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Smith J, Margalit D, Golledge J, Nastasi D, Nohria A, McDowell L. Carotid Artery Stenosis and Ischemic Stroke in Patients With Head and Neck Cancer Treated With Radiation Therapy: A Critical Review. Int J Radiat Oncol Biol Phys 2024; 119:1437-1454. [PMID: 38583496 DOI: 10.1016/j.ijrobp.2024.03.044] [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: 11/15/2023] [Revised: 03/21/2024] [Accepted: 03/27/2024] [Indexed: 04/09/2024]
Abstract
The purpose of this review is to summarize the literature on carotid artery stenosis (CAS) and ischemic stroke (IS) in patients with head and neck cancer (HNC) treated with radiation therapy (RT) to guide assessment, screening, and management strategies. Patients treated with RT for HNC are at an elevated risk of developing CAS, with published meta-analyses demonstrating that CAS >50% occurs in approximately 25% of patients. Previous research suggests a 10-year cumulative incidence of stroke between 5.7% and 12.5%. Cardiovascular disease (CVD) risk prediction tools such as Qstroke, QRISK-2, and Framingham risk score perform poorly for predicting IS for patients with HNC who received RT. Duplex ultrasound is the most common imaging modality to assess CAS, but controversy remains as to the utility of screening asymptomatic individuals. Only 3 of the 5 major HNC survivorship guidelines acknowledge RT as a risk factor for CAS or IS, while only 1 makes a specific recommendation on screening for CAS (American Head and Neck Society). Within the general population, only 1 CVD guideline discusses RT as a risk factor for CAS (Society for Vascular Surgery). Clinicians involved in the care of patients with HNC treated with RT should be aware of the increased risk of CAS and IS and the challenges in risk prediction. Although there is a lack of evidence to make firm recommendations, HNC survivorship recommendations should ensure HNC survivors and primary care providers are informed of these risks and the importance of assessment and management of CVD risk factors. Future studies are required to refine risk prediction models in patients with HNC and to determine those most likely to benefit from targeted screening and initiation of early preventative strategies.
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Affiliation(s)
- Justin Smith
- Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia.
| | - Danielle Margalit
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Australia; The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Australia; The Australian Institute of Tropical Health and Medicine, Townsville, Australia
| | - Domenico Nastasi
- Department of Vascular Surgery, Gold Coast University Hospital, Gold Coast, Australia
| | - Anju Nohria
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts; Adult Survivorship Program, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Lachlan McDowell
- Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia
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de Athayde Soares R, Câmara Costa Ferreira ZM, Viana Portela MV, Campelo Campos AB, Matielo MF, Pecego CS, Sacilotto R. A Comparative Analysis and Results of Carotid Interventions Based on Duplex Ultrasound as a Single Exam Versus Multiple Diagnose Exams. Ann Vasc Surg 2024; 104:10-17. [PMID: 37356654 DOI: 10.1016/j.avsg.2023.06.022] [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: 05/04/2023] [Revised: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND To determine the results, safety, and clinical outcomes of carotid interventions performed with duplex ultrasound (DUS) as a single preoperative image for internal carotid artery (ICA) assessment, compared to computed tomography angiography (CTA) and magnetic resonance angiography (MRA). METHODS Prospective, consecutive cohort study of 2 groups of patients submitted to carotid interventions, 1 group of patients with DUS as a sole exam (group DUS) compared to patients with DUS plus CTA or MRA for ICA stenosis diagnosis (group CTA/MRA) regarding clinical outcomes such as major stroke, minor stroke, transient ischemic attack and perioperative mortality. RESULTS Two groups of patients were identified: group DUS with 47 patients and group CTA/MRA plus DUS with 68 patients. The mean age of the patients was 71.67 years in total cohort, and most of them were male (66.1%). Group DUS had higher prevalence of male, dyslipidemia, ischemic heart disease, peripheral artery disease and chronic kidney disease than group CTA/MRA (83% vs. 54.4%, P = 0.001; 93.6% vs. 51.5%, P < 0.001; 36.2% vs. 16.2%, P = 0.009; 29.8% vs. 13.2%, P = 0.019; 14.9% vs. 5.9%, P = 0.007, respectively). We have performed a Kaplan-Meier regarding survival rates: Group DUS had 93.5%% and Group CTA/MRA had 90.3%% at 720 days. P = 0.15, standard error < 10 at 720 days. a Kaplan-Meier analysis regarding primary patency rates showed Group DUS with 92.7% and Group CTA/MRA with 94.7% at 720 days. P = 0.78, standard error < 10 at 720 days. Furthermore, the incidence of postoperative stroke was 2.6% (asymptomatic 1.7%, symptomatic 2.9%), with no differences among DUS and CTA/MRA groups (2.1% vs. 2.9%, P = 0.78, respectively). CONCLUSIONS Independently of the type of carotid intervention (carotid endarterectomy and carotid stenting (CAS)), DUS as an only preoperative carotid image has similar results regarding postoperative outcomes when compared to CTA/MRA for preoperative carotid evaluation.
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Affiliation(s)
- Rafael de Athayde Soares
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil.
| | | | - Matheus Vegas Viana Portela
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil
| | - Ana Beatriz Campelo Campos
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil
| | - Marcelo Fernando Matielo
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil
| | | | - Roberto Sacilotto
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil
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Long B, Marcolini E, Gottlieb M. Emergency medicine updates: Transient ischemic attack. Am J Emerg Med 2024; 83:82-90. [PMID: 38986211 DOI: 10.1016/j.ajem.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION Transient ischemic attack (TIA) is a condition commonly evaluated for in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning TIA for the emergency clinician. DISCUSSION TIA is a harbinger of ischemic stroke and can result from a variety of pathologic causes. While prior definitions incorporated symptoms resolving within 24 h, modern definitions recommend a tissue-based definition utilizing advanced imaging to evaluate for neurologic injury and the etiology. In the ED, emergent evaluation includes assessing for current signs and symptoms of neurologic dysfunction, appropriate imaging to investigate for minor stroke or stroke risk, and arranging appropriate disposition and follow up to mitigate risk of subsequent ischemic stroke. Imaging should include evaluation of great vessels and intracranial arteries, as well as advanced cerebral imaging to evaluate for minor or subclinical stroke. Non-contrast computed tomography (CT) has limited utility for this situation; it can rule out hemorrhage or a large mass causing symptoms but should not be relied on for any definitive diagnosis. Noninvasive imaging of the cervical vessels can also be used (CT angiography or Doppler ultrasound). Treatment includes antithrombotic medications if there are no contraindications. Dual antiplatelet therapy may reduce the risk of recurrent ischemic events in higher risk patients, while anticoagulation is recommended in patients with a cardioembolic source. A variety of scoring systems or tools are available that seek to predict stroke risk after a TIA. The Canadian TIA risk score appears to have the best diagnostic accuracy. However, these scores should not be used in isolation. Disposition may include admission, management in an ED-based observation unit with rapid diagnostic protocol, or expedited follow-up in a specialty clinic. CONCLUSIONS An understanding of literature updates concerning TIA can improve the ED care of patients with TIA.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Evie Marcolini
- Department of Emergency Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Zhu J, Jhang J, Yu H, Mushlin AI, Kamel H, Alemayehu N, Giardina JC, Gupta A, Pandya A. Cost-Effectiveness of Screening Asymptomatic Carotid Stenosis by Atherosclerotic Cardiovascular Risk. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2023.11.28.23299146. [PMID: 38798437 PMCID: PMC11118553 DOI: 10.1101/2023.11.28.23299146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Importance Extracranial internal carotid artery stenosis (50-99% arterial narrowing) is an important risk factor for ischemic stroke. Yet, the benefits and harms of targeted screening for asymptomatic carotid artery stenosis (ACAS) have not been assessed in population-based studies. Objective To estimate the cost-effectiveness of one-time, targeted ACAS screening stratified by atherosclerotic cardiovascular disease (ASCVD) risk using the American Heart Association's Pooled Cohort Equations. Design Setting and Participants We developed a lifetime microsimulation model of ACAS and stroke for a hypothetical cohort representative of US adults aged 50-80 years without stroke history. We used the Cardiovascular Health Study to estimate the probability and severity of ACAS based on individual characteristics (e.g., age, sex, smoking status, blood pressure, and cholesterol). Stroke risks were functions of these characteristics and ACAS severity. In the model, individuals testing positive for >70% stenosis with Duplex ultrasound and a confirmatory diagnostic test undergo revascularization, which may reduce the risk of stroke but also introduces complication risks. Diagnostic performance parameters, revascularization benefits and risks, utility weights, and costs were estimated from published sources. Cost-effectiveness was assessed from the health care sector perspective using a $100,000/quality-adjusted life year (QALY) threshold. Main Outcomes and Measures Estimated stroke events prevented, lifetime costs, QALYs, and incremental cost-effectiveness ratios (ICERs) associated with ACAS screening. Costs (2023 USD) and QALYs were discounted at 3% annually. Results We found that screening individuals with a 10-year ASCVD risk >30% was the most cost-effective strategy, with an ICER of $89,000/QALY. This strategy would make approximately 11.9% of the population eligible for screening, averting an estimated 24,084 strokes. Results were sensitive to variations in the efficacy and complication risk of revascularization. In probabilistic sensitivity analysis, screening those in lower ASCVD risk groups (0-20%) only had a 0.6% chance of being cost-effective. Conclusion and Relevance A one-time screening may only be cost-effective for adults at a relatively high ASCVD risk. Our findings provide a framework that can be adapted as future clinical trial data continue to improve our understanding of the role of revascularization and intensive medical therapy in contemporary stroke prevention secondary to carotid disease.
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Haasdijk EJ, Sadigh Y, Yildirim G, Dammers R, Volovici V. Limb-Shaking Transient Ischemic Attacks in Patients with Carotid Occlusion or Stenosis: A Systematic Review and Individual Patient Data Meta-Analysis. Neuroepidemiology 2024:1-10. [PMID: 38631313 DOI: 10.1159/000538977] [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: 02/09/2024] [Accepted: 04/11/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Limb-shaking transient ischemic attack (LSTIA) is a rare neurological condition which presents with involuntary jerky movements of the arm or leg, often because of carotid stenosis or occlusion. Due to the rarity of the condition, the epidemiology of LSTIA is poorly understood and the disease is frequently misdiagnosed. There is no standard treatment to date. The purpose of this study was to provide an overview of the epidemiology of LSTIA and its current treatment options. METHODS Embase, MEDLINE, Web of Science, Cochrane Central Register of Controlled Trials for randomized controlled trials, and Google Scholar were searched from database inception to December 30, 2023 for articles containing information on the epidemiology and treatment of LSTIA. An individual patient data meta-analysis (IPD-MA) was performed using data extracted from the included articles. Inclusion criteria were description of both the epidemiology and treatment of LSTIA in patients over the age of 18 with carotid stenosis/occlusion, confirmed by radiographic imaging. Exclusion criteria were studies focusing on pediatrics, no epidemiological data, internal carotid artery (ICA) stenosis/occlusion not radiologically confirmed, full text unavailable, full text not in English or Dutch, and non-original articles. RESULTS Of the 8,855 articles screened, 55 articles containing 251 patients were included. Fifty articles harboring 81 patients were included in the IPD-MA, and 7 articles harboring 187 patients were included in the cohort analysis. The results of the IPD-MA showed that LSTIA was caused by unilateral ICA stenosis/occlusion in 29 patients (36%) and most often from bilateral ICA stenosis/occlusion in 52 patients (64%). Limb-shaking was unilateral in 66 patients (83%) and was accompanied by weakness in 27 patients (33%). The intervention with the highest success rate was endovascular intervention (carotid stenting or balloon angioplasty), as all 10 patients remained asymptomatic after treatment. The cohort analysis showed that LSTIA can be caused by both unilateral and bilateral carotid stenosis or occlusion. The prevalence within cohorts of TIA patients of LSTIA varied considerably from 3.5 to 29%. CONCLUSION A large international clinical registry is warranted to gain a better understanding of the epidemiology of LSTIA. There is insufficient evidence available to suggest a standard treatment.
