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Viticchi G, Falsetti L, Altamura C, Di Felice C, Vernieri F, Bartolini M, Silvestrini M. Impact of carotid stenosis on the outcome of stroke patients submitted to reperfusion treatments: a narrative review. Rev Neurosci 2024; 35:575-583. [PMID: 38459676 DOI: 10.1515/revneuro-2024-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/18/2024] [Indexed: 03/10/2024]
Abstract
Intravenous thrombolysis (IT) and mechanical thrombectomy (MD) are the two interventional approaches that have changed the outcome of patients with acute ischemic stroke (AIS). Ipsilateral and contralateral carotid stenosis (ICS, CCS) play an important role in regulating cerebral hemodynamics, both in chronic and acute situations such as AIS. Several studies have explored their role in the incidence and severity of stroke, but very few have investigated the possible impact of ICS and CCS on the efficacy of interventional procedures. The purpose of this review was to I) highlight the incidence and prevalence of carotid stenosis (CS); II) assess the impact of ICS and CCS on cerebral hemodynamics; III) evaluate the effect of carotid stenosis on the efficacy of interventional therapies (IT and MT) for AIS; and IV) report therapeutic complications related to CS. We searched PubMed/Medline for case reports, reviews, and original research articles on English-language review topics during the period from January 1, 2000 to October 1, 2023. CS is associated with 15-20 % of the total number of AIS. ICS and CCS had a negative influence on both cerebral hemodynamics before AIS and outcome after interventional procedures (IT, MT alone or in bridging). Available data on cerebral hemodynamics and efficacy of interventional therapies for AIS suggest a negative role of CS. Therefore, early diagnosis of CS may be considered relevant to preventive and post-stroke treatment strategies.
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Affiliation(s)
- Giovanna Viticchi
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Lorenzo Falsetti
- Clinica Medica, Clinical and Molecular Sciences Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Claudia Altamura
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, via Álvaro del Portillo n.200, 00128, Rome, Italy
| | - Chiara Di Felice
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Fabrizio Vernieri
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, via Álvaro del Portillo n.200, 00128, Rome, Italy
| | - Marco Bartolini
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Mauro Silvestrini
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
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Saba L, Cau R, Spinato G, Suri JS, Melis M, De Rubeis G, Antignani P, Gupta A. Carotid stenosis and cryptogenic stroke. J Vasc Surg 2024; 79:1119-1131. [PMID: 38190926 DOI: 10.1016/j.jvs.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 12/30/2023] [Accepted: 01/04/2024] [Indexed: 01/10/2024]
Abstract
OBJECTIVES Cryptogenic stroke represents a type of ischemic stroke with an unknown origin, presenting a significant challenge in both stroke management and prevention. According to the Trial of Org 10,172 in Acute Stroke Treatment criteria, a stroke is categorized as being caused by large artery atherosclerosis only when there is >50% luminal narrowing of the ipsilateral internal carotid artery. However, nonstenosing carotid artery plaques can be an underlying cause of ischemic stroke. Indeed, emerging evidence documents that some features of plaque vulnerability may act as an independent risk factor, regardless of the degree of stenosis, in precipitating cerebrovascular events. This review, drawing from an array of imaging-based studies, explores the predictive values of carotid imaging modalities in the detection of nonstenosing carotid plaque (<50%), that could be the cause of a cerebrovascular event when some features of vulnerability are present. METHODS Google Scholar, Scopus, and PubMed were searched for articles on cryptogenic stroke and those reporting the association between cryptogenic stroke and imaging features of carotid plaque vulnerability. RESULTS Despite extensive diagnostic evaluations, the etiology of a considerable proportion of strokes remains undetermined, contributing to the recurrence rate and persistent morbidity in affected individuals. Advances in imaging modalities, such as magnetic resonance imaging, computed tomography scans, and ultrasound examination, facilitate more accurate detection of nonstenosing carotid artery plaque and allow better stratification of stroke risk, leading to a more tailored treatment strategy. CONCLUSIONS Early detection of nonstenosing carotid plaque with features of vulnerability through carotid imaging techniques impacts the clinical management of cryptogenic stroke, resulting in refined stroke subtype classification and improved patient management. Additional research is required to validate these findings and recommend the integration of these state-of-the-art imaging methodologies into standard diagnostic protocols to improve stroke management and prevention.
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Affiliation(s)
- Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), Cagliari, Italy.
| | - Riccardo Cau
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), Cagliari, Italy
| | - Giacomo Spinato
- Department of Neurosciences, Section of Otolaryngology and Regional Centre for Head and Neck Cancer, University of Padova, Treviso, Italy
| | - Jasjit S Suri
- Stroke Monitoring and Diagnostic Division, AtheroPoint™, Roseville, CA
| | - Marta Melis
- Department of Neurology, Azienda Ospedaliero Universitaria (A.O.U.), Cagliari, Italy
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Paraskevas KI, Dardik A, Schermerhorn ML, Liapis CD, Mansilha A, Lal BK, Gray WA, Brown MM, Myrcha P, Lavie CJ, Zeebregts CJ, Secemsky EA, Saba L, Blecha M, Gurevich V, Silvestrini M, Blinc A, Svetlikov A, Fernandes E Fernandes J, Schneider PA, Gloviczki P, White CJ, AbuRahma AF. Why selective screening for asymptomatic carotid stenosis is currently appropriate: a special report. Expert Rev Cardiovasc Ther 2024; 22:159-165. [PMID: 38480465 DOI: 10.1080/14779072.2024.2330660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/11/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Two of the main reasons recent guidelines do not recommend routine population-wide screening programs for asymptomatic carotid artery stenosis (AsxCS) is that screening could lead to an increase of carotid revascularization procedures and that such mass screening programs may not be cost-effective. Nevertheless, selective screening for AsxCS could have several benefits. This article presents the rationale for such a program. AREAS COVERED The benefits of selective screening for AsxCS include early recognition of AsxCS allowing timely initiation of preventive measures to reduce future myocardial infarction (MI), stroke, cardiac death and cardiovascular (CV) event rates. EXPERT OPINION Mass screening programs for AsxCS are neither clinically effective nor cost-effective. Nevertheless, targeted screening of populations at high risk for AsxCS provides an opportunity to identify these individuals earlier rather than later and to initiate a number of lifestyle measures, risk factor modifications, and intensive medical therapy in order to prevent future strokes and CV events. For patients at 'higher risk of stroke' on best medical treatment, a prophylactic carotid intervention may be considered.
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Affiliation(s)
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
- Department of Surgery, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Christos D Liapis
- Department of Vascular Surgery, Athens Vascular Research Center, Athens, Greece
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, USA
- Department of Vascular Surgery, Baltimore VA Medical Center, Baltimore, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Martin M Brown
- Stroke Research Centre, UCL Institute of Neurology, University College London, London, UK
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Eric A Secemsky
- Smith Center for Outcomes Research, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Matthew Blecha
- Division of Vascular Surgery, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, USA
| | - Victor Gurevich
- Center of Atherosclerosis and Lipid Disorders, Lab of Microangiopathic Mechanisms of Atherogenesis, Saint-Petersburg State University, Mechnikov, Saint-Petersburgh, Russia
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Ales Blinc
- Department of Vascular Diseases, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Alexei Svetlikov
- Division of Vascular & Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency, Department of Hospital Surgery, Saint-Petersburg State University, Saint-Petersburg, Russia
| | - Jose Fernandes E Fernandes
- Cardiovascular Center (CCUL), Faculty of Medicine University of Lisbon, Lisbon, Portugal
- Department of Vascular Surgery, Hospital da Luz Torres de Lisboa, Lisbon, Portugal
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Christopher J White
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Ali F AbuRahma
- Department of Surgery, Division of Vascular and Endovascular Surgery, Charleston Area Medical Center/West Virginia University Health Sciences Center, Charleston, WV, USA
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Albricker ACL, Freire CMV, Santos SND, Alcantara MLD, Cantisano AL, Porto CLL, Amaral SID, Veloso OCG, Morais Filho DD, Teodoro JAR, Petisco ACGP, Saleh MH, Barros MVLD, Barros FS, Engelhorn ALDV, Engelhorn CA, Nardino ÉP, Silva MADM, Biagioni LC, Souza AJD, Sarpe AKP, Oliveira ACD, Moraes MRDS, Francisco Neto MJ, Françolin PC, Rochitte CE, Iquizli R, Santos AASMDD, Muglia VF, Naves BDL. Recommendation Update for Vascular Ultrasound Evaluation of Carotid and Vertebral Artery Disease: DIC, CBR and SABCV - 2023. Arq Bras Cardiol 2023; 120:e20230695. [PMID: 37991060 DOI: 10.36660/abc.20230695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023] Open
Affiliation(s)
- Ana Cristina Lopes Albricker
- Centro Universitário de Belo Horizonte (UniBH), Belo Horizonte, MG - Brasil
- IMEDE - Instituto Mineiro de Ultrassonografia, Belo Horizonte, MG - Brasil
| | - Claudia Maria Vilas Freire
- Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brasil
- Empresa Brasileira de Serviços Hospitalares (UBSERH), Brasília, DF - Brasil
| | | | | | | | | | | | - Orlando Carlos Glória Veloso
- Rede UnitedHealth Group (UHG), Rio de Janeiro, RJ - Brasil
- Hospital Pasteur, Rio de Janeiro, RJ - Brasil
- Hospital Américas, Rio de Janeiro, RJ - Brasil
- Hospital de Clínicas Mário Lioni, Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | | | | | - Érica Patrício Nardino
- Faculdade de Medicina do ABC Paulista, SP - Brasil
- Faculdade de Medicina Unoeste, Guarujá, SP - Brasil
| | | | | | | | | | | | | | | | - Peter Célio Françolin
- Instituto do Coração (InCor) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | - Carlos Eduardo Rochitte
- Instituto do Coração (InCor) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
- Hospital do Coração (Hcor), São Paulo, SP - Brasil
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Viticchi G, Falsetti L, Riva A, Paolucci S, Malatini S, Guerrieri E, Bartolini M, Silvestrini M. Ipsilateral and contralateral carotid stenosis contribute to the outcome of reperfusion treatment for ischemic stroke. Front Neurol 2023; 14:1237721. [PMID: 37638193 PMCID: PMC10448052 DOI: 10.3389/fneur.2023.1237721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/20/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction Ipsilateral and contralateral carotid stenosis (ICS, CCS) influence acute ischemic stroke (AIS) severity and prognosis. Few data are available about their impact on reperfusion therapies efficacy. Aim of this study was to evaluate the impact of ICS and CCS on the effect of intravenous thrombolysis (IT), mechanical thrombectomy (MT) or both and of antiplatelet therapy (AT). Methods We enrolled all the consecutive patients admitted for AIS to our stroke unit and submitted to IT, MT, IT+MT, or AT. We established the presence of a significant ICS or CCS (≥70%) by ultrasound examination or brain angio-CT, or MRI. Clinical and instrumental information were collected; delta National Institutes of Health Stroke Scale (NIHSS) from pre-treatment to patients' discharge was employed as the main outcome measure. Results In total, 460 subjects were enrolled, 86 with ICS and 38 with CCS. We observed a significant linear trend of delta (NIHSS) between carotid stenosis categories for patients undergoing IT (p = 0.011), MT (p = 0.046), and MT+IT (p = 0.040), but no significant trend among subjects receiving no reperfusion treatments was observed (p = 0.174). Discussion According to our findings, ICS and CCS negatively influence AIS patients' outcome treated by interventional therapies. ICS might exert an unfavorable effect both by cerebral hypoperfusion and by continuous microembolization toward ischemic area, while CCS is probable involved in reducing the collateral circles effectiveness. The importance of early carotid stenosis detection and treatment should then be reevaluated not only to manage the prevention approaches but also to obtain insights about post-stroke treatment strategies efficacy.
