tip angle (P = 0.036), CCA-pouch tip angle (P = 0.036), ICA web-pouch angle (P = 0.036), and CCA web-pouch angle (P = 0.036) are the most important features associated with stroke risk. Conversely, CCA and ICA anatomy (diameter and angle) were not found to be risk factors. CONCLUSIONS This pilot study shows that using data from computed tomography angiography, carotid bifurcation, and CW angioarchitecture may be used to assess stroke risk, allowing physicians to tailor care for each patient according to risk stratification.
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Affiliation(s)
- Grace G von Oiste
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Karl L Sangwon
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA.
| | - Charlotte Chung
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Vinayak Narayan
- Department of Radiology, NYU Langone Health, New York, New York, USA
| | - Eytan Raz
- Department of Radiology, NYU Langone Health, New York, New York, USA
| | - Maksim Shapiro
- Department of Radiology, NYU Langone Health, New York, New York, USA
| | - Caleb Rutledge
- Department of Radiology, NYU Langone Health, New York, New York, USA
| | - Peter Kim Nelson
- Department of Radiology, NYU Langone Health, New York, New York, USA
| | - Koto Ishida
- Department of Neurology, NYU Langone Health, New York, New York, USA
| | - Jose L Torres
- Department of Neurology, NYU Langone Health, New York, New York, USA
| | - Sara K Rostanski
- Department of Neurology, NYU Langone Health, New York, New York, USA
| | - Cen Zhang
- Department of Neurology, NYU Langone Health, New York, New York, USA
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Howard Riina
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Eric K Oermann
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Erez Nossek
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
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14
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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15
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Gupta R, Hassankhani A, Ghozy S, Tolba H, Kobeissi H, Kanitra J, Kadirvel R, Kallmes DF. Effect of Treatment Choice on Short-Term and Long-Term Outcomes for Carotid Near-Occlusion: A Meta-Analysis. World Neurosurg 2024; 181:e1102-e1129. [PMID: 37979687 DOI: 10.1016/j.wneu.2023.11.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 11/13/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVE Current guidelines recommend best medical treatment (BMT) over revascularization for carotid near-occlusion (CNO); however, it remains unclear whether BMT, carotid artery stenting (CAS), or carotid endarterectomy (CEA) is the optimal treatment strategy. The present meta-analysis aimed to compare outcomes among patients with CNO receiving BMT, CAS, or CEA. METHODS PubMed, Web of Science, Scopus, and Embase were searched. English studies with ≥1 month follow-up, that used established CNO diagnostic guidelines, that provided outcomes by treatment, and in which 95% confidence intervals (CIs) were calculable were included. Studies on acute ischemic stroke (AIS) requiring emergent reperfusion therapy, nonatherosclerotic lesions, nonprimary research articles, non-English, and nonhuman studies were excluded. Outcomes were mortality, AIS, transient ischemic attack, myocardial infarction within and beyond 30 days, and restenosis. A generalized linear mixed model, subgroup analysis, and meta-regression were used to compare outcomes. RESULTS Thirty-eight studies were included. Pooled rates for AIS beyond 30 days were 9.90% (95% CI, 4.31%-21.16%), 0.79% (95% CI, 0.24%-2.53%), and 0.80% (95% CI, 0.15%-4.07%) for BMT, CAS, and CEA, respectively. Subgroup analysis was statistically significant (P < 0.001). Meta-regression showed lower incidence favoring procedural intervention (CAS vs. BMT, P = 0.001; CEA vs. BMT, P = 0.003). Subgroup analysis for mortality beyond 30 days was also significant (P = 0.016) but meta-regression did not favor one treatment over another. Other outcomes were not statistically significant. CONCLUSIONS Revascularization for CNO may decrease long-term stroke rates. Given that current guidelines are based on randomized controlled trials from the 1990s, updated randomized trials are warranted to determine the optimal treatment for CNO.
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Affiliation(s)
- Rishabh Gupta
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Twin Cities Medical School, University of Minnesota, Minneapolis, Minnesota, USA.
| | | | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hatem Tolba
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Hassan Kobeissi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - John Kanitra
- Department of Vascular Surgery, Baylor University Medical Center, Houston, Texas, USA
| | | | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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16
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Korshunov DA, Kulbak VA, Chupin AV. [Advisability of carotid endarterectomy in asymptomatic patients]. Khirurgiia (Mosk) 2024:45-53. [PMID: 38477243 DOI: 10.17116/hirurgia202403145] [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: 03/14/2024]
Abstract
OBJECTIVE To determine the optimal treatment strategy for patients with asymptomatic carotid stenosis. MATERIAL AND METHODS The authors reviewed clinical guidelines for the management of patients with asymptomatic carotid stenosis 60-99%, as well as medical studies and meta-analyses comparing carotid endarterectomy and optimal drug therapy in asymptomatic patients between 1993 and 2023. RESULTS The choice of treatment strategy for patients with asymptomatic carotid artery stenosis is still a controversial issue. There were several large randomized clinical trials comparing carotid endarterectomy with optimal medical therapy in asymptomatic patients at the end of the 20th century. However, drug therapy has undergone significant changes calling into question the relevance of previous results. This review highlights the evolution of management of patients with asymptomatic carotid stenosis and also presents modern approaches to the treatment of these patients. CONCLUSION Patients younger 75 years old gain an advantage from carotid endarterectomy with small perioperative risk compared to optimal drug therapy and yearly risk of cerebral embolism. Patients with asymptomatic carotid stenosis 80-99% are candidates for carotid endarterectomy due to higher risk of acute cerebrovascular accident at least until more data are available. The choice of the best tactics for a particular patient should be made individually depending on own experience and patient's adherence to therapy and lifestyle correction. The results of the ACTRIS (2025) and CREST-2 (2026) studies are expected to clarify this issue.
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Affiliation(s)
- D A Korshunov
- Vishnevsky National Medical Research Center for Surgery, Moscow, Russia
| | - V A Kulbak
- Lomonosov Moscow State University, Moscow, Russia
| | - A V Chupin
- Russian Medical Academy of Continuing Professional Education, Moscow, Russia
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17
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Saba L, Scicolone R, Johansson E, Nardi V, Lanzino G, Kakkos SK, Pontone G, Annoni AD, Paraskevas KI, Fox AJ. Quantifying Carotid Stenosis: History, Current Applications, Limitations, and Potential: How Imaging Is Changing the Scenario. Life (Basel) 2024; 14:73. [PMID: 38255688 PMCID: PMC10821425 DOI: 10.3390/life14010073] [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: 12/05/2023] [Revised: 12/24/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024] Open
Abstract
Carotid artery stenosis is a major cause of morbidity and mortality. The journey to understanding carotid disease has developed over time and radiology has a pivotal role in diagnosis, risk stratification and therapeutic management. This paper reviews the history of diagnostic imaging in carotid disease, its evolution towards its current applications in the clinical and research fields, and the potential of new technologies to aid clinicians in identifying the disease and tailoring medical and surgical treatment.
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Affiliation(s)
- Luca Saba
- Department of Radiology, University of Cagliari, 09042 Cagliari, Italy;
| | - Roberta Scicolone
- Department of Radiology, University of Cagliari, 09042 Cagliari, Italy;
| | - Elias Johansson
- Neuroscience and Physiology, Sahlgrenska Academy, 41390 Gothenburg, Sweden;
| | - Valentina Nardi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| | - Stavros K. Kakkos
- Department of Vascular Surgery, University of Patras, 26504 Patras, Greece;
| | - Gianluca Pontone
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy; (G.P.); (A.D.A.)
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20122 Milan, Italy
| | - Andrea D. Annoni
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy; (G.P.); (A.D.A.)
| | | | - Allan J. Fox
- Department of Medical Imaging, Neuroradiology Section, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada;
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18
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Lamarca MP, Flores Á, Martín A, Peinado J, Estébanez S, Arriola M, Llergo B, García E, Tique J, Torralbas F, Millán E, Rigolin M, Lobato P, Segundo JC, Morín M, Jamilena Á, Moreno R, Orgaz A. Prospective evaluation of acute cerebral injury by DW-MRI following transcarotid artery revascularization using a double-layer micromesh stent. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:583-590. [PMID: 38078708 DOI: 10.23736/s0021-9509.23.12764-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
BACKGROUND Transcervical carotid artery revascularization (TCAR) has demonstrated a low overall stroke rate in carotid artery stenting (CAS). Furthermore, the use of a double-layer micromesh stent is expected to reduce embolization and plaque prolapse. The combination of TCAR and the double layer stent may lead to improved results compared to previously reported outcomes. The objective of this study is to present the findings of a prospective study including patients treated with the Roadsaver stent and TCAR. METHODS Between January 2017 and May 2022, 85 patients were enrolled. Every patient underwent TCAR with the Roadsaver stent. As per our protocol, a neurological examination and an ultrasound were performed within 24 hours before and after the procedure, and again 30 days after. A diffusion-weighted magnetic resonance imaging (DW-MRI) was conducted 24 hours before the procedure and 48-72 hours after the procedure. The primary endpoint was the detection of new ischemic lesions on postoperative DW-MRI. The secondary endpoint was a composite of all strokes, death, and myocardial infarction within 30 days. RESULTS Sixty-four patients (75.29%) were symptomatic, out of which 25 were treated within 14 days of the onset of the symptoms. Pre and postprocedural DW-MRI were performed in 83 patients. Postprocedural lesions were found in nine patients (10.84%). There were no strokes or death within 30 days, but two patients experienced a myocardial infarction. CONCLUSIONS Our study suggests that the use of TCAR and the Roadsaver stent could be a safe alternative to carotid endarterectomy because it entails a low incidence of cerebral embolization, even in recently symptomatic and elderly patients.
