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Viticchi G, Falsetti L, Altamura C, Di Felice C, Vernieri F, Bartolini M, Silvestrini M. Impact of carotid stenosis on the outcome of stroke patients submitted to reperfusion treatments: a narrative review. Rev Neurosci 2024; 35:575-583. [PMID: 38459676 DOI: 10.1515/revneuro-2024-0002] [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: 01/04/2024] [Accepted: 02/18/2024] [Indexed: 03/10/2024]
Abstract
Intravenous thrombolysis (IT) and mechanical thrombectomy (MD) are the two interventional approaches that have changed the outcome of patients with acute ischemic stroke (AIS). Ipsilateral and contralateral carotid stenosis (ICS, CCS) play an important role in regulating cerebral hemodynamics, both in chronic and acute situations such as AIS. Several studies have explored their role in the incidence and severity of stroke, but very few have investigated the possible impact of ICS and CCS on the efficacy of interventional procedures. The purpose of this review was to I) highlight the incidence and prevalence of carotid stenosis (CS); II) assess the impact of ICS and CCS on cerebral hemodynamics; III) evaluate the effect of carotid stenosis on the efficacy of interventional therapies (IT and MT) for AIS; and IV) report therapeutic complications related to CS. We searched PubMed/Medline for case reports, reviews, and original research articles on English-language review topics during the period from January 1, 2000 to October 1, 2023. CS is associated with 15-20 % of the total number of AIS. ICS and CCS had a negative influence on both cerebral hemodynamics before AIS and outcome after interventional procedures (IT, MT alone or in bridging). Available data on cerebral hemodynamics and efficacy of interventional therapies for AIS suggest a negative role of CS. Therefore, early diagnosis of CS may be considered relevant to preventive and post-stroke treatment strategies.
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Affiliation(s)
- Giovanna Viticchi
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Lorenzo Falsetti
- Clinica Medica, Clinical and Molecular Sciences Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Claudia Altamura
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, via Álvaro del Portillo n.200, 00128, Rome, Italy
| | - Chiara Di Felice
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Fabrizio Vernieri
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, via Álvaro del Portillo n.200, 00128, Rome, Italy
| | - Marco Bartolini
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Mauro Silvestrini
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
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Fan Y, Lv Y, Fu M, Wang J, Cui Y, Zhang B, Lu Y, Chen L. Relationship between maximum carotid plaque area and prognosis of patients with acute ischaemic stroke. Ir J Med Sci 2024:10.1007/s11845-024-03739-w. [PMID: 38890259 DOI: 10.1007/s11845-024-03739-w] [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: 04/21/2024] [Accepted: 06/12/2024] [Indexed: 06/20/2024]
Abstract
OBJECTIVE In this study, the relationship between maximum carotid plaque area and stroke prognosis was analysed by carotid ultrasonography, and the relevant risk factors affecting the prognosis of acute ischaemic stroke (AIS) were investigated to provide novel insights into stroke prevention and management. METHODS A total of 205 AIS patients with carotid plaques were included in this study. Based on the mRS score at discharge, patients with AIS were classified into the good prognosis group (mRS ≤ 2) and poor prognosis group (mRS ≥ 3). SPSS 25.0 was used to analyse the data. Univariate and multivariate analyses were performed on the two groups with good and poor prognosis. Comparison between good and poor prognosis in patients with AIS in different circulatory systems was performed using the Kruskal-Wallis test. Differences were considered statistically significant at P < 0.05. RESULTS Comparison of baseline data revealed differences in carotid plaque diameter, carotid intima-media thickness, maximum carotid plaque area, history of previous stroke and plaque echogenicity between the good and poor prognosis groups (P < 0.05). Results of multifactorial analyses of logistic binary regression indicated that history of previous stroke and maximum carotid plaque area were predictors of poor prognosis, with odds ratio of 2.515 (95%CI [1.327-4.764]) and 1.019 (95%CI [1.006-1.032]), respectively. CONCLUSION The maximum carotid plaque area and history of previous stroke are important predictors for assessing prognosis in patients with AIS.
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Affiliation(s)
- Yani Fan
- Tangshan Gongren Hospital, Tangshan City, Hebei Province, China
| | - Yue Lv
- Tangshan Gongren Hospital, Tangshan City, Hebei Province, China
| | - Meng Fu
- The Third Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province, China
| | - Jianhua Wang
- Tangshan Gongren Hospital, Tangshan City, Hebei Province, China
| | - Ying Cui
- Tangshan Gongren Hospital, Tangshan City, Hebei Province, China
| | - Binbin Zhang
- Tangshan Gongren Hospital, Tangshan City, Hebei Province, China
| | - Yadan Lu
- Tangshan Gongren Hospital, Tangshan City, Hebei Province, China
| | - Lili Chen
- Tangshan Gongren Hospital, Tangshan City, Hebei Province, China.
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Teter K, Willems L, Harish K, Negash B, Warle M, Rockman C, Torres J, Ishida K, Jacobowitz G, Garg K, Maldonado T. Optimal medical therapy is lacking in patients undergoing intervention for symptomatic carotid artery stenosis and protects against larger areas of cerebral infarction. Vascular 2024:17085381241262927. [PMID: 38876778 DOI: 10.1177/17085381241262927] [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: 06/16/2024]
Abstract
OBJECTIVES Carotid interventions are indicated for both patients with symptomatic and a subset of patients with severe asymptomatic carotid artery stenosis (CAS). Symptomatic CAS accounts for up to 12%-25% of overall carotid interventions, but predictors of symptomatic presentation remain poorly defined. The aim of this study was to identify factors associated with symptomatic CAS in our patient population. METHODS Between January 2015 and February 2022, an institutional retrospective cohort study of prospectively collected data on patients undergoing interventions for CAS was performed. Procedures included carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TF-CAS). Demographic data, comorbidities, procedural details, and anatomic features from various imaging modalities were collected. Comparisons were made between symptomatic (symptoms within the prior 6 months) and asymptomatic patients. RESULTS During the study period, 279 patients who underwent intervention for symptomatic CAS were paired with a randomly selected cohort of 300 patients who underwent intervention for asymptomatic CAS from a total patient cohort of 1143 patients undergoing interventions for asymptomatic CAS. Demographic data did not differ between groups. Patients with symptomatic CAS more frequently had prior TIA/stroke (>6 months remote to the current event), but less frequently had coronary artery disease or chronic kidney disease and were less likely to receive adequate medical management including antihypertensive agents, lipid-lowering agents, and anti-platelet therapy. On multivariate analysis, remote prior TIA/stroke and lack of anti-platelet therapy remained significant. Among symptomatic patients presenting with stroke, lack of anti-platelet therapy was associated with an overall larger area of parenchymal involvement. No difference was observed with single versus dual anti-platelet therapy. Furthermore, symptomatic patients were more likely to have ulcerated plaques (30.9% vs 18%, p < .001), and symptomatic patients with ulcerated plaques more frequently had less than 50% compared to moderate/severe CAS. Nine patients who presented with symptoms had mild CAS and underwent intervention. CONCLUSIONS Symptomatic CAS was associated with a history of remote prior symptoms and lack of anti-platelet therapy at time of presentation. Furthermore, symptomatic patients not on anti-platelet agents were more likely to have a greater area of parenchymal involvement when presenting with stroke and symptomatic patients with ulcerated plaques were more likely to have mild CAS, suggesting the role of plaque instability in symptomatic presentation. These findings underscore the importance of appropriate medical management and adherence in all patients with CAS and perhaps a role for more frequent surveillance in those with potentially unstable plaque morphology.
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Affiliation(s)
| | - Loes Willems
- Radbound University Medical Center, Nijmegen, The Netherlands
| | | | | | - Michiel Warle
- Radbound University Medical Center, Nijmegen, The Netherlands
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Mohammadi T, Hooshanginezhad Z, Mohammadi B, Dolatshahi S. The association of stroke risk factors with the future thickness of carotid atherosclerotic plaques. Neurol Res 2023; 45:818-826. [PMID: 37125820 DOI: 10.1080/01616412.2023.2208484] [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: 01/06/2023] [Accepted: 04/23/2023] [Indexed: 05/02/2023]
Abstract
OBJECTIVES An advancing atherosclerotic plaque is a risk factor for stroke. We conducted this study to assess the relationship between risk factors of stroke with changing in the thickness of carotid plaques thickness evident on sonography. METHODS We carried out a secondary analysis of data from a study on carotid bifurcation plaques. Data were collected in the sonography laboratories of two university hospitals. In total, 564 (240; 42.6% men) patients with atherosclerotic plaques in the carotid bifurcation and internal carotid artery with stenosis ≥ 30% evident on duplex sonography were included. We developed machine learning models using an extreme gradient boosting algorithm with Shapley additive explanation method to find important risk factors and their interactions. The outcome was a change in the carotid plaque thickness after 36 months, and the predictors were initial plaque thickness and the risk factors of stroke. RESULTS Two regression models were developed for left and right carotid arteries. The R-squared values were 0.964 for the left, and 0.993 for the right model. Overall, the three top features were BMI, age, and initial plaque thickness for both left and right plaques. However, the risk factors of stroke showed stronger interaction in predicting plaque thickening of the left carotid more than the right carotid artery. DISCUSSION The effect of each predictor on plaque thickness is complicated by interactions with other risk factors, particularly for the left carotid artery. The side of carotid artery involvement should be considered for stroke prevention.
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Affiliation(s)
- Tanya Mohammadi
- College of Science, School of Mathematics, Statistics, and Computer Science, University of Tehran, Tehran, Iran
| | - Zahra Hooshanginezhad
- School of Medicine, Department of Cardiology, Jahrom University of Medical Sciences, Jahrom, Iran
| | | | - Sina Dolatshahi
- Shahid Rajaiee Heart Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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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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Altamura C, Viticchi G, Rizzo AC, Maggio P, Brunelli N, Marcosano M, Lazzaro VD, Fiacco F, Agostoni EC, Silvestrini M, Vernieri F. Stroke territory and atherosclerosis in ischemic stroke patients with a history of migraine with aura. Front Neurol 2023; 14:1142424. [PMID: 36923493 PMCID: PMC10008946 DOI: 10.3389/fneur.2023.1142424] [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: 01/11/2023] [Accepted: 02/02/2023] [Indexed: 03/01/2023] Open
Abstract
Introduction The mechanisms subtending the increased stroke risk in migraine with aura (MA) are not fully understood. Our study aims to evaluate if the clinical profile in stroke patients with MA differentiates from those without MA. Methods We retrieved the prospective registered electronic clinical dossiers of adult patients younger than 60 years with acute ischemic stroke admitted in four hospitals between January 2016 and June 2022. Patients were classified by the history of MA (MA+ and MA-). Results We identified 851 stroke patients (59 MA+, 6.9%). Compared to MA-, MA+ patients were characterized by younger age (44.0 ± 10.6 vs 50.1 ± 8.2 years), female sex (59.3% vs 29.0%), and affected by cryptogenic (OR 2.594 95% CI 1.483-4.537), and cerebellar stroke (OR 3.218 95% CI 1.657-6.250; p ≤ 0.001 for all comparisons). After adjusting for age and sex, MA+ patients presented less frequently hypertension (OR 0.349 95% CI 0.167-0.470; p=0.005) and dyslipidemia (OR 0.523 95% CI 0.280-0.974; p = 0.041). After adjusting also for risk factors, the MA+ group had less frequently symptomatic large vessel stenosis (OR 0.126 95% CI 0.017-0,924; p = 0.042) and clinical atherosclerosis (OR 0.103 95% CI 0.014-0.761; p = 0.026), while intima-media thickness did not differ (p = 0.395). Discussion Cryptogenic and cerebellar stroke and fewer vascular risk factors and clinical atherosclerosis seem to characterize stroke patients with MA.