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Affiliation(s)
| | - Lorenzo Falsetti
- Internal and Subintensive Medicine, Azienda Ospedaliero-Universitaria delle Marche, Ancona, Italy
| | - Alice Riva
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Silvia Paolucci
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Simone Malatini
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Emanuele Guerrieri
- Emergency Medicine Residency Program, Marche Polytechnic University, Ancona, Italy
| | - Marco Bartolini
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
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Fernández-Alvarez V, Linares-Sánchez M, Suárez C, López F, Guntinas-Lichius O, Mäkitie AA, Bradley PJ, Ferlito A. Novel Imaging-Based Biomarkers for Identifying Carotid Plaque Vulnerability. Biomolecules 2023; 13:1236. [PMID: 37627301 PMCID: PMC10452902 DOI: 10.3390/biom13081236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/30/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Carotid artery disease has traditionally been assessed based on the degree of luminal narrowing. However, this approach, which solely relies on carotid stenosis, is currently being questioned with regard to modern risk stratification approaches. Recent guidelines have introduced the concept of the "vulnerable plaque," emphasizing specific features such as thin fibrous caps, large lipid cores, intraplaque hemorrhage, plaque rupture, macrophage infiltration, and neovascularization. In this context, imaging-based biomarkers have emerged as valuable tools for identifying higher-risk patients. Non-invasive imaging modalities and intravascular techniques, including ultrasound, computed tomography, magnetic resonance imaging, intravascular ultrasound, optical coherence tomography, and near-infrared spectroscopy, have played pivotal roles in characterizing and detecting unstable carotid plaques. The aim of this review is to provide an overview of the evolving understanding of carotid artery disease and highlight the significance of imaging techniques in assessing plaque vulnerability and informing clinical decision-making.
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Affiliation(s)
- Verónica Fernández-Alvarez
- Department of Vascular and Endovascular Surgery, Hospital Universitario de Cabueñes, 33394 Gijón, Spain;
| | - Miriam Linares-Sánchez
- Department of Vascular and Endovascular Surgery, Hospital Universitario de Cabueñes, 33394 Gijón, Spain;
| | - Carlos Suárez
- Instituto de Investigacion Sanitaria del Principado de Asturias, 33011 Oviedo, Spain; (C.S.); (F.L.)
| | - Fernando López
- Instituto de Investigacion Sanitaria del Principado de Asturias, 33011 Oviedo, Spain; (C.S.); (F.L.)
- Department of Otorhinolaryngology, Hospital Universitario Central de Asturias, Instituto Universitario de Oncologia del Principado de Asturias, University of Oviedo, CIBERONC, 33011 Oviedo, Spain
| | | | - Antti A. Mäkitie
- Department of Otorhinolaryngology-Head and Neck Surgery, Helsinki University Hospital, University of Helsinki, P.O. Box 263, 00029 Helsinki, Finland;
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, 00014 Helsinki, Finland
- Division of Ear, Nose and Throat Diseases, Department of Clinical Sciences, Intervention and Technology, Karolinska Institute and Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Patrick J. Bradley
- Department of ORLHNS, Queens Medical Centre Campus, Nottingham University Hospitals, Derby Road, Nottingham NG7 2UH, UK;
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, 35100 Padua, Italy;
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Gasior SA, O'Donnell JPM, Davey M, Clarke J, Jalali A, Ryan É, Aherne TM, Walsh SR. Optimal Management of Asymptomatic Carotid Artery Stenosis: A Systematic Review and Network Meta-Analysis. Eur J Vasc Endovasc Surg 2023; 65:690-699. [PMID: 36682406 DOI: 10.1016/j.ejvs.2023.01.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 12/02/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Management of asymptomatic carotid artery stenosis (ACAS), including carotid endarterectomy (CEA), carotid artery stenting (CAS), and best medical treatment (BMT), remains inconsistent in current practice. Early studies reported a benefit of CEA vs. BMT; however, the current risk-benefit profile of invasive therapy lacks consensus. By evaluating the effects of modern BMT vs. invasive intervention on patient outcomes, this study aimed to influence the future management of ACAS. METHODS A systematic review and series of network meta-analyses were performed assessing peri-operative (within 30 days) and long term (30 days - 5 years) stroke and mortality risk between ACAS interventions. Total stroke, major, minor, ipsilateral, and contralateral stroke subtypes were assessed independently. Traditional (pre-2000) and modern (post-2000) BMT were compared to assess clinical improvements in medical therapy over the previous two decades. Risks of myocardial infarction (MI) and cranial nerve injury (CNI) were also assessed. RESULTS Seventeen reports of 14 310 patients with > 50% ACAS were included. CEA reduced the odds of a peri-operative stroke event occurring vs. CAS (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1 - 2.2 [0 - 20 fewer/1 000]). CEA and CAS reduced the long term odds of minor strokes (OR 0.35, 95% CI 0.21 - 0.59 [20 fewer/1 000]) and ipsilateral strokes (OR 0.27, 95% CI 0.19 - 0.39 [30 fewer/1 000]) vs. all BMT. CEA reduced the odds of major strokes and combined stroke and mortality vs. traditional BMT; however, no difference was found between CEA and modern BMT. CAS reduced the odds of peri-operative MI (OR 0.49, 95% CI 0. 26 - 0.91) and CNI (OR 0.07, 95% CI 0.01 - 0.42) vs. CEA. CONCLUSION Modern BMT demonstrates similar reductions in major stroke, combined stroke, and mortality to CEA. The overall risk reductions are low and data were unavailable to assess subgroups which may benefit from intervention. However, BMT carries the potential to reduce the requirement for surgical intervention in patients with ACAS.
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Affiliation(s)
- Sara A Gasior
- Department of Vascular Surgery, University Hospital Galway, Galway, Ireland.
| | - John P M O'Donnell
- Department of Vascular Surgery, University Hospital Galway, Galway, Ireland; Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | - Matthew Davey
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland; Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James Clarke
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | | | - Éanna Ryan
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | - Thomas M Aherne
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Stewart R Walsh
- Department of Vascular Surgery, University Hospital Galway, Galway, Ireland; Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
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Lineback CM, Stamm B, Sorond F, Caprio FZ. Carotid disease, cognition, and aging: time to redefine asymptomatic disease? GeroScience 2023; 45:719-725. [PMID: 36376618 PMCID: PMC9886762 DOI: 10.1007/s11357-022-00688-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/05/2022] [Indexed: 11/16/2022] Open
Abstract
There is an increasing appreciation of the vascular contributions in the development of age-related cognitive impairment and dementia1,2. Identifying risk and maintaining cognitive health for successful aging is ever relevant in our aging population. Carotid disease, a well-established risk factor for stroke and often a harbinger of other vascular disease states, is also emerging as another vascular risk factor for age-related cognitive decline. When combined with vascular risk factors, the incidence of age-related carotid disease can be as high as 70%3,4. Historically, carotid disease has been dichotomized into two large groups in trial design, outcome measurements, and treatment decisions: symptomatic and asymptomatic carotid artery stenosis. The dichotomous distinction between asymptomatic and symptomatic carotid stenosis based on existing definitions may be limiting the care we are able to provide for patients classified as "asymptomatic" from their carotid disease. Medically, we now know that these patients should be treated with the same intensive medical therapy as those with "symptomatic" carotid disease. Emerging data also shows that hypoperfusion from asymptomatic disease may lead to significant cognitive impairment in the aging population, and it is plausible that most "age-related" cognitive changes may be reflective of vascular impairment and neurovascular dysfunction. While over the past 30 years medical, surgical, and radiological advances have pushed the field of neurovascular disease to significantly reduce the number of ischemic strokes, we are far from any meaningful interventions to prevent vascular cognitive impairment. In addition to including cognitive outcome measures, future studies of carotid disease will also benefit from including advanced neuroimaging modalities not currently utilized in standard clinical imaging protocols, such as perfusion imaging and/or functional connectivity mapping, which may provide novel data to better assess for hypoxic-ischemic changes and neurovascular dysfunction across diffuse cognitive networks. While current recommendations advise against widespread population screening for asymptomatic carotid stenosis, emerging evidence linking carotid stenosis to cognitive impairment prompts us to re-consider our approach for older patients with vascular risk factors who are at risk for cognitive decline.
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Affiliation(s)
- Christina M Lineback
- Department of Neurology, Stroke Division, University of Michigan Medical School, 1500 E Medical Dr., Ann Arbor, MI, USA.