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Affiliation(s)
- Eva Joëlle Haasdijk
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC University Medical Centre, Rotterdam, The Netherlands,
| | - Yasmin Sadigh
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Gizem Yildirim
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Victor Volovici
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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Zhang SY, Blacquiere D, Dewar B, Stotts G, Dowlatshahi D. Spontaneous Recanalization of Internal Carotid Artery Occlusion: A Case Report. Neurologist 2023; 28:324-325. [PMID: 36715668 PMCID: PMC10521796 DOI: 10.1097/nrl.0000000000000485] [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] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Spontaneous recanalization of an occluded internal carotid artery (ICA) is thought to be unlikely. However, there has been a growing number of reports describing this phenomenon. Despite this, the frequency, time course, and mechanism of spontaneous recanalization remain unknown. In this paper, we describe a patient with a symptomatic recanalization of an occluded left ICA. CASE REPORT A 70-year-old woman presented with transient speech arrest and right upper extremity weakness related to an occluded ICA. After 3 days, her weakness and aphasia reappeared and worsened transiently. A repeat computed tomography angiography revealed recanalization of the occluded ICA, as well as new ischemic changes in the previously hypoperfused left insular region. This finding changed the management from medical management to revascularization with a stent, after which the patient was discharged home with acetylsalicylic acid and clopidogrel. CONCLUSIONS Although previously thought to be a rare occurrence, spontaneous recanalization is not uncommon. Further research into this phenomenon as proper identification and characterization of this phenomenon can influence follow-up and management.
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Affiliation(s)
- Sarah Y. Zhang
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec
| | - Dylan Blacquiere
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Brian Dewar
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Grant Stotts
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Ottakath N, Al-Maadeed S, Zughaier SM, Elharrouss O, Mohammed HH, Chowdhury MEH, Bouridane A. Ultrasound-Based Image Analysis for Predicting Carotid Artery Stenosis Risk: A Comprehensive Review of the Problem, Techniques, Datasets, and Future Directions. Diagnostics (Basel) 2023; 13:2614. [PMID: 37568976 PMCID: PMC10417708 DOI: 10.3390/diagnostics13152614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/25/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
The carotid artery is a major blood vessel that supplies blood to the brain. Plaque buildup in the arteries can lead to cardiovascular diseases such as atherosclerosis, stroke, ruptured arteries, and even death. Both invasive and non-invasive methods are used to detect plaque buildup in the arteries, with ultrasound imaging being the first line of diagnosis. This paper presents a comprehensive review of the existing literature on ultrasound image analysis methods for detecting and characterizing plaque buildup in the carotid artery. The review includes an in-depth analysis of datasets; image segmentation techniques for the carotid artery plaque area, lumen area, and intima-media thickness (IMT); and plaque measurement, characterization, classification, and stenosis grading using deep learning and machine learning. Additionally, the paper provides an overview of the performance of these methods, including challenges in analysis, and future directions for research.
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Affiliation(s)
- Najmath Ottakath
- Department of Computer Science and Engineering, Qatar University, Doha 2713, Qatar; (S.A.-M.); (O.E.); (H.H.M.)
| | - Somaya Al-Maadeed
- Department of Computer Science and Engineering, Qatar University, Doha 2713, Qatar; (S.A.-M.); (O.E.); (H.H.M.)
| | | | - Omar Elharrouss
- Department of Computer Science and Engineering, Qatar University, Doha 2713, Qatar; (S.A.-M.); (O.E.); (H.H.M.)
| | - Hanadi Hassen Mohammed
- Department of Computer Science and Engineering, Qatar University, Doha 2713, Qatar; (S.A.-M.); (O.E.); (H.H.M.)
| | | | - Ahmed Bouridane
- Centre for Data Analytics and Cybersecurity, University of Sharjah, Sharjah 27272, United Arab Emirates;
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Monteiro A, Donnelly BM, Recker MJ, Khan A, Davies JM, Snyder KV, Reynolds RM, Siddiqui AH, Levy EI. Head and neck angiography in the pediatric population: single-center experience with indications, safety, feasibility, and technical differences among infants, childhood, and adolescents. J Neurosurg Pediatr 2023; 31:221-227. [PMID: 36681958 DOI: 10.3171/2022.11.peds22385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/10/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Pediatric patients are candidates for head and neck endovascular procedures less frequently than adults. Data on utilization, feasibility, safety, and technical details of head and neck angiography in the pediatric population are scarce. METHODS The authors performed a retrospective review of their center's endovascular database to identify all patients ≤ 18 years of age who underwent diagnostic or interventional catheter-based angiography of the head and neck. Procedure-related variables for identified patients were compared across infancy (birth to 2 years), childhood (> 2-11 years), and adolescence (> 11-18 years). RESULTS One hundred twenty-one pediatric patients who underwent 274 angiogram procedures were included in this study. Of these angiograms, 197 were diagnostic and 118 were interventional (including 41 of the diagnostic angiogram procedures that were performed concurrently with the intervention). The most common indications for diagnostic angiograms were suspected vascular malformations in 52 cases (26.4%) and aneurysms in 23 (11.7%). The rate of positive findings on diagnostic angiograms ranged from 27.3% to 80% according to the indication. Access site-related complications were observed after 2 punctures (0.7%). Procedure-related complications occurred in 3 patients (1.1%). In adolescents, the rates of general anesthesia use and sheathless access were significantly lower (each p < 0.001), and the rates of radial artery access (p < 0.001); 5-French (5F) (p = 0.01), 6F (p < 0.001), and 8F (p = 0.03) access; and closure device usage (p < 0.001) were significantly higher. In infants, the rates of ultrasound guidance, 4F access, and failure of the primary puncture site were significantly higher (each p < 0.001). CONCLUSIONS Head and neck angiograms in the pediatric population were feasible and safe in the authors' overall experience. Technical differences were observed across the infant, childhood, and adolescent groups, but safe outcomes were similar throughout these age ranges.
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Affiliation(s)
- Andre Monteiro
- Departments of1Neurosurgery
- 2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Brianna M Donnelly
- Departments of1Neurosurgery
- 2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Matthew J Recker
- Departments of1Neurosurgery
- 2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Asham Khan
- Departments of1Neurosurgery
- 2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Jason M Davies
- Departments of1Neurosurgery
- 2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
- 3Bioinformatics, and
- 4Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York
- 5Jacobs Institute, Buffalo, New York; and
| | - Kenneth V Snyder
- Departments of1Neurosurgery
- 2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
- 4Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York
- 5Jacobs Institute, Buffalo, New York; and
| | - Renee M Reynolds
- Departments of1Neurosurgery
- 6Department of Pediatric Neurosurgery, John R. Oishei Children's Hospital, Buffalo, New York
| | - Adnan H Siddiqui
- Departments of1Neurosurgery
- 2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
- 4Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York
- 5Jacobs Institute, Buffalo, New York; and
- 7Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Elad I Levy
- Departments of1Neurosurgery
- 2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
- 4Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York
- 5Jacobs Institute, Buffalo, New York; and
- 7Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
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Cassola N, Baptista-Silva JC, Nakano LC, Flumignan CD, Sesso R, Vasconcelos V, Carvas Junior N, Flumignan RL. Duplex ultrasound for diagnosing symptomatic carotid stenosis in the extracranial segments. Cochrane Database Syst Rev 2022; 7:CD013172. [PMID: 35815652 PMCID: PMC9272405 DOI: 10.1002/14651858.cd013172.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Carotid artery stenosis is an important cause of stroke and transient ischemic attack. Correctly and rapidly identifying patients with symptomatic carotid artery stenosis is essential for adequate treatment with early cerebral revascularization. Doubts about the diagnostic value regarding the accuracy of duplex ultrasound (DUS) and the possibility of using DUS as the single diagnostic test before carotid revascularization are still debated. OBJECTIVES To estimate the accuracy of DUS in individuals with symptomatic carotid stenosis verified by either digital subtraction angiography (DSA), computed tomography angiography (CTA), or magnetic resonance angiography (MRA). SEARCH METHODS We searched CRDTAS, CENTRAL, MEDLINE (Ovid), Embase (Ovid), ISI Web of Science, HTA, DARE, and LILACS up to 15 February 2021. We handsearched the reference lists of all included studies and other relevant publications and contacted experts in the field to identify additional studies or unpublished data. SELECTION CRITERIA We included studies assessing DUS accuracy against an acceptable reference standard (DSA, MRA, or CTA) in symptomatic patients. We considered the classification of carotid stenosis with DUS defined with validated duplex velocity criteria, and the NASCET criteria for carotid stenosis measures on DSA, MRA, and CTA. We excluded studies that included < 70% of symptomatic patients; the time between the index test and the reference standard was longer than four weeks or not described, or that presented no objective criteria to estimate carotid stenosis. DATA COLLECTION AND ANALYSIS The review authors independently screened articles, extracted data, and assessed the risk of bias and applicability concerns using the QUADAS-2 domain list. We extracted data with an effort to complete a 2 × 2 table (true positives, true negatives, false positives, and false negatives) for each of the different categories of carotid stenosis and reference standards. We produced forest plots and summary receiver operating characteristic (ROC) plots to summarize the data. Where meta-analysis was possible, we used a bivariate meta-analysis model. MAIN RESULTS We identified 25,087 unique studies, of which 22 were deemed eligible for inclusion (4957 carotid arteries). The risk of bias varied considerably across the studies, and studies were generally of moderate to low quality. We narratively described the results without meta-analysis in seven studies in which the criteria used to determine stenosis were too different from the duplex velocity criteria proposed in our protocol or studies that provided insufficient data to complete a 2 × 2 table for at least in one category of stenosis. Nine studies (2770 carotid arteries) presented DUS versus DSA results for 70% to 99% carotid artery stenosis, and two (685 carotid arteries) presented results from DUS versus CTA in this category. Seven studies presented results for occlusion with DSA as the reference standard and three with CTA as the reference standard. Five studies compared DUS versus DSA for 50% to 99% carotid artery stenosis. Only one study presented results from 50% to 69% carotid artery stenosis. For DUS versus DSA, for < 50% carotid artery stenosis, the summary sensitivity was 0.63 (95% confidence interval [CI] 0.48 to 0.76) and the summary specificity was 0.99 (95% CI 0.96 to 0.99); for the 50% to 69% range, only one study was included and meta-analysis not performed; for the 50% to 99% range, the summary sensitivity was 0.97 (95% CI 0.95 to 0.98) and the summary specificity was 0.70 (95% CI 0.67 to 0.73); for the 70% to 99% range, the summary sensitivity was 0.85 (95% CI 0.77 to 0.91) and the summary specificity was 0.98 (95% CI 0.74 to 0.90); for occlusion, the summary sensitivity was 0.91 (95% CI 0.81 to 0.97) and the summary specificity was 0.95 (95% CI 0.76 to 0.99). For sensitivity analyses, excluding studies in which participants were selected based on the presence of occlusion on DUS had an impact on specificity: 0.98 (95% CI 0.97 to 0.99). For DUS versus CTA, we found two studies in the range of 70% to 99%; the sensitivity varied from 0.57 to 0.94 and the specificity varied from 0.87 to 0.98. For occlusion, the summary sensitivity was 0.95 (95% CI 0.80 to 0.99) and the summary specificity was 0.91 (95% CI 0.09 to 0.99). For DUS versus MRA, there was one study with results for 50% to 99% carotid artery stenosis, with a sensitivity of 0.88 (95% CI 0.70 to 0.98) and specificity of 0.60 (95% CI 0.15 to 0.95); in the 70% to 99% range, two studies were included, with sensitivity that varied from 0.54 to 0.99 and specificity that varied from 0.78 to 0.89. We could perform only a few of the proposed sensitivity analyses because of the small number of studies included. AUTHORS' CONCLUSIONS This review provides evidence that the diagnostic accuracy of DUS is high, especially at discriminating between the presence or absence of significant carotid artery stenosis (< 50% or 50% to 99%). This evidence, plus its less invasive nature, supports the early use of DUS for the detection of carotid artery stenosis. The accuracy for 70% to 99% carotid artery stenosis and occlusion is high. Clinicians should exercise caution when using DUS as the single preoperative diagnostic method, and the limitations should be considered. There was little evidence of the accuracy of DUS when compared with CTA or MRA. The results of this review should be interpreted with caution because they are based on studies of low methodological quality, mainly due to the patient selection method. Methodological problems in participant inclusion criteria from the studies discussed above apparently influenced an overestimated estimate of prevalence values. Most of the studies included failed to precisely describe inclusion criteria and previous testing. Future diagnostic accuracy studies should include direct comparisons of the various modalities of diagnostic tests (mainly DUS, CTA, and MRA) for carotid artery stenosis since DSA is no longer considered to be the best method for diagnosing carotid stenosis and less invasive tests are now used as reference standards in clinical practice. Also, for future studies, the participant inclusion criteria require careful attention.