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Affiliation(s)
- María P Lamarca
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain -
| | - Ángel Flores
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Alberto Martín
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Javier Peinado
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Santiago Estébanez
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Maite Arriola
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Belén Llergo
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Enrique García
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Julián Tique
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Fredy Torralbas
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Elisa Millán
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Martina Rigolin
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Paula Lobato
- Stroke Section, Department of Neurology, Complejo Hospitalario de Toledo, Toledo, Spain
| | - José C Segundo
- Stroke Section, Department of Neurology, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Mar Morín
- Stroke Section, Department of Neurology, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Álvaro Jamilena
- Stroke Section, Department of Neurology, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Raquel Moreno
- Neuroradiology Section, Department of Radiology, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Antonio Orgaz
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
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19
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Kassem M, de Kam SS, van Velzen TJ, van der Geest R, Wagner B, Sokolska M, Pizzini FB, Nederkoorn PJ, Rolf Jäger H, Brown MM, van Oostenbrugge RJ, Bonati LH, Eline Kooi M. Application of mask images of contrast-enhanced MR angiography to detect carotid intraplaque hemorrhage in patients with moderate to severe symptomatic and asymptomatic carotid stenosis. Eur J Radiol 2023; 168:111145. [PMID: 37837923 DOI: 10.1016/j.ejrad.2023.111145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/21/2022] [Accepted: 10/05/2023] [Indexed: 10/16/2023]
Abstract
PURPOSE Carotid intraplaque hemorrhage (IPH) on MRI predicts stroke. Magnetization-prepared rapid acquisition gradient (MP-RAGE) is widely used to detect IPH. CE-MRA is used routinely to assess stenosis. Initial studies indicated that IPH can be identified on mask images of CE-MRA, while Time-of-Flight (TOF) images were reported to have high specificity but lower sensitivity. We investigated the diagnostic accuracy of detecting IPH on mask images of CE-MRA and TOF. METHODS Thirty-six patients with ≥ 50% stenosis enrolled in the ongoing 2nd European Carotid Surgery Trial underwent carotid MRI. A 5-point quality score was used. Inter-observer agreement between two independent readers was determined. The sensitivity and specificity of IPH detection on mask MRA and TOF were calculated with MP-RAGE as a reference standard. RESULTS Of the 36 patients included in the current analysis, 66/72 carotid arteries could be scored. The inter-observer agreements for identifying IPH on MP-RAGE, mask, and TOF were outstanding (κ: 0.93, 0.96, and 0.85). The image quality of mask (1.42 ± 0.66) and TOF (2.42 ± 0.66) was significantly lower than MP-RAGE (3.47 ± 0.61). When T1w images were used to delineate the outer carotid wall, very high specificities (>95%) of IPH detection on mask and TOF images were found, while the sensitivity was high for mask images (>81%) and poor for TOF (50-60%). Without these images, the specificity was still high (>97%), while the sensitivity reduced to 62-71%. CONCLUSION Despite the lower image quality, routinely acquired mask images from CE-MRA, but not TOF, can be used as an alternative to MP-RAGE images to visualize IPH.
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Affiliation(s)
- Mohamed Kassem
- Cardiovascular Research Institute Maastrich (CARIM), Maastricht University: Universiteitssingel 50, PO Box 616, 6200 MD Maastricht, the Netherlands; Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+ (MUMC+): P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
| | - Soraya S de Kam
- Cardiovascular Research Institute Maastrich (CARIM), Maastricht University: Universiteitssingel 50, PO Box 616, 6200 MD Maastricht, the Netherlands; Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+ (MUMC+): P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
| | - Twan J van Velzen
- Department of Neurology, Amsterdam UMC: De Boelelaan 1108, 1081 HV Amsterdam, the Netherlands
| | - Rob van der Geest
- Department of Radiology, Leiden University Medical Centre: Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Benjamin Wagner
- Department of Neurology, University Hospital Basel: Universitätsspital CH, Petersgraben 4, 4031 Basel, Switzerland
| | - Magdalena Sokolska
- Department of Imaging, University College London Hospitals NHS Foundation Trust: 250 Euston Rd, London NW1 2PG, UK; Department of Medical Physics and Biomedical Engineering, University College London Hospitals NHS Foundation Trust: 250 Euston Rd, London NW1 2PG, UK
| | - Francesca B Pizzini
- Radiology, Department of Diagnostic and Public Health, University of Verona: Via S. Francesco, 22, 37129 Verona VR, Italy
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC: De Boelelaan 1108, 1081 HV Amsterdam, the Netherlands
| | - H Rolf Jäger
- Department of Imaging, University College London Hospitals NHS Foundation Trust: 250 Euston Rd, London NW1 2PG, UK
| | - Martin M Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London: Queen Square, London WC1N 3BG, UK
| | - Robert J van Oostenbrugge
- Cardiovascular Research Institute Maastrich (CARIM), Maastricht University: Universiteitssingel 50, PO Box 616, 6200 MD Maastricht, the Netherlands; Department of Neurology, Maastricht University Medical Center+ (MUMC+): P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
| | - Leo H Bonati
- Department of Neurology, University Hospital Basel: Universitätsspital CH, Petersgraben 4, 4031 Basel, Switzerland
| | - M Eline Kooi
- Cardiovascular Research Institute Maastrich (CARIM), Maastricht University: Universiteitssingel 50, PO Box 616, 6200 MD Maastricht, the Netherlands; Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+ (MUMC+): P. Debyelaan 25, 6229 HX Maastricht, the Netherlands.
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20
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Morris DR, Singh TP, Zaman T, Velu R, Quigley F, Jenkins J, Golledge J. Rates of Stroke in Patients With Different Presentations of Carotid Artery Stenosis. Eur J Vasc Endovasc Surg 2023; 66:484-491. [PMID: 37295600 DOI: 10.1016/j.ejvs.2023.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 05/09/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Carotid artery stenosis may present without the classical symptoms of transient ischaemic attack or stroke but the rates of stroke for these presentations is unknown. The aim of this study was to examine the rates of stroke in patients with different presentations of carotid artery stenosis. METHODS A multicentre prospective cohort study was conducted across three Australian vascular centres with low rates of surgical treatment of patients without transient ischaemic attack or stroke. Patients with a 50 - 99% carotid artery stenosis presenting with non-focal symptoms (e.g., dizziness or syncope; n = 47), prior contralateral carotid endarterectomy (n = 71), prior ipsilateral symptoms more than six months earlier (n = 82), and no symptoms (n = 304) were recruited. The primary outcome was ipsilateral ischaemic stroke. Secondary outcomes were any ischaemic stroke and cardiovascular death. Data were analysed using Cox proportional hazard and Kaplan-Meier analyses. RESULTS Between 2002 and 2020, 504 patients were enrolled (mean age 71 years, 30% women) and followed for a median of 5.1 years (interquartile range 2.5, 8.8; 2 981 person years). Approximately 82% were prescribed antiplatelet therapy, 84% were receiving at least one antihypertensive drug, and 76% were prescribed a statin at entry. After five years the incidence of ipsilateral stroke was 6.5% (95% confidence interval [CI] 4.3 - 9.5). There were no statistically significant differences in the annual rate of ipsilateral stroke among people with non-focal symptoms (2.1%; 95% CI 0.8 - 5.7), prior contralateral carotid endarterectomy (0.2%; 0.03 - 1.6) or ipsilateral symptoms > 6 months prior (1.0%; 0.4 - 2.5) compared with those with no symptoms (1.2%; 0.7 - 1.8; p = .19). There were no statistically significant differences in secondary outcomes across groups. CONCLUSION This cohort study showed no large differences in stroke rates among people with different presentations of carotid artery stenosis.
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Affiliation(s)
- Dylan R Morris
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia
| | - Tejas P Singh
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia
| | - Tahmid Zaman
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Ramesh Velu
- Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia; The Mater Hospital, Townsville, Queensland, Australia
| | | | - Jason Jenkins
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia.
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21
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Xu H, Han H, Liu Y, Huo R, Lang N, Yuan H, Wang T, Zhao X. Perioperative cerebral blood flow measured by arterial spin labeling with different postlabeling delay in patients undergoing carotid endarterectomy: a comparison study with CT perfusion. Front Neurosci 2023; 17:1200273. [PMID: 37781254 PMCID: PMC10536277 DOI: 10.3389/fnins.2023.1200273] [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: 04/04/2023] [Accepted: 08/21/2023] [Indexed: 10/03/2023] Open
Abstract
Background Arterial spin labeling (ASL) is a non-invasive technique for measuring cerebral perfusion. Its accuracy is affected by the arterial transit time. This study aimed to (1) evaluate the accuracy of ASL in measuring the cerebral perfusion of patients who underwent carotid endarterectomy (CEA) and (2) determine a better postlabeling delay (PLD) for pre- and postoperative perfusion imaging between 1.5 and 2.0 s. Methods A total of 24 patients scheduled for CEA due to severe carotid stenosis were included in this study. All patients underwent ASL with two PLDs (1.5 and 2.0 s) and computed tomography perfusion (CTP) before and after surgery. Cerebral blood flow (CBF) values were measured on the registered CBF images of ASL and CTP. The correlation in measuring perioperative relative CBF (rCBF) and difference ratio of CBF (DRCBF) between ASL with PLD of 1.5 s (ASL1.5) or 2.0 s (ASL2.0) and CTP were also determined. Results There were no significant statistical differences in preoperative rCBF measurements between ASL1.5 and CTP (p = 0.17) and between ASL2.0 and CTP (p = 0.42). Similarly, no significant differences were found in rCBF between ASL1.5 and CTP (p = 0.59) and between ASL2.0 and CTP (p = 0.93) after CEA. The DRCBF measured by CTP was found to be marginally lower than that measured by ASL2.0_1.5 (p = 0.06) and significantly lower than that measured by ASL1.5_1.5 (p = 0.01), ASL2.0_2.0 (p = 0.03), and ASL1.5_2.0 (p = 0.007). There was a strong correlation in measuring perioperative rCBF and DRCBF between ASL and CTP (r = 0.67-0.85, p < 0.001). Using CTP as the reference standard, smaller bias can be achieved in measuring rCBF by ASL2.0 (-0.02) than ASL1.5 (-0.07) before CEA. In addition, the same bias (0.03) was obtained by ASL2.0 and ASL1.5 after CEA. The bias of ASL2.0_2.0 (0.31) and ASL2.0_1.5 (0.32) on DRCBF measurement was similar, and both were smaller than that of ASL1.5_1.5 (0.60) and ASL1.5_2.0 (0.60). Conclusion Strong correlation can be found in assessing perioperative cerebral perfusion between ASL and CTP. During perioperative ASL imaging, the PLD of 2.0 s is better than 1.5 s for preoperative scan, and both 1.5 and 2.0 s are suitable for postoperative scan.