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Affiliation(s)
- Claudia Altamura
- Department of Medicine and Surgery, Unit of Headache and Neurosonology, Università Campus Bio-Medico di Roma, Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- *Correspondence: Claudia Altamura ✉
| | | | - Angelo Cascio Rizzo
- Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Paola Maggio
- Neurology Unit, ASST Bergamo Est, Seriate, Italy
| | - Nicoletta Brunelli
- Department of Medicine and Surgery, Unit of Headache and Neurosonology, Università Campus Bio-Medico di Roma, Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Marilena Marcosano
- Department of Medicine and Surgery, Unit of Headache and Neurosonology, Università Campus Bio-Medico di Roma, Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Vincenzo Di Lazzaro
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology, and Psychiatry, Università Campus Bio-Medico di Roma, Roma, Italy
| | | | | | | | - Fabrizio Vernieri
- Department of Medicine and Surgery, Unit of Headache and Neurosonology, Università Campus Bio-Medico di Roma, Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
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Carotid plaque components and other carotid artery features associated with risk of stroke: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2022; 31:106857. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/06/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022] Open
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Kim HW, Regenhardt RW, D'Amato SA, Nahhas MI, Dmytriw AA, Hirsch JA, Silverman SB, Martinez-Gutierrez JC. Asymptomatic carotid artery stenosis: a summary of current state of evidence for revascularization and emerging high-risk features. J Neurointerv Surg 2022:jnis-2022-018732. [DOI: 10.1136/jnis-2022-018732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/23/2022] [Indexed: 11/03/2022]
Abstract
Carotid artery stenosis is a leading cause of ischemic stroke. While management of symptomatic carotid stenosis is well established, the optimal approach in asymptomatic carotid artery stenosis (aCAS) remains controversial. The rapid evolution of medical therapies within the time frame of existing landmark aCAS surgical revascularization trials has rendered their findings outdated. In this review, we sought to summarize the controversies in the management of aCAS by providing the most up-to-date medical and surgical evidence. Subsequently, we compile the evidence surrounding high-risk clinical and imaging features that might identify higher-risk lesions. With this, we aim to provide a practical framework for a precision medicine approach to the management of aCAS.
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Lim EY, Cho AH. Dynamic Changes of Carotid Atherosclerosis and Their Relation with Stroke Recurrence in Patients with Stroke or Transient Ischemic Attack. Curr Neurovasc Res 2022; 19:303-310. [PMID: 35996235 DOI: 10.2174/1567202619666220822141804] [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: 06/15/2022] [Revised: 07/05/2022] [Accepted: 07/14/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to show dynamic changes in carotid and vertebral artery using carotid Doppler ultrasonography (DUS) through a long-term follow- up exam, and determine their associations with stroke recurrence. METHODS We consecutively enrolled stroke or transient ischemic attack (TIA) patients who had undergone DUS more than twice with intervals of three months or more. Stroke recurrence during follow-up was also investigated by reviewing medical records. Progress or regress of plaque was defined as more than 0.1 mm change from the initial scan with a semi-quantitative measurement. The development of new plaque was also regarded as plaque progress. Increased intima-media thickness and plaque presence were interpreted at the initial and follow-up scans. Factors related to progression or regression were analyzed. The relationship between plaque change and stroke recurrence was investigated. RESULTS A total of 201 patients were enrolled (186 ischemic stroke patients and 15 TIA patients). There were 61 (30.3%) females. Their mean age was 64.2 ± 9.9 years. During a follow-up of 35.0 ± 22.6 (mean ± SD) months, plaque progress was observed in 92 (45.8%) and plaque regress in 13 (6.5%). Stroke recurred in 18 patients. Plaque progression showed no significant association with age, risk factors, statin use, or subtype. After adjustment of age, sex, diabetes, and stroke subtype, multiple logistic regression showed a significant association of plaque progression with stroke recurrence (odds ratio: 3.8, 95% confidence interval: 1.1 to 13.1, p = 0.034). Patients with plaque regress were significantly younger than those without plaque regress (57.8 years vs. 64.6 years, p = 0.041). CONCLUSION Plaque progression occurred in 46% of stroke or TIA patients. Plaque progression was significantly associated with clinical stroke recurrence. Plaque regressed in 6.5% of patients. Patients with regression were younger than those without.
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Affiliation(s)
- Eun-Ye Lim
- Department of Neurology, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - A-Hyun Cho
- Department of Neurology, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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10
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Management of atherosclerotic extracranial carotid artery stenosis. Lancet Neurol 2022; 21:273-283. [DOI: 10.1016/s1474-4422(21)00359-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/30/2021] [Accepted: 10/08/2021] [Indexed: 02/05/2023]
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Carotid Artery Plaque Progression: Proposal of a New Predictive Score and Role of Carotid Intima-Media Thickness. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19020758. [PMID: 35055580 PMCID: PMC8776120 DOI: 10.3390/ijerph19020758] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/05/2022] [Accepted: 01/08/2022] [Indexed: 02/04/2023]
Abstract
Background: We aimed to investigate if the carotid intima-media thickness (IMT) at baseline and the HAD2S score, composed of the sum of single risk factors (hypertension, age ≥ 75 years, diabetes, dyslipidemia, smoking), were predictive of plaque progression. Methods: We performed a retrospective analysis on real-life prospectively collected data from patients with any detectable carotid plaque at follow up. The plaque score, calculated at baseline (T0) and at a median follow up of 36.6 months (IQR 39.6–34.3) (T3), was defined as 0: no plaque or stenosis < 30%; 1: stenosis in the range 30–49%; 2: in the range 50–69%; 3: in the range 70–99% and 4: occlusion. Carotid IMT was measured at T0 and T3; HAD2S score was calculated at baseline. Results: We included 340 patients with a mean age of 69.9 (9.1) years and 25.3% subjects had plaque progression. Individuals with progression had a median HAD2S score of 3 (1) while those without progression had 2 (1). Patients with progression had a mean baseline IMT of 0.86 (0.17) while those without progression had 0.77 (0.18) (p < 0.0001). A correlation between progression and baseline IMT was found (p = 0.002). Conclusion: Baseline IMT could be considered a predictor of progression. Patients with progression had an HAD2S score higher than those without evolution.
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Wang W, Wu J, Liu P, Tang X, Pang H, Xie T, Xu F, Shao J, Chen Y, Liu B, Zheng Y. Urinary Proteomics Identifying Novel Biomarkers for the Diagnosis and Phenotyping of Carotid Artery Stenosis. Front Mol Biosci 2021; 8:714706. [PMID: 34447787 PMCID: PMC8383446 DOI: 10.3389/fmolb.2021.714706] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/26/2021] [Indexed: 01/12/2023] Open
Abstract
Background: Carotid artery stenosis (CAS) is caused by the formation of atherosclerotic plaques inside the arterial wall and accounts for 20–30% of all strokes. The development of an early, noninvasive diagnostic method and the identification of high-risk patients for ischemic stroke is essential to the management of CAS in clinical practice. Methods: We used the data-independent acquisition (DIA) technique to conduct a urinary proteomic study in patients with CAS and healthy controls. We identified the potential diagnosis and risk stratification biomarkers of CAS. And Ingenuity pathway analysis was used for functional annotation of differentially expressed proteins (DEPs). Furthermore, receiver operating characteristic (ROC) analysis was performed to evaluate the diagnostic values of DEPs. Results: A total of 194 DEPs were identified between CAS patients and healthy controls by DIA quantification. The bioinformatics analysis showed that these DEPs were correlated with the pathogenesis of CAS. We further identified 32 DEPs in symptomatic CAS compared to asymptomatic CAS, and biological function analysis revealed that these proteins are mainly related to immune/inflammatory pathways. Finally, a biomarker panel of six proteins (ACP2, PLD3, HLA-C, GGH, CALML3, and IL2RB) exhibited potential diagnostic value in CAS and good discriminative power for differentiating symptomatic and asymptomatic CAS with high sensitivity and specificity. Conclusions: Our study identified novel potential urinary biomarkers for noninvasive early screening and risk stratification of CAS.
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Affiliation(s)
- Wei Wang
- State Key Laboratory of Complex Severe and Rare Disease, Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianqiang Wu
- State Key Laboratory of Complex Severe and Rare Disease, Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peng Liu
- State Key Laboratory of Complex Severe and Rare Diseases, Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoyue Tang
- State Key Laboratory of Complex Severe and Rare Diseases, Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haiyu Pang
- State Key Laboratory of Complex Severe and Rare Diseases, Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ting Xie
- State Key Laboratory of Complex Severe and Rare Diseases, Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fang Xu
- State Key Laboratory of Complex Severe and Rare Disease, Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiang Shao
- State Key Laboratory of Complex Severe and Rare Disease, Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuexin Chen
- State Key Laboratory of Complex Severe and Rare Disease, Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bao Liu
- State Key Laboratory of Complex Severe and Rare Disease, Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuehong Zheng
- State Key Laboratory of Complex Severe and Rare Disease, Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Viticchi G, Falsetti L, Potente E, Bartolini M, Silvestrini M. Impact of carotid stenosis on cerebral hemodynamic failure and cognitive impairment progression: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1209. [PMID: 34430650 PMCID: PMC8350657 DOI: 10.21037/atm-20-7226] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 03/05/2021] [Indexed: 11/13/2022]
Abstract
Carotid atherosclerosis has a relevant impact on cerebral blood flow regulation. There is accruing evidence that hemodynamic impairment related to the presence of a significant carotid lumen narrowing may predispose to the development of cerebral dysfunctions, including a reduction in cognitive abilities. In the last years an increasing number of findings showed that carotid stenosis did contribute to cognitive impairment not only in relation to the occurrence of cerebral ischemic lesions, but also as an independent risk factor. The principal mechanisms involved are chronic hypoperfusion, microembolization and cerebrovascular reactivity impairment. Moreover, more recent studies showed alterations of regional functional connectivity. In this narrative review, we analyzed the relationships between carotid stenosis, cerebral hemodynamic derangement and cognitive impairment onset and progression, and underlined that cognitive impairment is the final result of the complex interaction between different elements, including also collateral circulation, cerebral hemodynamic status, brain connectivity and pro-inflammatory state. Further, therapeutic approaches, with a specific focus on vascular risk factors correction and on the effectiveness of surgical or endovascular interventions were discussed. We particularly focused our attention on the concept of “asymptomatic carotid stenosis”, and how could a cognitive impairment improve after an intervention, and how this could change the indications to surgical approach. Larger studies and randomized controlled trials are urgently required to better define time, characteristics and effectiveness of both medical and surgical/endovascular approaches.