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Affiliation(s)
- Nicolle Cassola
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jose Cc Baptista-Silva
- Evidence Based Medicine, Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis Cu Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Carolina Dq Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ricardo Sesso
- Department of Medicine, Division of Nefrology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vladimir Vasconcelos
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Nelson Carvas Junior
- Evidence-Based Health Post-Graduation Program, Universidade Federal de São Paulo; Cochrane Brazil; Department of Physiotherapy, Universidade Paulista, São Paulo, Brazil
| | - Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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10
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Rein LCDS, Siqueira DED, Guillaumon AT, Avelar WM, Cendes F. Near Infrared Spectroscopy For Cerebral Hemodynamic Monitoring During Carotid Endarterectomy Under General Anesthesia. Open Cardiovasc Med J 2022. [DOI: 10.2174/18741924-v16-e2203250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:
Near infrared spectroscopy (NIRS) is a noninvasive method for continuous monitoring of cerebral oxygenation.
Objective:
To describe the intraoperative behavior of NIRS variables used to evaluate hemodynamic response in patients with atherosclerotic disease undergoing carotid endarterectomy under general anesthesia.
Methods:
Fifteen volunteers with atherosclerotic carotid disease with indications for endarterectomy were evaluated. After selection of patients, carotid stenosis was confirmed by appropriate diagnostic methods. NIRS was used for intraoperative monitoring. The variables total hemoglobin (Hb), oxygenated hemoglobin (O2Hb), deoxygenated hemoglobin (HHb), and regional oxygen saturation (rSO2) were evaluated at three intraoperative time points: before, during, and after carotid clamping.
Results and Discussion:
Measurements recorded by NIRS showed that, during the first 5 min of clamp time, patients experienced a decline in O2Hb levels, an increase in HHb levels, and a marked decrease in rSO2. Hb remained constant throughout the procedure. At the post-clamping time point, HHb, O2Hb, and rSO2 returned to patterns similar to those observed before clamping.
Conclusion:
NIRS was able to reliably and accurately identify the three stages of carotid endarterectomy and may predict the risk of cerebral hypoxia during carotid clamping under general anesthesia.
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11
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Mbonde AA, O'Carroll CB, Dulamea OA, Anghel D, Chong BW, Dumitrascu OM. Current Guidelines on Management of Amaurosis Fugax and Transient Ischemic Attacks. Asia Pac J Ophthalmol (Phila) 2022; 11:168-176. [PMID: 35213421 DOI: 10.1097/apo.0000000000000511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
ABSTRACT Transient ischemic attack (TIA) is defined as a transient episode of neurological dysfunction resulting from focal brain, spinal cord, or retinal ischemia, without associated infarction. Consequently, a TIA encompasses amaurosis fugax (AF) that is a term used to denote momentary visual loss from transient retinal ischemia. In this review, we use the word TIA to refer to both cerebral TIAs (occurring in the brain) and AF (occurring in the retina). We summarize the key components of a comprehensive evaluation and management of patients presenting with cerebral and retinal TIA.All TIAs should be treated as medical emergencies, as they may herald permanent disabling visual loss and devastating hemispheric or vertebrobasilar ischemic stroke. Patients with suspected TIA should be expeditiously evaluated in the same manner as those with an acute stroke. This should include a detailed history and examination followed by specific diagnostic studies. Imaging of the brain and extracranial and intracranial blood vessels forms the cornerstone of diagnostic workup of TIA. Cardiac investigations and serum studies to evaluate for etiological risk factors are also recommended.The management of all TIAs, whether cerebral or retinal, is similar and should focus on stroke prevention strategies, which we have categorized into general and specific measures. General measures include the initiation of appropriate antiplatelet therapy, encouraging a healthy lifestyle, and managing traditional risk factors, such as hypertension, dyslipidemia, and diabetes. Specific management measures require the identification of a specific TIA etiology, such as moderate-severe (greater than 50% of stenosis) symptomatic extracranial large vessel or intracranial steno-occlusive atherosclerotic disease, aortic arch atherosclerosis, and atrial fibrillation.
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Affiliation(s)
- Amir A Mbonde
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
| | - Cumara B O'Carroll
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
| | - Octaviana A Dulamea
- Department of Neurology, Fundeni Clinical institute and University of Medicine Carol Davila, Bucharest, Romania
| | - Daniela Anghel
- Department of Neurology, Fundeni Clinical institute and University of Medicine Carol Davila, Bucharest, Romania
| | - Brian W Chong
- Department of Neuroradiology, Mayo Clinic College of Medicine and Science, Phoenix, AZ, US
| | - Oana M Dumitrascu
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
- Department of Ophthalmology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
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12
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Cryptogenic Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00044-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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13
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Chen J, Niu Z, Zhan K, Tao X, Tian F, Ding J, Jin Z, Hu X. Evaluation of Modified Calcium Removal Algorithm in dual energy CT of Internal Carotid Artery. Eur J Radiol 2021; 145:109927. [PMID: 34773829 DOI: 10.1016/j.ejrad.2021.109927] [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: 04/12/2021] [Revised: 06/23/2021] [Accepted: 08/14/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the performance of a dual-energy (DE) calcium removal software based on a modified three-material decomposition algorithm in assessing the stenosis of the internal carotid artery (ICA) in comparison with mixed images using digital subtraction angiography (DSA) as the reference standard. METHODS Forty-six patients (38 men; 67±8 years old), including 154 calcified ICA segments C1-C2 (59), C3-C5 (63), C6 (24), and C7 (8), were recruited in this retrospective study. Mixed images and virtual non-calcium (VNCa) images using the modified dual-energy computed tomography (DECT) algorithm were reconstructed. The differences between VNCa and DSA images vs. mixed and DSA images of degree of stenosis were compared. The intraclass correlation coefficient (ICC) was used for assessing the agreement between VNCa, mixed images, and DSA. RESULTS The degree of stenosis differed significantly between mixed and DSA images in the C3-C5 (30%±17.9% vs. 23.0%±16.9%, p = 0.026) and C6 (38.3%±15.4% vs. 28.5%±13.3%, p = 0.023) segments. The stenosis of VNCa images showed no significant difference with DSA images in all segments (all p > 0.05). The ICCs between VNCa and DSA images (0.86-0.97) were higher than those between the mixed and DSA images (0.68-0.96) in all segments. CONCLUSION The performance of a modified three-material decomposition DECT algorithm for calcium removal in ICA stenosis evaluation, particularly for the C3-C5 and C6 ICA segments, was promising.
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Affiliation(s)
- Jiao Chen
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou City 310016, Zhejiang Province, China
| | - Zhongfeng Niu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou City 310016, Zhejiang Province, China
| | - Kun Zhan
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou City 310016, Zhejiang Province, China
| | - Xinwei Tao
- Siemens Healthineers China, No.399, West Haiyang Road, Shanghai, China
| | - Fengjuan Tian
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou City 310016, Zhejiang Province, China
| | - Jing Ding
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou City 310016, Zhejiang Province, China
| | - Zhexia Jin
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou City 310016, Zhejiang Province, China
| | - Xiuhua Hu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou City 310016, Zhejiang Province, China.
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14
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An J, Kim HD, Kim SO, Kim HI, Song GW, Lee HC, Shim JH. Cervicocerebral atherosclerosis and its hepatic and coronary risk factors in patients with liver cirrhosis. Clin Mol Hepatol 2021; 28:67-76. [PMID: 34637612 PMCID: PMC8755468 DOI: 10.3350/cmh.2021.0202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/11/2021] [Indexed: 11/16/2022] Open
Abstract
Background/Aims We aimed to investigate the silent atherosclerotic burden of cervicocephalic vessels in cirrhotic patients compared with the general population, as well as the relevant risk factors including coronary parameters. Methods This study included 993 stroke-free patients with liver cirrhosis (LC) who underwent magnetic resonance angiography (MRA) of the head and neck as a pre-liver transplant assessment and 6,099 health checkup participants who underwent MRA examination. The two cohorts were matched for cerebrovascular risk factors, and the prevalence of atherosclerosis in major intracranial and extracranial arteries was compared in 755 matched pairs. Moreover, traditional, hepatic, and coronary variables related to cerebral atherosclerosis were assessed in cirrhotic patients. Results Overall, intracranial atherosclerosis was significantly less prevalent in the LC group than in the matched control group (2.3% vs. 5.4%, P=0.002), whereas the prevalence of extracranial atherosclerosis was similar (4.4% vs. 5.8%, P=0.242). These results were maintained in multivariate analyses of the pooled samples, with corresponding adjusted odds ratios [ORs] of LC of 0.56 and 0.77 (95% confidence intervals [CIs], 0.36–0.88 and 0.55–1.09). In the LC group, lower platelet count was inversely correlated with intracranial atherosclerosis (adjusted OR, 0.31; 95% CI, 0.13–0.76). Coronary artery calcium (CAC) score ≥100 was the only predictive factor for both intracranial and extracranial atherosclerosis (adjusted ORs, 4.06 and 5.43, respectively). Conclusions LC confers protection against intracranial atherosclerosis, and thrombocytopenia may be involved in this protective effect. High CAC score could serve as a potential surrogate for cervicocerebral vascular screening in asymptomatic cirrhotic patients.
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Affiliation(s)
- Jihyun An
- Gastroenterology and Hepatology, Hanyang University College of Medicine, Guri, Gyeonggi, Republic of Korea
| | - Hyung-Don Kim
- Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seon-Ok Kim
- Biostatistics and Clinical Epidemiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ha Il Kim
- Gastroenterology, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Gi-Won Song
- Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Han Chu Lee
- Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ju Hyun Shim
- Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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15
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Golovin DA, Rostovtseva TM, Kudryavtsev YS, Berdalin AB, Lelyuk SE, Lelyuk VG. Carotid artery elongation (dolichoarteriopathy) and cerebral perfusion: results of a pilot study. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2021. [DOI: 10.15829/1728-8800-2021-2778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Among the causes of brain ischemia, including stroke, the impaired straightness of internal carotid arteries (ICAs) are considered. The article discusses modern views on the causes of ICA geometry disorders, their pathogenetic and hemodynamic significance, and a possible contribution to cerebral lesions.Aim. To study the relationship between the anomalies of ICA configuration and the brain perfusion parameters using cerebral multislice computed tomographic angiography.Material and methods. Seventeen patients after ischemic stroke who had ICA elongation on the contralateral side of infarction: 7 women aged 60-87 years (median [1st quartile; 3rd quartile]: 73 [64; 75]) and 10 men aged 54-80 years (62 [60; 73]). There were also 10 patients of the control group with normal ICA configuration on the contralateral side of infarction: 5 women aged 50-71 years (59 [50; 68]) and 5 men aged 55-81 years (58 [57; 62]). Brain multislice computed tomographic angiography and magnetic resonance imaging were performed. Results. A significant perfusion decrease within normal values in the blood systems of the elongated ICAs was established. The relationship between the degree of ICA elongation and the age of patients, in the absence of such for brain white matter lesions, was recorded. There is the need to continue the study to clarify the nature of the severity and causes of the revealed phenomena.