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Affiliation(s)
- Huimin Xu
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Hualu Han
- Department of Biomedical Engineering, Center for Biomedical Imaging Research, School of Medicine, Tsinghua University, Beijing, China
| | - Ying Liu
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Ran Huo
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Ning Lang
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Huishu Yuan
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Peking University Third Hospital, Beijing, China
| | - Xihai Zhao
- Department of Biomedical Engineering, Center for Biomedical Imaging Research, School of Medicine, Tsinghua University, Beijing, China
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Mihály Z, István L, Czakó C, Benyó F, Borzsák S, Varga A, Magyar-Stang R, Banga PV, Élő Á, Debreczeni R, Kovács I, Sótonyi P. The Effect of Circle of Willis Morphology on Retinal Blood Flow in Patients with Carotid Stenosis Measured by Optical Coherence Tomography Angiography. J Clin Med 2023; 12:5335. [PMID: 37629376 PMCID: PMC10455622 DOI: 10.3390/jcm12165335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/11/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023] Open
Abstract
The Circle of Willis (CoW) is the main collateral system, and its morphological variants are more common in patients who have severe carotid artery stenosis. Earlier data suggest that optical coherence tomography angiography (OCTA) may help to assess the changes in cerebral vascular perfusion by imaging the retinal blood flow. In this single-center prospective clinical study, patients scheduled for carotid endarterectomy (CEA) underwent preoperative computed tomography angiography (CTA) of the extra- and intracranial cerebral circulation. OCTA imaging was performed one week before surgery and postoperatively one month later. The patients were divided into two subgroups based on CTA evaluation of CoW: compromised CoW or non-compromised CoW (containing hypoplastic and normal segments). The effect of the patient's age, OCTA scan quality (SQ), CoW morphology, laterality, and surgery on superficial capillary vessel density (VD) in the macula were assessed in multivariable regression models using linear mixed models. We found that VD significantly decreased with aging (-0.12%; 95%CI: -0.07--0.15; p < 0.001) and was significantly higher in patients with non-compromised CoW morphology (by 0.87% 95%CI (0.26-1.50); p = 0.005). After CEA, retinal blood flow significantly improved by 0.71% (95%CI: 0.18-1.25; p = 0.01). These results suggest that in the case of carotid artery occlusion, patients with non-compromised CoW have more preserved ocular blood flow than subjects with compromised CoW due to remodeling of the intra-orbital blood flow. Measuring the retinal blood flow might be used as a relevant and sensitive indicator of collateral cerebrovascular circulation.
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Affiliation(s)
- Zsuzsanna Mihály
- Department of Vascular and Endovascular Surgery Heart and Vascular Centre, Semmelweis University, 1122 Budapest, Hungary; (Z.M.)
| | - Lilla István
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary (Á.É.)
| | - Cecilia Czakó
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary (Á.É.)
| | - Fruzsina Benyó
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary (Á.É.)
| | - Sarolta Borzsák
- Department of Vascular and Endovascular Surgery Heart and Vascular Centre, Semmelweis University, 1122 Budapest, Hungary; (Z.M.)
| | - Andrea Varga
- Department of Vascular and Endovascular Surgery Heart and Vascular Centre, Semmelweis University, 1122 Budapest, Hungary; (Z.M.)
| | - Rita Magyar-Stang
- Department of Neurology, Semmelweis University, 1085 Budapest, Hungary (R.D.)
| | - Péter Vince Banga
- Department of Vascular and Endovascular Surgery Heart and Vascular Centre, Semmelweis University, 1122 Budapest, Hungary; (Z.M.)
| | - Ágnes Élő
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary (Á.É.)
| | - Róbert Debreczeni
- Department of Neurology, Semmelweis University, 1085 Budapest, Hungary (R.D.)
| | - Illés Kovács
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary (Á.É.)
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY 10021, USA
- Department of Clinical Ophthalmology, Faculty of Health Sciences, Semmelweis University, 1085 Budapest, Hungary
| | - Péter Sótonyi
- Department of Vascular and Endovascular Surgery Heart and Vascular Centre, Semmelweis University, 1122 Budapest, Hungary; (Z.M.)
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McCabe JJ, Evans NR, Gorey S, Bhakta S, Rudd JHF, Kelly PJ. Imaging Carotid Plaque Inflammation Using Positron Emission Tomography: Emerging Role in Clinical Stroke Care, Research Applications, and Future Directions. Cells 2023; 12:2073. [PMID: 37626883 PMCID: PMC10453446 DOI: 10.3390/cells12162073] [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] [Received: 07/11/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 08/27/2023] Open
Abstract
Atherosclerosis is a chronic systemic inflammatory condition of the vasculature and a leading cause of stroke. Luminal stenosis severity is an important factor in determining vascular risk. Conventional imaging modalities, such as angiography or duplex ultrasonography, are used to quantify stenosis severity and inform clinical care but provide limited information on plaque biology. Inflammatory processes are central to atherosclerotic plaque progression and destabilization. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) is a validated technique for quantifying plaque inflammation. In this review, we discuss the evolution of FDG-PET as an imaging modality to quantify plaque vulnerability, challenges in standardization of image acquisition and analysis, its potential application to routine clinical care after stroke, and the possible role it will play in future drug discovery.
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Affiliation(s)
- John J. McCabe
- Health Research Board Stroke Clinical Trials Network Ireland, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland; (S.G.); (P.J.K.)
- Neurovascular Unit for Applied Translational and Therapeutics Research, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
- Stroke Service, Department of Medicine for the Elderly, Mater Misericordiae University Hospital, Eccles Street, D07 R2WY Dublin, Ireland
| | - Nicholas R. Evans
- Department of Clinical Neurosciences, Box 83, Addenbrooke’s Hospital, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK; (N.R.E.); (S.B.)
| | - Sarah Gorey
- Health Research Board Stroke Clinical Trials Network Ireland, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland; (S.G.); (P.J.K.)
- Neurovascular Unit for Applied Translational and Therapeutics Research, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
- Stroke Service, Department of Medicine for the Elderly, Mater Misericordiae University Hospital, Eccles Street, D07 R2WY Dublin, Ireland
| | - Shiv Bhakta
- Department of Clinical Neurosciences, Box 83, Addenbrooke’s Hospital, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK; (N.R.E.); (S.B.)
| | - James H. F. Rudd
- Division of Cardiovascular Medicine, Addenbrooke’s Hospital, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK;
| | - Peter J. Kelly
- Health Research Board Stroke Clinical Trials Network Ireland, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland; (S.G.); (P.J.K.)
- Neurovascular Unit for Applied Translational and Therapeutics Research, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
- Stroke Service, Department of Medicine for the Elderly, Mater Misericordiae University Hospital, Eccles Street, D07 R2WY Dublin, Ireland
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Mohd AB, Alabdallat Y, Mohd OB, Ghannam RA, Sawaqed S, Hasan H, Ellebedy M, Turkmani K, Al-Ezzi S. Medical and Surgical Management of Symptomatic and Asymptomatic Carotid Artery Stenosis: A Comprehensive Literature Review. Cureus 2023; 15:e43263. [PMID: 37692579 PMCID: PMC10491926 DOI: 10.7759/cureus.43263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/12/2023] Open
Abstract
Carotid artery stenosis is a condition where the carotid artery is blocked by fatty cholesterol deposits called plaque, increasing the risk of stroke. Elderly individuals with high cardiovascular risk are more susceptible, along with smokers, those with high cholesterol, males, and older individuals. Young females may also be affected by fibromuscular dysplasia. Carotid stenosis significantly raises stroke risk, and the severity is closely linked to stroke incidence and other cardiovascular events. Early detection and treatment are essential to prevent complications. Treatment options include medical and surgical interventions, such as carotid endarterectomy (CEA) and carotid artery stenting (CAS). The choice between surgery and medical management varies depending on patient characteristics and risk factors. This review explores carotid artery stenosis pathophysiology, risk factors, the importance of early detection and treatment, and the surgical approaches of CEA and CAS, addressing their roles and controversies. Healthcare professionals must understand these aspects to provide optimal care to patients with this condition.
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Affiliation(s)
- Ahmed B Mohd
- Faculty of Medicine, Hashemite University, Zarqa, JOR
| | | | - Omar B Mohd
- Faculty of Medicine, Hashemite University, Zarqa, JOR
| | | | - Seri Sawaqed
- Infectious Disease, Faculty of Medicine, Hashemite University, Zarqa, JOR
| | - Hanan Hasan
- Medical Laboratory, The Lab Medical Laboratories, Amman, JOR
| | | | | | - Shakir Al-Ezzi
- Internal Medicine, Hospital Corporation of America (HCA) Medical City Arlington, Dallas, USA
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Delgardo M, Rabin G, Tudor T, Tang AJ, Reeves G, Connolly ES. Monitoring risk and preventing ischemic stroke in the very old. Expert Rev Neurother 2023; 23:791-801. [PMID: 37540092 DOI: 10.1080/14737175.2023.2244674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Stroke is a significant cause of death, and the leading cause of severe long-term disability for individuals over 80 (the very old), yet few studies of such risk factors for ischemic stroke, or the known mitigation techniques, in this population, and the evidence base regarding risk modification strategies in this susceptible population can be inconsistent and incomplete. This article examines current guidelines and evidence regarding medical management, lifestyle changes, and psychosocial interactions that can contribute to the primary and secondary prevention of ischemic stroke in the very old. AREAS COVERED The authors conducted a literature search for ischemic stroke prevention and risk assessment in the elderly via PubMed. Furthermore, they describe current strategies for monitoring risk and preventing ischemic stroke in the elderly population. EXPERT OPINION Ischemic stroke poses a significant health risk to the elderly, with prevention relying on managing modifiable risk factors such as hypertension, atrial fibrillation, diabetes, and high cholesterol, as well as promoting healthy lifestyle choices like quitting smoking, regular physical activity and a heart-healthy diet. Healthcare providers must adopt a multifaceted approach, addressing individual and population-level factors while remaining vigilant in monitoring and managing risk factors to reduce the incidence and impact of stroke in older adults.
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Affiliation(s)
- Mychael Delgardo
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Grant Rabin
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Thilan Tudor
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Anthony J Tang
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Geoffrey Reeves
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
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Wadén K, Hultgren R, Kotopouli MI, Gillgren P, Roy J, Hedin U, Matic L. Long Term Mortality Rate in Patients Treated with Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2023; 65:778-786. [PMID: 36871924 DOI: 10.1016/j.ejvs.2023.02.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 02/10/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) is an effective surgical method for stroke prevention in selected patients with carotid stenosis. Few contemporary studies report on the long term mortality rate in CEA treated patients, despite continuous changes in medication, diagnostics, and patient selection. Here, the long term mortality rate is described in a well characterised cohort of asymptomatic and symptomatic CEA patients, sex differences evaluated, and mortality ratio compared with the general population. METHODS This was a two centre, non-randomised, observational study evaluating all cause, long term mortality in CEA patients from Stockholm, Sweden between 1998 and 2017. Death and comorbidities were extracted from national registries and medical records. Cox regression was adapted to analyse associations between clinical characteristics and outcome. Sex differences and standardised mortality ratio (SMR, age and sex matched) were studied. RESULTS A total of 1 033 patients were followed for 6.6 ± 4.8 years. Of those, 349 patients died during follow up where the overall mortality rate was similar in asymptomatic and symptomatic patients (34.2% vs. 33.7%, p = .89). Symptomatic disease did not influence the mortality risk (adjusted HR 1.14, 95% CI 0.81 - 1.62). Women had lower crude mortality rate than men in the first 10 years (20.8% vs. 27.6%, p = .019). In women, cardiac disease was associated with increased mortality (adjusted HR 3.55, 95% CI 2.18 - 5.79), while in men, lipid lowering medication was protective (adjusted HR 0.61, 95% CI 0.39 - 0.96). Within the first five years after surgery, SMR was increased for all patients (men 1.50, 95% CI 1.21 - 1.86; women 2.41, 95% CI 1.74 - 3.35), as well as in patients < 80 years (SMR 1.46, 95% CI 1.23 - 1.73). CONCLUSION Symptomatic and asymptomatic carotid patients have similar long term mortality rates after CEA, but men had worse outcome than women. Sex, age, and time after surgery were shown to influence SMR. These results highlight the need for targeted secondary prevention, to alter the long term adverse effects in CEA patients.