- Davee Department of Neurology, Stroke and Neurocritical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Brian Stamm
- Davee Department of Neurology, Stroke and Neurocritical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Farzaneh Sorond
- Davee Department of Neurology, Stroke and Neurocritical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Fan Z Caprio
- Davee Department of Neurology, Stroke and Neurocritical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Pizzarelli G, Gennai S, Leone N, Covic T, Moratto R, Silingardi R. Transcranial Doppler detects micro emboli in patients with asymptomatic carotid stenoses undergoing endarterectomy. J Vasc Surg 2023; 77:811-817.e2. [PMID: 36243263 DOI: 10.1016/j.jvs.2022.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to assess the primary endpoint defined as the detection of micro-embolic signals (MES) by the use of transcranial Doppler (TCD) in patients with asymptomatic carotid stenosis (≥70%) scheduled for carotid endarterectomy. The secondary endpoint consisted of testing the association of MES with stenosis severity, histopathological, and ultrasound characteristics. METHODS This was a single-center, single-arm, prospective, observational trial. Computed tomography angiography and ultrasound assessment (Geroulakos classification) were mandatory as well as being under best medical therapy. MES number and characteristics were investigated in Holter mode TCD-X device with a standard 1.5 MHz probe. The time points of evaluation were: 24 hours preoperative, 24 hours postoperative, and 30 days postoperative. The histopathological analysis was performed according to the modified American Heart Association classification. One-way analysis of variance tested MES differences over time. Univariable and multivariable logistic regression tested variables potentially associated with MES. RESULTS A total of 120 patients demonstrated a significant reduction of the mean number of MES (3.35 ± 10.04 and 0.82 ± 2.39; pre- and post-carotid endarterectomy, respectively), becoming undetectable at 30 days (P = .001). Hypoechogenic plaques assessed by ultrasound were a significant risk factor for MES (P = .001). The features of plaque vulnerability, such as hemorrhagic component (P = .011), neovascularization (P = .025), signs of inflammation (P = .027), and rupture of the fibrous cap (P = .002) were predictors of MES. Cap rupture was the only predictor in the multivariate analysis (odds ratio, 5.98; P = .030). The stenosis severity was not associated with MES (P = .95) CONCLUSIONS: Patients under best medical therapy had a preoperative embolic activity becoming no more detectable after surgery. Both ultrasound and histologic markers of vulnerability were predictors of MES, and stenosis severity was not associated. TCD gives better insight into the real embolic risk, and future studies should evaluate clinical results coming from its implementation with standard imaging techniques. CLINICALTRIAL gov registration number NCT05134493.
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Affiliation(s)
- Ginevra Pizzarelli
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Gennai
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy.
| | - Tea Covic
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Moratto
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Silingardi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
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10
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Chan MYM, Ling YT, Chen XY, Chan ST, Kwong KK, Zheng YP. Success Rate of Transcranial Doppler Scanning of Cerebral Arteries at Different Transtemporal Windows in Healthy Elderly Individuals. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:588-598. [PMID: 36400675 DOI: 10.1016/j.ultrasmedbio.2022.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 10/19/2022] [Accepted: 10/21/2022] [Indexed: 06/16/2023]
Abstract
This study measured the rates of success in applying transcranial Doppler (TCD) scanning at the middle, posterior and anterior temporal windows (MTW, PTW and ATW) in the elderly. A hand-held 1.6-MHz pulsed-wave TCD transducer was used to search for cerebral arteries at MTW, PTW and ATW locations. Physical attributes of the head, including head circumference and the distance between tragi on both sides ("tragus-to-tragus arc length"), were also measured to explore the associations with successful rates. Among 396 healthy elderly participants (aged 62.6 ± 6.0 y, 140 men), 81.1% (n = 321; 127 men) had one or more temporal windows penetrable by TCD ultrasound (n = 286 [72.2%] at MTW, n = 195 [49.2%] at PTW and n = 106 [26.8%] at ATW). Regression analysis revealed that successful scanning increased significantly in male participants at three window locations. Younger age significantly increased successful scanning at the MTW and ATW. Smaller tragus-to-tragus arc length increased successful scanning at the MTW, but unsuccessful scanning at the ATW. Our findings support using MTW as the first location when positioning the TCD transducer for the scanning of cerebral arteries in the elderly population. When performing TCD scanning on two temporal windows, we propose choosing the MTW and PTW.
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Affiliation(s)
- Mandy Yuen-Man Chan
- Department of Biomedical Engineering, Hong Kong Polytechnic University, Hong Kong, China
| | - Yan To Ling
- Department of Biomedical Engineering, Hong Kong Polytechnic University, Hong Kong, China
| | - Xiang-Yan Chen
- Department of Health Technology and Informatics, Hong Kong Polytechnic University, Hong Kong, China; Research Institute for Smart Ageing, Hong Kong Polytechnic University, Hong Kong, China
| | - Suk-Tak Chan
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Kenneth K Kwong
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Yong-Ping Zheng
- Department of Biomedical Engineering, Hong Kong Polytechnic University, Hong Kong, China; Research Institute for Smart Ageing, Hong Kong Polytechnic University, Hong Kong, China.
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11
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Kim HW, Regenhardt RW, D'Amato SA, Nahhas MI, Dmytriw AA, Hirsch JA, Silverman SB, Martinez-Gutierrez JC. Asymptomatic carotid artery stenosis: a summary of current state of evidence for revascularization and emerging high-risk features. J Neurointerv Surg 2022:jnis-2022-018732. [DOI: 10.1136/jnis-2022-018732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/23/2022] [Indexed: 11/03/2022]
Abstract
Carotid artery stenosis is a leading cause of ischemic stroke. While management of symptomatic carotid stenosis is well established, the optimal approach in asymptomatic carotid artery stenosis (aCAS) remains controversial. The rapid evolution of medical therapies within the time frame of existing landmark aCAS surgical revascularization trials has rendered their findings outdated. In this review, we sought to summarize the controversies in the management of aCAS by providing the most up-to-date medical and surgical evidence. Subsequently, we compile the evidence surrounding high-risk clinical and imaging features that might identify higher-risk lesions. With this, we aim to provide a practical framework for a precision medicine approach to the management of aCAS.
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12
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Leth-Olsen M, Døhlen G, Torp H, Nyrnes SA. Detection of Cerebral High-Intensity Transient Signals by NeoDoppler during Cardiac Catheterization and Cardiac Surgery in Infants. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:1256-1267. [PMID: 35410742 DOI: 10.1016/j.ultrasmedbio.2022.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 06/14/2023]
Abstract
There is a risk of gaseous and solid micro-embolus formation during transcatheter cardiac interventions and surgery in children with congenital heart disease (CHD). Our aim was to study the burden of high-intensity transient signals (HITS) during these procedures in infants. We used a novel color M-mode Doppler (CMD) technique by NeoDoppler, a non-invasive ultrasound system based on plane wave transmissions for transfontanellar continuous monitoring of cerebral blood flow in infants. The system displays CMD with 24 sample volumes and a Doppler spectrogram. Infants with CHD undergoing transcatheter interventions (n = 15) and surgery (n = 13) were included. HITS were manually detected based on an "embolic signature" in the CMD with corresponding intensity increase in the Doppler spectrogram. Embolus-to-blood ratio (EBR) defined HITS size. A total of 1169 HITS with a median EBR of 9.74 dB (interquartile range [IQR]: 5.10-15.80 dB) were detected. The median number of HITS in the surgery group was 45 (IQR: 11-150), while in the transcatheter group the median number was 12 (IQR: 7-24). During cardiac surgery, the highest number of HITS per hour was seen from initiation of cardiopulmonary bypass to aortic X-clamp. In this study we detected frequent HITS and determined the feasibility of using NeoDoppler monitoring for HITS detection.
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Affiliation(s)
- Martin Leth-Olsen
- Department of Circulation and Medical Imaging (ISB), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Children's Clinic, St. Olav's University Hospital, Trondheim, Norway.
| | - Gaute Døhlen
- Department of Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Hans Torp
- Department of Circulation and Medical Imaging (ISB), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Siri Ann Nyrnes
- Department of Circulation and Medical Imaging (ISB), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Children's Clinic, St. Olav's University Hospital, Trondheim, Norway
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13
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Gargani L, Baldini M, Berchiolli R, Bort IR, Casolo G, Chiappino D, Cosottini M, D'Angelo G, De Santis M, Erba P, Fabiani I, Fabiani P, Gabbriellini I, Galeotti GG, Ghicopulos I, Goncalves I, Lapi S, Masini G, Morizzo C, Napoli V, Nilsson J, Orlandi G, Palombo C, Pieraccini F, Ricci S, Siciliano G, Slart RHJA, De Caterina R. Detecting the vulnerable carotid plaque: the Carotid Artery Multimodality imaging Prognostic study design. J Cardiovasc Med (Hagerstown) 2022; 23:466-473. [PMID: 35763768 DOI: 10.2459/jcm.0000000000001314] [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: 01/22/2023]
Abstract
BACKGROUND Carotid artery disease is highly prevalent and a main cause of ischemic stroke and vascular dementia. There is a paucity of information on predictors of serious vascular events. Besides percentage diameter stenosis, international guidelines also recommend the evaluation of qualitative characteristics of carotid artery disease as a guide to treatment, but with no agreement on which qualitative features to assess. This inadequate knowledge leads to a poor ability to identify patients at risk, dispersion of medical resources, and unproven use of expensive and resource-consuming techniques, such as magnetic resonance imaging, positron emission tomography, and computed tomography. OBJECTIVES The Carotid Artery Multimodality imaging Prognostic (CAMP) study will: prospectively determine the best predictors of silent and overt ischemic stroke and vascular dementia in patients with asymptomatic subcritical carotid artery disease by identifying the noninvasive diagnostic features of the 'vulnerable carotid plaque'; assess whether 'smart' use of low-cost diagnostic methods such as ultrasound-based evaluations may yield at least the same level of prospective information as more expensive techniques. STUDY DESIGN We will compare the prognostic/predictive value of all proposed techniques with regard to silent or clinically manifest ischemic stroke and vascular dementia. The study will include ≥300 patients with asymptomatic, unilateral, intermediate degree (40-60% diameter) common or internal carotid artery stenosis detected at carotid ultrasound, with a 2-year follow-up. The study design has been registered on Clinicaltrial.gov on December 17, 2020 (ID number NCT04679727).