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Affiliation(s)
- D. A. Golovin
- Research Center for Radiology and Clinical Physiology, Federal Center for Brain Research and Neurotechnologies, Federal Medical Biological Agency
| | - T. M. Rostovtseva
- Research Center for Radiology and Clinical Physiology, Federal Center for Brain Research and Neurotechnologies, Federal Medical Biological Agency
| | - Yu. S. Kudryavtsev
- Research Center for Radiology and Clinical Physiology, Federal Center for Brain Research and Neurotechnologies, Federal Medical Biological Agency
| | - A. B. Berdalin
- Research Center for Radiology and Clinical Physiology, Federal Center for Brain Research and Neurotechnologies, Federal Medical Biological Agency
| | - S. E. Lelyuk
- Research Center for Radiology and Clinical Physiology, Federal Center for Brain Research and Neurotechnologies, Federal Medical Biological Agency
| | - V. G. Lelyuk
- Research Center for Radiology and Clinical Physiology, Federal Center for Brain Research and Neurotechnologies, Federal Medical Biological Agency
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16
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Flow velocity quantification by exploiting the principles of the Doppler effect and magnetic particle imaging. Sci Rep 2021; 11:4529. [PMID: 33633162 PMCID: PMC7907137 DOI: 10.1038/s41598-021-83821-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 02/01/2021] [Indexed: 12/03/2022] Open
Abstract
Changes in blood flow velocity play a crucial role during pathogenesis and progression of cardiovascular diseases. Imaging techniques capable of assessing flow velocities are clinically applied but are often not accurate, quantitative, and reliable enough to assess fine changes indicating the early onset of diseases and their conversion into a symptomatic stage. Magnetic particle imaging (MPI) promises to overcome these limitations. Existing MPI-based techniques perform velocity estimation on the reconstructed images, which restricts the measurable velocity range. Therefore, we developed a novel velocity quantification method by adapting the Doppler principle to MPI. Our method exploits the velocity-dependent frequency shift caused by a tracer motion-induced modulation of the emitted signal. The fundamental theory of our method is deduced and validated by simulations and measurements of moving phantoms. Overall, our method enables robust velocity quantification within milliseconds, with high accuracy, no radiation risk, no depth-dependency, and extended range compared to existing MPI-based velocity quantification techniques, highlighting the potential of our method as future medical application.
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17
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Yan Z, Wang H, Liang J, Li Y, Li X. MicroRNA-503-5p improves carotid artery stenosis by inhibiting the proliferation of vascular smooth muscle cells. Exp Ther Med 2020; 20:85. [PMID: 32968442 PMCID: PMC7500050 DOI: 10.3892/etm.2020.9213] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 02/11/2020] [Indexed: 02/06/2023] Open
Abstract
Carotid artery stenosis (CAS) is a common arteriosclerotic vascular disease affected by vascular smooth muscle cells (VSMCs). The aim of the present study was to investigate the expression and diagnostic value of microRNA (miR)-503-5p in asymptomatic patients with CAS and to further explore the effect of miR-503-5p on VSMC proliferation. The levels of miR-503-5p in the serum of 62 asymptomatic patients with CAS and 60 healthy controls were detected by reverse transcription-quantitative PCR. The association between miR-503-5p and the clinical characteristics of the patients was analyzed using the χ2 test. A receiver operating characteristic curve was drawn to evaluate the diagnostic value of miR-503-5p to distinguish asymptomatic patients with CAS from healthy controls. Finally, miR-503-5p inhibitors and mimics were transfected into VSMCs in vitro to detect the effect of miR-503-5p on the proliferation ability through Cell Counting Kit-8 assays. The serum levels of miR-503-5p in asymptomatic patients with CAS were significantly reduced as compared with those in healthy individuals. The expression levels of miR-503-5p were significantly associated with diabetes and arterial stenosis. Furthermore, the area under the ROC curve was 0.817, the specificity was 79.03% and the sensitivity was 83.30%, which proved that miR-503-5p had a high diagnostic accuracy in patients with CAS. Finally, the in vitro proliferation assay indicated that overexpression of miR-503-5p significantly inhibited the proliferation of VSMCs. In conclusion, miR-503-5p is a potential diagnostic biomarker for asymptomatic CAS and overexpression of miR-503-5p may inhibit the proliferation of VSMCs and improve CAS.
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Affiliation(s)
- Zhiyuan Yan
- Department of Neurology, Anqiu People's Hospital, Weifang, Shandong 262100, P.R. China
| | - Hong Wang
- Department of Neurology, Anqiu People's Hospital, Weifang, Shandong 262100, P.R. China
| | - Junjun Liang
- Department of Neurosurgery, Anqiu People's Hospital, Weifang, Shandong 262100, P.R. China
| | - Yuan Li
- Department of Electrocardiography, Anqiu People's Hospital, Weifang, Shandong 262100, P.R. China
| | - Xiaodong Li
- Department of Neurology, Anqiu People's Hospital, Weifang, Shandong 262100, P.R. China
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18
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Brandt AH, Nguyen TQ, Gutte H, Frederik Carlsen J, Moshavegh R, Jensen JA, Bachmann Nielsen M, Hansen KL. Carotid Stenosis Assessment with Vector Concentration before and after Stenting. Diagnostics (Basel) 2020; 10:E420. [PMID: 32575759 PMCID: PMC7345475 DOI: 10.3390/diagnostics10060420] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/08/2020] [Accepted: 06/18/2020] [Indexed: 11/16/2022] Open
Abstract
Digital subtraction angiography (DSA) is considered the reference method for the assessment of carotid artery stenosis; however, the procedure is invasive and accompanied by ionizing radiation. Velocity estimation with duplex ultrasound (DUS) is widely used for carotid artery stenosis assessment since no radiation or intravenous contrast is required; however, the method is angle-dependent. Vector concentration (VC) is a parameter for flow complexity assessment derived from the angle independent ultrasound method vector flow imaging (VFI), and VC has shown to correlate strongly with stenosis degree. The aim of this study was to compare VC estimates and DUS estimated peak-systolic (PSV) and end-diastolic velocities (EDV) for carotid artery stenosis patients, with the stenosis degree obtained with DSA. Eleven patients with symptomatic carotid artery stenosis were examined with DUS, VFI, and DSA before and after stent treatment. Compared to DSA, VC showed a strong correlation (r = -0.79, p < 0.001), while PSV (r = 0.68, p = 0.002) and EDV (r = 0.51, p = 0.048) obtained with DUS showed a moderate correlation. VFI using VC calculations may be a useful ultrasound method for carotid artery stenosis and stent patency assessment.
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Affiliation(s)
- Andreas Hjelm Brandt
- Department of Radiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark; (T.-Q.N.); (H.G.); (J.F.C.); (M.B.N.); (K.L.H.)
| | - Tin-Quoc Nguyen
- Department of Radiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark; (T.-Q.N.); (H.G.); (J.F.C.); (M.B.N.); (K.L.H.)
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Henrik Gutte
- Department of Radiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark; (T.-Q.N.); (H.G.); (J.F.C.); (M.B.N.); (K.L.H.)
| | - Jonathan Frederik Carlsen
- Department of Radiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark; (T.-Q.N.); (H.G.); (J.F.C.); (M.B.N.); (K.L.H.)
| | | | - Jørgen Arendt Jensen
- Center for Fast Ultrasound Imaging, Department of Health Technology, Technical University of Denmark, 2800 Lyngby, Denmark;
| | - Michael Bachmann Nielsen
- Department of Radiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark; (T.-Q.N.); (H.G.); (J.F.C.); (M.B.N.); (K.L.H.)
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Kristoffer Lindskov Hansen
- Department of Radiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark; (T.-Q.N.); (H.G.); (J.F.C.); (M.B.N.); (K.L.H.)
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
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19
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Kohlman-Trigoboff D, Rich K, Foley A, Fitzgerald K, Arizmendi D, Robinson C, Brown R, Treat-Jacobson D. Society for Vascular Nursing endovascular repair of abdominal aortic aneurysm updated nursing clinical practice guideline. JOURNAL OF VASCULAR NURSING 2020; 38:36-65. [PMID: 32534654 PMCID: PMC7707638 DOI: 10.1016/j.jvn.2020.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 01/26/2020] [Indexed: 12/24/2022]
Affiliation(s)
- Debra Kohlman-Trigoboff
- Duke University Medical Center, Division of Cardiology, Duke Heart and Vascular, Durham, North Carolina.
| | - Kathleen Rich
- Critical Care Administration, Franciscan Health-Michigan City, Michigan City, Indiana
| | - Anne Foley
- Department of Vascular Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karen Fitzgerald
- The Vascular Group, PLLC, Albany Medical Center Hospital, Albany, New York
| | - Dianne Arizmendi
- Corporal Michael Crescenz VA Hospital, Philadelphia, Pennsylvania
| | | | - Rebecca Brown
- National Institutes of Health's National Center for Advancing Translational Sciences, University of Minnesota School of Nursing, Minneapolis, Minnesota
| | - Diane Treat-Jacobson
- Nursing Research for Improved Care, University of Minnesota School of Nursing, Minneapolis, Minnesota
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20
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Papanikolaou P, Antonopoulos AS, Mastorakou I, Angelopoulos A, Kostoula E, Mystakidi XV, Simantiris S, Galiatsatos N, Oikonomou E, Tousoulis D. Antithrombotic Therapy in Carotid Artery Disease. Curr Pharm Des 2020; 26:2725-2734. [PMID: 32418521 DOI: 10.2174/1381612826666200518111359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/08/2020] [Indexed: 12/19/2022]
Abstract
The management of asymptomatic atherosclerotic carotid artery disease and the role of antithrombotic therapy is of increasing importance for stroke prevention. Non-invasive imaging of carotid plaques can identify high-risk plaque features that are associated with the risk of plaque rupture. Carotid plaque necrosis, hemorrhage, fibrous cap thinning, and the presence of foam cells have all been correlated with the risk of rupture and onset of neurological symptoms in patients with carotid stenosis. Antiplatelets are currently recommended for patients with a history of ischemic stroke and/or significant carotid artery stenosis, with aspirin and clopidogrel being the most widely used and studied agents. The role of dual antiplatelet therapy remains controversial. Moreover, there is scarce evidence on the role of newer anticoagulant agents in stable patients with carotid artery stenosis. In this review article, we discuss the pathophysiology of carotid atherosclerosis, the use of non-invasive imaging for detecting the vulnerable carotid plaque and summarize the existing clinical evidence on the use of antiplatelet and antithrombotic agents in carotid artery disease.
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Affiliation(s)
- Paraskevi Papanikolaou
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Alexios S Antonopoulos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Irene Mastorakou
- Imaging Department - Onassis Cardiac Surgery Centre, Athens, Greece
| | - Andreas Angelopoulos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | | | - Xara-Vasiliki Mystakidi
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Spyros Simantiris
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Nikolaos Galiatsatos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Evangelos Oikonomou
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Dimitris Tousoulis
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
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21
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Samber DD, Ramachandran S, Sahota A, Naidu S, Pruzan A, Fayad ZA, Mani V. Segmentation of carotid arterial walls using neural networks. World J Radiol 2020; 12:1-9. [PMID: 31988700 PMCID: PMC6928332 DOI: 10.4329/wjr.v12.i1.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/11/2019] [Accepted: 11/20/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Automated, accurate, objective, and quantitative medical image segmentation has remained a challenging goal in computer science since its inception. This study applies the technique of convolutional neural networks (CNNs) to the task of segmenting carotid arteries to aid in the assessment of pathology. AIM To investigate CNN's utility as an ancillary tool for researchers who require accurate segmentation of carotid vessels. METHODS An expert reader delineated vessel wall boundaries on 4422 axial T2-weighted magnetic resonance images of bilateral carotid arteries from 189 subjects with clinically evident atherosclerotic disease. A portion of this dataset was used to train two CNNs (one to segment the vessel lumen and the other to segment the vessel wall) with the remaining portion used to test the algorithm's efficacy by comparing CNN segmented images with those of an expert reader. RESULTS Overall quantitative assessment between automated and manual segmentations was determined by computing the DICE coefficient for each pair of segmented images in the test dataset for each CNN applied. The average DICE coefficient for the test dataset (CNN segmentations compared to expert's segmentations) was 0.96 for the lumen and 0.87 for the vessel wall. Pearson correlation values and the intra-class correlation coefficient (ICC) were computed for the lumen (Pearson = 0.98, ICC = 0.98) and vessel wall (Pearson = 0.88, ICC = 0.86) segmentations. Bland-Altman plots of area measurements for the CNN and expert readers indicate good agreement with a mean bias of 1%-8%. CONCLUSION Although the technique produces reasonable results that are on par with expert human assessments, our application requires human supervision and monitoring to ensure consistent results. We intend to deploy this algorithm as part of a software platform to lessen researchers' workload to more quickly obtain reliable results.