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Affiliation(s)
- Katarina Wadén
- Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Rebecka Hultgren
- Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Ioanna Kotopouli
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - Peter Gillgren
- Section of Vascular Surgery, Department of Clinical Science and Education, Karolinska Institutet at Södersjukhuset, Stockholm, Sweden
| | - Joy Roy
- Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Ulf Hedin
- Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Ljubica Matic
- Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.
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Ranasinghe T, Gurol ME. Are Ischemic Strokes the Same? The Special Case Argument of Atrial Fibrillation. Card Electrophysiol Clin 2023; 15:111-117. [PMID: 37076223 DOI: 10.1016/j.ccep.2023.01.003] [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: 04/21/2023]
Abstract
A comprehensive evaluation is necessary to identify the etiologic factors in order to select optimal stroke-prevention measures. Atrial fibrillation is one of the most important stroke causes. Although anticoagulant therapy is the treatment of choice for patients with nonvalvular atrial fibrillation, it should not be considered uniformly to treat all patients given the high mortality associated with anticoagulant-related hemorrhages. The authors propose a risk-stratified individualized approach for stroke prevention in patients with nonvalvular atrial fibrillation by considering nonpharmacologic approaches for patients at high hemorrhage risk or otherwise unsuitable for lifelong anticoagulation.
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Affiliation(s)
- Tamra Ranasinghe
- Department of Neurology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Mahmut Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA 02114, USA.
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Dubs L, Charitatos V, Buoso S, Wegener S, Winklhofer S, Alkadhi H, Kurtcuoglu V. Assessment of extracranial carotid artery disease using digital twins - A pilot study. Neuroimage Clin 2023; 38:103435. [PMID: 37245493 PMCID: PMC10238877 DOI: 10.1016/j.nicl.2023.103435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/05/2023] [Accepted: 05/12/2023] [Indexed: 05/30/2023]
Abstract
To improve risk stratification in extracranial internal carotid artery disease (CAD), patients who would benefit maximally from revascularization must be identified. In cardiology, the fractional flow reserve (FFR) has become a reference standard for evaluating the functional severity of coronary artery stenosis, and noninvasive surrogates thereof relying on computational fluid dynamics (CFD) have been developed. Here, we present a CFD-based workflow using digital twins of patients' carotid bifurcations derived from computed tomography angiography for the noninvasive functional assessment of CAD. We reconstructed patient-specific digital twins of 37 carotid bifurcations. We implemented a CFD model using common carotid artery peak systolic velocity (PSV) acquired with Doppler ultrasound (DUS) as inlet boundary condition and a two-element Windkessel model as oulet boundary condition. The agreement between CFD and DUS on the PSV in the internal carotid artery (ICA) was then compared. The relative error for the agreement between DUS and CFD was 9% ± 20% and the intraclass correlation coefficient was 0.88. Furthermore, hyperemic simulations in a physiological range were feasible and unmasked markedly different pressure drops along two ICA stenoses with similar degree of narrowing under comparable ICA blood flow. Hereby, we lay the foundation for prospective studies on noninvasive CFD-based derivation of metrics similar to the FFR for the assessment of CAD.
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Affiliation(s)
- Linus Dubs
- University of Zurich, Institute of Physiology, The Interface Group, Winterthurerstrasse 190, 8057 Zürich, Switzerland.
| | - Vasileios Charitatos
- University of Zurich, Institute of Physiology, The Interface Group, Winterthurerstrasse 190, 8057 Zürich, Switzerland; University Hospital Zurich, University of Zurich, Institute of Diagnostic and Interventional Radiology, Rämistrasse 100, 8091 Zürich, Switzerland.
| | - Stefano Buoso
- University of Zurich, Institute of Physiology, The Interface Group, Winterthurerstrasse 190, 8057 Zürich, Switzerland; ETH Zurich, Institute for Biomedical Engineering, Gloriastrasse 35, 8092 Zürich, Switzerland.
| | - Susanne Wegener
- University Hospital Zurich, University of Zurich, Clinical Neuroscience Center, Department of Neurology, Frauenklinikstrasse 10, 8091 Zürich, Switzerland.
| | - Sebastian Winklhofer
- University Hospital Zurich, University of Zurich, Clinical Neuroscience Center, Department of Neuroradiology, Frauenklinikstrasse 10, 8091 Zürich, Switzerland.
| | - Hatem Alkadhi
- University Hospital Zurich, University of Zurich, Institute of Diagnostic and Interventional Radiology, Rämistrasse 100, 8091 Zürich, Switzerland.
| | - Vartan Kurtcuoglu
- University of Zurich, Institute of Physiology, The Interface Group, Winterthurerstrasse 190, 8057 Zürich, Switzerland.
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Smith LC, Funnell JP, Richards T, Best LMJ. Carotid plaque ulceration: unquantified predictor of stroke. BJS Open 2023; 7:zrad058. [PMID: 37352871 PMCID: PMC10289828 DOI: 10.1093/bjsopen/zrad058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 04/29/2023] [Indexed: 06/25/2023] Open
Affiliation(s)
- Luke C Smith
- Intensive Care Unit, Royal Hampshire County Hospital, Winchester, UK
| | | | - Toby Richards
- Division of Surgery, The University of Western Australia (M581), Perth, Western Australia, Australia
| | - Lawrence M J Best
- UCL Division of Surgery and Interventional Science, Royal Free Hospital, London, UK
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Walubembe J, Ssinabulya I, Mubuuke AG, Kagwa MM, Babirye D, Okot J, Bongomin F, Nakku M, Ongom DO, Ameda F. Carotid Doppler findings among patients admitted with stroke in two tertiary care facilities in Uganda: A Hospital-based Cross-sectional Study. RESEARCH SQUARE 2023:rs.3.rs-2800534. [PMID: 37162833 PMCID: PMC10168469 DOI: 10.21203/rs.3.rs-2800534/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Background Carotid Atherosclerotic Disease (CAD) Doppler findings including carotid artery stenosis, thickened intima media thickness, and high-risk atherosclerotic plaques are associated with increased risk of stroke and symptomatic cerebrovascular disease. However, few studies have explored these Doppler characteristics among stroke patients in Africa. This study, therefore, investigates these carotid artery Doppler characteristics among stroke patients in Uganda. Methods A hospital-based cross-sectional study of 95 stroke patients attending two national referral hospitals in Uganda between March and July 2022. Following the caption of their sociodemographic and clinical characteristics, they underwent Doppler sonography of the extracranial carotid arteries using a standard carotid Doppler protocol. Multivariate logistic regression was used to determine factors associated with abnormal carotid Doppler parameters (i.e., carotid intima-media thickness, carotid stenosis). Results The mean age of the study participants was 61 ± 13 years with 60% (57/95) of the participants being male. Most participants had an ischemic stroke (67%), hypertension (76.4%), and used alcohol (58.9%). The prevalence of significant carotid stenosis in participants with ischemic stroke was 12.5% (8/64) (i.e., 7.8% had severe carotid stenosis and 4.7% had moderate stenosis). The prevalence of high carotid intima media thickness (CIMT) and atherosclerotic plaques were 31.6% (30/95) and 26.3% (25/95), respectively. Most atherosclerotic plaques were echogenic. Age above 60 years (adjusted odds ratio [aOR] = 5.2, 95% Confidence Interval [CI]:1.97-14; p < 0.010), high low-density lipoprotein cholesterol (aOR = 4.2, 95% CI: 1.29-8.79; p = 0.013) increased the likelihood of having abnormal CIMT. Conclusion The burden of carotid atherosclerotic disease is increasing among stroke patients in Uganda. Large-scale epidemiological studies are needed to further profile the disease in high risk populations.
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Using eZIS of SPECT to evaluate the therapeutic effect of carotid endarterectomy. Nucl Med Commun 2023; 44:252-258. [PMID: 36756768 DOI: 10.1097/mnm.0000000000001662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
OBJECTIVE Stroke is an acute cerebrovascular disease with high morbidity and mortality. The main causes of ischemic stroke include carotid artery stenosis, and carotid endarterectomy (CEA) can be used to improve the blood flow of the lesion site. Regional cerebral blood flow (rCBF) can be decreased by using single photon emission computed tomography (SPECT). The Easy Z-Score imaging system (eZIS) can display the changes of rCBF as Z-Score. The purpose of this study was to determine whether eZIS of SPECT can be used to evaluate the therapeutic effect of CEA in the treatment of carotid artery stenosis. METHODS In this study, subjects were divided into the surgery group and the control group. The surgery group included seven patients with unilateral or bilateral internal carotid artery stenosis who received CEA treatment, and the control group included 11 patients who only received conventional drug treatment but did not receive surgery. Cerebral perfusion imaging (CPI) was collected twice before and after the corresponding treatment (within 6 months). rCBF of the lesion site was measured and Z-score was calculated before and after treatment by the eZIS technique. RESULTS The postoperative Z-score of the surgery group was 0.54 ± 2.71 compared with that of the preoperative -1.34 ± 2.68 ( P = 0.0034; t = 4.687; df = 6), while the z-score of the control group was -0.33 ± 2.58 compared with that of the pretreatment 1.84 ± 2.62 ( P = 0.0010; t = 4.618; df = 10). CONCLUSION CEA can effectively improve the blood flow in the lesion area of patients with carotid artery stenosis. eZIS of SPECT can be used to evaluate the therapeutic effect of CEA on carotid artery stenosis visually.
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Abstract
The health burden of ischemic stroke is high and will continue to increase with an aging population. Recurrent ischemic stroke is increasingly recognized as a major public health concern with potentially debilitating sequelae. Thus, it is imperative to develop and implement effective strategies for stroke prevention. When considering secondary ischemic stroke prevention, it is important to consider the mechanism of the first stroke and the related vascular risk factors. Secondary ischemic stroke prevention typically includes multiple medical and, potentially, surgical treatments, but with the shared goal of reducing the risk of recurrent ischemic stroke. Providers, health care systems, and insurers also need to consider the availability of treatments, their cost and patient burden, methods for improving adherence, and interventions that target lifestyle risk factors such as diet or activity. In this article, we discuss aspects from the 2021 AHA Guideline on Secondary Stroke Prevention as well as highlight additional information relevant to best practices for reducing recurrent stroke risk.
