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Saba L, Scicolone R, Johansson E, Nardi V, Lanzino G, Kakkos SK, Pontone G, Annoni AD, Paraskevas KI, Fox AJ. Quantifying Carotid Stenosis: History, Current Applications, Limitations, and Potential: How Imaging Is Changing the Scenario. Life (Basel) 2024; 14:73. [PMID: 38255688 PMCID: PMC10821425 DOI: 10.3390/life14010073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/24/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024] Open
Abstract
Carotid artery stenosis is a major cause of morbidity and mortality. The journey to understanding carotid disease has developed over time and radiology has a pivotal role in diagnosis, risk stratification and therapeutic management. This paper reviews the history of diagnostic imaging in carotid disease, its evolution towards its current applications in the clinical and research fields, and the potential of new technologies to aid clinicians in identifying the disease and tailoring medical and surgical treatment.
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Affiliation(s)
- Luca Saba
- Department of Radiology, University of Cagliari, 09042 Cagliari, Italy;
| | - Roberta Scicolone
- Department of Radiology, University of Cagliari, 09042 Cagliari, Italy;
| | - Elias Johansson
- Neuroscience and Physiology, Sahlgrenska Academy, 41390 Gothenburg, Sweden;
| | - Valentina Nardi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| | - Stavros K. Kakkos
- Department of Vascular Surgery, University of Patras, 26504 Patras, Greece;
| | - Gianluca Pontone
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy; (G.P.); (A.D.A.)
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20122 Milan, Italy
| | - Andrea D. Annoni
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy; (G.P.); (A.D.A.)
| | | | - Allan J. Fox
- Department of Medical Imaging, Neuroradiology Section, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada;
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Benson JC, Saba L, Bathla G, Brinjikji W, Nardi V, Lanzino G. MR Imaging of Carotid Artery Atherosclerosis: Updated Evidence on High-Risk Plaque Features and Emerging Trends. AJNR Am J Neuroradiol 2023; 44:880-888. [PMID: 37385681 PMCID: PMC10411837 DOI: 10.3174/ajnr.a7921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/14/2023] [Indexed: 07/01/2023]
Abstract
MR imaging is well-established as the criterion standard for carotid artery atherosclerosis imaging. The capability of MR imaging to differentiate numerous plaque components has been demonstrated, including those features that are associated with a high risk of sudden changes, thrombosis, or embolization. The field of carotid plaque MR imaging is constantly evolving, with continued insight into the imaging appearance and implications of various vulnerable plaque characteristics. This article will review the most up-to-date knowledge of these high-risk plaque features on MR imaging and will delve into 2 major emerging topics: the role of vulnerable plaques in cryptogenic strokes and the potential use of MR imaging to modify carotid endarterectomy treatment guidelines.
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Affiliation(s)
- J C Benson
- From the Departments of Radiology (J.C.B., G.B., W.B.)
| | - L Saba
- Department of Medical Sciences (L.S.), University of Cagliari, Cagliari, Italy
| | - G Bathla
- From the Departments of Radiology (J.C.B., G.B., W.B.)
| | - W Brinjikji
- From the Departments of Radiology (J.C.B., G.B., W.B.)
| | - V Nardi
- Cardiovascular Medicine (V.N.)