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Affiliation(s)
- Luna Gargani
- Institute of Clinical Physiology, National Research Council
| | | | - Raffaella Berchiolli
- Vascular Surgery Unit, Cardio Thoracic and Vascular Department, University of Pisa
| | | | | | | | | | | | - Mariella De Santis
- Cardiology Unit, Cardio-Thoracic and Vascular Department, University of Pisa, Pisa, Italy
| | - Paola Erba
- Department of Nuclear Medicine, University of Pisa, Pisa, Italy
- Medical Imaging Center, Department of Nuclear Medicine & Molecular Imaging, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Plinio Fabiani
- Internal Medicine, S.M. Annunziata Hospital, Florence, Italy
| | - Ilaria Gabbriellini
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Gian Giacomo Galeotti
- Cardiology Unit, Cardio-Thoracic and Vascular Department, University of Pisa, Pisa, Italy
| | - Irene Ghicopulos
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Isabel Goncalves
- Department of Clinical Sciences - Malmö University Hospital, University of Lund, Malmö, Sweden
| | - Simone Lapi
- BMS Multispecialistic Biobank-Biobank Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Gabriele Masini
- Cardiology Unit, Cardio-Thoracic and Vascular Department, University of Pisa, Pisa, Italy
| | - Carmela Morizzo
- Cardiology Unit, Cardio-Thoracic and Vascular Department, University of Pisa, Pisa, Italy
| | - Vinicio Napoli
- Diagnostic and Interventional Radiology, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Jan Nilsson
- Department of Clinical Sciences - Malmö University Hospital, University of Lund, Malmö, Sweden
| | - Giovanni Orlandi
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Carlo Palombo
- Cardiology Unit, Cardio-Thoracic and Vascular Department, University of Pisa, Pisa, Italy
| | | | - Stefano Ricci
- Department of Information Engineering (DINFO), University of Florence, Florence, Italy
| | - Gabriele Siciliano
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Riemer H J A Slart
- Medical Imaging Center, Department of Nuclear Medicine & Molecular Imaging, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - Raffaele De Caterina
- Cardiology Unit, Cardio-Thoracic and Vascular Department, University of Pisa, Pisa, Italy
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14
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Abbott AL. Extra-Cranial Carotid Artery Stenosis: An Objective Analysis of the Available Evidence. Front Neurol 2022; 13:739999. [PMID: 35800089 PMCID: PMC9253595 DOI: 10.3389/fneur.2022.739999] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 01/24/2022] [Indexed: 12/26/2022] Open
Abstract
Background and Purpose Carotid stenosis is arterial disease narrowing of the origin of the internal carotid artery (main brain artery). Knowing how to best manage this is imperative because it is common in older people and an important cause of stroke. Inappropriately high expectations have grown regarding the value of carotid artery procedures, such as surgery (endarterectomy) and stenting, for lowering the stroke risk associated with carotid stenosis. Meanwhile, the improving and predominant value of medical intervention (lifestyle coaching and medication) continues to be underappreciated. Methods and Results This article aims to be an objective presentation and discussion of the scientific literature critical for decision making when the primary goal is to optimize patient outcome. This compilation follows from many years of author scrutiny to separate fact from fiction. Common sense conclusions are drawn from factual statements backed by original citations. Detailed research methodology is given in cited papers. This article has been written in plain language given the importance of the general public understanding this topic. Issues covered include key terminology and the economic impact of carotid stenosis. There is a summary of the evidence-base regarding the efficacy and safety of procedural and medical (non-invasive) interventions for both asymptomatic and symptomatic patients. Conclusions are drawn with respect to current best management and research priorities. Several "furphies" (misconceptions) are exposed that are commonly used to make carotid stenting and endarterectomy outcomes appear similar. Ongoing randomized trials are mentioned and why they are unlikely to identify a routine practice indication for carotid artery procedures. There is a discussion of relevant worldwide guidelines regarding carotid artery procedures, including how they should be improved. There is an outline of systematic changes that are resulting in better application of the evidence-base. Conclusion The cornerstone of stroke prevention is medical intervention given it is non-invasive and protects against all arterial disease complications in all at risk. The "big" question is, does a carotid artery procedure add patient benefit in the modern era and, if so, for whom?
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Affiliation(s)
- Anne L. Abbott
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Neurology Private Practice, Knox Private Hospital, Wantirna, VIC, Australia
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15
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van Dam-Nolen DH, Truijman MT, van der Kolk AG, Liem MI, Schreuder FH, Boersma E, Daemen MJ, Mess WH, van Oostenbrugge RJ, van der Steen AF, Bos D, Koudstaal PJ, Nederkoorn PJ, Hendrikse J, van der Lugt A, Kooi ME. Carotid Plaque Characteristics Predict Recurrent Ischemic Stroke and TIA. JACC Cardiovasc Imaging 2022; 15:1715-1726. [DOI: 10.1016/j.jcmg.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/18/2022] [Accepted: 04/01/2022] [Indexed: 01/01/2023]
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16
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Identifying High-Risk Nonstenotic Carotid Artery Disease. JACC Cardiovasc Imaging 2022; 15:1727-1729. [DOI: 10.1016/j.jcmg.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 04/07/2022] [Indexed: 11/23/2022]
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17
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Bounajem MT, Grandhi R, Kilburg CJ, Taussky P. Patient-Tailored Stenting versus Endarterectomy for the Treatment of Asymptomatic Carotid Artery Stenosis. J Pers Med 2022; 12:882. [PMID: 35743667 PMCID: PMC9224726 DOI: 10.3390/jpm12060882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/26/2022] [Accepted: 05/23/2022] [Indexed: 02/05/2023] Open
Abstract
Carotid artery stenosis is a major cause of acute ischemic strokes in adults. Given the consequences and sequelae of an acute ischemic stroke, intervention while patients are still asymptomatic is a key opportunity for stroke prevention. Although carotid endarterectomy has been the gold standard of treatment for carotid stenosis for many years, recent advances in carotid stenting technology, practitioner experience, and dual antiplatelet therapy have expanded the use for treatments other than endarterectomy. Review of the current literature has demonstrated that endarterectomy and carotid artery stenting produce overall similar results for the treatment of asymptomatic carotid stenosis, but certain factors may help guide physicians and patients in choosing one treatment over the other. Age 70 years and older, renal disease, poor medication compliance, and unstable plaque features all portend better outcomes from endarterectomy, whereas age under 70 years, high cervical location of disease, cardiac disease, and reliable medication compliance favor stenting. The decision to pursue endarterectomy versus stenting is therefore complex, and although large studies have demonstrated similar outcomes, the approach to treatment of asymptomatic carotid stenosis must be optimized for each individual patient to achieve the best possible outcome.
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Affiliation(s)
| | | | | | - Philipp Taussky
- Clinical Neurosciences Center, Department of Neurosurgery, University of Utah, Salt Lake City, UT 84132, USA; (M.T.B.); (R.G.); (C.J.K.)
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18
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King AH, Kim AH, Kwan S, Lee J, Schmaier AH, Kumins NH, Harth KC, Wong VL, Colvard BD, Kashyap VS, Cho JS. Elevated Neutrophil to Lymphocyte Ratio is Associated with Worse Outcomes after Carotid Endarterectomy in Asymptomatic Patients. J Stroke Cerebrovasc Dis 2021; 30:106120. [PMID: 34597986 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/23/2021] [Accepted: 09/13/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Management of carotid artery stenosis (CAS) remains controversial and proper patient selection critical. Elevated neutrophil to lymphocyte ratio (NLR) has been associated with poor outcomes after vascular procedures. The effect of NLR on outcomes after carotid endarterectomy (CEA) in asymptomatic and symptomatic patients is assessed. MATERIALS AND METHODS A retrospective review was conducted of all patients between 2010 and 2018 with carotid stenosis >70% as defined by CREST 2 criteria. A total of 922 patients were identified, of whom 806 were treated with CEA and 116 non-operatively with best medical therapy (BMT). Of patients undergoing CEA, 401 patients (290 asymptomatic [aCEA], 111 symptomatic [sCEA]) also had an available NLR calculated from a complete blood count with differential. All patients treated with BMT were asymptomatic and had a baseline NLR available. Kaplan-Meier analysis assessed composite ipsilateral stroke or death over 3 years. RESULTS In sCEA group, the 3-year composite stroke/death rates did not differ between NLR < 3.0 (22.9%) vs NLR > 3.0 (38.1%) (P=.10). In aCEA group, patients with a baseline NLR >3.0 had an increased risk of 3-year stroke/death (42.6%) compared to both those with NLR <3.0 (9.3%, P<.0001) and those treated with BMT (23.6%, P=.003). In patients with NLR <3.0, aCEA showed a superior benefit over BMT with regard to stroke or death (9.3% vs. 26.2%, P=.02). However, in patients with NLR >3.0, there was no longer a benefit to prophylactic CEA compared to BMT (42.6% vs. 22.2%, P=.05). Multivariable analysis identified NLR >3.0 (HR, 3.23; 95% CI, 1.93-5.42; P<.001) and congestive heart failure (HR, 2.18; 95% CI, 1.33-3.58; P=.002) as independent risk factors for stroke/death in patients with asymptomatic carotid artery stenosis. CONCLUSIONS NLR >3.0 is associated with an increased risk of late stroke/death after prophylactic CEA for asymptomatic carotid artery stenosis, with benefits not superior to BMT. NLR may be used to help with selecting asymptomatic patients for CEA. The effect of NLR and outcomes in symptomatic patients requires further study. Better understanding of the mechanism(s) for NLR elevation and medical intervention strategies are needed to modulate outcome risk in these patients.
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Affiliation(s)
- Alexander H King
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Ann H Kim
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Stephen Kwan
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Jasmine Lee
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Alvin H Schmaier
- Division of Hematology/Oncology, Department of Medicine, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Norman H Kumins
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Karem C Harth
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Virginia L Wong
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Benjamin D Colvard
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States.
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19
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Donners SJA, Toorop RJ, de Kleijn DPV, de Borst GJ. A narrative review of plaque and brain imaging biomarkers for stroke risk stratification in patients with atherosclerotic carotid artery disease. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1260. [PMID: 34532397 PMCID: PMC8421959 DOI: 10.21037/atm-21-1166] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/20/2021] [Indexed: 12/20/2022]
Abstract
Objective In this narrative review, we aim to review imaging biomarkers that carry the potential to non-invasively guide stroke risk stratification for treatment optimization. Background Carotid atherosclerosis plays a fundamental part in the occurrence of ischemic stroke. International guidelines select the optimal treatment strategy still mainly based on the presence of clinical symptoms and the degree of stenosis for stroke prevention in patients with atherosclerotic carotid plaques. These guidelines, based on randomized controlled trials that were conducted three decades ago, recommend carotid revascularization in symptomatic patients with high degree of stenosis versus a conservative approach for most asymptomatic patients. Due to optimization of best medical therapy and risk factor control, it is suggested that a subgroup of symptomatic patients is at lower risk of stroke and may not benefit from revascularization, whereas a selective subgroup of high-risk asymptomatic patients would benefit from this procedure. Methods A literature search was performed for articles published up to December 2020 using PubMed, EMBASE and Scopus. Based on the literature found, change in stenosis degree and volume, plaque echolucency, plaque surface, intraplaque haemorrhage, lipid-rich necrotic core, thin fibrous cap, inflammation, neovascularization, microembolic signals, cerebrovascular reserve, intracranial collaterals, silent brain infarcts, diffusion weighted imaging lesions and white matters lesions have the potential to predict stroke risk. Conclusions The applicability of imaging biomarkers needs to be further improved before the potential synergistic prognostic ability of imaging biomarkers can be verified on top of the clinical biomarkers. In the future, the routine and combined assessment of both plaque and brain imaging biomarkers might help to improve optimization of treatment strategies in individual patients with atherosclerotic carotid artery disease.