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Affiliation(s)
| | - Lorenzo Falsetti
- Internal and Subintensive Medicine, Ospedali Riuniti Ancona, Italy
| | - Eleonora Potente
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Marco Bartolini
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
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Kamtchum-Tatuene J, Noubiap JJ, Wilman AH, Saqqur M, Shuaib A, Jickling GC. Prevalence of High-risk Plaques and Risk of Stroke in Patients With Asymptomatic Carotid Stenosis: A Meta-analysis. JAMA Neurol 2021; 77:1524-1535. [PMID: 32744595 DOI: 10.1001/jamaneurol.2020.2658] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Importance There is an ongoing debate regarding the management of asymptomatic carotid stenosis. Previous studies have reported imaging features of high-risk plaques that could help to optimize the risk-benefit ratio of revascularization. However, such studies have not provided an accurate estimate of the prevalence of high-risk plaques and the associated annual incidence of ipsilateral ischemic cerebrovascular events to inform the design of clinical trials using a risk-oriented selection of patients before randomization. Objective To assess the relevance and feasibility of risk-oriented selection of patients for revascularization. Data Sources A systematic search of PubMed and Ovid Embase from database inception to July 31, 2019, was performed. Study Selection Prospective observational studies that reported prevalence of high-risk plaques and incidence of ipsilateral ischemic cerebrovascular events were included. Data Extraction and Synthesis Aggregated data were pooled using random-effects meta-analysis. Data were analyzed from December 16, 2019, to January 15, 2020. Main Outcomes and Measures Prevalence of high-risk plaques and annual incidence of ipsilateral ischemic events. Results Overall, 64 studies enrolling 20 751 participants aged 29 to 95 years (mean age range, 55.0-76.5 years; proportion of men, 45%-87%) were included in the meta-analysis. Among all participants, the pooled prevalence of high-risk plaques was 26.5% (95% CI, 22.9%-30.3%). The most prevalent high-risk plaque features were neovascularization (43.4%; 95% CI, 31.4%-55.8%) in 785 participants, echolucency (42.3%; 95% CI, 32.2%-52.8%) in 12 364 participants, and lipid-rich necrotic core (36.3%; 95% CI, 27.7%-45.2%) in 3728 participants. The overall incidence of ipsilateral ischemic cerebrovascular events was 3.2 events per 100 person-years (22 cohorts with 10 381 participants; mean follow-up period, 2.8 years; range, 0.7-6.5 years). The incidence of ipsilateral ischemic cerebrovascular events was higher in patients with high-risk plaques (4.3 events per 100 person-years; 95% CI, 2.5-6.5 events per 100 person-years) than in those without high-risk plaques (1.2 events per 100 person-years; 95% CI, 0.6-1.8 events per 100 person-years), with an odds ratio of 3.0 (95% CI, 2.1-4.3; I2 = 48.8%). In studies focusing on severe stenosis (9 cohorts with 2128 participants; mean follow-up period, 2.8 years; range, 1.4-6.5 years), the incidence of ipsilateral ischemic cerebrovascular events was 3.7 events per 100 person-years (95% CI, 1.9-6.0 events per 100 person-years). The incidence of ipsilateral ischemic cerebrovascular events was also higher in patients with high-risk plaques (7.3 events per 100 person-years; 95% CI, 2.0-15.0 events per 100 person-years) than in those without high-risk plaques (1.7 events per 100 person-years; 95% CI, 0.6-3.3 events per 100 person-years), with an odds ratio of 3.2 (95% CI, 1.7-5.9; I2 = 39.6%). Conclusions and Relevance High-risk plaques are common in patients with asymptomatic carotid stenosis, and the associated risk of an ipsilateral ischemic cerebrovascular event is higher than the currently accepted estimates. Extension of routine assessment of asymptomatic carotid stenosis beyond the grade of stenosis may help improve risk stratification and optimize therapy.
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Affiliation(s)
- Joseph Kamtchum-Tatuene
- Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jean Jacques Noubiap
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, Royal Adelaide Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Alan H Wilman
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Maher Saqqur
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Glen C Jickling
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Zhang K, Lin Q, Zhang T, Guo D, Cao L. Contemporary Prevalence and risk factors of carotid artery stenosis in asymptomatic low-income Chinese individuals: a population-based study. Postgrad Med 2020; 132:650-656. [PMID: 32590917 DOI: 10.1080/00325481.2020.1788319] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Carotid artery stenosis (CAS) is an established risk factor for cerebrovascular disease. However, the contemporary prevalence and risk factors of CAS in asymptomatic rural Chinese individuals, especially low-income populations, remains unclear. Therefore, we aimed to explore the present prevalence and risk factors of CAS in a low-income Chinese population. METHODS A total of 3126 people aged ≥ 45 years without history of stroke or cardiovascular disease were recruited for this study. B-mode ultrasonography was performed to evaluate the presence of CAS. We used multivariate analysis to determine potential risk factors for CAS. RESULTS The overall prevalence of CAS in this population was 6.7%, with a prevalence of 8.8% for men and 5.0% for women. The risk of CAS increased with older age and a higher level of low-density lipoprotein cholesterol (LDL-C), systolic blood pressure (SBP), and fasting blood glucose (FBG) (all P < 0.05). Each 1-mmHg increase in SBP increased the risk of CAS by 0.011 times, each 1-mmol/L increase in LDL-C increased the risk of CAS by 0.192 times, and each 1-mmol/L increase in FBG increased the risk of CAS by 0.067 times. In addition, the risk of CAS increased 52.9% in men compared to that in women, increased 100.2% in current drinkers compared to that in never drinkers, and increased 38.9% in patients with diabetes compared to those without diabetes (all P < 0.05). CONCLUSIONS These findings suggest that the prevalence of CAS remains high in low-income individuals. Male sex, older age, current drinking, diabetes, and high levels of LDL-C, SBP, and FBG increase the risk of CAS. Thus, to prevent cerebrovascular disease and reduce the severe disease-associated burden for low-income individuals, there is a definitive need to control the risk factors of CAS.
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Affiliation(s)
- Kai Zhang
- Department of Geriatrics, Tianjin Medical University General Hospital , Tianjin, China
| | - Qiuxing Lin
- Department of Neurology, Tianjin Medical University General Hospital , Tianjin, China.,Laboratory of Epidemiology, Tianjin Neurological Institute , Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City , Tianjin, China
| | - Tianyu Zhang
- Department of Geriatrics, Tianjin Medical University General Hospital , Tianjin, China
| | - Dandan Guo
- Centre of Ultrasound, Tianjin Medical University General Hospital , Tianjin, China
| | - Li Cao
- Department of Geriatrics, Tianjin Medical University General Hospital , Tianjin, China
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Pathakota SR, Durgaprasad R, Velam V, Ay L, Kasala L. Correlation of coronary artery calcium score and carotid artery intima-media thickness with severity of coronary artery disease. J Cardiovasc Thorac Res 2020; 12:78-83. [PMID: 32626546 PMCID: PMC7321008 DOI: 10.34172/jcvtr.2020.14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 04/08/2020] [Indexed: 12/26/2022] Open
Abstract
Introduction: Coronary artery calcium score (CACS) and carotid artery intima-media thickness (CIMT) are the markers of atherosclerosis. An association between CACS and CIMT with presence of atherosclerotic coronary artery disease (CAD) is well established. However relationship between severity of CAD with CACS and CIMT is less clear. This study aimed to investigate the correlation between severity of CAD assessed by SYNTAX and Gensini scores with CACS and CIMT. Methods: This prospective study was conducted on 351 patients with CAD between June 2015 to December 2016. CACS was obtained using AGATSTON algorithm with 128 slice multidetector computer tomography (MDCT) before conventional coronary angiography (CCA). CIMT was measured by using Philips IE33 Echo machine. The severity of CAD was assessed by SYNTAX score (SS) and Gensini score on CCA. Correlation between severity of CAD with CACS and CIMT was analysed. Results: Mean CACS was 241.5±463.7, and this was positively correlated with over all SS (r=0.417, P <0.0001) and Gensini score (r=0.405, P<0.0001). Mean CIMT was 0.80±0.18 mm and this was also significantly correlated with SS (r=0.450, P<0.0001) and Gensini score (r=0.459,<0.0001). Multivariate analysis showed that CACS was independently associated with diabetes mellitus (β:0.11, P=0.021), SS (β:0.251, P =0.010) and mean CIMT (β:0.128, P =0.028). Receiver-operating characteristic (ROC) curve analysis revealed a cut off CACS of >493 for SS≥33 (high-SS tertile). Conclusion: Our study confirmed a significant correlation between CACS and CIMT with the severity of CAD assessed by SS and Gensini scores. CACS and CIMT may be considered as important noninvasive diagnostic modalities in the assessment of the severity of CAD.
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Affiliation(s)
- Sudhakar Reddy Pathakota
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Rajasekhar Durgaprasad
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Vanajakshamma Velam
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Lakshmi Ay
- Department of Radiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Latheef Kasala
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
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Connolly F, Röhl JE, Guthke C, Wengert O, Valdueza JM, Schreiber SJ. Emergency Room Use of "Fast-Track" Ultrasound in Acute Stroke: An Observational Study. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:1103-1111. [PMID: 30773376 DOI: 10.1016/j.ultrasmedbio.2019.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 01/01/2019] [Accepted: 01/04/2019] [Indexed: 06/09/2023]
Abstract
Early information on vascular status in acute stroke is essential. We analyzed whether duplex ultrasound (DUS) using a fast-track protocol provides this information without relevant delay. One hundred forty-six patients were prospectively enrolled. DUS was performed by sonographers with two levels of experience. The carotid and vertebral arteries, as well as all basal cerebral arteries, were bilaterally analyzed. Criteria for vessel analysis were (i) normal or stenosis <50%, (ii) stenosis ≥50% and (iii) occlusion. The mean duration of the ultrasound investigation was 6:07 ± 2:06 min with a significant difference between more and less experienced investigators (p < 0.0001). Insonation times decreased during the study in both groups. The sensitivity, specificity, positive predictive value and negative predictive value of ultrasound findings in comparison with computed tomography angiography were 73%, 99%, 84% and 98%, respectively. Our data suggest that "fast track" DUS is feasible and reliable. The time required for DUS assessment depends on the sonographer´s experience.