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Affiliation(s)
- Aaron Bangad
- Department of Neurology, Yale University, 15 York Street, New Haven, CT, 06510, USA
| | - Mehdi Abbasi
- Department of Neurology, Yale University, 15 York Street, New Haven, CT, 06510, USA
| | - Adam de Havenon
- Department of Neurology, Yale University, 15 York Street, New Haven, CT, 06510, USA.
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Mead GE, Sposato LA, Sampaio Silva G, Yperzeele L, Wu S, Kutlubaev M, Cheyne J, Wahab K, Urrutia VC, Sharma VK, Sylaja PN, Hill K, Steiner T, Liebeskind DS, Rabinstein AA. A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization. Int J Stroke 2023; 18:499-531. [PMID: 36725717 DOI: 10.1177/17474930231156753] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines. AIMS To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1 January 2011, evaluate quality (The international Appraisal of Guidelines, Research and Evaluation (AGREE II)), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced). SUMMARY OF REVIEW Searches identified 15,400 titles; 911 texts were retrieved, 200 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing etiological diagnosis; management of hypertension, weight, diabetes, lipids, and lifestyle modification; and for ischemic stroke, management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, and antithrombotics in non-cardioembolic stroke. For rehabilitation, there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task-specific training, fitness training, and specific interventions for post-stroke impairments. Most recommendations were from high-income countries, and most did not consider comorbidity, resource implications, and implementation. Patient and public involvement was limited. CONCLUSION The review identified a number of areas of stroke care where there was strong consensus. However, there was extensive repetition and redundancy in guideline recommendations. Future guideline groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.
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Affiliation(s)
- Gillian E Mead
- Usher Institute, University of Edinburgh and Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Luciano A Sposato
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada.,Heart & Brain Lab, Western University, London, ON, Canada.,Robarts Research Institute, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil.,Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Laetitia Yperzeele
- Antwerp NeuroVascular Center and Stroke Unit, Antwerp University Hospital, Antwerp, Belgium.,Research Group on Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Mansur Kutlubaev
- Department of Neurology, Bashkir State Medical University, Ufa, Russia
| | - Joshua Cheyne
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kolawole Wahab
- Department of Medicine, University of Ilorin, Ilorin, Nigeria
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vijay K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Neurology, University Medicine Cluster, National University Health System, Singapore
| | - P N Sylaja
- Neurology and Comprehensive Stroke Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Kelvin Hill
- Stroke Treatment, Stroke Foundation, Melbourne, VIC, Australia
| | - Thorsten Steiner
- Departments of Neurology, Klinikum Frankfurt Höchst and Heidelberg University Hospital, Frankfurt, Germany
| | - David S Liebeskind
- UCLA Department of Neurology, Neurovascular Imaging Research Core, UCLA Comprehensive Stroke Center, Los Angeles, CA, USA
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Components of carotid atherosclerotic plaque in spectral photon-counting CT with histopathologic comparison. Eur Radiol 2023; 33:1612-1619. [PMID: 36205768 DOI: 10.1007/s00330-022-09155-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 08/08/2022] [Accepted: 09/18/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This study aimed to demonstrate the effectiveness of spectral photon-counting CT (SPCCT) in quantifying fibrous cap (FC) thickness, FC area, and lipid-rich necrotic core (LRNC) area, in excised carotid atherosclerotic plaques by comparing it with histopathological measurements. METHODS This is a single-center ex vivo cross-sectional observational study. Excised plaques of 20 patients (71 +/- 6 years; 13 men), obtained from carotid endarterectomy were scanned with SPCCT using standardized acquisition settings (120k Vp/19 μA; 7-18 keV, 18-30 keV, 30-45 keV, 45-75 keV, and 75-118 keV). FC thickness, FC area, and LRNC area were quantified and compared between high-resolution 3D multi-energy CT images and histopathology using the Wilcoxon signed-ranks test and Bland-Altman analysis. Images were interpreted twice by two radiologists separately, blinded to the histopathology; inter- and intra-rater reliability were assessed with the intra-class correlation coefficients (ICC). RESULTS FC thickness and FC area did not show significant differences between the SPCCT-derived radiological measurements versus the histopathological measurements (p value range 0.15-0.51 for FC thickness and 0.053-0.30 for FC area). For the LRNC area, the p value was statistically non-significant for reader 1 (range 0.36-0.81). The Bland-Altman analysis showed mean difference and 95% confidence interval for FC thickness, FC area, and LRNC area, 0.04 (-0.36 to 0.12) square root mm, -0.18 (-0.34 to -0.02) log10 mm2 and 0.10 (-0.088. to 0.009) log10 mm2 respectively. CONCLUSION The result demonstrated a viable technique for quantifying FC thickness, FC area, and LRNC area due to the combined effect of high spatial and energy resolution of SPCCT. KEY POINTS • SPCCT can identify and quantify different components of carotid atherosclerotic plaque in ex vivo study. • Components of atherosclerotic plaque did not show significant differences between the SPCCT-derived radiological measurements versus the histopathological measurements.
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De Blasis S, Pulli R, Di Domenico R, Nesi M, Nencini P, Fargion AT, Pratesi C, Dorigo W. Elective or Urgent Carotid Endarterectomy in Symptomatic Patients: Analysis Based on the Type and Timing of Neurological Symptoms. Ann Vasc Surg 2023; 90:7-16. [PMID: 36503019 DOI: 10.1016/j.avsg.2022.10.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 09/23/2022] [Accepted: 10/23/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to retrospectively analyse perioperative and long-term outcomes of carotid endarterectomy (CEA) performed in symptomatic patients in a high-volume academic vascular centre, stratifying them according to the type of preoperative symptoms and the timing of surgery with respect to the indexed neurological event. METHODS From January 2014 to December 2020, 1,369 consecutive CEAs were performed at our institution. Data concerning these interventions were prospectively collected in a dedicated database including data concerning preoperative assessment, surgical details, perioperative (<30 days) outcomes, and long-term outcomes. A retrospective analysis of the database was performed, and 213 interventions performed in symptomatic patients were found. We identified 2 subgroups of patients: patients with stable neurological symptoms (not recent transient ischemic attack (TIA) or stable major disabling stroke, stable group, and 157 patients) and patients with unstable neurological symptoms (recent TIA, crescendo TIAs, stroke in evolution, acute/recent minor stroke, unstable group, and 56 patients). Perioperative outcomes were analysed in terms of mortality, major neurological events, and local or systemic complications The results were compared using the χ2 test; these were also analysed on the basis of the presenting symptom (isolated TIA, crescendo TIA, stroke in evolution, acute/recent minor stroke, stabilized stroke) and the timing of the intervention relative to the onset of the symptom. Long term results were analysed using the life-table analysis and Kaplan-Meier curves in terms of survival, stroke-free survival, absence of neurological symptoms, and absence of significant restenosis. RESULTS Overall, 30-day stroke and death rate were 4.2%. (3.1% vs. 7%, P = 0.2). Two deaths occurred at 30 days, both in the stable group (mortality 1.2%, P = 0.4 compared to the unstable group), but no fatal strokes were recorded in the overall sample. No differences were found in terms of new perioperative neurological events and local complications between the 2 groups. We found a trend toward poorer perioperative results in patients operated on within 48 hr from the indexed event and in patients operated on for stroke in evolution or acute/recent stroke, whereas we found a trend toward better results in favour of patients operated on between 8 and 14 days (P = 0.08). The median duration of follow-up was 24.8 months (range 1-78); at 5 years we did not find significant differences in terms of survival and stroke-free survival rates between 2 groups. CONCLUSIONS In our experience, carotid surgery in symptomatic patients provided satisfactory results, particularly in patients with stable neurological status. Among unstable patients, the rate of complications significantly increases, mainly among treated in the very early (<48 hr) period for stroke in evolution or acute/recent stroke. Once the perioperative risk is overcome, the results in the long-term setting are similarly good, both in stable and in unstable patients.
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Affiliation(s)
- Serena De Blasis
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy.
| | - Raffaele Pulli
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
| | | | - Mascia Nesi
- Stroke Unit, Careggi University Hospital, Florence, Italy
| | | | | | - Carlo Pratesi
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
| | - Walter Dorigo
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
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Huang Z, Cheng XQ, Liu YN, Bi XJ, Deng YB. Value of Intraplaque Neovascularization on Contrast-Enhanced Ultrasonography in Predicting Ischemic Stroke Recurrence in Patients With Carotid Atherosclerotic Plaque. Korean J Radiol 2023; 24:338-348. [PMID: 36907591 PMCID: PMC10067694 DOI: 10.3348/kjr.2022.0977] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 02/22/2023] Open
Abstract
OBJECTIVE Patients with a history of ischemic stroke are at risk for a second ischemic stroke. This study aimed to investigate the relationship between carotid plaque enhancement on perfluorobutane microbubble contrast-enhanced ultrasonography (CEUS) and future recurrent stroke, and to determine whether plaque enhancement can contribute to risk assessment for recurrent stroke compared with the Essen Stroke Risk Score (ESRS). MATERIALS AND METHODS This prospective study screened 151 patients with recent ischemic stroke and carotid atherosclerotic plaques at our hospital between August 2020 and December 2020. A total of 149 eligible patients underwent carotid CEUS, and 130 patients who were followed up for 15-27 months or until stroke recurrence were analyzed. Plaque enhancement on CEUS was investigated as a possible risk factor for stroke recurrence and as a possible adjunct to ESRS. RESULTS During follow-up, 25 patients (19.2%) experienced recurrent stroke. Patients with plaque enhancement on CEUS had an increased risk of stroke recurrence events (22/73, 30.1%) compared to those without plaque enhancement (3/57, 5.3%), with an adjusted hazard ratio (HR) of 38.264 (95% confidence interval [CI]:14.975-97.767; P < 0.001) according to a multivariable Cox proportional hazards model analysis, indicating that the presence of carotid plaque enhancement was a significant independent predictor of recurrent stroke. When plaque enhancement was added to the ESRS, the HR for stroke recurrence in the high-risk group compared to that in the low-risk group (2.188; 95% CI, 0.025-3.388) was greater than that of the ESRS alone (1.706; 95% CI, 0.810-9.014). A net of 32.0% of the recurrence group was reclassified upward appropriately by the addition of plaque enhancement to the ESRS. CONCLUSION Carotid plaque enhancement was a significant and independent predictor of stroke recurrence in patients with ischemic stroke. Furthermore, the addition of plaque enhancement improved the risk stratification capability of the ESRS.