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Affiliation(s)
- Simone J A Donners
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Raechel J Toorop
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Dominique P V de Kleijn
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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20
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Aarli SJ, Thomassen L, Waje-Andreassen U, Logallo N, Kvistad CE, Næss H, Fromm A. The Course of Carotid Plaque Vulnerability Assessed by Advanced Neurosonology. Front Neurol 2021; 12:702657. [PMID: 34489850 PMCID: PMC8417551 DOI: 10.3389/fneur.2021.702657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/28/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Carotid artery atherosclerosis is a major risk factor for ischemic stroke. This risk is related to plaque vulnerability and is characterized by plaque morphology, intraplaque neovascularization, and cerebral microembolization. Advanced neurosonology can identify vulnerable plaques and aid in preventing subsequent stroke. We aimed to assess the time course of cerebral microembolization and intraplaque neovascularization during 6 months of follow-up and to explore the utility of advanced neurosonology in patients with acute cerebral ischemia. Methods: Fifteen patients with acute cerebral ischemia and carotid artery plaques underwent comprehensive extra- and intracranial ultrasound examinations, including microemboli detection and contrast-enhanced ultrasound. The examinations were repeated after 3 and 6 months. Results: We examined 28 plaques in 15 patients. The ultrasonographic features of plaque vulnerability were frequent in symptomatic and asymptomatic plaques. There were no significant differences in stenosis degree, plaque composition, plaque surface, neovascularization, or cerebral microembolization between symptomatic and asymptomatic plaques, but symptomatic plaques had a higher number of vulnerable features. None of the patients had recurrent clinical stroke or transient ischemic attack during the follow-up period. We observed a decrease in cerebral microembolization at 6 months, but no significant change in intraplaque neovascularization. Conclusions: In patients with acute cerebral ischemia and carotid artery plaques, cerebral microembolization decreased during 6 months of follow-up, indicating plaque stabilization. Clinical Trial Registration:ClinicalTrial.gov, identifier NCT02759653.
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Affiliation(s)
- Sander Johan Aarli
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Thomassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ulrike Waje-Andreassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway
| | - Nicola Logallo
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Christopher Elnan Kvistad
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Halvor Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,SESAM - Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Annette Fromm
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
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21
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Mechtouff L, Rascle L, Crespy V, Canet-Soulas E, Nighoghossian N, Millon A. A narrative review of the pathophysiology of ischemic stroke in carotid plaques: a distinction versus a compromise between hemodynamic and embolic mechanism. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1208. [PMID: 34430649 PMCID: PMC8350662 DOI: 10.21037/atm-20-7490] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 05/31/2021] [Indexed: 12/13/2022]
Abstract
Atherosclerotic carotid artery stenosis causes about 10–20% of all ischemic strokes through two main mechanisms: hemodynamic impairment in case of significant stenosis and thromboembolism from an atherosclerotic plaque regardless of the degree of stenosis. The latter is the most frequent mechanism and appear to result from embolization from a vulnerable atherosclerotic plaque or acute occlusion of the carotid artery and propagation of thrombus distally. Downstream infarcts may occur in a territory of major cerebral artery or at the most distal areas between two territories of major cerebral arteries, the so-called watershed (WS), or border zone area. Although WS infarcts, especially deep WS infarct, were historically thought to be due to hemodynamic compromise, the role of microembolism has also been documented, both mechanisms may act synergistically to promote WS infarcts. Routine and more advanced imaging techniques may provide information on the underlying mechanism involved in ipsilateral ischemic stroke. A better understanding of ischemic stroke pathogenesis in carotid stenosis may limit the use of routine non-selective shunt, whose benefit-risk balance is debated, to patients with hemodynamic impairment. After reviewing existing evidence underpinning the contribution of the two mechanisms in downstream ischemic stroke and the various imaging techniques available to investigate them, we will focus on the pathogenesis of WS infarcts that remains debated.
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Affiliation(s)
- Laura Mechtouff
- Stroke Center, Hospices Civils de Lyon, Lyon, France.,INSERM U1060, CarMeN Laboratory, University Claude Bernard Lyon 1, Lyon, France
| | - Lucie Rascle
- Stroke Center, Hospices Civils de Lyon, Lyon, France
| | - Valentin Crespy
- Vascular Surgery Department, Hospices Civils de Lyon, Lyon, France
| | | | - Norbert Nighoghossian
- Stroke Center, Hospices Civils de Lyon, Lyon, France.,INSERM U1060, CarMeN Laboratory, University Claude Bernard Lyon 1, Lyon, France
| | - Antoine Millon
- Vascular Surgery Department, Hospices Civils de Lyon, Lyon, France.,LIBM EA7424, Team Atherosclerosis, Thrombosis and Physical Activity, University Claude Bernard Lyon 1, Lyon, France
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22
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Reiff T, Ringleb PA. [Asymptomatic carotid artery stenosis - treatment recommendations]. Dtsch Med Wochenschr 2021; 146:793-800. [PMID: 34130321 DOI: 10.1055/a-1221-7065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
For the asymptomatic carotid stenosis, defined as an atherosclerotic carotid stenosis without neurological symptoms for more than 6 months, there are in contrast to a symptomatic carotid stenosis still no reliable treatment recommendations. Possible therapy recommendations based on current data are presented below.
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23
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Abstract
Asymptomatic carotid stenosis (ACS) due to atherosclerosis is a risk factor for ipsilateral ischemic cerebrovascular events and cognitive impairment. The prognosis of ACS has improved over the past 4 decades due largely to improvements in medical management. Most patients with ACS can be managed without revascularization, but some patients with vulnerable plaque should be considered for revascularization. Regardless of the decision to refer for revascularization, all patients with ACS should receive intensive medical management. This includes lifestyle modification (Mediterranean diet, exercise, and smoking cessation) and pharmacological therapy (antiplatelets, lipid-lowering agents, blood pressure reduction, and glycemic control). Patients with ACS often have atherosclerosis in other critical locations, and thus optimal medical therapy is likely to reduce events outside the carotid arteries. The nature of optimal medical therapy is described.
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Affiliation(s)
- Daniel G Hackam
- Division of Clinical Pharmacology, Department of Medicine, Department of Clinical Neurological Sciences, and Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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24
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Abstract
Patients with asymptomatic carotid stenosis (ACS) are at very high risk of coronary events, so they should all receive intensive medical therapy. What is often accepted as “best medical therapy” is usually suboptimal. Truly intensive medical therapy includes lifestyle modification, particularly smoking cessation and a Mediterranean diet. All patients with ACS should receive intensive lipid-lowering therapy, should have their blood pressure well controlled, and should receive B vitamins for lowering of plasma total homocysteine (tHcy) if levels are high; a commonly missed cause of elevated tHcy is metabolic B12 deficiency, which should be diagnosed and treated. Most patients with ACS would be better treated with intensive medical therapy than with either carotid endarterectomy (CEA) or stenting (CAS). A process called “treating arteries instead of treating risk factors” markedly reduced the risk of ACS in an observational study; a randomized trial vs. usual care should be carried out. The few patients with ACS who could benefit (~15%, or perhaps more if recent evidence regarding the risk of intraplaque hemorrhage is borne out) can be identified by a number of features. These include microemboli on transcranial Doppler, intraplaque hemorrhage, reduced cerebrovascular reserve, and echolucency of plaques, particularly “juxtaluminal black plaque”. No patient should be subjected to CAS or CEA without evidence of high-risk features, because in most cases the 1-year risk of stroke or death with intervention is higher with either CEA (~2%) or CAS (~4%) than with intensive medical therapy (~0.5%). Most patients, particularly the elderly, would be better treated with CEA than CAS. Most strokes can be prevented in patients with ACS, but truly intensive medical therapy is required.
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Affiliation(s)
- J David Spence
- Neurology & Clinical Pharmacology, Western University, London, ON, Canada.,Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, London, ON, Canada
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25
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Pini R, Vacirca A, Palermo S, Gallitto E, Mascoli C, Gargiulo M, Faggioli G. Impact of cerebral ischemic lesions on the outcome of carotid endarterectomy. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1264. [PMID: 33178796 PMCID: PMC7607094 DOI: 10.21037/atm-20-1098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patients with carotid artery stenosis (CAS) are commonly defined as asymptomatic or symptomatic according with their neurological conditions, however, emerging evidences suggest stratifying patients according also with the presence of cerebral ischemic lesions (CIL). In asymptomatic patients, the presence of CIL increases the risk of future neurologic event from 1% to 4% per year, leading to a stronger indication to carotid revascularization. In symptomatic patients, the presence of CIL does not seem to influence the outcome of the carotid revascularization if the volume of the lesion is small (<4,000 mm3); the benefit of the revascularization is also more significant if performed within 2 weeks from the index event. However, high volume (>4,000 mm3) CIL are associated in some experiences with a higher risk of carotid revascularization suggesting to delay the carotid revascularization for at least 4 weeks. As a matter of fact, the evaluation of CIL dimensions and characteristics in patients with CAS gives to the physician involved in the treatment a valuable adjunctive tool in the choice of the ideal treatment.
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Affiliation(s)
- Rodolfo Pini
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
| | - Andrea Vacirca
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
| | - Sergio Palermo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
| | - Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
| | - Chiara Mascoli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
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26
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Search for Reliable Circulating Biomarkers to Predict Carotid Plaque Vulnerability. Int J Mol Sci 2020; 21:ijms21218236. [PMID: 33153204 PMCID: PMC7662861 DOI: 10.3390/ijms21218236] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/30/2020] [Accepted: 11/01/2020] [Indexed: 02/06/2023] Open
Abstract
Atherosclerosis is responsible for 20% of ischemic strokes, and the plaques from the internal carotid artery the most frequently involved. Lipoproteins play a key role in carotid atherosclerosis since lipid accumulation contributes to plaque progression and chronic inflammation, both factors leading to plaque vulnerability. Carotid revascularization to prevent future vascular events is reasonable in some patients with high-grade carotid stenosis. However, the degree of stenosis alone is not sufficient to decide upon the best clinical management in some situations. In this context, it is essential to further characterize plaque vulnerability, according to specific characteristics (lipid-rich core, fibrous cap thinning, intraplaque hemorrhage). Although these features can be partly detected by imaging techniques, identifying carotid plaque vulnerability is still challenging. Therefore, the study of circulating biomarkers could provide adjunctive criteria to predict the risk of atherothrombotic stroke. In this regard, several molecules have been found altered, but reliable biomarkers have not been clearly established yet. The current review discusses the concept of vulnerable carotid plaque, and collects existing information about putative circulating biomarkers, being particularly focused on lipid-related and inflammatory molecules.