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Affiliation(s)
- Florian Connolly
- Department of Neurology, Charité, Universitätsmedizin Berlin, Berlin, Germany.
| | - Jens-Eric Röhl
- Department of Neurology, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Carolin Guthke
- Department of Neurology, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Oliver Wengert
- Department of Neurology, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - José M Valdueza
- Neurological Center, Segeberger Kliniken, Bad Segeberg, Germany
| | - Stephan J Schreiber
- Department of Neurology, Asklepios Fachklinikum Brandenburg, Brandenburg an der Havel, Germany
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Transfemoral Carotid Artery Stents Should Be Used with Caution in Patients with Asymptomatic Carotid Artery Stenosis. Ann Vasc Surg 2019; 54:1-11. [DOI: 10.1016/j.avsg.2018.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 09/30/2018] [Accepted: 10/09/2018] [Indexed: 11/24/2022]
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Functional Assessment of Intermediate Vascular Disease. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7619092. [PMID: 29850561 PMCID: PMC5925208 DOI: 10.1155/2018/7619092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 09/12/2017] [Accepted: 01/28/2018] [Indexed: 11/19/2022]
Abstract
Interventional treatment in various vascular beds has advanced tremendously. However, there are several problems to be considered. We searched the literature and tried to analyze major parts of it. One is safety and applicability of coronary proven methods in other vascular beds. An unresolved problem is the functional assessment of intermediate lesions, as far as various target organs have quite different circulation from the coronary one and the functional tests should be modified in order to be applicable and meaningful. In the majority of the acute vascular syndromes, the culprit lesion is of intermediate size on visual assessment. On the other hand, a procedurally successfully managed high-degree stenosis is not always followed by clinical and prognostic benefit. In vascular beds, where collateral network naturally exists, the readings from the functional assessment are complicated and thus the decision for interventional treatment is even more difficult. Here come into help the functional assessment and imaging with IVUS, OCT, high-resolution MRI, and contrast enhanced CT or SPECT. The focus of the current review is on the functional assessment of intermediate stenosis in other vascular beds, unlike the coronary arteries.
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Paraskevas KI, Veith FJ, Spence JD. How to identify which patients with asymptomatic carotid stenosis could benefit from endarterectomy or stenting. Stroke Vasc Neurol 2018; 3:92-100. [PMID: 30022795 PMCID: PMC6047337 DOI: 10.1136/svn-2017-000129] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 02/06/2018] [Accepted: 02/07/2018] [Indexed: 11/23/2022] Open
Abstract
Offering routine carotid endarterectomy (CEA) or carotid artery stenting (CAS) to patients with asymptomatic carotid artery stenosis (ACS) is no longer considered as the optimal management of these patients. Equally suboptimal, however, is the policy of offering only best medical treatment (BMT) to all patients with ACS and not considering any of them for prophylactic CEA. In the last few years, there have been many studies aiming to identify reliable predictors of future cerebrovascular events that would allow the identification of patients with high-risk ACS and offer a prophylactic carotid intervention only to these patients to prevent them from becoming symptomatic. All patients with ACS should receive BMT. The present article will summarise the evidence suggesting ways to identify these high-risk asymptomatic individuals, namely: (1) microemboli detection on transcranial Doppler, (2) plaque echolucency on Duplex ultrasound, (3) progression in the severity of ACS, (4) silent embolic infarcts on brain CT/MRI, (5) reduced cerebrovascular reserve, (6) increased size of juxtaluminal hypoechoic area, (7) identification of intraplaque haemorrhage using MRI and (8) carotid ulceration. The evidence suggests that approximately 10%-15% of patents with asymptomatic stenosis might benefit from intervention; this will become more clear after publication of ongoing studies comparing stenting or endarterectomy with best medical therapy. In the meantime, no patient should be offered intervention unless there is evidence of high risk of ipsilateral stroke, from modalities such as those discussed here.
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Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular and Endovascular Surgery, Royal Free Hospital, London, UK
| | - Frank J Veith
- Department of Vascular Surgery, New York University Langone Medical Center, New York, USA
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Canada
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21
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Methods for Ultrasound Screening of Cardiovascular Diseases in Type 2 Diabetic Patients. ACTA MEDICA BULGARICA 2018. [DOI: 10.2478/amb-2018-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract
Diabetes mellitus is a chronic disorder that affects predominantly the carbohydrate metabolism, but also the biotransformation of proteins and fat. Many intra- and extracellular metabolic mechanisms are impaired which leads to structural changes in the vascular wall and the heart muscle. This eventually causes their functional deterioration and the end result is clinical manifestation of macrovascular incidents or heart failure. People with perturbations of the glucose metabolism (impaired fasting glucose, impaired glucose tolerance and insulin resistance) are also with a higher risk of cardiovascular diseases, even before the diagnosis of diabetes. Nowadays we have a cheap, easy and non-invasive method for early diagnosis of cardiovascular disorders, way before their clinical manifestation, and that is the ultrasound methodology. The echocardiography is a valuable technique for the detection of changes in the myocardial structure and its contractility. The tissue Doppler ultrasound is a more precise method that can detect the slightest aberrations in the heart muscle function, that could not be seen with the conventional echocardiography. Subclinical atherosclerotic changes can be determined with a Doppler scan of the big arteries (carotids, renal arteries), and the subsequent calculation of their resistive index and of the intima-media thickness. There are a lot of studies in this field which show that the structural and functional impairment could be diagnosed in diabetic patients without any complaints and with otherwise healthy hearts. This means that these diagnostic methods should be used in the routine clinical examination of every diabetic individual in order to predict and possibly prevent major cardiovascular events and severe heart failure.
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Abbott AL, Silvestrini M, Topakian R, Golledge J, Brunser AM, de Borst GJ, Harbaugh RE, Doubal FN, Rundek T, Thapar A, Davies AH, Kam A, Wardlaw JM. Optimizing the Definitions of Stroke, Transient Ischemic Attack, and Infarction for Research and Application in Clinical Practice. Front Neurol 2017; 8:537. [PMID: 29104559 PMCID: PMC5654955 DOI: 10.3389/fneur.2017.00537] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 09/25/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND PURPOSE Until now, stroke and transient ischemic attack (TIA) have been clinically based terms which describe the presence and duration of characteristic neurological deficits attributable to intrinsic disorders of particular arteries supplying the brain, retina, or (sometimes) the spinal cord. Further, infarction has been pathologically defined as death of neural tissue due to reduced blood supply. Recently, it has been proposed we shift to definitions of stroke and TIA determined by neuroimaging results alone and that neuroimaging findings be equated with infarction. METHODS We examined the scientific validity and clinical implications of these proposals using the existing published literature and our own experience in research and clinical practice. RESULTS We found that the proposals to change to imaging-dominant definitions, as published, are ambiguous and inconsistent. Therefore, they cannot provide the standardization required in research or its application in clinical practice. Further, we found that the proposals are scientifically incorrect because neuroimaging findings do not always correlate with the clinical status or the presence of infarction. In addition, we found that attempts to use the proposals are disrupting research, are otherwise clinically unhelpful and do not solve the problems they were proposed to solve. CONCLUSION We advise that the proposals must not be accepted. In particular, we explain why the clinical focus of the definitions of stroke and TIA should be retained with continued sub-classification of these syndromes depending neuroimaging results (with or without other information) and that infarction should remain a pathological term. We outline ways the established clinically based definitions of stroke and TIA, and use of them, may be improved to encourage better patient outcomes in the modern era.
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Affiliation(s)
- Anne L. Abbott
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- The Neurology Department, The Alfred Hospital, Melbourne, VIC, Australia
| | | | - Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, QLD, Australia
| | - Alejandro M. Brunser
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana – Universidad del Desarrollo, Santiago, Chile
| | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Centre of Utrecht, Utrecht, Netherlands
| | - Robert E. Harbaugh
- Department of Neurosurgery, Penn State University, State College, PA, United States
| | - Fergus N. Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Department of Medicine, Elderly Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, Miami, FL, United States
| | - Ankur Thapar
- Imperial College Healthcare NHS Trust, London, United Kingdom
- Imperial College, London, United Kingdom
| | - Alun H. Davies
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, United Kingdom
| | - Anthony Kam
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia
| | - Joanna M. Wardlaw
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences, UK Dementia Research Institute at the University of Edinburgh, Edinburgh, United Kingdom
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Dharmakidari S, Bhattacharya P, Chaturvedi S. Carotid Artery Stenosis: Medical Therapy, Surgery, and Stenting. Curr Neurol Neurosci Rep 2017; 17:77. [DOI: 10.1007/s11910-017-0786-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Vasudeva Chetty P, Rajasekhar D, Vanajakshamma V, Ranganayakulu KP, Kranthi Chaithanya D. Aortic velocity propagation: A novel echocardiographic method in predicting atherosclerotic coronary artery disease burden. J Saudi Heart Assoc 2017; 29:176-184. [PMID: 28652671 PMCID: PMC5475356 DOI: 10.1016/j.jsha.2016.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 10/02/2016] [Accepted: 10/13/2016] [Indexed: 11/26/2022] Open
Abstract
Background The major burden of cardiovascular disease mortality around the globe is due to atherosclerosis and its complications. Hence its early detection and management with easily accessible and noninvasive methods are valuable. Aortic velocity propagation (AVP) through color M-mode of the proximal descending aorta determines aortic stiffness, reflecting atherosclerosis. The aim of this study was to find the utility of AVP in predicting coronary artery disease (CAD) burden assessed through SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) score and compared with carotid intima-media thickness (CIMT), which is an established surrogate marker of atherosclerosis. Methods In this cross-sectional comparative study, we measured AVP by color M-mode and CIMT by using Philips QLAB-IMT software in 100 patients, who underwent conventional coronary angiogram (CAG) between May 2013 and November 2014. Coronary artery disease is considered significant if >50% diameter stenosis is present in any epicardial coronary artery and insignificant if otherwise. Results Initially, to know the normal range we measured AVP and CIMT in 50 patients without any major risk factors for CAD but CAG was not done. Aortic velocity propagation ranged from 46 cm/s to 76 cm/s (mean = 58.62 ± 6.46 cm/s), CIMT ranged from 0.50 mm to 0.64 mm (mean = 0.55 ± 0.03 mm). Among 100 patients who underwent CAG we found 69% had significant CAD, 13% had insignificant CAD, and 18% had normal coronaries. Those with significant CAD had significantly lower AVP (41.65 ± 4.94 cm/s) [F (2,97) = 44.05, p < 0.0001] and significantly higher CIMT (0.86 ± 0.11 mm) [F (2,97) =35.78, p < 0.0001]. AVP had significant strong negative correlation with CIMT (r = −0.836, p < 0.0001, n = 100) and SYNTAX score (r = –0.803, p < 0.0001, n = 69), while CIMT was positively correlated with SYNTAX score significantly (r = 0.828, p < 0.0001, n = 69). Conclusions AVP and CIMT can predict CAD burden in a robust way. AVP may emerge as an exquisite bedside tool to predict atherosclerotic burden and guide in implementing preventive therapy for cardiovascular disease.