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Affiliation(s)
- Zhe Huang
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xue-Qing Cheng
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ya-Ni Liu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiao-Jun Bi
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - You-Bin Deng
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Perez-Troncoso D, Epstein D, Davies AH, Thapar A. Cost-effectiveness of carotid endarterectomy in symptomatic patients. Br J Surg 2023; 110:193-199. [PMID: 36422995 DOI: 10.1093/bjs/znac386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 10/05/2022] [Accepted: 10/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Medical therapy for stroke prevention has improved significantly over the past 30 years. Recent analyses of medically treated cohorts have suggested that early rates of stroke may have reduced, and reports of the safety of carotid surgery have also shown improvements. Since the effectiveness of carotid surgery versus medical therapy was established in the 1990s, there is an urgent need to evaluate whether surgery remains cost-effective in the UK. METHODS A decision model was developed to estimate the lifetime costs and utilities of modern medical therapy with and without carotid endarterectomy in patients with symptomatic stenosis from the perspective of the UK National Health Service. The base-case population consisted of adults aged 70 years with 70-99 per cent stenosis. Model data were obtained from clinical studies and wider literature. Univariate and probabilistic sensitivity analyses were carried out. RESULTS In the base-case scenario, the 5-year absolute risk reduction with carotid endarterectomy was 5 per cent, and the incremental cost-effectiveness ratio was €12 021 (exchange rate £1 GBP = €1.1125 (Tuesday 1 January 2019)) per quality-adjusted life-year. Surgery was more cost-effective if performed rapidly after presentation. In patients with 50-69 per cent carotid stenosis, surgery appeared less clinically effective. However, there was considerable uncertainty. CONCLUSION Surgery may not now be clinically effective and cost-effective in those with moderate carotid stenosis. However, these results are uncertain because of the limited data on modern medical therapy and an RCT may be justified.
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Affiliation(s)
- Daniel Perez-Troncoso
- Health Technology Assessment and Quality of Care Area, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - David Epstein
- Department Applied Economics, University of Granada, Granada, Spain
| | - Alun Huw Davies
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ankur Thapar
- Mid and South Essex Vascular Unit, Mid and South Essex Hospitals NHS Foundation Trust, Essex, England.,Centre for Circulatory Health, Anglia Ruskin University, Cambridge, England
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Fan W, Shi W, Lu S, Guo W, Tong J, Tan J, Yu B. Analysis of the anatomic eligibility for transcarotid artery revascularization in Chinese patients who underwent carotid endarterectomy and transfemoral carotid artery stenting. Front Cardiovasc Med 2023; 9:1045598. [PMID: 36684575 PMCID: PMC9852860 DOI: 10.3389/fcvm.2022.1045598] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 12/06/2022] [Indexed: 01/09/2023] Open
Abstract
Objective Transcarotid artery revascularization (TCAR) is thought to be a promising technique and instrument for treating carotid stenosis with favorable outcomes. Since there remain several differences in anatomic characteristics among races, this study was conducted to investigate the anatomic eligibility of TCAR in Chinese patients who underwent carotid revascularization. Methods A retrospective review of patients with carotid stenosis from 2019 to 2021 was conducted. The anatomic eligibility of TCAR was based on the instruction of the ENROUTE Transcarotid Neuroprotection System. The carotid artery characteristics and configuration of the circle of Willis (CoW) were evaluated by CT angiography. The demographic and clinical characteristics and procedure-related complications were recorded. Logistic regression was used to analyze the independent factors for TCAR eligibility. Results Of 289 consecutive patients [222 for carotid endarterectomy (CEA) and 67 for transfemoral carotid artery stenting (TF-CAS)] identified, a total of 215 patients (74.4%) met TCAR anatomic eligibility. Specifically, 83.7% had mild common carotid artery (CCA) puncture site plaque, 95.2% had 4-9 mm internal carotid artery diameters, 95.8% had >6 mm CCA diameter, and 98.3% had >5 cm clavicle to carotid bifurcation distance. Those who were female (OR, 5.967; 95% CI: 2.545-13.987; P < 0.001), were of an older age (OR, 1.226; 95% CI: 1.157-1.299; P < 0.001), and higher body mass index (OR, 1.462; 95% CI: 1.260-1.697; P < 0.001) were prone to be associated with TCAR ineligibility. In addition, 71 patients with TCAR eligibility (33.0%) were found to combine with incomplete CoW. A high risk for CEA was found in 29 patients (17.3%) with TCAR eligibility, and a high risk for TF-CAS was noted in nine patients (19.1%) with TCAR eligibility. Overall, cranial nerve injury (CNI) was found in 22 patients after CEA, while 19 of them (11.3%) met TCAR eligibility. Conclusion A significant proportion of Chinese patients meet the anatomic criteria of TCAR, making TCAR a feasible treatment option in China. Anatomic and some demographic factors play key roles in TCAR eligibility. Further analysis indicates a potential reduction of procedure-related complications in patients with high-risk carotid stenosis under the TCAR procedure.
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Affiliation(s)
- Weijian Fan
- Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China,Fudan Zhangjiang Institute, Shanghai, China,Department of Vascular Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Weihao Shi
- Department of Vascular Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Shuangshuang Lu
- Department of Nursing, Huashan Hospital of Fudan University, Shanghai, China
| | - Wencheng Guo
- Department of Vascular Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Jindong Tong
- Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China
| | - Jinyun Tan
- Fudan Zhangjiang Institute, Shanghai, China,Department of Vascular Surgery, Huashan Hospital of Fudan University, Shanghai, China,*Correspondence: Jinyun Tan ✉
| | - Bo Yu
- Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China,Fudan Zhangjiang Institute, Shanghai, China,Bo Yu ✉
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Liu L, Yi X, Luo H, Yu M. Inflammation and endothelial function relevant genetic polymorphisms in carotid stenosis in southwestern China. Front Neurol 2023; 13:1076898. [PMID: 36686520 PMCID: PMC9848733 DOI: 10.3389/fneur.2022.1076898] [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: 10/22/2022] [Accepted: 12/01/2022] [Indexed: 01/05/2023] Open
Abstract
Aim To evaluate the relationship between carotid stenosis with variants in genes referred to inflammation and endothelial function. Methods There was a multi-center, cross sectional survey in southwestern China. The eight communities were selected at random in southwestern China. The residents aged ≥40 years volunteered to participate in face-to-face survey. Subjects with at least three of the aforementioned eight stroke related risk factors or a history of stroke were classified as high-risk population for stroke. A total of 2,377 subjects were the high-risk population for stroke in the eight communities, and degree of carotid stenosis was assessed by carotid ultrasound. Genotypes of 6 variants in 3 genes related to inflammation and endothelial function were examined. Gene-gene interaction was analyzed by generalized multifactor dimensionality reduction (GMDR). Results Carotid stenosis were found in 295 (12.41%) subjects, of whom 51 (17.29%) had moderate or severe stenosis. According to multivariate logistic regression analysis, we found that HABP2rs7923349TT was independent risk factor for carotid stenosis (OR, 1.96, 95% CI: 1.22-3.13, P = 0.005) and ITGA2rs1991013AG and HABP2rs7923349TT were independent risk factors for moderate to severe carotid stenosis (OR, 2.28, 95% CI: 1.28-4.07, P = 0.005; OR, 2.90, 95% CI: 1.19-7.08, P = 0.019). GMDR analysis showed that there was a significant gene-gene interaction between ITGA2 rs4865756 and HABP2 rs7923349, and the high-risk interactive genotype in the two variants was independently associated with a higher risk for carotid stenosis after adjusting the covariates (OR,1. 42, 95% CI 1.10-1.84, P = 0.008). Conclusions Prevalence of carotid stenosis was very high in the high-risk stroke population in southwestern China. Variants in genes referred in endothelial function were associated with the carotid stenosis. The high-risk interactive genotype in ITGA2 rs4865756 and HABP2 rs7923349 was independently associated with a higher risk for carotid stenosis.
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Affiliation(s)
- Lin Liu
- Department of Neurology, The People's Hospital of Deyang City, Deyang, China
| | - Xingyang Yi
- Department of Neurology, The People's Hospital of Deyang City, Deyang, China,*Correspondence: Xingyang Yi ✉
| | - Hua Luo
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ming Yu
- Department of Neurology, The Suining Central Hospital, Suining, China
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 184] [Impact Index Per Article: 184.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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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: 2] [Impact Index Per Article: 2.0] [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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Hernandez AM, Burkett GW, Pham N, Abbey CK, Boone JM. Performance of high-resolution CT for detection and discrimination tasks related to stenotic lesions - A phantom study using model observers. Med Phys 2022; 50:2037-2048. [PMID: 36583447 DOI: 10.1002/mp.16194] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/04/2022] [Accepted: 12/15/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Accurate detection and grading of atheromatous stenotic lesions within the cardiac, renal, and intracranial vasculature is imperative for early recognition of disease and guiding treatment strategies. PURPOSE In this work, a stenotic lesion phantom was used to compare high resolution and normal resolution modes on the same CT scanner in terms of detection and size discrimination performance. MATERIALS AND METHODS The phantom is comprised of three acrylic cylinders (each 15.0 cm in diameter and 1.3 cm thick) with a matching array of holes in each module. The outer two modules contain holes that are slightly larger than the corresponding hole in the central module to simulate stenotic narrowing in vasculature. The stack of modules was submerged in an iodine solution simulating contrast-enhanced stenotic lesions with a range of lumen diameters (1.32-10.08 mm) and stenosis severity (0%, 50%, 60%, 70%, and 80%). The phantom was imaged on the Canon Aquilion Precision high-resolution CT scanner in high-resolution (HR) mode (0.25 mm × 0.50 mm detector element size) and normal-resolution (NR) mode (0.50 mm × 0.50 mm) using 120 kV and two dose levels (14 and 21 mGy SSDE) with 30 repeat scans acquired for each combination. Filtered back-projection (FBP) and a hybrid-iterative reconstruction (AIDR) were used with the FC18 kernel, as well as a deep learning algorithm (AiCE) which is only available for HR. A non-prewhitening model observer with an eye filter was implemented to quantify performance for detection and size discrimination tasks in the axial plane. RESULTS Detection performance improved with increasing diameter, dose, and for AIDR in comparison to FBP for a fixed resolution mode. Performance in the HR mode was generally higher than NR for the smaller lumen diameters (1-5 mm) with decreasing differences as the diameter increased. Performance in NR mode surpassed HR mode for lumen diameters greater than ∼4 mm and ∼5 mm for 14 mGy and 21 mGy, respectively. AiCE provided consistently higher detection performance compared with AIDR-FC18 (48% higher for a 6 mm lumen diameter). Discrimination performance increased with increasing nominal diameter, dose, and for larger differences in stenosis severity. When comparing discrimination performance in HR to NR modes, the largest relative differences occur at the smallest nominal diameters and smallest differences in stenosis severity. The AiCE reconstruction algorithm produced the highest overall discrimination performance values, and these were significantly higher than AIDR-FC18 for nominal diameters of 7.14 and 10.08 mm. CONCLUSIONS HR mode outperforms NR for detection up to a specific diameter and the results improve with AiCE and for higher dose levels. For the task of size discrimination, HR mode consistently outperforms NR if AIDR-FC18 is used for dose levels of at least 21 mGy, and the results improve with AiCE and for the smallest differences in stenosis severity investigated (50% vs. 60%). High-resolution CT appears to be beneficial for detecting smaller simulated lumen diameters (<5 mm) and is generally advantageous for discrimination tasks related to stenotic lesions, which inherently contain information at higher frequencies, given the right reconstruction algorithm and dose level.