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Murphy SJ, Lim ST, Kinsella JA, Tierney S, Egan B, Feeley TM, Dooley C, Kelly J, Murphy SM, Walsh RA, Collins R, Coughlan T, O'Neill D, Harbison JA, Madhavan P, O'Neill SM, Colgan MP, Meaney JF, Hamilton G, McCabe DJ. Simultaneous assessment of plaque morphology, cerebral micro-embolic signal status and platelet biomarkers in patients with recently symptomatic and asymptomatic carotid stenosis. J Cereb Blood Flow Metab 2020; 40:2201-2214. [PMID: 31711341 PMCID: PMC7585923 DOI: 10.1177/0271678x19884427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The relationship between plaque morphology, cerebral micro-embolic signals (MES) and platelet biomarkers in carotid stenosis patients warrants investigation.We combined data from two prospective, observational studies to assess carotid plaque morphology and relationship with cerebral MES and platelet biomarkers in patients with recently symptomatic (≤4 weeks of transient ischaemic attack (TIA)/ischaemic stroke) versus asymptomatic carotid stenosis. Plaque morphology on ultrasound was graded with Grey-Scale Median (GSM) and Gray-Weale (GW) scoring. Bilateral transcranial Doppler ultrasound classified patients as 'MES+ve' or 'MES-ve'. Full blood counts were analysed and flow cytometry quantified CD62P and CD63 expression, leucocyte-platelet complexes and reticulated platelets.Data from 42 recently symptomatic carotid stenosis patients were compared with those from 36 asymptomatic patients. There were no differences in median GSM scores between symptomatic and asymptomatic patients (25 vs. 30; P = 0.31) or between MES+ve vs. MES-ve symptomatic patients (36 vs. 25; P = 0.09). Symptomatic patients with GSM-echodense plaques (GSM ≥25) had higher platelet counts (228 vs. 191 × 109/L), neutrophil-platelet (3.3 vs. 2.7%), monocyte-platelet (6.3 vs. 4.55%) and lymphocyte-platelet complexes (2.91 vs. 2.53%) than 'asymptomatic patients with GSM-echodense plaques' (P ≤ 0.03).Recently, symptomatic carotid stenosis patients with 'GSM-echodense plaques' have enhanced platelet production/secretion/activation compared with their asymptomatic counterparts. Simultaneous assessment with neurovascular imaging and platelet biomarkers may aid risk-stratification in carotid stenosis.
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Affiliation(s)
- Stephen J Murphy
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland.,Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland
| | - Soon T Lim
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland.,Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland
| | - Justin A Kinsella
- Department of Neurology, St Vincent's University Hospital, University College Dublin, Dublin, Ireland
| | - Sean Tierney
- Department of Vascular Surgery, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland
| | - Bridget Egan
- Department of Vascular Surgery, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland
| | - Tim M Feeley
- Department of Vascular Surgery, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland.,Dublin Midlands Hospital Group, Dublin, Ireland
| | - Clare Dooley
- Department of Vascular Surgery, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland
| | - James Kelly
- Department of Vascular Surgery, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland
| | - Sinead M Murphy
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland.,Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland.,Age-Related Health Care Department, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland
| | - Richard A Walsh
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland.,Age-Related Health Care Department, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland
| | - Ronan Collins
- Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland.,Age-Related Health Care Department, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland
| | - Tara Coughlan
- Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland.,Department of Medicine for the Elderly/Stroke Service, St James's Hospital/Trinity College Dublin, Dublin, Ireland
| | - Desmond O'Neill
- Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland.,Age-Related Health Care Department, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland
| | - Joseph A Harbison
- Department of Medicine for the Elderly/Stroke Service, St James's Hospital/Trinity College Dublin, Dublin, Ireland
| | - Prakash Madhavan
- Department of Vascular Surgery, St James's Hospital/Trinity College Dublin, Dublin, Ireland
| | - Sean M O'Neill
- Department of Vascular Surgery, St James's Hospital/Trinity College Dublin, Dublin, Ireland
| | - Mary P Colgan
- Centre for Advanced Medical Imaging, Department of Radiology, St James's Hospital/Trinity College Dublin, Dublin, Ireland
| | - Jim F Meaney
- Centre for Advanced Medical Imaging, Department of Radiology, St James's Hospital/Trinity College Dublin, Dublin, Ireland
| | - George Hamilton
- Department of Vascular Surgery, University Department of Surgery, Royal Free Hampstead NHS Trust, London, UK
| | - Dominick Jh McCabe
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland.,Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland.,Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Dublin, Ireland.,Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, UK.,Vascular Neurology Research Foundation c/o Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland.,Irish Centre for Vascular Biology, Dublin, Ireland.,Stroke Clinical Trials Network Ireland, Dublin, Ireland
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28
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Vessel Wall–Imaging Biomarkers of Carotid Plaque Vulnerability in Stroke Prevention Trials. JACC Cardiovasc Imaging 2020; 13:2445-2456. [DOI: 10.1016/j.jcmg.2020.07.046] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/27/2020] [Accepted: 07/31/2020] [Indexed: 02/06/2023]
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29
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Kang J, Kim YW, Kim DI, Woo SY, Park YJ. Outcomes of Carotid Revascularization versus Optimal Medical Treatment Alone for Asymptomatic Carotid Stenosis: Inverse-Probability-of-Treatment Weighting Using Propensity Scores. World Neurosurg 2020; 146:e419-e430. [PMID: 33223129 DOI: 10.1016/j.wneu.2020.10.104] [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] [Received: 07/17/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The benefits and necessity of revascularization for asymptomatic carotid stenosis remains under debate. This study aimed to determine the more durable and beneficial alternative between carotid revascularization and optimal medical treatment (OMT) alone for asymptomatic carotid stenosis. METHODS We performed a retrospective analysis of patients with asymptomatic severe carotid stenosis at a tertiary institution between 1994 and 2017. We compared revascularization (carotid endarterectomy [CEA] and carotid artery stenting [CAS]) with OMT alone by using inverse-probability-of-treatment weighting with propensity scores to account for selection bias. The primary end point was a composite of any stroke, myocardial infarction, and death within 30 days, plus ipsilateral stroke thereafter. RESULTS A total of 1089 patients were included in the analysis (56% CEA, 25% CAS, 19% OMT alone). Patients who underwent CAS consistently showed greater risk regarding the primary composite end point compared with those who received OMT alone (hazard radio [HR] 3.32, 95% confidence interval 1.014-10.868; P = 0.047), but the CEA group showed no significant difference (HR 1.19, 95% confidence interval 0.385-4.584; P = 0.761). The CAS group had the greatest rates of any stroke within 30 days (4.0%, P = 0.0006) and ipsilateral stroke thereafter (3.68%, P = 0.0009). There was no death within 30 days. In the long-term outcomes, neither CEA nor CAS showed significant differences in HR compared with OMT alone. CONCLUSIONS Our study suggests that for stroke prevention in asymptomatic severe carotid stenosis, CAS might be inferior to the other 2 options regarding early outcomes. However, further investigation is required regarding the efficacy and durability of OMT alone.
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Affiliation(s)
- Jihee Kang
- Division of Vascular Surgery, Department of Surgery, Inha University Hospital, Inha University School of Medicine, Joong-gu, Incheon, South Korea
| | - Young-Wook Kim
- Division of Vascular Surgery, Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seodaemun-gu, Seoul, South Korea
| | - Dong-Ik Kim
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
| | - Shin-Young Woo
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
| | - Yang-Jin Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea.
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30
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Lanza G, Giannandrea D, Lanza J, Ricci S, Gensini GF. Personalized-medicine on carotid endarterectomy and stenting. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1274. [PMID: 33178806 PMCID: PMC7607117 DOI: 10.21037/atm-20-1126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Evidence based medicine (EBM) is the core of current clinical guidelines and is considered as the gold standard of clinical practice. Despite this, a number of limitations and criticisms are moved to EBM. The major one is that this method privileges randomized controlled trials (RCTs), in which the selection of patients is often based on rigid inclusion criteria. The lack of “pragmatism” of some RCTs sometimes makes it difficult to apply guidelines that derive from them to patients observed in clinical practice, who are often affected by comorbidities and disabilities. The new paradigm to overcome this limitation is personalized medicine (PM), which aims to take into account the particular characteristics displayed by the individual. In order to tailor the best treatment for the patient, PM uses EBM but emphasizes the person's specific information from the assessment of the clinic, lifestyle and risk/benefit scores. This narrative review tries to find the best evidence by analysing subgroups and risk scores of patients from meta-analysis and RCTs in order to try to apply PM and to provide good practice points (GPP) on grey aspects and open questions not fully covered by current guidelines on carotid endarterectomy (CEA) and stenting for stroke prevention.
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Affiliation(s)
- Gaetano Lanza
- Vascular Surgery Department, IRCCS MultiMedica Hospital, Castellanza, Italy
| | - David Giannandrea
- Neurology Department-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy.,Association "Naso Sano", Umbria Regional Registry of No-Profit Organization, Corciano, Italy
| | - Jessica Lanza
- ASST Fatebenefratelli Sacco, Angioma Center, Vittore Buzzi Hospital, Milan, Italy
| | - Stefano Ricci
- Neurology Department-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | - Gian Franco Gensini
- Permanent Technical Committee for Guidelines, Tuscany Regional Health Service, Florence, Italy
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31
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Abstract
PURPOSE OF REVIEW To describe the uses of measurement of carotid plaque burden, as total plaque area (TPA), total plaque volume (TPV), and vessel wall volume (VWV), which includes plaque burden and wall volume. RECENT FINDINGS Measurement of plaque burden is useful for risk stratification, research into the genetics and biology of atherosclerosis, for measuring effects of new therapies for atherosclerosis, and for treatment of high-risk patients with severe atherosclerosis. SUMMARY Measurement of plaque burden is far superior to measurement of carotid intima-media thickness (IMT) in many ways, and should replace it. Vessel wall volume can be measured in persons with no plaque as an alternative to IMT.