| | - G Lanzino
- Neurosurgery (G.L.), Mayo Clinic, Rochester, Minnesota
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Larson AS, Brinjikji W, Lekah A, Klaas JP, Lanzino G, Huston J, Saba L, Benson JC. Nonstenotic Carotid Plaques and Embolic Stroke of Undetermined Source: A Multimodality Review. AJNR Am J Neuroradiol 2023; 44:118-124. [PMID: 36549844 PMCID: PMC9891333 DOI: 10.3174/ajnr.a7750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/10/2022] [Indexed: 12/24/2022]
Abstract
Symptomatic nonstenotic carotid artery disease has been increasingly recognized as a thromboembolic source in patients who would otherwise be classified as having embolic stroke of undetermined source. Evidence suggests that certain plaque features seen on sonography, CT, and MR imaging in nonstenotic carotid artery disease may predispose to recurrent stroke in patients with embolic stroke of undetermined source. We performed a focused literature review to further study plaque features in the context of embolic stroke of undetermined source and to determine which plaque features may be associated with ipsilateral ischemic events in such patients. Plaque thickness as seen on both ultrasound and CT appears to have a consistent association with ipsilateral stroke in patients with embolic stroke of undetermined source across multiple studies. Intraplaque hemorrhage as seen on MR imaging is now understood to have a strong association with ipsilateral stroke in patients with embolic stroke of undetermined source. Continued study of various plaque features as seen on different modalities is warranted to uncover other potential associations.
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Affiliation(s)
- A S Larson
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
| | - W Brinjikji
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
- Neurosurgery (W.B., G.L.)
| | - A Lekah
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
| | - J P Klaas
- Neurology (J.P.K.), Mayo Clinic, Rochester, Minnesota
| | - G Lanzino
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
- Neurosurgery (W.B., G.L.)
| | - J Huston
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
| | - L Saba
- Department of Medical Sciences (L.S.), University of Cagliari, Cagliari, Italy
| | - J C Benson
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
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Jumah A, Aboul Nour H, Fana M, Choudhury O, Eltous L, Zoghoul S, Jumah F, Alsrouji OK, Alhajala H, Intikhab O, Marin H, Chebl A, Miller D. The role of non-stenosing carotid artery plaques in embolic stroke of undetermined source, is it a silent offender? A review of literature. Interv Neuroradiol 2022:15910199221143172. [PMID: 36451548 DOI: 10.1177/15910199221143172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
PURPOSE Atherosclerotic cervical internal carotid artery disease is one of the major causes of ischemic stroke and transient ischemic attacks. The risk of stroke from mild to moderate stenoses (i.e. <50% stenosis) might be underestimated. There is increasing evidence that plaque morphological features reflect plaque instability that may harbor high risk for embolization. In this narrative review, we will review the literature on plaque features that predict vulnerability beyond the degree of stenosis, discuss the clinical association with stroke, and evaluate the evidence that these lesions serve as a source for embolic stroke of unknown source (ESUS). METHODS We performed a literature search using PubMed, EMBASE, and Web of Science. The terms "embolic stroke of undetermined source" and "plaque morphology" were used either alone or in combination with "non-flow limiting stenosis," "non-stenosing plaques," "high-risk plaque features" or "internal carotid artery plaque." Data on plaque morphology and ESUS were mainly taken from review articles, observational studies including retrospective cohort and cross-sectional studies, meta-analyses, and systematic reviews. CONCLUSION Nonstenosing carotid artery plaques with high-risk features carry a remarkable risk for stroke occurrence and randomized clinical trials are warranted for further evaluation of using carotid artery stenting or carotid endarterectomy to mitigate the risk of stroke.