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Affiliation(s)
- Andrew M Hernandez
- Department of Radiology, University of California Davis, Sacramento, California, USA
| | - George W Burkett
- Department of Radiology, University of California Davis, Sacramento, California, USA
| | - Nancy Pham
- Department of Radiology, University of California Los Angeles, Los Angeles, California, USA
| | - Craig K Abbey
- Department of Psychological & Brain Sciences, University of California Santa Barbara, Santa Barbara, California, USA
| | - John M Boone
- Department of Radiology, University of California Davis, Sacramento, California, USA.,Department of Biomedical Engineering, University of California Davis, Davis, California, USA
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Paramasivan NK, Sylaja PN, Pitchai S, Madathipat U, Sreedharan SE, Sukumaran S, Vinoda Thulaseedharan J. Carotid Endarterectomy for Symptomatic Carotid Stenosis: Differences in Patient Profile in a Low-Middle-Income Country. Cerebrovasc Dis Extra 2022; 13:56-62. [PMID: 36481594 PMCID: PMC10080201 DOI: 10.1159/000528515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/20/2022] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Carotid endarterectomy (CEA) is the standard treatment for patients with symptomatic carotid stenosis. Data from low- and middle-income countries are sparse on CEA and its outcomes. We aimed to describe the profile of our patients and factors associated with periprocedural cerebral ischemic events in patients with symptomatic carotid stenosis who underwent CEA in our institute. METHODS Retrospective review of patients with symptomatic carotid stenosis (50-99%) who underwent CEA between January 2011 and December 2021 was done. Clinical and imaging parameters and their influence on periprocedural cerebral ischemic events were analyzed. RESULTS Of the 319 patients (77% males) with a mean age of 64 years (SD±8.6), 207 (65%) presented only after a stroke. Majority (85%) had high-grade stenosis (≥70%) of the symptomatic carotid. The mean time to CEA was 50 days (SD±36); however, only 26 patients (8.2%) underwent surgery within 2 weeks. Minor strokes and TIA occurred in 2.2%, while major strokes and death occurred in 4.1% patients. None of the clinical or imaging parameters predicted the periprocedural cerebral ischemic events. The presence of co-existing significant (≥50%) tandem intracranial atherosclerosis (n = 77, 24%) or contralateral occlusion (n = 24, 7.5%) did not influence the periprocedural stroke risk. CONCLUSION There is a delay in patients undergoing CEA for symptomatic carotid stenosis. Majority have high-grade stenosis and present late only after a stroke reflecting a lack of awareness. CEA can be performed safely even in patients with significant intracranial tandem stenosis and contralateral carotid occlusion.
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Affiliation(s)
- Naveen Kumar Paramasivan
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Padmavathy N Sylaja
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Shivanesan Pitchai
- Department of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Unnikrishnan Madathipat
- Department of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Sapna Erat Sreedharan
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Sajith Sukumaran
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Jissa Vinoda Thulaseedharan
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
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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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Puig N, Camps-Renom P, Camacho M, Aguilera-Simón A, Jiménez-Altayó F, Fernández-León A, Marín R, Martí-Fàbregas J, Sánchez-Quesada JL, Jiménez-Xarrié E, Benitez S. Plasma sICAM-1 as a Biomarker of Carotid Plaque Inflammation in Patients with a Recent Ischemic Stroke. Transl Stroke Res 2022; 13:745-756. [PMID: 35237947 PMCID: PMC9391243 DOI: 10.1007/s12975-022-01002-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/24/2022] [Accepted: 02/23/2022] [Indexed: 11/12/2022]
Abstract
18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) identifies carotid plaque inflammation and predicts stroke recurrence in patients with atherothrombotic stroke. The aim of the study was to identify plasma inflammatory biomarkers associated with plaque inflammation according to 18F-FDG uptake. We conducted a prospective study of consecutive adult patients with a recent (< 7 days) anterior circulation ischemic stroke and at least one atherosclerotic plaque in the ipsilateral internal carotid artery. We included 64 patients, 57.8% of whom showed a carotid stenosis ≥ 50%. All patients underwent an early (< 15 days from inclusion) 18F-FDG PET, and a blood sample was obtained at days 7 ± 1 from the stroke. The plasma concentration of 16 inflammation-related molecules was analyzed in a Luminex using xMAP technology. Multivariable linear regression was used to assess the association between plasma biomarkers and the standardized uptake value (SUV) of 18F-FDG uptake. Soluble intercellular adhesion molecule-1 (sICAM-1), soluble vascular adhesion molecule-1 (sVCAM-1), and fractalkine (FKN) were independently associated with plaque inflammation (β = 0.121, 95% CI 0.061-0.181, p < 0.001; β = 0.144, 95% CI 0.012-0.276, p = 0.033; β = 0.136, 95% CI 0.037-0.235, p = 0.008). In a multivariable logistic regression analysis, sICAM-1 was associated with SUVmax ≥ 2.85 (OR = 1.02, 95% CI 1.00-1.03, p = 0.020). Multivariable Cox regression was used to assess the association between biomarkers and stroke recurrence. sICAM-1 was associated with stroke recurrence (HR = 1.03, 95% CI 1.00-1.05, p = 0.002). In summary, elevated concentrations of sICAM-1 were associated with carotid plaque inflammation and an increased risk of stroke recurrence in patients with recent ischemic stroke and carotid atherosclerosis.
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Affiliation(s)
- Núria Puig
- Cardiovascular Biochemistry, Biomedical Research Institute Sant Pau (IIB-Sant Pau), Barcelona, Spain
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, Building M, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Barcelona, Spain
| | - Pol Camps-Renom
- Stroke Unit, Department of Neurology, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Mercedes Camacho
- Genetic of Complexes Diseases, Biomedical Research Institute Sant Pau (IIB-Sant Pau), Barcelona, Spain
| | - Ana Aguilera-Simón
- Stroke Unit, Department of Neurology, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Francesc Jiménez-Altayó
- Department of Pharmacology, Neuroscience Institute, Faculty of Medicine, UAB, Cerdanyola del Vallès, Barcelona, Spain
| | - Alejandro Fernández-León
- Department of Nuclear Medicine, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Rebeca Marín
- Stroke Unit, Department of Neurology, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Joan Martí-Fàbregas
- Stroke Unit, Department of Neurology, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Jose Luis Sánchez-Quesada
- Cardiovascular Biochemistry, Biomedical Research Institute Sant Pau (IIB-Sant Pau), Barcelona, Spain
- CIBER of Diabetes and Metabolic Diseases (CIBERDEM), Madrid, Spain
| | - Elena Jiménez-Xarrié
- Stroke Unit, Department of Neurology, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Sonia Benitez
- Cardiovascular Biochemistry, Biomedical Research Institute Sant Pau (IIB-Sant Pau), Barcelona, Spain.
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Gao HL, Han BS, Zhang K, Wang ZL, Gao BL, Li TX, Zhu LF. Effects of carotid artery stenting on cognitive impairment in patients with severe symptomatic carotid artery stenosis. Medicine (Baltimore) 2022; 101:e30605. [PMID: 36123929 PMCID: PMC9478282 DOI: 10.1097/md.0000000000030605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The effect of carotid artery stenting and medication on improvement of cognitive function in patients with severe symptomatic carotid artery stenosis is unknown. To investigate the effect of stenting compared with medication alone for severe carotid atherosclerotic stenosis on cognitive impairment. Patients with carotid stenosis and cognitive impairment were prospectively randomly divided into 2 groups of stenting or medication alone. Cognitive function was evaluated with the Montreal cognitive assessment (MoCA), Mini-Mental State Examination, and Barthel Index of Activities of Daily Living (BI). Continuous data in normal distribution were tested with the t-test but with the Mann-Whitney U test if not in normal distribution. Categorical data were presented as frequency and percentages and tested with the Fisher exact test. A P value < .05 was regarded as statistical significant. Carotid artery stenting was successfully performed in all patients (100%) in the stenting group. Compared with before treatment, the Mini-Mental State Examination, MoCA and BI scores at 6 months in the medication alone group and at 1, 3, and 6 months in the stenting group were significantly (P < .005) improved. The stenting group had significantly (P < .05) better scores than the medication alone group at the same time. At 6-month follow-up, the visuospatial/executive functions (3.69 ± 1.42 vs 2.42 ± 1.23), attention (5.24 ± 1.52 vs 3.63 ± 1.47), and language (2.64 ± 0.71 vs 1.96 ± 0.69) were significantly (P < .05) improved in the stenting group compared with the medication alone group. Carotid artery stenting may significantly improve cognitive impairment and neurological function compared with medication alone in patients with severe carotid atherosclerotic stenosis concurrent with cognitive impairment.