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Affiliation(s)
- Pakala Vasudeva Chetty
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, IndiaaIndia
| | - Durgaprasad Rajasekhar
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, IndiaaIndia
| | - Velam Vanajakshamma
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, IndiaaIndia
| | | | - Dommara Kranthi Chaithanya
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, IndiaaIndia
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Kurosaki Y, Yoshida K, Fukuda H, Handa A, Chin M, Yamagata S. Asymptomatic Carotid T1-High-Intense Plaque as a Risk Factor for a Subsequent Cerebrovascular Ischemic Event. Cerebrovasc Dis 2017; 43:250-256. [DOI: 10.1159/000455973] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 01/10/2017] [Indexed: 01/06/2023] Open
Abstract
Background: Intraplaque hemorrhage, detected as a high-signal intensity on carotid MRI, is also strongly associated with ischemic events in symptomatic patients. However, in asymptomatic patients, the relationship of the T1-high intense plaque and the subsequent stroke is not clear. The aim of this study is to test the hypothesis that asymptomatic carotid T1-high intense plaque is a risk factor for a subsequent cerebrovascular ischemic event. Methods: Of the 1,353 consecutive patients, who underwent head and carotid MRI as part of their annual medical check-up, the imaging quality of 13 was poor and 150 did not present for follow-up examination, thus leaving 1,190 subjects for evaluation. Of the 1,190 patients, 96 patients had findings of high-signal intensity on carotid MRI and 1,094 patients did not. Cerebrovascular events were retrospectively evaluated. Results: During a mean follow-up period of 53 months, 4 patients with high-signal intensities on carotid MRI (4%) and 3 with no findings (0.3%) had a cerebrovascular ischemic event, with the occurrences significantly higher in the high-signal-intensity group. (p < 0.01) Cox regression analysis indicated that the presence of the high-intense plaque on carotid MRI (hazard ratio [HR] 4.2; 95% CI 1.0-17.1; p = 0.04), age (HR 1.1; 95% CI 1.0-1.2; p = 0.003), and diabetes mellitus (HR 7.2; 95% CI 1.8-27.4; p = 0.004) were associated with the occurrence of subsequent ischemic cerebrovascular events. Conclusions: Asymptomatic carotid T1-high-intense plaque might be a potential high-risk factor for a subsequent cerebrovascular ischemic event.
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Kurkowska-Jastrzebska I, Karlinski MA, Błazejewska-Hyzorek B, Sarzynska-Dlugosz I, Filipiak KJ, Czlonkowska A. Carotid intima media thickness and blood biomarkers of atherosclerosis in patients after stroke or myocardial infarction. Croat Med J 2017; 57:548-557. [PMID: 28051279 PMCID: PMC5209935 DOI: 10.3325/cmj.2016.57.548] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
AIM To test if circulating levels of markers of inflammation, endothelial function, and chronic infections, as well as association between these markers and carotid intima media thickness (CIMT), depend on the stage of atherosclerosis expressed as a history of a major vascular event. METHODS The associations were analyzed separately in 75 healthy controls, 79 patients 3-6 months after the first-ever non-cardioembolic ischemic stroke (IS), and 37 patients 3-6 months after the first-ever myocardial infarction (MI). Data were collected prospectively in 2005. We measured high sensitivity C-reactive protein (hs-CRP), procalcitonin, E-selectin, intercellular adhesion molecule-1 (ICAM-1), serum level of immune complexes (IC), and identified antibodies against Herpes simplex virus type 1 (HSV), Cytomegalovirus, Chlamydia pneumonia, and Helicobacter pylori. Correlations with CIMT were determined using Pearson R and verified after adjustment for age, sex, hypertension, diabetes, and statin therapy. RESULTS Median ICAM-1 concentration was significantly lower in controls than in post-IS patients (188 μg/L vs 215 μg/L), and significantly lower in post-IS patients than in post-MI patients (215 μg/L vs 260 μg/L). Control patients also had significantly lower IC level (0.03 U/L) and HSV antibody index (6.0) compared to both post-IS (0.6 U/L, 9.6) and post-MI (0.4 U/L, 9.2) patients. CIMT was correlated with age (Pearson R=0.38, P=0.001) in the control group, immune complexes (R=0.26, P=0.023) in the post-IS group, and with hs-CRP (R=0.40, P=0.017) in the post-MI group. These correlations were confirmed using multiple regression analysis. CONCLUSIONS Our study supports linear correlations between CIMT and IC and hs-CRP levels. However, these associations seem to depend on the type of vascular burden.
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Affiliation(s)
- Iwona Kurkowska-Jastrzebska
- Iwona Kurkowska-Jastrzebska, 2nd Department of Neurology, Institute of Psychiatry and Neurology, ul. Sobieskiego 9, 02-957 Warsaw, Poland,
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Wang D, Wang J, Jin C, Ji R, Wang A, Li X, Gao X, Wu S, Zhou Y, Zhao X. Asymptomatic Extracranial Artery Stenosis and the Risk of Cardiovascular and Cerebrovascular Diseases. Sci Rep 2016; 6:33960. [PMID: 27650877 PMCID: PMC5030632 DOI: 10.1038/srep33960] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 09/02/2016] [Indexed: 11/23/2022] Open
Abstract
Asymptomatic extracranial artery stenosis (ECAS) is a well-known risk factor for stroke events, but it remains unclear whether it has the same role in predicting cardiovascular and cerebrovascular diseases, especially in China. We investigated the potential associations between ECAS, carotid plaque and carotid intima-media thickness and the new occurrence of cardiovascular and cerebrovascular diseases in the study. Out of 5440 study participants, 364 showed an asymptomatic ECAS at baseline, and 185 had come up to the final vascular events (brain infarction, intracerebral hemorrhage, subarachnoid hemorrhage, coronary heart disease and death due to the vascular diseases). During the follow- up. ECAS, carotid plaque and its instability and increased CIMT have associated with vascular events significantly (P < 0.05). After adjusting relevant vascular risk factors, ECAS still has a strong relationship with the new occurrence of vascular events, especially the brain infarction (HR: 2.101; 95% CI: 1.027–4.298; P = 0.042). We observed a clear relationship between ECAS and the new occurrence of cardiovascular and cerebrovascular disease, especially the brain infarction event. Carotid plaque and its instability and increased CIMT have all relevant with the occurrence of vascular events. Our findings provide direct evidence for the importance of ECAS in vascular events occurrence.
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Affiliation(s)
- Dandan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jing Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Cheng Jin
- Department of Cardiology, Kailuan Hospital, Tangshan, China
| | - Ruijun Ji
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xin Li
- Department of interventional neurology, the affiliated hospital of Qingdao university, Qingdao, China
| | - Xiang Gao
- Department of Nutrition, Harvard University School of Public Health, Boston, MA, USA.,Channing Laboratory, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Shouling Wu
- Department of Cardiology, Kailuan Hospital, Tangshan, China
| | - Yong Zhou
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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Jashari F, Ibrahimi P, Bajraktari G, Grönlund C, Wester P, Henein MY. Carotid plaque echogenicity predicts cerebrovascular symptoms: a systematic review and meta-analysis. Eur J Neurol 2016; 23:1241-7. [PMID: 27106563 DOI: 10.1111/ene.13017] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 03/02/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE Many reports have shown an association between hypoechoic (echolucent) carotid atherosclerotic plaques and unstable features. In this meta-analysis our aim was to determine the role of carotid plaque echogenicity in predicting future cerebrovascular (CV) symptoms. METHODS Electronic databases (PubMed, MEDLINE, EMBASE and Cochrane Center Register) up to September 2015 were systematically searched. Studies with ultrasound-based characterization of carotid artery plaque echogenicity and its association with focal neurological symptoms of vascular origin were eligible for analysis. In the meta-analysis, heterogeneity was measured using I(2) statistics and publication bias was evaluated using the Begg-Mazumdar test. In addition several comparisons between subgroups were performed. RESULTS Of 1387 identified reports, eight studies with asymptomatic patients and three studies with symptomatic patients were meta-analyzed. Pooled analysis showed an association between echolucent carotid plaques and future CV events in asymptomatic patients [relative risk 2.72 (95% confidence interval 1.86-3.96)] and recurrent symptoms in symptomatic patients [relative risk 2.97 (95% confidence interval 1.85-4.78)]. The association was preserved for all stenosis degrees in asymptomatic patients, whilst patients with echolucent plaques and severe stenosis were at higher risk of future events. Also, computer-assisted methods for assessment of carotid plaque echogenicity and studies analyzing ultrasound data collected after the year 2000 showed better prediction. CONCLUSIONS In asymptomatic and symptomatic patients, analysis of carotid plaque echogenicity could identify those at high risk of CV events.
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Affiliation(s)
- F Jashari
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - P Ibrahimi
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - G Bajraktari
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - C Grönlund
- Department of Biomedical Engineering - Radiation Sciences, Umeå University, Umeå, Sweden
| | - P Wester
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institute, Stockholm, Sweden
| | - M Y Henein
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Vouillarmet J, Helfre M, Maucort-Boulch D, Riche B, Thivolet C, Grange C. Carotid atherosclerosis progression and cerebrovascular events in patients with diabetes. J Diabetes Complications 2016; 30:638-43. [PMID: 26969577 DOI: 10.1016/j.jdiacomp.2016.01.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 01/25/2016] [Accepted: 01/27/2016] [Indexed: 10/22/2022]
Abstract
AIM Carotid atherosclerosis progression is associated with a higher risk of cerebrovascular events but there is no specific data for diabetes. We assessed in a cohort of patients with diabetes the rate of atherosclerosis progression by Doppler ultrasonography and the association with cerebrovascular events. METHODS We analyzed a retrospective cohort of 342 patients with a mean duration of diabetes of 13.6 ± 10.6 years. The mean delay between the first and last Doppler ultrasonography was 6.4 ± 4.6 years, with a mean of 3.4 examinations per person. Cerebrovascular events were noted. RESULTS A progression of carotid atherosclerosis was observed in 20.1% of cases. No factor was significantly associated with progression. A prophylactic carotid endarterectomy was performed on 6 of the 27 patients with a stenosis ≥50%. A cerebrovascular event occurred in 1.2% of patients; none of them had carotid atherosclerosis progression. CONCLUSIONS Carotid atherosclerosis progression in patients with diabetes is frequent but surgical treatment and cerebrovascular events are low. The benefit of a systematic follow-up of carotid atherosclerosis seems limited.