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Affiliation(s)
- J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
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32
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Abstract
Ultrasound methods are useful in stroke prevention in several ways. Measurement of carotid plaque burden, as either total plaque area (TPA) or total plaque volume (TPV) are strong predictors of cardiovascular risk: much stronger than intima-media thickness, which does not represent true atherosclerosis, but a biologically and genetically distinct phenotype. Measurement of plaque burden is also useful for the study of genetics, and of new risk factors such as toxic products of the intestinal microbiome. Carotid plaque burden is highly correlated with and as predictive of risk as coronary calcium scores, but is less costly and does not require radiation. Furthermore, because carotid plaques change in time over a period of months, they can be used for a new approach to vascular prevention: "Treating arteries instead of treating risk factors". In high-risk patients with asymptomatic carotid stenosis (ACS), this approach, implemented in 2003 in our clinics, was associated with a >80% reduction of stroke and myocardial infarction over 2 years. "Treating arteries without measuring plaque would be like treating hypertension without measuring blood pressure". Ultrasound methods can also be used to assess plaque vulnerability, by detecting echolucency, ulceration and plaque inhomogeneity on assessment of plaque texture. Transcranial Doppler (TCD) embolus detection is useful for risk stratification in patients with ACS; patients with two or more microemboli in an hour of monitoring have a 1-year risk of 15.6%, vs. 1% without microemboli, so this very clearly distinguishes which patients with ACS could benefit from intervention. TCD saline studies are more sensitive than trans-esophageal echocardiography for detection of patent foramen ovale, and more predictive of recurrent stroke. These methods should be more widely used, to reduce the increasing burden of stroke in our aging populations.
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Affiliation(s)
- J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada
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33
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Abstract
In 44 years of practicing stroke prevention, I have learned many lessons; in this article, I hope to impart some of them. Three areas of my research are discussed. Controlling resistant hypertension is markedly improved by physiologically individualized therapy based on renin/aldosterone phenotyping; this is particularly important in black patients. Measurement of carotid plaque burden strongly predicts cardiovascular risk and is useful for genetic research and for a process called treating arteries instead of risk factors. Doing so in high-risk patients with asymptomatic carotid stenosis was associated with a >80% reduction in the 2-year risk of stroke and myocardial infarction. It also permitted the identification of extremes of atherosclerosis that are useful for studying both the genetics and the biology of atherosclerosis. Patients with very high plaque burden despite low levels of risk factors have an unexplained phenotype; those with little or no plaque despite high levels of risk factors are protected. Patients with unexplained atherosclerosis have higher plasma levels of toxic metabolites produced by the intestinal microbiome largely from egg yolk, red meat, and protein, and those metabolites are renally excreted. This has important dietary implications for stroke prevention. Lowering of plasma total homocysteine with B vitamins significantly reduces the risk of stroke. That was not apparent in early studies because harm from cyanocobalamin among participants with renal failure obscured the benefit among those with good renal function. We should be using B vitamins to prevent stroke but should use methylcobalamin or oxocobalamin instead of cyanocobalamin.
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Affiliation(s)
- J. David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada
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34
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Gray VL, Goldberg AP, Rogers MW, Anthony L, Terrin ML, Guralnik JM, Blackwelder WC, Lam DFH, Sikdar S, Lal BK. Asymptomatic carotid stenosis is associated with mobility and cognitive dysfunction and heightens falls in older adults. J Vasc Surg 2020; 71:1930-1937. [PMID: 31699511 PMCID: PMC7196504 DOI: 10.1016/j.jvs.2019.09.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 09/02/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Atherosclerosis of the carotid bifurcation with plaque formation causes asymptomatic carotid artery stenosis (ACAS), which may also be associated with cerebral hypoperfusion. Cerebral hypoperfusion adversely affects multiple aspects of mobility and cognition. This study tests the hypothesis that community-dwelling older adults with a 50% or greater diameter-reducing ACAS will have mobility and cognitive impairments that heighten their risk for falls. METHODS Eighty community-dwelling adults completed a mobility assessment (Short Physical Performance Battery, Berg Balance Scale, Four Square Step Test, Dynamic Gait Index, Timed Up and Go, and gait speed), self-reported physical function (Activities-Specific Balance Confidence, SF-12 Physical Function Component), and cognitive tests (Mini-Mental State Examination). Falls were recorded for the past 6 months. Standardized carotid ultrasound examination classified participants into no stenosis (<50% diameter reduction) (n = 54), moderate stenosis (50%-69%) (n = 17), and high-grade stenosis (70%-99%) (n = 9) groups. Linear and logistic regression analyses determined the associations between these measures and the degree of stenosis (three groups). RESULTS Logistic regression analysis showed their degree of stenosis was associated with reductions in mobility (Short Physical Performance Battery [P = .008], Berg Balance Scale [P = .0008], Four Square Step Test [P = .005], DGI [P = .0001], TUG [P = .0004], gait speed [P = .02]), perceived physical function (ABC [P < .0001], SF-12 Physical Function Component [P < .0001]), and cognition (MMSE [P = .003]). Adults with moderate- and high-grade stenosis had a greater incidence of falls compared with those without stenosis (relative risk, 2.86; P = .01). Results remained unchanged after adjustment for age, sex and cardiovascular risk factors. CONCLUSIONS ACAS is associated with impaired mobility and cognition that are accompanied with increased fall risk. These impairments increased with worsening severity.
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Affiliation(s)
- Vicki L Gray
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, Md
| | - Andrew P Goldberg
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Maryland School of Medicine, and Department of Veterans Affairs Baltimore VA Geriatric Research Education and Clinical Center, Baltimore, Md
| | - Mark W Rogers
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, Md
| | - Laila Anthony
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Md; Vascular Service, Veterans Affairs Medical Center, Baltimore, Md
| | - Michael L Terrin
- Department of Epidemiology and Public Health, and Department of Medicine, University of Maryland School of Medicine, Baltimore, Md
| | - Jack M Guralnik
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Md
| | | | - Diana F H Lam
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Md
| | | | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Md; Vascular Service, Veterans Affairs Medical Center, Baltimore, Md.
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Bogiatzi C, Azarpazhooh MR, Spence JD. Choosing the right therapy for a patient with asymptomatic carotid stenosis. Expert Rev Cardiovasc Ther 2020; 18:53-63. [PMID: 32043917 DOI: 10.1080/14779072.2020.1729127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: Most patients with asymptomatic carotid stenosis (ACS) now have a lower risk with intensive medical therapy than with stenting (CAS) or endarterectomy (CEA); the annual risk of stroke or death with intensive medical therapy is ~ 0.5%, vs. a periprocedural risk with CAS of ~ 2.5-4.1% with CAS, and ~ 1.4-1.8% with CEA. The excess risk of CAS is greater in older patients.Areas covered: Discussed are the need for intensive medical therapy, the nature of intensive medical therapy, approaches to identifying the few patients with ACS who could benefit from CEA or CAS, and which patients would be better suited to CEA vs. CAS.Expert opinion: All patients with ACS are at high risk of cardiovascular events, soshould receive intensive medical therapy including lifestyle modification, intensive lipid-lowering, B vitamins to lower homocysteine (using methylcobalamin rather than cyanocobalamin), and appropriate antithrombotic therapy. High-risk patients who could benefit from intervention can be identified by clinical and imaging features including transcranial Doppler embolus detection, ulceration, intraplaque hemorrhage, reduced cerebrovascular reserve, plaque echolucency, silent infarction on brain imaging, and progression of stenosis. Most patients whose risk of stroke warrants intervention would be better treated with CEA than with CAS.
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Affiliation(s)
- Chrysi Bogiatzi
- Department of Neurology, McMaster University, Hamilton, Ontario, Canada
| | - M Reza Azarpazhooh
- Department of Clinical Neurological Sciences (Neurology), Western University, London, Ontario, Canada
| | - J David Spence
- Departments of Clinical Neurological Sciences (Neurology) and Internal Medicine (Clinical Pharmacology), Robarts Research Institute, London, Ontario, Canada
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Bazan R, Luvizutto GJ, Braga GP, Bazan SGZ, Hueb JC, de Freitas CCM, Hamamoto Filho PT, Módolo GP, Trindade AP, Sobreira ML, Nunes HRDC, Leite JP, Pontes-Neto OM. Relationship of spontaneous microembolic signals to risk stratification, recurrence, severity, and mortality of ischemic stroke: a prospective study. Ultrasound J 2020; 12:6. [PMID: 32048064 PMCID: PMC7013020 DOI: 10.1186/s13089-020-0156-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 01/26/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction The presence of microembolic signals (MES) during the acute phase of stroke is poorly understood, and its role and clinical application in relation to risk stratification and prognosis in patients remain uncertain. We assessed the prevalence of spontaneous MES in acute stroke and their relationship with risk stratification, stroke recurrence, morbidity, and mortality. Patients and methods This was a prospective cohort study conducted in the Stroke Unit. The MES presence was evaluated by transcranial Doppler (TCD) in patients with ischemic stroke within 48 h. The outcomes (risk stratification, morbidity, mortality, and recurrence of a stroke) were followed up for 6 months. The relationship between risk stratification and MES was obtained by odds ratios and that between MES and stroke recurrence, morbidity, and mortality using multiple logistic regression; considering statistical significance at P < 0.05. Results Of the 111 patients studied, 70 were men (63.1%) and 90 were white (81.1%), with a median age of 68 years. The MES frequency was 7%. There was a significant relationship between MES and symptomatic carotid disease (OR = 22.7; 95% CI 4.1–125.7; P < 0.001), a shorter time to monitoring (OR = 12.4; 95% CI 1.4–105.4; P = 0.02), and stroke recurrence (OR = 16.83; 95% CI 2.01–141; P = .009). Discussion It was observed that the stroke recurrence adjusted for prior stroke was higher and earlier among patients with MES detection. In conclusion, MES demonstrated a significant correlation with symptomatic carotid disease and a shorter DELAY until monitoring, and could be a predictor for the early recurrence of stroke in the long term.