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Affiliation(s)
- Hui-Li Gao
- Henan Provincial People’s Hospital, Henan University, Zhengzhou, China
| | - Bing-Sha Han
- Henan Provincial People’s Hospital, Henan University, Zhengzhou, China
| | - Kun Zhang
- Henan Provincial People’s Hospital, Henan University, Zhengzhou, China
| | - Zi-Liang Wang
- Henan Provincial People’s Hospital, Henan University, Zhengzhou, China
| | - Bu-Lang Gao
- Henan Provincial People’s Hospital, Henan University, Zhengzhou, China
| | - Tian-Xiao Li
- Henan Provincial People’s Hospital, Henan University, Zhengzhou, China
- * Correspondence: Tian-Xiao Li, MD, PhD, Department of Interventional Therapy, Henan Provincial People’s Hospital, Henan University, 7 Wei-Wu Road, Zhengzhou, Henan Province, 450003 PR China (e-mail: )
| | - Liang-Fu Zhu
- Henan Provincial People’s Hospital, Henan University, Zhengzhou, China
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Perioperative Medical Management for Symptomatic Carotid Artery Interventions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2022. [DOI: 10.1007/s11936-022-00966-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Štěchovský C, Hulíková Tesárková K, Hájek P, Horváth M, Hansvenclová E, Veselka J. Comparison of 30-Day Outcomes after Carotid Artery Stenting in Patients with Near-Occlusion and Severe Stenosis: A Propensity Score Matching Analysis. AJNR Am J Neuroradiol 2022; 43:1311-1317. [PMID: 35981760 PMCID: PMC9451624 DOI: 10.3174/ajnr.a7598] [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: 03/02/2022] [Accepted: 06/17/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Carotid artery near-occlusion is a type of severe stenosis with complete or partial distal luminal collapse and intracranial collaterals. This study aimed to compare 30-day outcomes and 10-year survival in patients undergoing carotid artery stenting for near-occlusion with a control group of patients with severe stenosis. MATERIALS AND METHODS We used data from a registry of 639 patients who underwent 789 carotid artery stenting procedures between 2005 and 2021. The primary end point was any stroke or death within 30 days after carotid artery stenting. Patients were matched using propensity scores based on 6 variables. RESULTS Propensity score matching yielded 84 subjects in the near-occlusion group matched with 168 subjects in the control group. In the matched cohort, the primary end point occurred in 7 (8.3%) and 11 (6.6%) patients in the near-occlusion and control groups, respectively (P = .611). In the unmatched cohort, the primary end point occurred in 7 (8.3%) and 19 (4.1%) patients (P = .101). Survival in the near-occlusion group versus the control group in the matched cohort at 5 and 10 years was 69.8% (95% CI, 58.0%-78.8%) versus 77.3% (95% CI, 70.0%-83.1%) and 53.3% (95% CI, 39.9%-65.0%) versus 53.3% (95% CI, 44.5%-61.4%) (log-rank, P = .798). CONCLUSIONS Carotid stent placement in patients with ICA near-occlusion was not associated with an increased 30-day risk of stroke or death compared with severe stenosis. Survival up to 10 years after carotid artery stenting was similar in both groups.
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Affiliation(s)
- C Štěchovský
- From the Department of Cardiology (C.Š., P,H., M.H., E.H., J.V.), Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
| | - K Hulíková Tesárková
- Department of Demography and Geodemography (K.H.T.), Faculty of Science, Charles University, Prague, Czech Republic
| | - P Hájek
- From the Department of Cardiology (C.Š., P,H., M.H., E.H., J.V.), Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
| | - M Horváth
- From the Department of Cardiology (C.Š., P,H., M.H., E.H., J.V.), Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
| | - E Hansvenclová
- From the Department of Cardiology (C.Š., P,H., M.H., E.H., J.V.), Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
| | - J Veselka
- From the Department of Cardiology (C.Š., P,H., M.H., E.H., J.V.), Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
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Garcia-Pastor A, Gil-Núñez A, Ramirez-Moreno JM, González-Nafría N, Tejada J, Moniche F, Portilla-Cuenca JC, Martínez-Sánchez P, Fuentes B, Gamero-García MA, de Leciñana MA, Masjuan J, Verge DC, Aladro Y, Parkhutik V, Lago A, de Arce-Borda AM, Usero-Ruiz M, Delgado-Mederos R, Pampliega A, Ximenez-Carrillo Á, Bártulos-Iglesias M, Castro-Reyes E. Endarterectomy, Stenting, or Medical Treatment for Symptomatic Carotid Near-Occlusion: Results from CAOS, a Multicenter Registry Study. AJNR Am J Neuroradiol 2022; 43:1304-1310. [PMID: 35981762 PMCID: PMC9451631 DOI: 10.3174/ajnr.a7617] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/17/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE The treatment of symptomatic carotid near-occlusion is controversial. Our aim was to analyze the results of carotid endarterectomy and carotid artery stent placement in patients with symptomatic carotid near-occlusion and to identify factors related to technical failure, periprocedural complications, and restenosis. MATERIALS AND METHODS We conducted a multicenter, prospective nonrandomized study. Patients with angiography-confirmed carotid near-occlusion were included. We assessed the revascularization rate and periprocedural stroke or death. Twenty-four-month clinical and carotid imaging follow-up was performed, and rates of carotid restenosis or occlusion, ipsilateral stroke, and mortality were analyzed. Carotid artery stent placement, carotid endarterectomy, and medical treatment were compared. RESULTS One hundred forty-one patients were included. Forty-four carotid artery stent placement and 23 carotid endarterectomy procedures were performed within 6 months after the event. Complete revascularization was achieved in 83.6%, 81.8% in the carotid artery stent placement group and 87% with carotid endarterectomy (P = .360). Periprocedural stroke or death occurred in 6% (carotid artery stent placement = 2.3%; carotid endarterectomy = 13%; P = .077) and was not related to revascularization failure. The carotid restenosis or occlusion rate was 8.3% (5% restenosis, 3.3% occlusion); with carotid artery stent placement it was 10.5%; and with carotid endarterectomy it was 4.5% (P = .419). The 24-month cumulative rate of ipsilateral stroke was 4.8% in the carotid artery stent placement group, 17.4% for carotid endarterectomy, and 13.1% for medical treatment (P = .223). Mortality was 12%, 4.5%, and 5.6%, respectively (P = .422). Revascularization failure and restenosis occurred more frequently in patients with full collapse compared with patients without full collapse (33.3% versus 5.6%, P = .009; 21.4% versus 2.9%, P = .032, respectively). CONCLUSIONS Carotid artery stent placement and carotid endarterectomy are associated with high rates of failure and periprocedural stroke. Carotid near-occlusion with full collapse appears to be associated with an increased risk of technical failure and restenosis. Carotid near-occlusion revascularization does not seem to reduce the risk of stroke at follow-up compared with medical treatment.
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Affiliation(s)
- A Garcia-Pastor
- From the Department of Neurology (A.G.-P., A.G.-N., E.C.-R.), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - A Gil-Núñez
- From the Department of Neurology (A.G.-P., A.G.-N., E.C.-R.), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - J M Ramirez-Moreno
- Department of Neurology (J.M.R.-M.), Hospital Universitario Infanta Cristina, Badajoz, Spain
| | - N González-Nafría
- Department of Neurology (N.G.-N., J.T.), Complejo Asistencial Universitario de León, Neurology, Leon, Spain
| | - J Tejada
- Department of Neurology (N.G.-N., J.T.), Complejo Asistencial Universitario de León, Neurology, Leon, Spain
| | - F Moniche
- Department of Neurology (F.M.), Hospital Universitario Virgen del Rocío, Sevilla, Sevilla, Spain
| | - J C Portilla-Cuenca
- Department of Neurology (J.C.P.-C.), Hospital San Pedro Alcántara, Cáceres, Spain
| | - P Martínez-Sánchez
- Department of Neurology (P.M.-S., B.F.), Hospital Universitario La Paz, Madrid, Spain
| | - B Fuentes
- Department of Neurology (P.M.-S., B.F.), Hospital Universitario La Paz, Madrid, Spain
| | - M A Gamero-García
- Department of Neurology (M.A.G.-G.), Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - M A de Leciñana
- Department of Neurology (M.A.d.L., J.M.), Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J Masjuan
- Department of Neurology (M.A.d.L., J.M.), Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - D C Verge
- Department of Neurology (D.C.V.), Corporació Sanitaria Parc Taulí, Sabadell, Spain
| | - Y Aladro
- Department of Neurology (Y.A.), Hospital Universitario de Getafe, Getafe, Spain
| | - V Parkhutik
- Department of Neurology (V.P., A.L.), Hospital Universitari La Fe, Valencia, Spain
| | - A Lago
- Department of Neurology (V.P., A.L.), Hospital Universitari La Fe, Valencia, Spain
| | - A M de Arce-Borda
- Department of Neurology (A.M.d.A.-B), Hospital Universitario de Donostia, Donostia, Spain
| | - M Usero-Ruiz
- Department of Neurology (M.U.-R.), Hospital Universitario de Valladolid, Valladolid, Spain
| | - R Delgado-Mederos
- Department of Neurology (R.D.-M.), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - A Pampliega
- Department of Neurology (A.P.), Hospital General Univeristario de Alicante, Alicante, Spain
| | - Á Ximenez-Carrillo
- Department of Neurology (Á.X.-C.), Hospital Universitario de La Princesa, Madrid, Spain
| | - M Bártulos-Iglesias
- Department of Neurology (M.B.-I.), Hospital Universitario de Burgos, Burgos, Spain
| | - E Castro-Reyes
- From the Department of Neurology (A.G.-P., A.G.-N., E.C.-R.), Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Webb AJS, Wartolowska KA, Li L, Mazzucco S, Rothwell PM. Consistencies and Differences in Intermediate Physiological Phenotypes of Vascular Ageing between Ischaemic Stroke Aetiologies. Cerebrovasc Dis 2022; 52:194-201. [PMID: 35998558 PMCID: PMC7615998 DOI: 10.1159/000525764] [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] [Received: 11/22/2021] [Accepted: 03/24/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Arterial stiffness, cerebral pulsatility, and beat-to-beat blood pressure variability partly mediate the relationship between hypertension and stroke, but it is unknown if these intermediate phenotypes of vascular ageing differ between stroke aetiologies. We therefore aimed to characterize differences in these intermediate cardiovascular phenotypes between patients presenting with strokes of different aetiologies. METHODS In consecutive patients on best medical management 1 month after TIA or nondisabling stroke (Oxford Vascular Study), arterial stiffness (PWV) was measured by applanation tonometry (Sphygmocor), middle cerebral blood flow velocity, and pulsatility index (MCA-PI) were measured by transcranial ultrasound (TCD, DWL Doppler Box), and beat-to-beat BP variability was measured with a Finometer. Differences between patients with large artery (LAS), small vessel (SVD), cardioembolic (CE), or undetermined events were derived, including adjustment for cardiovascular risk factors. Relationships were characterized by mixed linear models. RESULTS In 909 eligible patients, MCA-PI, PWV, and SBPV were all positively skewed. Mean values were greatest in LAS than CE and lowest in SVD (p < 0.001). However, after adjustment for age, sex, and risk factors, PI was greatest in LAS and lowest in CE stroke, whilst PWV was greatest in SVD and undetermined stroke (p < 0.001). In multivariate linear models, age was more strongly associated with PWV and PI in patients with small vessel stroke than other aetiologies, particularly under the age of 65, but SBPV was only weakly associated with demographic indices in all stroke subtypes. CONCLUSIONS Intermediate cardiovascular phenotypes of vascular ageing had similar demographic associations between stroke aetiologies, but these were particularly strong in patients with small vessel stroke under the age of 65, implying a potential role of these phenotypes in increasing stroke risk in this patient group.
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Affiliation(s)
| | | | - Linxin Li
- Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, UK
| | - Sara Mazzucco
- Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, UK
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, UK
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