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Affiliation(s)
- Julien Vouillarmet
- Department of Endocrinology, Diabetes and Nutrition, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France.
| | - Marjorie Helfre
- Department of Vascular Medicine, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France
| | - Delphine Maucort-Boulch
- Department of Biostatistics, Hospices Civil de Lyon, Lyon, France; Université Lyon I, Villeurbanne, France; CNRS, UMR 5558, Laboratoire Biostatistiques Sante, Pierre-Bénite, France
| | - Benjamin Riche
- Department of Biostatistics, Hospices Civil de Lyon, Lyon, France; Université Lyon I, Villeurbanne, France; CNRS, UMR 5558, Laboratoire Biostatistiques Sante, Pierre-Bénite, France
| | - Charles Thivolet
- Department of Endocrinology, Diabetes and Nutrition, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France; Inserm U1060, Faculté de Médecine Lyon sud, Oullins, France
| | - Claire Grange
- Department of Vascular Medicine, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France
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Duplex-assisted carotid artery stenting without administration of contrast medium for patients with chronic kidney disease or allergic reaction. Neuroradiology 2016; 58:679-86. [DOI: 10.1007/s00234-016-1678-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/15/2016] [Indexed: 01/03/2023]
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Huibers A, de Borst GJ, Bulbulia R, Pan H, Halliday A. Plaque Echolucency and the Risk of Ischaemic Stroke in Patients with Asymptomatic Carotid Stenosis Within the First Asymptomatic Carotid Surgery Trial (ACST-1). Eur J Vasc Endovasc Surg 2015; 51:616-21. [PMID: 26725253 DOI: 10.1016/j.ejvs.2015.11.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE/BACKGROUND On ultrasound, potentially "high risk" carotid plaques may appear echolucent. In this study, whether a confident classification of echolucent plaque was a predictor of future ipsilateral ischaemic stroke in asymptomatic patients randomized to medical therapy in the Asymptomatic Carotid Surgery Trial-1 (ACST-1) was assessed. METHODS We performed a post-hoc analysis of 814 ACST-1 patients randomized to medical therapy alone with baseline plaque assessment classified as definitely echolucent (> 25% soft plaque) or nonecholucent (< 25% soft plaque). Kaplan-Meier survival curves were used to compare cumulative rates of ipsilateral ischaemic stroke in both groups. RESULTS In the first 5 years after randomization, a significantly higher risk of ipsilateral stroke was observed in patients with definitely echolucent plaques (8.0%; 95% confidence interval [CI] 6.4-9.6) when compared with patients with definitely nonecholucent plaques (3.1%; 95% CI 2.1-4.1; p = .009). After adjustments for other risk factors, plaque echolucency was associated with a 2.5-times increased risk of ipsilateral ischaemic stroke (hazard ratio 2.52; 95% CI 1.20-5.25; p = .014). Use of lipid-lowering therapy was low in both groups during the first 5 years after randomization but rose sharply during years 5-10 of follow-up, and was significantly more likely to be prescribed for patients with echolucent plaques (p = .001). The risk of ipsilateral ischaemic stroke at 10 years was similar for both groups of patients (p = .233). CONCLUSION Although the numbers of events in this study was low, definite plaque echolucency (> 25% soft plaque) was associated with a higher 5-year ipsilateral stroke risk in ACST-1 and may therefore help to identify patients at increased risk of stroke for whom carotid intervention may be particularly beneficial.
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Affiliation(s)
- A Huibers
- Nuffield Department of Surgical Sciences, University of Oxford, Level 6 John Radcliffe Hospital, Oxford OX3 9DU, UK; Department of Vascular Surgery, University Medical Center Utrecht, PO Box 85500, Utrecht, The Netherlands
| | - G J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, PO Box 85500, Utrecht, The Netherlands
| | - R Bulbulia
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
| | - H Pan
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
| | - A Halliday
- Nuffield Department of Surgical Sciences, University of Oxford, Level 6 John Radcliffe Hospital, Oxford OX3 9DU, UK.
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Viticchi G, Falsetti L, Buratti L, Luzzi S, Bartolini M, Acciarri MC, Provinciali L, Silvestrini M. Metabolic syndrome and cerebrovascular impairment in Alzheimer's disease. Int J Geriatr Psychiatry 2015; 30:1164-70. [PMID: 25754252 DOI: 10.1002/gps.4269] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 11/21/2014] [Accepted: 01/23/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Metabolic Syndrome (MeS) has inconstantly been associated with cognitive impairment. The aim of this study was to investigate the influence of MeS on cerebrovascular reactivity and the possible consequences on cognitive impairment in patients with Alzheimer's disease (AD). METHODS A total of 162 AD patients were enrolled and grouped depending on the presence/absence of MeS. An ultrasound assessment of the neck vessels was performed to evaluate common carotid artery intima-media thickness (IMT). Cerebral hemodynamics was assessed by the transcranial Doppler-based breath-holding index (BHI) test. The relationship between BHI and MeS was explored first with a nested binary logistic model and then with a general linear model/adjusted model. Both models were corrected for sex, age, education, BMI, smoking attitude, and IMT treated as covariates. RESULTS Pathologic BHI values were significantly more frequent among patients with MeS (risk ratio (RR):1.477; 95% CI: 1.177-1.848). MeS significantly improved the prediction of a pathologic BHI in the binary logistic model (odds ratio (OR):11.64; 95% CI: 1.001-135.304; p < 0.05). Moreover, AD patients affected by MeS had significantly lower mean Mini-Mental State Evaluation values than the unaffected ones (16.06; 95% CI: 14.96-17.15 vs 17.79; 95% CI: 17.05-18.53; p < 0.0001). CONCLUSIONS Our data show an association between the presence of MeS and cerebral hemodynamics. The possibility that a cluster of potentially treatable vascular risk factors may influence AD patients' prognosis deserves consideration.
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Affiliation(s)
- Giovanna Viticchi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Lorenzo Falsetti
- Internal and Subintensive Medicine, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Laura Buratti
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Simona Luzzi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Marco Bartolini
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Maria Cristina Acciarri
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Leandro Provinciali
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Mauro Silvestrini
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
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Viticchi G, Falsetti L, Buratti L, Boria C, Luzzi S, Bartolini M, Provinciali L, Silvestrini M. Framingham risk score can predict cognitive decline progression in Alzheimer's disease. Neurobiol Aging 2015; 36:2940-2945. [PMID: 26279114 DOI: 10.1016/j.neurobiolaging.2015.07.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 07/17/2015] [Accepted: 07/18/2015] [Indexed: 10/23/2022]
Abstract
The role of vascular factors in influencing cognitive decline has been extensively investigated, and some difficulties in defining their weight in dementia pathogenesis have emerged. The aim of the study was to investigate the relevance of the Framingham cardiovascular risk profile (FCRP) in influencing cognitive deterioration in a population of Alzheimer's disease (AD) patients. Two hundred eighty-four consecutive AD patients were enrolled. For each patient, FCRP score was calculated. We did a 1-year follow-up to quantify the cognitive decline by recording changes in the Clinical Dementia Rating score. The FCRP score predicted cognitive deterioration with an area under the curve of 0.63 (95% confidence interval: 0.57-0.69; p < 0.0001). In the subpopulation of patients with a genetic increased predisposition to develop cognitive deterioration and with an advanced vascular impairment, the FCRP predictive value significantly increased with an area under the curve of 0.77 (95% confidence interval: 0.52-0.93; p < 0.05). Our findings show that FCRP can predict the progression of deterioration in AD patients. This was particularly evident in patients with major genetic and atherosclerotic risk factors.
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Affiliation(s)
- Giovanna Viticchi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Lorenzo Falsetti
- Internal and Subintensive Medicine, Department of Internal Medicine, Ospedali Riuniti Ancona, Ancona, Italy
| | - Laura Buratti
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Cristiano Boria
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Simona Luzzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Marco Bartolini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Leandro Provinciali
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy.
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Dharmadhikari S, Chaturvedi S. Medical and Revascularization Therapies for Asymptomatic Carotid Stenosis. Curr Atheroscler Rep 2015; 17:44. [PMID: 26068476 DOI: 10.1007/s11883-015-0522-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Asymptomatic internal carotid artery stenosis increases with age and is more common in men. Carotid endarterectomy and stenting have reduced stroke rates in patients with asymptomatic carotid stenosis in clinical trials. A variety of risk stratification methods are available for selection of patients with carotid stenosis for revascularization. In the past decade, there is increasing evidence that the rate of stroke declined with the use of aggressive multi-modal medical therapy. These developments have led to new clinical trials to compare revascularization versus aggressive medical therapy in patients with asymptomatic carotid stenosis.
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Affiliation(s)
- Sushrut Dharmadhikari
- Department of Neurology & Stroke Program, University of Miami Miller School of Medicine, Miami, FL, USA
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Gupta A, Marshall RS. Moving beyond luminal stenosis: imaging strategies for stroke prevention in asymptomatic carotid stenosis. Cerebrovasc Dis 2015; 39:253-61. [PMID: 25870952 DOI: 10.1159/000381108] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 02/17/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND With progressive improvements in medical therapy and resultant reductions in stroke risk, luminal stenosis criteria are no longer adequate to inform decisions to pursue surgical revascularization in patients with asymptomatic carotid artery stenosis. SUMMARY In this evidence-based review, we discuss the imaging-based risk stratification strategies that take into account factors beyond luminal stenosis measurements, including cerebral hemodynamics and plaque composition. The existing literature lends support to the use of certain imaging tests in patients with asymptomatic carotid stenosis including cerebrovascular reserve testing, MRI of plaque composition, ultrasound of plaque echolucency, and transcranial Doppler evaluation for microemboli. The highest quality evidence thus far in the literature includes only systematic reviews and meta-analyses of cohort studies with no randomized trials having yet been performed to show how these newer imaging biomarkers could be used to inform treatment decisions in asymptomatic carotid stenosis. Beyond the need for randomized trials, there are additional important steps needed to improve the relevance of evidence supporting risk assessment strategies. Imaging studies evaluating the risk of stroke in carotid disease should clearly define asymptomatic versus symptomatic disease, use uniform definitions of clearly defined outcome measures such as ipsilateral stroke, ensure that imaging interpretations are performed in a manner blinded to treatments and other risk factors, and include cohorts which are on modern intensive medical therapy. Such studies of risk stratification for asymptomatic carotid stenosis will be most valuable if they can integrate multiple high-risk features (including clinical risk factors) into a multi-factorial risk assessment strategy in a manner that is relatively simple to implement and generalizable across a wide range of practice settings. Key Messages: Together, modern imaging strategies allow for a more mechanistic assessment of stroke risk in carotid disease compared to luminal stenosis measurements alone, which, with further validation in randomized controlled trials, may improve current efforts at stroke prevention in asymptomatic carotid stenosis.