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Affiliation(s)
- Daniel D Samber
- Translational and Molecular Imaging Institute (TMII), Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Sarayu Ramachandran
- Translational and Molecular Imaging Institute (TMII), Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Anoop Sahota
- Translational and Molecular Imaging Institute (TMII), Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Sonum Naidu
- Translational and Molecular Imaging Institute (TMII), Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Alison Pruzan
- Translational and Molecular Imaging Institute (TMII), Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Zahi A Fayad
- Translational and Molecular Imaging Institute (TMII), Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Venkatesh Mani
- Translational and Molecular Imaging Institute (TMII), Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
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Rojoa DM, Lodhi AQD, Kontopodis N, Ioannou CV, Labropoulos N, Antoniou GA. Ultrasonography for the diagnosis of extra-cranial carotid occlusion - diagnostic test accuracy meta-analysis. VASA 2020; 49:195-204. [PMID: 31983286 DOI: 10.1024/0301-1526/a000850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background: The correct diagnosis of internal carotid artery (ICA) occlusion is crucial as it limits unnecessary intervention, whereas correct identification of patients with severe ICA stenosis is paramount in decision making and selecting patients who would benefit from intervention. We aimed to evaluate the accuracy of ultrasonography (US) in the diagnosis of ICA occlusion. Methods: We conducted a systematic review in compliance with the Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) of diagnostic test accuracy studies. We interrogated electronic bibliographic sources using a combination of free text and thesaurus terms to identify studies assessing the diagnostic accuracy of US in ICA occlusion. We used a mixed-effects logistic regression bivariate model to estimate summary sensitivity and specificity. We developed hierarchical summary receiver operating characteristic (HSROC) curves. Results: We identified 23 studies reporting a total of 5,675 arteries of which 722 were proven to be occluded by the reference standard. The reference standard was digital subtraction or cerebral angiography in all but two studies, which used surgery to ascertain a carotid occlusion. The pooled estimates for sensitivity and specificity were 0.97 (95% confidence interval (CI) 0.94 to 0.99) and 0.99 (95% CI 0.98 to 1.00), respectively. The diagnostic odds ratio was 3,846.15 (95% CI 1,375.74 to 10,752.65). The positive and negative likelihood ratio were 114.71 (95% CI 58.84 to 223.63) and 0.03 (95% CI 0.01 to 0.06), respectively. Conclusions: US is a reliable and accurate method in diagnosing ICA occlusion. US can be used as a screening tool with cross-sectional imaging being reserved for ambiguous cases.
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Affiliation(s)
- Djamila M Rojoa
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Ahmad Q D Lodhi
- Department of Radiology, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Nikos Kontopodis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, University of Crete, Heraklion, Greece
| | - Christos V Ioannou
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, University of Crete, Heraklion, Greece
| | - Nicos Labropoulos
- Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK.,Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
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Beheshtian E, Emamzadehfard S, Sahraian S, Jalilianhasanpour R, Yousem DM. Redundant Neurovascular Imaging: Who Is to Blame and What Is the Value? AJNR Am J Neuroradiol 2019; 41:35-39. [PMID: 31806598 DOI: 10.3174/ajnr.a6329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 10/02/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE Excessive use of neurovascular imaging studies such as Doppler ultrasound, CTA, MRA, and DSA adds cost to the evaluation of patients with new neurologic deficits. We sought to determine to what extent redundant neurovascular imaging is generated by radiologists' recommendations and the agreement rates among modalities in this setting. MATERIALS AND METHODS The radiology reports of 300 consecutive patients admitted for acute stroke to determine the frequency of the following: 1) >1 neurovascular study performed, 2) recommendation for another study, 3) recommendation made by the radiologist, and 4) agreement rates among these redundant neurovascular imaging studies. RESULTS Among the 300 consecutive patients, 125 had redundant neurovascular imaging, accounting for 144 redundant studies. These included 75/125 redundant neurovascular imaging studies after MRA, 48/125 after CTA, and 2/125 after Doppler ultrasound. The radiologist recommended another vascular study in 22/125 (17.6%) patients; the rest of the recommendations were made by clinicians. The second study agreed with the first in 54.6% (12/22) of cases recommended by radiologists and 73.8% (76/103) recommended by clinicians (P value = .06). CTA agreed with MRA, carotid Doppler ultrasound, and DSA in 66.7%, 66.7%, and 55.6%, respectively. MRA agreed with Doppler ultrasound and DSA in 78.3% and 66.7%, respectively. CONCLUSIONS Of cases with redundant neurovascular imaging, most were generated by clinicians, but radiologists recommended redundant neurovascular imaging in 17.6% of patients; 81.8% occurred following MRA. Overall, most secondary studies (68.8%) confirmed the findings of the first study. Such low-value, same-result redundant neurovascular imaging was more common when clinicians ordered the studies (73.8%) than when radiologists ordered them (54.6%).
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Affiliation(s)
- E Beheshtian
- From the Russell H. Morgan Department of Radiology and Radiological Science (E.B., S.S., R.J., D.M.Y.), Johns Hopkins Medical Institution, Baltimore, Maryland
| | - S Emamzadehfard
- Department of Radiology (S.E.), University of Texas Health Science Center, San Antonio, Texas
| | - S Sahraian
- From the Russell H. Morgan Department of Radiology and Radiological Science (E.B., S.S., R.J., D.M.Y.), Johns Hopkins Medical Institution, Baltimore, Maryland
| | - R Jalilianhasanpour
- From the Russell H. Morgan Department of Radiology and Radiological Science (E.B., S.S., R.J., D.M.Y.), Johns Hopkins Medical Institution, Baltimore, Maryland
| | - D M Yousem
- From the Russell H. Morgan Department of Radiology and Radiological Science (E.B., S.S., R.J., D.M.Y.), Johns Hopkins Medical Institution, Baltimore, Maryland
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Sui B, Gao P. High-resolution vessel wall magnetic resonance imaging of carotid and intracranial vessels. Acta Radiol 2019; 60:1329-1340. [PMID: 30727746 DOI: 10.1177/0284185119826538] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Binbin Sui
- Radiology Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
- Radiology Department, Beijing Neurosurgical Institute, Beijing, PR China
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, PR China
| | - Peiyi Gao
- Radiology Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
- Radiology Department, Beijing Neurosurgical Institute, Beijing, PR China
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, PR China
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25
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Miceli M, Baldi D, Cavaliere C, Soricelli A, Salvatore M, Napoli C. Peripheral artery disease: the new frontiers of imaging techniques to evaluate the evolution of regenerative medicine. Expert Rev Cardiovasc Ther 2019; 17:511-532. [PMID: 31220944 DOI: 10.1080/14779072.2019.1635012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Stem cells (ESC, iPSC, MSC) are known to have intrinsic regenerative properties. In the last decades numerous findings have favored the development of innovative therapeutic protocols based on the use of stem cells (Regenerative Medicine/Cell Therapy) for the treatment of numerous diseases including PAD, with promising results in preclinical studies. So far, several clinical studies have shown a general improvement of the patient's clinical outcome, however they possess many critical issues caused by the non-randomized design of the limited number of patients examined, the type cells to be used, their dosage, the short duration of treatment and also their delivery strategy. Areas covered: In this context, the use of the most advanced molecular imaging techniques will allow the visualization of very important physio-pathological processes otherwise invisible with conventional techniques, such as angiogenesis, also providing important structural and functional data. Expert opinion: The new frontier of cell therapy applied to PAD, potentially able to stop or even the process that causes the disease, with particular emphasis on the clinical aspects that different types of cells involve and on the use of more innovative molecular imaging techniques now available.
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Affiliation(s)
| | | | | | - Andrea Soricelli
- a IRCCS SDN , Naples , Italy.,b Department of Exercise and Wellness Sciences , University of Naples Parthenope , Naples , Italy
| | | | - Claudio Napoli
- a IRCCS SDN , Naples , Italy.,c University Department of Advanced Medical and Surgical Sciences, Clinical Department of Internal Medicine and Specialty Medicine , Università degli Studi della Campania 'Luigi Vanvitelli' , Napes , Italy
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26
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Seo J, Kim GS, Lee HY, Byun YS, Jung IH, Rhee KJ, Kim BO. Prevalence and Clinical Outcomes of Asymptomatic Carotid Artery Stenosis in Patients Undergoing Concurrent Coronary and Carotid Angiography. Yonsei Med J 2019; 60:542-546. [PMID: 31124337 PMCID: PMC6536396 DOI: 10.3349/ymj.2019.60.6.542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 03/28/2019] [Accepted: 04/15/2019] [Indexed: 01/25/2023] Open
Abstract
PURPOSE The prevalence and clinical outcomes of asymptomatic carotid artery stenosis (CAS) in patients with coronary artery disease (CAD) have not been thoroughly studied. We examined the prevalence and predictors of asymptomatic CAS detected by carotid angiography and determined the impact of concomitant CAS on prognosis in patients undergoing coronary angiography (CAG) due to CAD. MATERIALS AND METHODS Between January 2013 and July 2015, 395 patients who underwent carotid digital subtraction angiography to screen for CAS during CAG were analyzed. The presence of CAS was defined as angiographically significant stenosis (≥50%). Major adverse cardiac and cerebrovascular event (MACCE) rates were compared between patients with and without CAS. MACCEs included a composite of cardiac death, cerebrovascular death, acute myocardial infarction, and stroke. RESULTS Of the 395 patients, 101 (25.5%) patients had significant CAS. The independent predictors of CAS were age, male sex, hypertension, diabetes, and multi-vessel disease. In patients with CAD, the presence of CAS was as an independent predictor for MACCEs after adjusting for confounding factors (hazard ratio 2.47, 95% confidence interval 1.16-5.24, p=0.018). CONCLUSION Asymptomatic CAS was documented in up to 25% of patients with CAD. The presence of CAS in patients with CAD was associated with a higher rate of MACCEs. Therefore, detection of CAS by carotid angiography during CAG may be important for risk stratification for CAD patients, particularly those with multi-vessel disease.
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Affiliation(s)
- Jongkwon Seo
- Division of Cardiology, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Gwang Sil Kim
- Division of Cardiology, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Hye Young Lee
- Division of Cardiology, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Young Sup Byun
- Division of Cardiology, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - In Hyun Jung
- Division of Cardiology, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Kun Joo Rhee
- Division of Cardiology, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Byung Ok Kim
- Division of Cardiology, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea.
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Saxena A, Ng EYK, Lim ST. Imaging modalities to diagnose carotid artery stenosis: progress and prospect. Biomed Eng Online 2019; 18:66. [PMID: 31138235 PMCID: PMC6537161 DOI: 10.1186/s12938-019-0685-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/17/2019] [Indexed: 12/25/2022] Open
Abstract
In the past few decades, imaging has been developed to a high level of sophistication. Improvements from one-dimension (1D) to 2D images, and from 2D images to 3D models, have revolutionized the field of imaging. This not only helps in diagnosing various critical and fatal diseases in the early stages but also contributes to making informed clinical decisions on the follow-up treatment profile. Carotid artery stenosis (CAS) may potentially cause debilitating stroke, and its accurate early detection is therefore important. In this paper, the technical development of various CAS diagnosis imaging modalities and its impact on the clinical efficacy is thoroughly reviewed. These imaging modalities include duplex ultrasound (DUS), computed tomography angiography (CTA) and magnetic resonance angiography (MRA). For each of the imaging modalities considered, imaging methodology (principle), critical imaging parameters, and the extent of imaging the vulnerable plaque are discussed. DUS is usually the initial recommended CAS diagnostic examination. However, for the therapeutic intervention, either MRA or CTA is recommended for confirmation, and for added information on intracranial cerebral circulation and aortic arch condition for procedural planning. Over the past few decades, the focus of CAS diagnosis has also shifted from pure stenosis quantification to plaque characterization. This has led to further advancement in the existing imaging tools and development of other potential imaging tools like Optical coherence tomography (OCT), photoacoustic tomography (PAT), and infrared (IR) thermography.