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Affiliation(s)
- Ammar Jumah
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Hassan Aboul Nour
- Department of Vascular Neurology, Emory University Hospital, Atlanta, GA, USA
| | - Michael Fana
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Omar Choudhury
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Lara Eltous
- 37251Jordan University of Science and Technology, Irbid, Jordan
| | - Sohaib Zoghoul
- Department of Radiology, 36977Hamad Medical Corporation, Doha, Qatar
| | - Fareed Jumah
- Department of Neurosurgery, University of Missouri Hospital, Columbia, MO, USA
| | - Owais K Alsrouji
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Hisham Alhajala
- Department of Vascular Neurology, University of Toledo, Toledo, OH, USA
| | - Osama Intikhab
- Department of Interventional Neuroradiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Horia Marin
- Department of Neuroradiology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Alex Chebl
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Daniel Miller
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
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Savastano L, Mousavi H, Liu Y, Khalsa SSS, Zheng Y, Davis E, Reddy A, Brinjikji W, Bhambri A, Cockrum J, Pandey AS, Thompson BG, Gordon D, Seibel EJ, Yonas H. Unifying theory of carotid plaque disruption based on structural phenotypes and forces expressed at the lumen/wall interface. Stroke Vasc Neurol 2022; 7:465-475. [PMID: 35649687 PMCID: PMC9811551 DOI: 10.1136/svn-2021-001451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 04/08/2022] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To integrate morphological, haemodynamic and mechanical analysis of carotid atheroma driving plaque disruption. MATERIALS AND METHODS First, we analysed the phenotypes of carotid endarterectomy specimens in a photographic dataset A, and matched them with the likelihood of preoperative stroke. Second, laser angioscopy was used to further define the phenotypes in intact specimens (dataset B) and benchmark with histology. Third, representative vascular geometries for each structural phenotype were analysed with Computational Fluid Dynamics (CFD), and the mechanical strength of the complicated atheroma to resist penetrating forces was quantified (n=14). RESULTS In dataset A (n=345), ulceration (fibrous cap disruption) was observed in 82% of all plaques, intraplaque haemorrhage in 68% (93% subjacent to an ulcer) and false luminal formation in 48%. At least one of these 'rupture' phenotypes was found in 97% of symptomatic patients (n=69) compared with 61% in asymptomatic patients. In dataset B (n=30), laser angioscopy redemonstrated the structural phenotypes with near-perfect agreement with histology. In CFD, haemodynamic stress showed a large pulse magnitude, highest upstream to the point of maximal stenosis and on ulceration the inflow stream excavates the necrotic core cranially and then recirculates into the true lumen. Based on mechanical testing (n=14), the necrotic core is mechanically weak and penetrated by the blood on fibrous cap disruption. CONCLUSIONS Fibrous cap ulceration, plaque haemorrhage and excavation are sequential phenotypes of plaque disruption resulting from the chiselling effect of haemodynamic forces over unmatched mechanical tissue strength. This chain of events may result in thromboembolic events independently of the degree of stenosis.
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Affiliation(s)
| | - Hossein Mousavi
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Yang Liu
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Siri Sahib S Khalsa
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Yihao Zheng
- Department of Mechanical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts, USA
| | - Evan Davis
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Adithya Reddy
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Ankur Bhambri
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Joshua Cockrum
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Aditya S Pandey
- Neurosurgery, Michigan Medicine, Ann Arbor, Michigan, USA,Radiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - David Gordon
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Eric J Seibel
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, USA
| | - Howard Yonas
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
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Holmes DR, Alkhouli MA, Klaas JP, Brinjikji W, Savastano LE, Lanzino G, Benson JC. Change of Heart: The Underexplored Role of Plaque Hemorrhage in the Evaluation of Stroke of Undetermined Etiology. J Am Heart Assoc 2022; 11:e025323. [PMID: 35475334 PMCID: PMC9238607 DOI: 10.1161/jaha.122.025323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In the evaluation of embolic strokes of undetermined source, great emphasis is often placed on cardiovascular disease, namely on atrial fibrillation. Other pathophysiologic mechanisms, however, may also be involved. Carotid artery intraplaque hemorrhage (IPH)—the presence of blood components within an atheromatous plaque—has become increasingly recognized as a possible etiologic mechanism in some cryptogenic strokes. IPH is a marker of plaque instability and is associated with ipsilateral neurologic ischemic events, even in nonstenotic carotid plaques. As recognition of carotid IPH as an etiology of embolic strokes has grown, so too has the complexity with which such patients are evaluated and treated, particularly because overlaps exist in the risk factors for atrial fibrillation and IPH. In this article, we review what is currently known about carotid IPH and how this clinical entity should be approached in the context of the evaluation of embolic strokes of undetermined source.
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Affiliation(s)
- David R Holmes
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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