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Affiliation(s)
- Ajay Gupta
- Department of Radiology, Weill Cornell Medical College, New York, N.Y., USA
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Sex-associated differences in the modulation of vascular risk in patients with asymptomatic carotid stenosis. J Cereb Blood Flow Metab 2015; 35:684-8. [PMID: 25586143 PMCID: PMC4420889 DOI: 10.1038/jcbfm.2014.248] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 10/27/2014] [Accepted: 12/11/2014] [Indexed: 11/09/2022]
Abstract
In this study, we aimed to identify determinants of the different sex-related stroke risk in subjects with asymptomatic internal carotid artery (ICA) stenosis. In all, 492 women (44.4%) and 617 men (55.6%), with unilateral ⩾ 60% asymptomatic ICA stenosis, were prospectively evaluated with a median follow-up of 37 months (interquartile range, 26 to 43). Vascular risk profile, plaque characteristics, stenosis progression, and common carotid artery intima-media thickness were investigated. Outcome measure was the occurrence of ischemic stroke ipsilateral to ICA stenosis. Myocardial infarction, contralateral stroke and transient ischemic attack were considered as competing events. The incidence rate of ipsilateral stroke over the entire follow-up period was 0.16%: 0.09% (95% confidence interval (CI) 0.05 to 0.15) in women and 0.22% (95% CI 0.17 to 0.29) in men (log-rank test, P<0.001). Stenosis progression significantly influenced the risk of ipsilateral stroke in both men (subhazard ratio, SHR, 8.99) and women (SHR 4.89). Stenosis degree (71% to 90%, SHR 2.35; 91% to 99%, SHR 3.38) and irregular plaque surface (SHR 2.32) were relevant risk factors for ipsilateral stroke only in men. Our findings suggest that characteristics of the stenosis and plaque exert a different effect in modulating vascular risk in the two sexes. Understanding sex differences in cardiovascular disease could help to target sex-specific future therapies.
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Gupta A, Baradaran H, Mtui EE, Kamel H, Pandya A, Giambrone A, Iadecola C, Sanelli PC. Detection of Symptomatic Carotid Plaque Using Source Data from MR and CT Angiography: A Correlative Study. Cerebrovasc Dis 2015; 39:151-61. [PMID: 25721945 DOI: 10.1159/000373918] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 01/07/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Carotid plaque MRI has been a useful method to characterize vulnerable atherosclerotic plaque elements. Recent investigations have suggested that source images from CT angiography (CTA) and MR angiography (MRA) can identify the simple high-risk features of symptom-producing carotid artery plaque. We studied the correlation and relative diagnostic accuracies of CTA and MRA source images in detecting symptomatic carotid artery plaque. METHODS Subjects were eligible if they had carotid stenosis between 50 and 99% and had MRA and CTA exams performed within 10 days of one another. We measured the soft (non-calcified) plaque and hard (calcified) plaque thickness on CTA axial source images and intraplaque high-intensity signal (IHIS) on 3D-time-of-flight MRA source images in subjects. We assessed whether a correlation existed between increasing CTA soft plaque thicknesses and the presence of MRA IHIS using the Student's t-test. We calculated the differences in sensitivity and specificity measures of CTA and MRA source-imaging data with the occurrence of recent ipsilateral stroke or transient ischemic attack (TIA) as the reference standard. We also performed logistic regression analyses to evaluate the predictive strength of plaque showing both IHIS and increased CTA soft plaque thickness in predicting symptomatic disease status. RESULTS Of 1994 screened patients, 48 arteries met the final inclusion criteria with MRA and CTA performed within 10 days of one another. The mean and median time between CTA and MRA exams were 2.0 days and 1 day, respectively. A total of 34 of 48 stenotic vessels (70.8%) were responsible for giving rise to ipsilateral stroke or TIA. CTA mean soft plaque thickness was significantly greater (4.47 vs. 2.30 mm, p < 0.0001) in patients with MRA-defined IHIS, while CTA hard plaque thickness was significantly greater (2.09 vs. 1.16 mm, p = 0.0134) in patients without MRA evidence of IHIS. CTA soft plaque thickness measurements were more sensitive than MRA IHIS (91.2 vs. 67.6%, p = 0.011) in detecting symptomatic plaque, while differences in specificity were not significantly different (p = 0.1573). In the subset of patients with both IHIS on MRA and plaque thickness >2.4 mm on CTA, the odds ratio of detecting symptomatic plaque, corrected for stenosis severity, was 45.3 (p < 0.0005). CONCLUSIONS Unprocessed source images from CTA and MRA, which are routinely evaluated for clinical studies demonstrate the highly correlated presence of IHIS and increasing soft plaque thickness. In particular, plaque that shows high-risk features on both MRA and CTA are very strongly associated with symptom-producing carotid plaque. With further validation, such techniques are promising practical methods of extracting risk information from routine neck angiographic imaging.
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Affiliation(s)
- Ajay Gupta
- Department of Radiology, Weill Cornell Medical College, New York, N.Y., USA
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Hashimura N, Mutoh T, Matsuda K, Matsumoto K. Evaluation and management of plaque protrusion or thrombus following carotid artery stenting. Neurol Med Chir (Tokyo) 2015; 55:149-54. [PMID: 25746309 PMCID: PMC4533408 DOI: 10.2176/nmc.oa.2014-0105] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Carotid artery stenting (CAS) has become a common treatment for carotid artery stenosis. However, complications, such as an ischemic event, can occur with CAS during intra- and post-operative periods. Among these ischemic complications, plaque protrusion into the stent and thrombus on the stent have occurred after CAS. We retrospectively evaluated the temporal profile and treatment options for these complications in 32 consecutive cases who underwent CAS at our hospital between April 2009 and December 2011. The cases were evaluated pre-operatively for risk factors, as well as the plaque morphology and characteristics using computed tomographic angiography (CTA), ultrasound (US), and magnetic resonance imaging (MRI). Post-operatively, lesions were examined by CTA and/or US within 1 week of CAS. As a result, among the 32 cases, 8 experienced plaque protrusions or thrombus, which were treated with medication (anti-platelet and/or anti-coagulation reinforcement). In 7 of these 8 cases, the plaque protrusion or thrombus was stabilized with medication alone. However, the remaining case showed growth and migration of the plaque protrusion or thrombus when treated with medication alone, and therefore, required further endovascular treatment. We identified that a history of symptomatic cerebral infarction and plaques with ulceration were risk factors for plaque protrusion or thrombus formation after CAS, and pre dilatation can decrease the risk of these complications. Medication was effective in most cases of plaque protrusion or thrombus; however, further endovascular treatment was required when medication alone was unsuccessful.
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Gupta A, Kesavabhotla K, Baradaran H, Kamel H, Pandya A, Giambrone AE, Wright D, Pain KJ, Mtui EE, Suri JS, Sanelli PC, Mushlin AI. Plaque echolucency and stroke risk in asymptomatic carotid stenosis: a systematic review and meta-analysis. Stroke 2014; 46:91-7. [PMID: 25406150 DOI: 10.1161/strokeaha.114.006091] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Ultrasonographic plaque echolucency has been studied as a stroke risk marker in carotid atherosclerotic disease. We performed a systematic review and meta-analysis to summarize the association between ultrasound-determined carotid plaque echolucency and future ipsilateral stroke risk. METHODS We searched the medical literature for studies evaluating the association between carotid plaque echolucency and future stroke in asymptomatic patients. We included prospective observational studies with stroke outcome ascertainment after baseline carotid plaque echolucency assessment. We performed a meta-analysis and assessed study heterogeneity and publication bias. We also performed subgroup analyses limited to patients with stenosis ≥50%, studies in which plaque echolucency was determined via subjective visual interpretation, studies with a relatively lower risk of bias, and studies published after the year 2000. RESULTS We analyzed data from 7 studies on 7557 subjects with a mean follow-up of 37.2 months. We found a significant positive relationship between predominantly echolucent (compared with predominantly echogenic) plaques and the risk of future ipsilateral stroke across all stenosis severities (0% to 99%; relative risk, 2.31; 95% confidence interval, 1.58-3.39; P<0.001) and in subjects with ≥50% stenosis (relative risk, 2.61; 95% confidence interval, 1.47-4.63; P=0.001). A statistically significant increased relative risk for future stroke was preserved in all additional subgroup analyses. No statistically significant heterogeneity or publication bias was present in any of the meta-analyses. CONCLUSIONS The presence of ultrasound-determined carotid plaque echolucency provides predictive information in asymptomatic carotid artery stenosis beyond luminal stenosis. However, the magnitude of the increased risk is not sufficient on its own to iden tify patients likely to benefit from surgical revascularization.
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Affiliation(s)
- Ajay Gupta
- From the Department of Radiology (A.G., K.K., H.B., E.E.M., P.C.S.), Brain and Mind Research Institute (A.G., H.K.), Department of Neurology (H.K.), Department of Healthcare Policy and Research (A.P., A.E.G., P.C.S., A.I.M.), and Samuel J. Wood Library and C.V. Starr Biomedical Information Center (D.W., K.J.P.), Weill Cornell Medical College, New York, NY; and Stroke Screening and Monitoring Division, AtheroPoint LLC, Roseville, CA (J.S.S.).
| | - Kartik Kesavabhotla
- From the Department of Radiology (A.G., K.K., H.B., E.E.M., P.C.S.), Brain and Mind Research Institute (A.G., H.K.), Department of Neurology (H.K.), Department of Healthcare Policy and Research (A.P., A.E.G., P.C.S., A.I.M.), and Samuel J. Wood Library and C.V. Starr Biomedical Information Center (D.W., K.J.P.), Weill Cornell Medical College, New York, NY; and Stroke Screening and Monitoring Division, AtheroPoint LLC, Roseville, CA (J.S.S.)
| | - Hediyeh Baradaran
- From the Department of Radiology (A.G., K.K., H.B., E.E.M., P.C.S.), Brain and Mind Research Institute (A.G., H.K.), Department of Neurology (H.K.), Department of Healthcare Policy and Research (A.P., A.E.G., P.C.S., A.I.M.), and Samuel J. Wood Library and C.V. Starr Biomedical Information Center (D.W., K.J.P.), Weill Cornell Medical College, New York, NY; and Stroke Screening and Monitoring Division, AtheroPoint LLC, Roseville, CA (J.S.S.)
| | - Hooman Kamel
- From the Department of Radiology (A.G., K.K., H.B., E.E.M., P.C.S.), Brain and Mind Research Institute (A.G., H.K.), Department of Neurology (H.K.), Department of Healthcare Policy and Research (A.P., A.E.G., P.C.S., A.I.M.), and Samuel J. Wood Library and C.V. Starr Biomedical Information Center (D.W., K.J.P.), Weill Cornell Medical College, New York, NY; and Stroke Screening and Monitoring Division, AtheroPoint LLC, Roseville, CA (J.S.S.)
| | - Ankur Pandya
- From the Department of Radiology (A.G., K.K., H.B., E.E.M., P.C.S.), Brain and Mind Research Institute (A.G., H.K.), Department of Neurology (H.K.), Department of Healthcare Policy and Research (A.P., A.E.G., P.C.S., A.I.M.), and Samuel J. Wood Library and C.V. Starr Biomedical Information Center (D.W., K.J.P.), Weill Cornell Medical College, New York, NY; and Stroke Screening and Monitoring Division, AtheroPoint LLC, Roseville, CA (J.S.S.)