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Affiliation(s)
- Ashish Saxena
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, 50 Nanyang Ave, Block N3, Singapore, 639798, Singapore
| | - Eddie Yin Kwee Ng
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, 50 Nanyang Ave, Block N3, Singapore, 639798, Singapore.
| | - Soo Teik Lim
- Department of Cardiology, National Heart Center Singapore, 5 Hospital Dr, Singapore, 169609, Singapore
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Abstract
Stroke is the clinical syndrome of acute onset of neurologic deficit caused by ischemia or hemorrhage. Neuroimaging has a crucial role in differentiating ischemic from hemorrhagic stroke. Advanced neuroimaging has become essential in the management of patients with acute ischemic stroke mainly because of improved awareness of the imaging findings and their role in patient selection for novel treatment options as highlighted in recent clinical trials, including "late window" (8-24 hours post ictus!) intra-arterial thrombectomy. This article focuses on the role of neuroimaging in the management of patients with acute ischemic stroke.
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Affiliation(s)
- Shahmir Kamalian
- Department of Radiology, Division of Emergency Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Blake SB Room 29A, Boston, MA 02114, USA.
| | - Michael H Lev
- Department of Radiology, Division of Emergency Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Blake SB Room 29A, Boston, MA 02114, USA
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Abstract
Stroke is one of the leading causes of death in the world and carotid artery stenosis is a major cause of ischaemic strokes. Symptomatic patients are often treated with either carotid endarterectomy (CEA) or carotid artery stenting (CAS). Asymptomatic patients can be treated with best medical therapy, CEA or CAS. While guidelines exist for the management of carotid artery stenosis, the results of recent studies are controversial regarding the safety of CAS compared with CEA. This review aims to outline the current guidelines while reviewing up-to- date studies and analyses. Future studies and emerging technologies are outlined in an attempt to provide an evaluation of the current data and management of this complex problem.
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Affiliation(s)
- Edward Y Woo
- Medstar Washington Hopsital Center, Washington DC, US
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30
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Jo YJ, Choi SK, Park SH, Lee JJ, Lee JE, Park SW. Initial Clinical Manifestations of Ocular Ischemic Syndrome in Koreans. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2019. [DOI: 10.3341/jkos.2019.60.12.1231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Yeon Ji Jo
- Department of Ophthalmology, Pusan National University School of Medicine, Yangsan, Korea
| | - Seung Kwon Choi
- Department of Ophthalmology, Pusan National University School of Medicine, Yangsan, Korea
| | - Sun Ho Park
- Department of Ophthalmology, Pusan National University School of Medicine, Yangsan, Korea
| | - Jae Jung Lee
- Department of Ophthalmology, Pusan National University School of Medicine, Yangsan, Korea
| | - Ji Eun Lee
- Department of Ophthalmology, Pusan National University School of Medicine, Yangsan, Korea
| | - Sung Who Park
- Department of Ophthalmology, Pusan National University School of Medicine, Yangsan, Korea
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31
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Balaji A, Rajagopal N, Yamada Y, Teranishi T, Kawase T, Kato Y. Carotid Endarterectomy: The Need for In vivo Optical Spectroscopy in the Decision-Making on Intraoperative Shunt Usage - A Technical Note. Asian J Neurosurg 2019; 14:206-210. [PMID: 30937036 PMCID: PMC6417291 DOI: 10.4103/ajns.ajns_223_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Carotid endarterectomy (CEA) is the surgical excision of the atherosclerotic plaque in patients with severe carotid artery stenosis. It is a common surgical technique required by neurosurgeons that should be mastered. In this article, we provide an outline of the technique and multimodality adjuncts involved in performing an effective CEA with a better surgical outcome. Materials and Methods: We have operated a total of 14 patients in our institute from 2015 to 2018. The male to female ratio is 13:1. Four (28.5%) patients were symptomatic and 10 (71.5%) were asymptomatic; with an average percentage of carotid stenosis being 81.2% in symptomatic and 76.6% in asymptomatic patients. Two patients have undergone bilateral CEA. Intraoperative monitoring was done with continuous in vivo optical spectroscopy (INVOS). Furui's double balloon shunt system was used to maintain blood flow from common carotid artery to the internal carotid artery, thus preventing cerebral ischemia in selected cases with significantly lateralized cerebral oximetry (CO) recordings. Results: Of the 14 patients with 16 CEA procedures, continuous INVOS monitoring was used in 12 CEA procedures. Of the 12 cases, only 5 (41.6%) needed a shunt. Furui's shunt was not used in 7 (58.3%) CEA procedures, where there were no changes in the intraoperative CO and these patients had an uneventful postoperative period. INVOS monitoring not only reduced the use of routine intraoperative shunt but also reduced the total surgical time and thus aided in preventing neurological complications. Conclusion: CEA should be strongly considered for symptomatic patients with >70% of carotid stenosis and in patients with 50%–69% stenosis if no other etiological basis for the ischemic symptoms can be identified. Continuous INVOS monitoring is mandatory for the decision of the use of intraoperative shunt, which reduces the perioperative morbidity and mortality significantly.
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Affiliation(s)
- Arun Balaji
- Department of Neurosurgery, Kovai Medical Centre and Hospital, Coimbatore, Tamil Nadu, India
| | - Niranjana Rajagopal
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, Karnataka, India
| | - Yasuhiro Yamada
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Takao Teranishi
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Tsukasa Kawase
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Yoko Kato
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
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32
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Cassola N, Baptista-Silva JCC, Flumignan CDQ, Sesso R, Vasconcelos V, Flumignan RLG. Duplex ultrasound for diagnosing symptomatic carotid stenosis in the extracranial segments. Hippokratia 2018. [DOI: 10.1002/14651858.cd013172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Nicolle Cassola
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil 04038-001
| | - Jose CC Baptista-Silva
- Universidade Federal de São Paulo; Evidence Based Medicine, Cochrane Brazil; Rua Borges Lagoa, 564, cj 124 São Paulo São Paulo Brazil 04038-000
| | - Carolina DQ Flumignan
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil 04038-001
| | - Ricardo Sesso
- Escola Paulista de Medicina, Universidade Federal de São Paulo; Disciplina de Nefrologia; Rua Botucato 740 São Paulo São Paulo Brazil 04023-900
| | - Vladimir Vasconcelos
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil 04038-001
| | - Ronald LG Flumignan
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil 04038-001
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Brandt AH, Hansen KL, Ewertsen C, Holbek S, Olesen JB, Moshavegh R, Thomsen C, Jensen JA, Nielsen MB. A Comparison Study of Vector Velocity, Spectral Doppler and Magnetic Resonance of Blood Flow in the Common Carotid Artery. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:1751-1761. [PMID: 29804906 DOI: 10.1016/j.ultrasmedbio.2018.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 04/26/2018] [Accepted: 05/01/2018] [Indexed: 06/08/2023]
Abstract
Magnetic resonance phase contrast angiography (MRA) is the gold standard for blood flow evaluation. Spectral Doppler ultrasound (SDU) is the first clinical choice, although the method is angle dependent. Vector flow imaging (VFI) is an angle-independent ultrasound method. The aim of the study was to compare VFI- and SDU-estimated peak systolic velocities (PSV) of the common carotid artery (CCA) with PSV obtained by MRA. Furthermore, intra- and inter-observer agreement was determined. MRA estimates were significantly different from SDU estimates (left CCA: p < 0.001, right CCA: p < 0.001), but not from VFI estimates (left CCA: p = 0.28, right CCA: p = 0.18). VFI measured lower PSV in both CCAs compared with SDU (p < 0.001) with improved precision (VFI: left: 24%, right: 18%; SDU: left 38%, right: 23%). Intra- and inter-observer agreement was almost perfect for VFI and SDU (inter-observer correlation coefficient: VFI 0.88, SDU 0.91; intra-observer correlation coefficient: VFI 0.96, SDU 0.97). VFI is more accurate than SDU in evaluating PSV compared with MRA.
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Affiliation(s)
- Andreas Hjelm Brandt
- Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | | | - Caroline Ewertsen
- Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Simon Holbek
- Center for Fast Ultrasound Imaging, Department of Electrical Engineering, Technical University of Denmark, Lyngby, Denmark
| | - Jacob Bjerring Olesen
- Center for Fast Ultrasound Imaging, Department of Electrical Engineering, Technical University of Denmark, Lyngby, Denmark
| | - Ramin Moshavegh
- Center for Fast Ultrasound Imaging, Department of Electrical Engineering, Technical University of Denmark, Lyngby, Denmark
| | - Carsten Thomsen
- Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Radiology, Zealand University Hospital Roskilde, Roskilde, Denmark
| | - Jørgen Arendt Jensen
- Center for Fast Ultrasound Imaging, Department of Electrical Engineering, Technical University of Denmark, Lyngby, Denmark
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Boyko M, Kalashyan H, Becher H, Romanchuk H, Saqqur M, Rempel JL, Derksen C, Shuaib A, Khan K. Comparison of Carotid Doppler Ultrasound to Other Angiographic Modalities in the Measurement of Carotid Artery Stenosis. J Neuroimaging 2018; 28:683-687. [PMID: 29917285 DOI: 10.1111/jon.12532] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 05/30/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to compare Doppler ultrasound (DUS) to other angiographic modalities: computed tomography angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA). METHODS All DUS studies performed at Stroke Prevention Clinic (SPC) from 2011 to 2013 and referred for further angiographic modalities were included. Patients were excluded if the corresponding angiographic modality was not performed within 6 months of DUS. Patients were also excluded if they underwent interventions before DUS or between the time of DUS and the corresponding angiographic modality. The degree of stenosis was classified as mild (<50%), moderate (50-69%), severe (70-99%), or occlusion (100%). RESULTS In total, 245 patients were identified. Nine patients were excluded (3.7%). Overall 472 Doppler studies of single ICAs from 236 patients were included in our analysis. Age was 65 ± 13 years and 136 patients were males (57.6%). There was an excellent agreement between DUS and CTA (kappa = .9 [P < .001], n = 274), good agreement with MRA (kappa = .8 [P < .001], n = 242), and excellent agreement with DSA (kappa = .92 [P < .001], n = 18). There was excellent agreement between CTA and MRA (kappa = .87, n = 46). CONCLUSION Doppler ultrasound performed in a dedicated SPC by an experienced sonographer and reviewed by a certified stroke neurologist serves as a reliable initial screening tool in determining carotid artery stenosis.
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Affiliation(s)
- Matthew Boyko
- Department of Neurology, University of Calgary, Calgary, AB, Canada
| | - Hayrapet Kalashyan
- Department of Medicine, University of Alberta Stroke Program, Edmonton, AB, Canada
| | - Harald Becher
- Department of Cardiology, University of Alberta Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| | - Helen Romanchuk
- Department of Medicine, University of Alberta Stroke Program, Edmonton, AB, Canada
| | - Maher Saqqur
- Department of Medicine, University of Alberta Stroke Program, Edmonton, AB, Canada
| | | | - Carol Derksen
- Department of Medicine, University of Alberta Stroke Program, Edmonton, AB, Canada
| | - Ashfaq Shuaib
- Department of Medicine, University of Alberta Stroke Program, Edmonton, AB, Canada
| | - Khurshid Khan
- Department of Medicine, University of Alberta Stroke Program, Edmonton, AB, Canada
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35
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Kamalian S, Lev MH. The Adult Patient with Acute Neurologic Deficit: An Update on Imaging Trends. Neuroimaging Clin N Am 2018; 28:319-334. [PMID: 30007748 DOI: 10.1016/j.nic.2018.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Stroke is the clinical syndrome of abrupt onset of acute neurologic deficit owing to decreased oxygen delivery to the brain, resulting in ischemia or infarction. Approximately 87% of strokes are ischemic and 13% are hemorrhagic. Improved awareness of the neuroimaging findings highlighted in recent stroke clinical trials, as well as of their role in patient selection for novel treatment options-including "late window" (8-24 hours post-ictus!) intraarterial thrombectomy-has become increasingly important. This article focuses on the role of neuroimaging in the assessment and management of patients with acute ischemic stroke.
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Affiliation(s)
- Shahmir Kamalian
- Division of Emergency Radiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Blake SB Room 29A, Boston, MA 02114, USA.
| | - Michael H Lev
- Division of Emergency Radiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Blake SB Room 29A, Boston, MA 02114, USA
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Simon B, Mani SE, Keshava SN, Alexander M, Aaron S. Role of Noninvasive Imaging of Cerebral Arterial System in Ischemic Stroke: Comparison of Transcranial Color-coded Doppler Sonography with Magnetic Resonance Angiography. J Clin Imaging Sci 2018; 8:19. [PMID: 29770267 PMCID: PMC5939038 DOI: 10.4103/jcis.jcis_13_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 03/27/2018] [Indexed: 11/04/2022] Open
Abstract
Aim To determine the accuracy of transcranial color-coded Doppler sonography (TCCS) in the evaluation of cerebral arterial system in patients with ischemic stroke attending a tertiary care hospital in South India. Objectives (1) To describe the topographical distribution of atherosclerotic lesions in the cerebral circulation in patients presenting with ischemic stroke from the Indian subcontinent and (2) to determine the accuracy of TCCS for detection and quantification of intracranial stenoses in various segments of the intracerebral arterial system in comparison with magnetic resonance angiography (MRA). Materials and Methods The demographic profile and risk factors of consecutive patients who presented to neurology outpatient department with cerebral ischemia and scheduled for MRA were determined. These patients had undergone neck Doppler, TCCS, and MRA. The agreement between the MRA and TCCS was assessed using kappa statistics. The sensitivity, specificity, and positive and negative predictive values of TCCS as compared to MRA were calculated. Results Ninety patients were included in the final analysis. Intracranial atherosclerosis was found in 35.6% of cases. The agreement between TCCS and MRA in detecting lesions for the different arterial segments in the intracranial circulation was 0.83 for anterior cerebral artery (ACA), 0.66 for M1 segment of middle cerebral artery (MCA), 0.45 for M2 segment of MCA, 0.86 for terminal internal carotid artery (TICA), 0.46 for posterior cerebral artery (PCA), and 0.81 for vertebral artery (VA). The sensitivity for the detection of hemodynamically significant arterial lesions in different vascular segments was 100%, 70%, 33.3%, 90.9%, 33.3%, and 72.7% for ACA, M1, M2, TICA, PCA, and VA, respectively. Conclusion Intracranial atherosclerosis was found to be the predominant distribution of cerebral atherosclerosis. TCCS is a safe method for evaluation of proximal basal cerebral arteries in the intracranial circulation with relatively better sensitivity in the anterior circulation.
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Affiliation(s)
- Betty Simon
- Department of Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India
| | | | | | - Mathew Alexander
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sanjith Aaron
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India
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Comparison of Measurement and Grading of Carotid Stenosis with Computed Tomography Angiography and Doppler Ultrasound. Ann Vasc Surg 2018. [PMID: 29522870 DOI: 10.1016/j.avsg.2018.01.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Doppler ultrasound (DUS) and computed tomography angiography (CTA) are the most commonly used imaging modalities for carotid disease. The aim of this study was to test the accuracy and reproducibility of CTA-derived measurements of carotid stenosis and compare them with those obtained by DUS. METHODS Images of 100 carotid arteries of patients who underwent carotid DUS at our unit and CTA of the carotids within a 28-day period were identified retrospectively from multidisciplinary team meeting records. CTAs were assessed by 2 investigators, each using a manual and a semi-automated method. With both methods, the degree of stenosis was calculated using the North American Symptomatic Carotid Endarterectomy Trial equation and graded as mild (0-49%), moderate (50-69%), or severe (70-99%). Cohen's kappa and specificity and sensitivity for ≥50% stenosis were calculated. RESULTS The interobserver agreement was moderate (κ 0.407, weighted-κ 0.517) for the manual method and good (κ 0.786, weighted-κ 0.842) for the semi-automated method. Using DUS as the gold standard, the semi-automated method had greater sensitivity (75%) and specificity (91%) in detecting clinically significant carotid artery stenosis (≥50%) than the manual one (63% and 86%, respectively). Agreement between DUS and the semi-automated method of CTA reporting was moderate (κ 0.453, 95% confidence interval [CI]: 0.320-0.586, weighted-κ 0.598, 95% CI: 0.486-0.710), whereas DUS and the manual method of CTA reporting had only fair agreement (κ 0.344, 95% CI: 0.209-0.478, weighted-κ 0.446, 95% CI: 0.315-0.577). CONCLUSIONS CTA tends to underestimate the degree of stenosis when compared with DUS. The semi-automated method of CTA reporting has greater reproducibility and greater agreement with DUS. These findings have practical implications when CTA is used to measure the degree of carotid stenosis in clinical practice.
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Yan Y, Gao S, Yang H, Qin S, Li F, Zhang G, Yang B, He Y, Zhao Y, Li E, Xu L, Zhang N, Fan D, Liu D, Yu K, Ji R. ECAS score: a web-based risk model to predict moderate and severe extracranial carotid artery stenosis. Neurol Res 2018; 40:249-257. [PMID: 29392984 DOI: 10.1080/01616412.2018.1431592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background and purpose To develop and validate a risk model (Extracranial Carotid Artery Stenosis score, ECAS score) to predict moderate and severe ECAS. Furthermore, we compared discrimination of the ECAS score and three existing models with regard to both moderate and severe ECAS. Methods The ECAS score was developed based on the Renqiu Stroke Screening Study (RSSS), in which eligible patients were randomly divided into derivation (60%) and validation (40%) cohorts. ECAS was diagnosed by carotid duplex ultrasound according to the published criteria. Independent predictors of moderate (≥50%) and severe (≥70%) ECAS were obtained using multivariable logistic regression. The area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow test were used to assess model discrimination and calibration. Results A total of 5010 participants were included and the mean age was 64.3. The proportion of ECAS of < 50%, 50-69%, 70-99% and occlusion was 4.4, 0.5, 0.4, and 0.4%, respectively. The ECAS score was developed from sets of predictors of moderate and severe ECAS. The ECAS score demonstrated good discrimination in the derivation and validation cohorts (AUROC range: 0.785-0.846). The Hosmer-Lemeshow tests of ECAS score for moderate and severe ECAS were not significant in the derivation and validation cohorts (all P > 0.05). When compared to the three existing models, the ECAS score showed significantly better discrimination for both moderate and severe ECAS (all P < 0.001). Conclusion The ECAS score is a valid model for predicting moderate and severe ECAS. Further validation of the ECAS score in different populations and larger samples is warranted.
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Affiliation(s)
- Yinglin Yan
- a Department of Neurology , Kangji Hospital , Hebei province , China
| | - Suying Gao
- a Department of Neurology , Kangji Hospital , Hebei province , China
| | - Hongna Yang
- a Department of Neurology , Kangji Hospital , Hebei province , China
| | - Shangmin Qin
- b Department of Ultrasonography , Kangji Hospital , Hebei province , China
| | - Fang Li
- a Department of Neurology , Kangji Hospital , Hebei province , China
| | - Guangbo Zhang
- a Department of Neurology , Kangji Hospital , Hebei province , China
| | - Bo Yang
- c Department of Cardiology , Kangji Hospital , Hebei province , China
| | - Yan He
- d Department of Endocrinology , Kangji Hospital , Hebei province , China
| | - Yongna Zhao
- a Department of Neurology , Kangji Hospital , Hebei province , China
| | - Enjing Li
- c Department of Cardiology , Kangji Hospital , Hebei province , China
| | - Lihua Xu
- a Department of Neurology , Kangji Hospital , Hebei province , China
| | - Na Zhang
- a Department of Neurology , Kangji Hospital , Hebei province , China
| | - Dongna Fan
- c Department of Cardiology , Kangji Hospital , Hebei province , China
| | - Dongliang Liu
- c Department of Cardiology , Kangji Hospital , Hebei province , China
| | - Kai Yu
- a Department of Neurology , Kangji Hospital , Hebei province , China
| | - Ruijun Ji
- e Department of Neurology , Tiantan Hospital, Capital Medical University , Beijing , China.,f China National Clinical Research Center for Neurological Diseases , Beijing , China.,g Center of Stroke , Beijing Institute for Brain Disorders , Beijing , China.,h Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease , Beijing Municipal Science and Technology Commission , Beijing , China.,i Beijing Key Laboratory of Brain Function Reconstruction , Beijing Municipal Science and Technology Commission , Beijing , China
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İnternal Karotid Arter Darlıklarında Time-Resolved Kontrastlı Manyetik Rezonans Anjiyografi ve Dijital Substraksiyon Anjiyografinin Karşılaştırılması. JOURNAL OF CONTEMPORARY MEDICINE 2017. [DOI: 10.16899/gopctd.349805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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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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Sigovan M, Bidet C, Bros S, Boussel L, Mechtouff L, Robson PM, Fayad ZA, Millon A, Douek P. 3D black blood MR angiography of the carotid arteries. A simple sequence for plaque hemorrhage and stenosis evaluation. Magn Reson Imaging 2017. [PMID: 28629953 DOI: 10.1016/j.mri.2017.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To evaluate the diagnostic performance of a new three-dimensional T1-weighted turbo-spin-echo sequence (3D T1-w TSE) compared to 3D contrast-enhanced angiography (CE-MRA) for stenosis measurement and compared to 2D T1-w TSE for intra-plaque hemorrhage (IPH) detection. METHODS Eighty three patients underwent carotid MRI, using a new elliptic-centric phase encoding T1-weighted 3D TSE sequence in addition to the clinical protocol. Two observers evaluated image quality, presence of flow artifacts, and presence of intra-plaque hemorrhage, and computed the NASCET degree of stenosis for CE-MRA and for the new sequence. Inter-observer agreement and correlation between 3D TSE and CE-MRA for NASCET stenosis was estimated using Cohen's kappa, and correlation using linear regression and Bland-Altman plots. Histology was performed on endarterectomy samples for 18 patients. Sensitivity and specificity of 2D and 3D TSE for IPH diagnosis were computed. RESULTS 3D TSE showed better image quality than 2D TSE (p<0.05). Interobserver agreement was good (kappa≥0.86). Correlation between 3D TSE and CE-MRA was excellent (R=0.95) for NASCET stenosis. Sensitivity and specificity for IPH diagnosis was 50% and 100% for 2D TSE and 100% and 83% for the 3D TSE. CONCLUSIONS The new 3D T1-w TSE allows both reliable measures of carotid stenosis, with a slight overestimation compared to CE-MRA (5%), and improved IPH identification, compared to 2D TSE.
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Affiliation(s)
- Monica Sigovan
- CNRS UMR5220; CREATIS Laboratory, University of Lyon, Inserm U1044, INSA-Lyon, Université Lyon 1; Hospices Civils de Lyon, France.
| | - Clément Bidet
- University of Lyon, Department of Radiology, Hospices Civils de Lyon, France
| | - Sébastien Bros
- University of Lyon, Department of Radiology, Hospices Civils de Lyon, France
| | - Loic Boussel
- CNRS UMR5220; CREATIS Laboratory, University of Lyon, Inserm U1044, INSA-Lyon, Université Lyon 1; Hospices Civils de Lyon, France; University of Lyon, Department of Radiology, Hospices Civils de Lyon, France
| | - Laura Mechtouff
- University of Lyon, Department of Vascular Neurology, Hospices Civils de Lyon, France
| | - Philip M Robson
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zahi A Fayad
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Antoine Millon
- University of Lyon, Department of Vascular Surgery, Hospices Civils de Lyon, France
| | - Philippe Douek
- CNRS UMR5220; CREATIS Laboratory, University of Lyon, Inserm U1044, INSA-Lyon, Université Lyon 1; Hospices Civils de Lyon, France; University of Lyon, Department of Radiology, Hospices Civils de Lyon, France
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Rich K, Treat-Jacobson D, DeVeaux T, Fitzgerald K, Kirk L, Thomson L, Foley A, Hill D. Society for Vascular Nursing-Carotid endarterectomy (CEA) updated nursing clinical practice guideline. JOURNAL OF VASCULAR NURSING 2017; 35:90-111. [PMID: 28527733 DOI: 10.1016/j.jvn.2017.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 03/24/2017] [Indexed: 01/22/2023]
Affiliation(s)
| | | | | | | | - Laura Kirk
- University of Minnesota School of Nursing, Minneapolis, Minnesota
| | - Lily Thomson
- Section of Vascular Surgery, Health Sciences Centre, Vascular Research Lab, Winnipeg, Manitoba, Canada
| | - Anne Foley
- Department of Vascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Debbie Hill
- Vascular Health Partners, Community Care Physicians, Albany, New York
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Koh W, Kallenberg K, Karch A, Frank T, Knauth M, Bähr M, Liman J. Transcranial doppler sonography is not a valid diagnostic tool for detection of basilar artery stenosis or in-stent restenosis: a retrospective diagnostic study. BMC Neurol 2017; 17:89. [PMID: 28490351 PMCID: PMC5426050 DOI: 10.1186/s12883-017-0872-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 05/06/2017] [Indexed: 11/26/2022] Open
Abstract
Background There are contradictory reports concerning the validity of transcranial sonography (TCD and TCCS) for examinations of the basilar artery. Here we investigated sensitivity and specificity of transcranial sonography for the detection of basilar artery stenosis and in-stent-restenosis compared to cerebral angiography. Methods We analyzed data of 104 examinations of the basilar artery. The association between sonographic peak systolic velocity (PSV) and degree of stenosis obtained by cerebral angiography was evaluated applying Spearman’s correlation coefficient. Receiver Operating Characteristics (ROC) curves and areas under the curve (AUC) were calculated for the detection of a ≥50% stenosis defined by angiography. Optimal cut-off was derived using the Youden-index. Results A weak but statistically significant correlation between PSV and the degree of stenosis was found (n=104, rho=0.35, p<0.001). ROC analysis for a detection of ≥50% stenosis showed an AUC of 0.70, a sensitivity of 74.0% and a specificity of 65.0% at the optimal cut off of 124 cm/s. Results were consistent when analyzing examinations done in stented and unstented arteries separately (TCD VS DSA/CTA in unstented artery: AUC=0.66, sensitivity 61.0%, specificity 65.0%, TCD/TCCS VS DSA in stented artery: AUC=0.63, sensitivity 71.0%, specificity 82.0%). Comparing TCCS measurements exclusively to angiography, ROC analysis showed an AUC of 1.00 for the detection of an in-stent-restenosis ≥50% with a sensitivity and specificity of 100% when a PSV of 132 cm/s was used as a cut off value. Conclusion Validity of TCD in the assessment of basilar artery stenosis or in-stent restenosis is poor. First results for TCCS are promising, but due to the small samplesize further studies with larger samples sizes are warranted.