| | - Ashley E Giambrone
- From the Department of Radiology (A.G., K.K., H.B., E.E.M., P.C.S.), Brain and Mind Research Institute (A.G., H.K.), Department of Neurology (H.K.), Department of Healthcare Policy and Research (A.P., A.E.G., P.C.S., A.I.M.), and Samuel J. Wood Library and C.V. Starr Biomedical Information Center (D.W., K.J.P.), Weill Cornell Medical College, New York, NY; and Stroke Screening and Monitoring Division, AtheroPoint LLC, Roseville, CA (J.S.S.)
| | - Drew Wright
- From the Department of Radiology (A.G., K.K., H.B., E.E.M., P.C.S.), Brain and Mind Research Institute (A.G., H.K.), Department of Neurology (H.K.), Department of Healthcare Policy and Research (A.P., A.E.G., P.C.S., A.I.M.), and Samuel J. Wood Library and C.V. Starr Biomedical Information Center (D.W., K.J.P.), Weill Cornell Medical College, New York, NY; and Stroke Screening and Monitoring Division, AtheroPoint LLC, Roseville, CA (J.S.S.)
| | - Kevin J Pain
- From the Department of Radiology (A.G., K.K., H.B., E.E.M., P.C.S.), Brain and Mind Research Institute (A.G., H.K.), Department of Neurology (H.K.), Department of Healthcare Policy and Research (A.P., A.E.G., P.C.S., A.I.M.), and Samuel J. Wood Library and C.V. Starr Biomedical Information Center (D.W., K.J.P.), Weill Cornell Medical College, New York, NY; and Stroke Screening and Monitoring Division, AtheroPoint LLC, Roseville, CA (J.S.S.)
| | - Edward E Mtui
- From the Department of Radiology (A.G., K.K., H.B., E.E.M., P.C.S.), Brain and Mind Research Institute (A.G., H.K.), Department of Neurology (H.K.), Department of Healthcare Policy and Research (A.P., A.E.G., P.C.S., A.I.M.), and Samuel J. Wood Library and C.V. Starr Biomedical Information Center (D.W., K.J.P.), Weill Cornell Medical College, New York, NY; and Stroke Screening and Monitoring Division, AtheroPoint LLC, Roseville, CA (J.S.S.)
| | - Jasjit S Suri
- From the Department of Radiology (A.G., K.K., H.B., E.E.M., P.C.S.), Brain and Mind Research Institute (A.G., H.K.), Department of Neurology (H.K.), Department of Healthcare Policy and Research (A.P., A.E.G., P.C.S., A.I.M.), and Samuel J. Wood Library and C.V. Starr Biomedical Information Center (D.W., K.J.P.), Weill Cornell Medical College, New York, NY; and Stroke Screening and Monitoring Division, AtheroPoint LLC, Roseville, CA (J.S.S.)
| | - Pina C Sanelli
- From the Department of Radiology (A.G., K.K., H.B., E.E.M., P.C.S.), Brain and Mind Research Institute (A.G., H.K.), Department of Neurology (H.K.), Department of Healthcare Policy and Research (A.P., A.E.G., P.C.S., A.I.M.), and Samuel J. Wood Library and C.V. Starr Biomedical Information Center (D.W., K.J.P.), Weill Cornell Medical College, New York, NY; and Stroke Screening and Monitoring Division, AtheroPoint LLC, Roseville, CA (J.S.S.)
| | - Alvin I Mushlin
- From the Department of Radiology (A.G., K.K., H.B., E.E.M., P.C.S.), Brain and Mind Research Institute (A.G., H.K.), Department of Neurology (H.K.), Department of Healthcare Policy and Research (A.P., A.E.G., P.C.S., A.I.M.), and Samuel J. Wood Library and C.V. Starr Biomedical Information Center (D.W., K.J.P.), Weill Cornell Medical College, New York, NY; and Stroke Screening and Monitoring Division, AtheroPoint LLC, Roseville, CA (J.S.S.)
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Buratti L, Balucani C, Viticchi G, Falsetti L, Altamura C, Avitabile E, Provinciali L, Vernieri F, Silvestrini M. Cognitive deterioration in bilateral asymptomatic severe carotid stenosis. Stroke 2014; 45:2072-7. [PMID: 24903984 DOI: 10.1161/strokeaha.114.005645] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE This study aimed to monitor cognitive performance during a 3-year period in subjects with bilateral asymptomatic severe internal carotid artery stenosis and to explore the role of cerebral hemodynamics and atherosclerotic disease in the development of cognitive dysfunction. METHODS One hundred fifty-nine subjects with bilateral asymptomatic severe internal carotid artery stenosis were included and prospectively evaluated for a 3-year period. At entry, demographics, vascular risk profile, and pharmacological treatments were defined. Cognitive status was evaluated using the Mini-Mental State Examination at baseline and at follow-up. Cerebral hemodynamics was assessed by transcranial Doppler-based breath-holding index test. As a measure of the extent of systemic atherosclerotic disease, common carotid artery intima-media thickness was measured. A cutoff for pathological values was set at 0.69 for breath-holding index and 1.0 mm for intima-media thickness. RESULTS The risk of decreasing in Mini-Mental State Examination score increased progressively from patients with bilaterally normal to those with unilaterally abnormal breath-holding index, reaching the highest probability in patients with bilaterally abnormal breath-holding index (P<0.0001). Pathological values of intima-media thickness did not influence the risk of Mini-Mental State Examination score change. CONCLUSIONS Our findings suggest that patients with asymptomatic bilateral severe internal carotid artery stenosis may be at risk of developing cognitive impairment. The evaluation of the hemodynamic status, besides providing insights about the possible mechanism behind the cognitive dysfunction present in carotid atherosclerotic disease, may be of help for the individuation of subjects deserving earlier and more aggressive treatments.
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Affiliation(s)
- Laura Buratti
- From the Neurological Clinic, Marche Polytechnic University, Ancona, Italy (L.B., G.V., E.A., L.P., M.S.); Department of Neurology, SUNY Downstate Medical Center, Brooklyn, NY (C.B.); Internal and Subintensive Medicine, Ospedali Riuniti Ancona, Ancona, Italy (L.F.); and Neurology Unit, Campus Bio-Medico University, Rome, Italy (C.A., F.V.)
| | - Clotilde Balucani
- From the Neurological Clinic, Marche Polytechnic University, Ancona, Italy (L.B., G.V., E.A., L.P., M.S.); Department of Neurology, SUNY Downstate Medical Center, Brooklyn, NY (C.B.); Internal and Subintensive Medicine, Ospedali Riuniti Ancona, Ancona, Italy (L.F.); and Neurology Unit, Campus Bio-Medico University, Rome, Italy (C.A., F.V.)
| | - Giovanna Viticchi
- From the Neurological Clinic, Marche Polytechnic University, Ancona, Italy (L.B., G.V., E.A., L.P., M.S.); Department of Neurology, SUNY Downstate Medical Center, Brooklyn, NY (C.B.); Internal and Subintensive Medicine, Ospedali Riuniti Ancona, Ancona, Italy (L.F.); and Neurology Unit, Campus Bio-Medico University, Rome, Italy (C.A., F.V.)
| | - Lorenzo Falsetti
- From the Neurological Clinic, Marche Polytechnic University, Ancona, Italy (L.B., G.V., E.A., L.P., M.S.); Department of Neurology, SUNY Downstate Medical Center, Brooklyn, NY (C.B.); Internal and Subintensive Medicine, Ospedali Riuniti Ancona, Ancona, Italy (L.F.); and Neurology Unit, Campus Bio-Medico University, Rome, Italy (C.A., F.V.)
| | - Claudia Altamura
- From the Neurological Clinic, Marche Polytechnic University, Ancona, Italy (L.B., G.V., E.A., L.P., M.S.); Department of Neurology, SUNY Downstate Medical Center, Brooklyn, NY (C.B.); Internal and Subintensive Medicine, Ospedali Riuniti Ancona, Ancona, Italy (L.F.); and Neurology Unit, Campus Bio-Medico University, Rome, Italy (C.A., F.V.)
| | - Emma Avitabile
- From the Neurological Clinic, Marche Polytechnic University, Ancona, Italy (L.B., G.V., E.A., L.P., M.S.); Department of Neurology, SUNY Downstate Medical Center, Brooklyn, NY (C.B.); Internal and Subintensive Medicine, Ospedali Riuniti Ancona, Ancona, Italy (L.F.); and Neurology Unit, Campus Bio-Medico University, Rome, Italy (C.A., F.V.)
| | - Leandro Provinciali
- From the Neurological Clinic, Marche Polytechnic University, Ancona, Italy (L.B., G.V., E.A., L.P., M.S.); Department of Neurology, SUNY Downstate Medical Center, Brooklyn, NY (C.B.); Internal and Subintensive Medicine, Ospedali Riuniti Ancona, Ancona, Italy (L.F.); and Neurology Unit, Campus Bio-Medico University, Rome, Italy (C.A., F.V.)
| | - Fabrizio Vernieri
- From the Neurological Clinic, Marche Polytechnic University, Ancona, Italy (L.B., G.V., E.A., L.P., M.S.); Department of Neurology, SUNY Downstate Medical Center, Brooklyn, NY (C.B.); Internal and Subintensive Medicine, Ospedali Riuniti Ancona, Ancona, Italy (L.F.); and Neurology Unit, Campus Bio-Medico University, Rome, Italy (C.A., F.V.)
| | - Mauro Silvestrini
- From the Neurological Clinic, Marche Polytechnic University, Ancona, Italy (L.B., G.V., E.A., L.P., M.S.); Department of Neurology, SUNY Downstate Medical Center, Brooklyn, NY (C.B.); Internal and Subintensive Medicine, Ospedali Riuniti Ancona, Ancona, Italy (L.F.); and Neurology Unit, Campus Bio-Medico University, Rome, Italy (C.A., F.V.).
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Diomedi M, Scacciatelli D, Misaggi G, Balestrini S, Balucani C, Sallustio F, Di Legge S, Stanzione P, Silvestrini M. Increased Common Carotid Artery Wall Thickness Is Associated with Rapid Progression of Asymptomatic Carotid Stenosis. J Neuroimaging 2013; 24:473-8. [DOI: 10.1111/jon.12068] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Marina Diomedi
- Stroke Unit; Neuroscience Department; Tor Vergata University of Rome
- IRCCS; Santa Lucia Foundation; Rome
| | - Daria Scacciatelli
- Center for Biostatistics and Bioinformatics; Tor Vergata University of Rome; Rome
| | - Giulia Misaggi
- Stroke Unit; Neuroscience Department; Tor Vergata University of Rome
| | | | - Clotilde Balucani
- Neurological Clinic; Marche Polytechnic University; Ancona
- Department of Neurology; SUNY Downstate Medical Center; Brooklyn NY
| | | | - Silvia Di Legge
- Stroke Unit; Neuroscience Department; Tor Vergata University of Rome
| | - Paolo Stanzione
- Stroke Unit; Neuroscience Department; Tor Vergata University of Rome
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