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Affiliation(s)
- Woori Koh
- Department of Neurology, University of Goettingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany
| | - Kai Kallenberg
- Department of Neuroradiology, University of Goettingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany
| | - André Karch
- Epidemiological and Statistical Methods, Department of Epidemiology, Helmholtz Centre for Infection Research, Inhoffenstr. 7, 38124, Braunschweig, Germany
| | - Tobias Frank
- Department of Neurology, University of Goettingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany
| | - Michael Knauth
- Department of Neuroradiology, University of Goettingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany
| | - Mathias Bähr
- Department of Neurology, University of Goettingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany
| | - Jan Liman
- Department of Neurology, University of Goettingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany.
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Long B, Koyfman A. Best Clinical Practice: Controversies in Transient Ischemic Attack Evaluation and Disposition in the Emergency Department. J Emerg Med 2017; 52:299-310. [DOI: 10.1016/j.jemermed.2016.10.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 02/07/2023]
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Abstract
In this chapter we review the optimal imaging modalities for subacute and chronic stroke. We discuss the utility of computed tomography (CT) and multimodal CT imaging. Further, we analyze the importance of specific magnetic resonance imaging sequences, such as diffusion-weighted imaging for acute ischemic stroke, T2/fluid-attenuated inversion recovery for subacute and chronic stroke, and susceptibility imaging for detection of intracranial hemorrhages. Different ischemic stroke mechanisms are reviewed, and how these imaging modalities may aid in the determination of such. Further, we analyze how topographic patterns in ischemic stroke may provide important clues to the diagnosis, in addition to the temporal evolution of the stroke. Lastly, specific cerebrovascular occlusive diseases are reviewed, with emphasis on the optimal imaging modalities and their findings in each condition.
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Bosch FT, Hendrikse J, Davagnanam I, Bonati LH, van der Lugt A, van der Worp HB, de Borst GJ, Mali W, Brown MM, Nederkoorn PJ. Optimal cut-off criteria for duplex ultrasound compared with computed tomography angiography for the diagnosis of restenosis in stented carotid arteries in the international carotid stenting study. Eur Stroke J 2016; 2:37-45. [PMID: 31008301 DOI: 10.1177/2396987316678361] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 10/08/2016] [Indexed: 11/16/2022] Open
Abstract
Introduction Previous studies that reported duplex-ultrasound cut-off criteria, based on blood velocity parameters, for the degree of stenosis in a stented carotid artery were either retrospective, or the reference test was carried out only when a patient was suspected of having restenosis at duplex ultrasound, which is likely to have resulted in verification bias. We performed a prospective study of diagnostic accuracy to find new blood velocity cut-offs in duplex ultrasound for in-stent restenosis. Patients and methods Stented patients within the international carotid stenting study were eligible. Patients had a carotid computed tomography angiography in addition to routine duplex ultrasound performed at a yearly follow-up. Duplex-ultrasound bloodflow velocity parameters were compared to the degree of stenosis on computed tomography angiography. The results were analysed using receiver-operating-characteristic curves. Results We included 103 patients in this study. On computed tomography angiography, 30 (29.1%) patients had a 30%-49% in-stent restenosis, 21 (20.4%) patients had 50%-69% in-stent restenosis and 5 (4.9%) patients a ≥70% in-stent restenosis. The cut-off value ≥50% stenosis was a peak systolic velocity of 125 cm/s (sensitivity: 63% (95% CI: 41-79), specificity: 83% (95% CI: 72-90)). Discussion This study provides a level 2b evidence for new cut-off values for in-stent restenosis. Unfortunately, we could not say anything about severe stenosis because of the low number of severe stenosis after one year. Conclusions The 125 cm/s cut-off value on duplex ultrasound is lower than found in previous studies and equal to unstented arteries. Duplex-ultrasound measurements made in stented carotid arteries should not be corrected for the presence of a stent when determining the degree of stenosis.
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Affiliation(s)
- Floris Tm Bosch
- Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands
| | - Jeroen Hendrikse
- Department of Neurology and Neurosurgery, UMCU, Utrecht, the Netherlands
| | - Indran Davagnanam
- UCL Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Leo H Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | | | - H B van der Worp
- Department of Neurology and Neurosurgery, UMCU, Utrecht, the Netherlands
| | - Gert J de Borst
- Department of Neurology and Neurosurgery, UMCU, Utrecht, the Netherlands
| | - Willem Mali
- Department of Neurology and Neurosurgery, UMCU, Utrecht, the Netherlands
| | - Martin M Brown
- UCL Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Paul J Nederkoorn
- Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands
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Clinical Policy: Critical Issues in the Evaluation of Adult Patients With Suspected Transient Ischemic Attack in the Emergency Department. Ann Emerg Med 2016; 68:354-370.e29. [DOI: 10.1016/j.annemergmed.2016.06.048] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Di Gioia G, Scordino D, Campanale CM, Miglionico M, Creta A, Proscia C, Ragni L, Colaiori I, Di Sciascio G. In-Stent Restenosis After Carotid Artery Stenting: From Diagnosis to Treatment. EUROPEAN MEDICAL JOURNAL 2016. [DOI: 10.33590/emj/10312518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
Although carotid artery stenting is a safe and effective treatment for preventing ischaemic stroke in significant carotid atherosclerotic disease, it can be complicated by in-stent restenosis (ISR). Factors involved in the ISR process are both mechanical and patient-related, but the most important is the neointimal thickening within stent struts, leading to lumen reduction. Overall incidence of carotid ISR is low and related embolic risk seems to be lower than native disease. Digital subtraction angiography is the gold standard for diagnosis. Nowadays, Doppler ultrasound should be considered the first-line investigation, due to its non-invasiveness and reproducibility. Computed tomography angiography remains useful when Doppler ultrasound is inconclusive. Indication and modality of treatment of ISR are still debated: both surgery (carotid endarterectomy with stent removal in most cases) or interventional procedures such as percutaneous transluminal angioplasty with simple balloon, cutting-balloon, drug-eluting balloon, and stenting, showed safety and efficacy in follow-up. Surgery is currently reserved for selected cases. Carotid ISR is an overall rare complication which can be easily identified at routine follow-up. This paper is a literature review and state-of-the-art assessment of ISR, clinical features, diagnosis, and treatment.
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Affiliation(s)
- Giuseppe Di Gioia
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Domenico Scordino
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Cosimo Marco Campanale
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Marco Miglionico
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Antonio Creta
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Claudio Proscia
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Laura Ragni
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Iginio Colaiori
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Germano Di Sciascio
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
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Elevated Peak Systolic Velocity and Velocity Ratio from Duplex Ultrasound are Associated with Hemodynamically Significant Lesions in Arteriovenous Access. Ann Vasc Surg 2016; 35:68-74. [DOI: 10.1016/j.avsg.2016.01.056] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 01/17/2016] [Accepted: 01/26/2016] [Indexed: 11/19/2022]
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Preoperative Computed Tomography Angiography for Evaluation of Feasibility of Free Flaps in Difficult Reconstruction of Head and Neck. Ann Plast Surg 2016; 76 Suppl 1:S19-24. [PMID: 26808762 DOI: 10.1097/sap.0000000000000690] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Free tissue transfer has been advocated for anatomic and functional reconstruction of soft tissue defects after surgical removal of an extensive recurrent tumor and/or arising from previous irradiation in the head and neck. We report a case series of difficult reconstruction in the head and neck in which preoperative computed tomography (CT) angiography was utilized to evaluate the feasibility of free flap reconstruction. The preoperative radiological evaluation was performed to determine the availability of reliable vessels for anastomosis in free flap reconstruction. If none was found, regional pedicle flap or palliative treatment was applied instead. The use of CT angiography allows the clinical surgeon to perform precise surgical planning with greater confidence. This may improve surgical results, thereby potentially reducing perioperative morbidity. METHODS Twenty CT angiograms were obtained from 20 patients. All patients were men with a mean age of 57.2 years (range, 42-72 years) and were scheduled to undergo difficult reconstruction in the head and neck. All patients (20/20 [100%]) suffered from oral squamous cell carcinoma. They had all received extensive operations and radiation therapy. Eighteen patients (18/20 [90%]) had completed a course of perioperative irradiation. The CT angiography reports were used to perform detailed preoperative surgical planning accordingly. The findings of CT angiography were classified into 3 groups: group I: normal CT angiography (patent recipient arteries) (Fig. 3); group II: abnormal CT angiography (recipient vessels were present but stenosis or atherosclerotic lesions were noted) (Fig. 4); group III: abnormal CT angiography with no patent recipient arteries in bilateral sides of the neck (Fig. 5); CT angiography results were correlated to the operative findings. RESULTS The patients were classified into 3 groups based on the angiographic findings. Six patients (6/20 [30%]) were assigned to group I, 8 patients (8/20 [40%]) to group II, and 6 patients (6/20 [30%]) to group III. In groups I and III, all patients (12/12 [100%]) underwent the treatment according to the original preoperative detailed planning. No flap failure was noted in these 2 groups. In group II, 4 patients' recipient vessels (4/8 [50%]) possessed adequate blood flow intraoperatively; hence, microvascular free flaps were transplanted. Venous congestion in 1 case (1/4 [25%]) was noted. The remaining patients in this group (4/8 [50%]) underwent reconstruction with pedicle flaps rather than free flaps because of the lack of suitable target vessels intraoperatively. All flaps (4/4 [100%]) survived. Among the patients who were treated surgically, intraoperative findings were in accordance with those predicted by CT angiography. The total abnormality rate of CT angiography was 70%. Vascular abnormalities detected as a result of preoperative CT angiography led to changes in the operative plan in 50% (10/20) of the patients. CONCLUSIONS The use of CT angiography should be considered for difficult microsurgical reconstructions in the head and neck. When an abnormality in vascular anatomy is detected by CT angiography, the surgeon is advised to consider altering the operative plan accordingly. This allows precise operation, thereby maximizing the possibility of an optimal outcome. Changing the operative plan based on results of CT angiography may also help to avoid the difficult situation in which the surgeon finds that there are no suitable recipient vessels for free flap reconstruction during the operation. In addition, CT angiography enables surgeons to conduct the preoperative surgical planning with greater confidence, thereby potentially enhancing the success rate of difficult reconstructions in the head and neck, which in turn would tend to improve the perioperative course for the patient and consequently to improve results by decreasing vascular complication rates.
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