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Affiliation(s)
- Rodrigo Bazan
- Department of Neurology, Psychology and Psychiatry, Botucatu Medical School, UNESP-Univ Estadual Paulista, Campus de Botucatu, Distrito de Rubião Jr, s/n, Botucatu, Brazil
| | - Gustavo José Luvizutto
- Department of Applied Physical Therapy, Institute of Health Sciences, UFTM-Univ Federal do Triângulo Mineiro, Uberaba, Brazil
| | - Gabriel Pereira Braga
- Department of Neurology, Psychology and Psychiatry, Botucatu Medical School, UNESP-Univ Estadual Paulista, Campus de Botucatu, Distrito de Rubião Jr, s/n, Botucatu, Brazil
| | | | - João Carlos Hueb
- Department of Internal Medicine, Botucatu Medical School, UNESP-Univ Estadual Paulista, Botucatu, Brazil
| | - Carlos Clayton Macedo de Freitas
- Department of Neurology, Psychology and Psychiatry, Botucatu Medical School, UNESP-Univ Estadual Paulista, Campus de Botucatu, Distrito de Rubião Jr, s/n, Botucatu, Brazil
| | - Pedro Tadao Hamamoto Filho
- Department of Neurology, Psychology and Psychiatry, Botucatu Medical School, UNESP-Univ Estadual Paulista, Campus de Botucatu, Distrito de Rubião Jr, s/n, Botucatu, Brazil.
| | - Gabriel Pinheiro Módolo
- Department of Neurology, Psychology and Psychiatry, Botucatu Medical School, UNESP-Univ Estadual Paulista, Campus de Botucatu, Distrito de Rubião Jr, s/n, Botucatu, Brazil
| | - André Petean Trindade
- Department of Tropical Diseases and Imaging Diagnosis, Botucatu Medical School, UNESP-Univ Estadual Paulista, Botucatu, Brazil
| | - Marcone Lima Sobreira
- Department of Surgery and Orthopedics, Botucatu Medical School, UNESP-Univ Estadual Paulista, Botucatu, Brazil
| | - Hélio Rubens de Carvalho Nunes
- Department of Neurology, Psychology and Psychiatry, Botucatu Medical School, UNESP-Univ Estadual Paulista, Campus de Botucatu, Distrito de Rubião Jr, s/n, Botucatu, Brazil
| | - João Pereira Leite
- Department of Neuroscience and Behavior, Ribeirão Preto School of Medicine, USP-Univ São Paulo, Ribeirão Preto, Brazil
| | - Octávio Marques Pontes-Neto
- Department of Neuroscience and Behavior, Ribeirão Preto School of Medicine, USP-Univ São Paulo, Ribeirão Preto, Brazil
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Abbott AL, Brunser AM, Giannoukas A, Harbaugh RE, Kleinig T, Lattanzi S, Poppert H, Rundek T, Shahidi S, Silvestrini M, Topakian R. Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis. J Vasc Surg 2020; 71:257-269. [PMID: 31564585 DOI: 10.1016/j.jvs.2019.04.490] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 04/11/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Medical intervention (risk factor identification, lifestyle coaching, and medication) for stroke prevention has improved significantly. It is likely that no more than 5.5% of persons with advanced asymptomatic carotid stenosis (ACS) will now benefit from a carotid procedure during their lifetime. However, some question the adequacy of medical intervention alone for such persons and propose using markers of high stroke risk to intervene with carotid endarterectomy (CEA) and/or carotid angioplasty/stenting (CAS). Our aim was to examine the scientific validity and implications of this proposal. METHODS We reviewed the evidence for using medical intervention alone or with additional CEA or CAS in persons with ACS. We also reviewed the evidence regarding the validity of using commonly cited makers of high stroke risk to select such persons for CEA or CAS, including markers proposed by the European Society for Vascular Surgery in 2017. RESULTS Randomized trials of medical intervention alone versus additional CEA showed a definite statistically significant CEA stroke prevention benefit for ACS only for selected average surgical risk men aged less than 75 to 80 years with 60% or greater stenosis using the North American Symptomatic Carotid Endarterectomy Trial criteria. However, the most recent measurements of stroke rate with ACS using medical intervention alone are overall lower than for those who had CEA or CAS in randomized trials. Randomized trials of CEA versus CAS in persons with ACS were underpowered. However, the trend was for higher stroke and death rates with CAS. There are no randomized trial results related to comparing current optimal medical intervention with CEA or CAS. Commonly cited markers of high stroke risk in relation to ACS lack specificity, have not been assessed in conjunction with current optimal medical intervention, and have not been shown in randomized trials to identify those who benefit from a carotid procedure in addition to current optimal medical intervention. CONCLUSIONS Medical intervention has an established role in the current routine management of persons with ACS. Stroke risk stratification studies using current optimal medical intervention alone are the highest research priority for identifying persons likely to benefit from adding a carotid procedure.
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Affiliation(s)
- Anne L Abbott
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.
| | - Alejandro M Brunser
- Department of Neurology, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Athanasios Giannoukas
- University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Robert E Harbaugh
- Department of Neurosurgery, Penn State University, State College, Pa
| | - Timothy Kleinig
- Neurology Department, Royal Adelaide Hospital, Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Simona Lattanzi
- Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Holger Poppert
- Neurology Department, Helios Dr Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Tatjana Rundek
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Fla
| | - Saeid Shahidi
- Department of Vascular and Endovascular Surgery, Acute Regional Hospital Slagelse, Copenhagen & South Denmark University, Copenhagen, Denmark
| | | | - Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
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Abstract
PURPOSE OF REVIEW The goal of this paper is to provide the reader with a review of the evidence supporting the surgical and medical management of patients with asymptomatic internal carotid artery (ICA) stenosis. RECENT FINDINGS Based on the results of earlier clinical trials, surgical intervention with carotid endarterectomy (CEA) has long been the preferred method of management for patients with asymptomatic severe carotid stenosis. Carotid artery stenting (CAS) is another less invasive surgical option that has similar outcomes over the long-term. However, more recent improvements in medical management have reduced the risk of stroke in this population to comparable rates seen with CEA. As a result, medical management alone is advocated as well for patients with asymptomatic carotid stenosis. In addition to stenosis severity, there are a number of features of plaque morphology associated with vulnerable plaque that predict future stroke risk. Rates of stroke in patients with asymptomatic severe carotid stenosis with modern surgical techniques, CEA and CAS, are similar to modern medical therapy alone. Both surgery and medical therapy are good treatment options but it is not known which treatment is superior. The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2), an NIH-sponsored, multicenter, randomized trial that aims to answer this important management decision.
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Affiliation(s)
- Scott Silverman
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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39
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Hariri N, Russell T, Kasper G, Lurie F. Reply. J Vasc Surg 2019; 70:1724-1725. [DOI: 10.1016/j.jvs.2019.06.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 06/30/2019] [Indexed: 11/24/2022]
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Lim S, Mora-Pinzon M, Park T, Yoon W, Crisostomo PR, Cho JS. Medical therapy does not confer stroke prevention for all patients: identification of high-risk patients with asymptomatic carotid stenosis is still needed. INT ANGIOL 2019; 38:372-380. [DOI: 10.23736/s0392-9590.19.04143-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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41
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Abbott AL, Merican J, Pearce DC, Juric A, Worsnop C, Foster E, Chambers B. Asymptomatic Carotid Stenosis Is Associated With Circadian and Other Variability in Embolus Detection. Front Neurol 2019; 10:322. [PMID: 31040812 PMCID: PMC6476949 DOI: 10.3389/fneur.2019.00322] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 03/14/2019] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Variability in transcranial Doppler (TCD) detection of embolic signals (ES) is important for risk stratification. We tested the effect of time of day on ES associated with 60–99% asymptomatic carotid stenosis. Materials and Methods: Subjects were from the Asymptomatic Carotid Stenosis Embolus Detection (ASED) Study such that half were previously ES-positive and half ES-negative with 6-monthly 60-min TCD monitoring. All underwent bilateral TCD monitoring for two 12-h sessions separated by 24 h. ES detection rates were calculated using 6 and 4-h intervals from midnight and effective TCD monitoring time. Results: Ten subjects (8 male, mean age 79.5 years) were monitored. Over 24 h, 5/10 study arteries with 60–99% asymptomatic carotid stenosis were ES-positive (range 1–28 ES/artery, 56 total ES from 177.9 total effective monitoring hours). The remaining five study arteries and all eight successfully monitored contralateral arteries were ES-negative. Using 6-h intervals the mean ES detection rate peaked at 0600-midday (0.64/h) and was lowest 1800-midnight (0.09/h) with an incidence rate ratio of 7.26 (95% CI 2.52–28.64, P ≤ 0.001). Using 4-h intervals the mean ES detection rate peaked at 0800-midday (0.64/h) and was lowest midnight-0400 (0.12/h) with an incidence rate ratio of 5.51 (95% CI 1.78–22.67, P = 0.001). Conclusions: Embolism associated with asymptomatic carotid stenosis shows circadian variation with highest rates 4–6 h before midday. This corresponds with peak circadian incidence of stroke and other vascular complications. These and ASED Study results show that monitoring frequency, duration, and time of day are important in ES detection.
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Affiliation(s)
- Anne L Abbott
- Central Clinical School, Monash University, Melbourne, VIC, Australia.,Neurology Network, Knox Private Hospital, Wantirna, VIC, Australia
| | - Julia Merican
- Neurology and Neurosurgery Centre, Princecourt Medical Centre, Kuala Lumpur, Malaysia
| | - Dora C Pearce
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia.,School of Science, Engineering and Information Technology, Federation University, Ballarart, VIC, Australia
| | - Ana Juric
- Independent Researcher, Melbourne, VIC, Australia
| | - Christopher Worsnop
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC, Australia
| | - Emma Foster
- Central Clinical School, Monash University, Melbourne, VIC, Australia.,Neurology Department, Alfred Health, Melbourne, VIC, Australia.,Neurology Department, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Brian Chambers
- Department of Neurology, Austin Health, Melbourne, VIC, Australia.,Faculty of Medicine, University of Melbourne, Melbourne, VIC, Australia
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Reiff T, Eckstein HH, Mansmann U, Jansen O, Fraedrich G, Mudra H, Böckler D, Böhm M, Brückmann H, Debus ES, Fiehler J, Lang W, Mathias K, Ringelstein EB, Schmidli J, Stingele R, Zahn R, Zeller T, Hetzel A, Bodechtel U, Binder A, Glahn J, Hacke W, Ringleb PA. Angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy compared to best medical treatment: One-year interim results of SPACE-2. Int J Stroke 2019; 15:1747493019833017. [PMID: 30873912 PMCID: PMC7416333 DOI: 10.1177/1747493019833017] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 12/10/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Treatment of individuals with asymptomatic carotid artery stenosis is still handled controversially. Recommendations for treatment of asymptomatic carotid stenosis with carotid endarterectomy (CEA) are based on trials having recruited patients more than 15 years ago. Registry data indicate that advances in best medical treatment (BMT) may lead to a markedly decreasing risk of stroke in asymptomatic carotid stenosis. The aim of the SPACE-2 trial (ISRCTN78592017) was to compare the stroke preventive effects of BMT alone with that of BMT in combination with CEA or carotid artery stenting (CAS), respectively, in patients with asymptomatic carotid artery stenosis of ≥70% European Carotid Surgery Trial (ECST) criteria. METHODS SPACE-2 is a randomized, controlled, multicenter, open study. A major secondary endpoint was the cumulative rate of any stroke (ischemic or hemorrhagic) or death from any cause within 30 days plus an ipsilateral ischemic stroke within one year of follow-up. Safety was assessed as the rate of any stroke and death from any cause within 30 days after CEA or CAS. Protocol changes had to be implemented. The results on the one-year period after treatment are reported. FINDINGS It was planned to enroll 3550 patients. Due to low recruitment, the enrollment of patients was stopped prematurely after randomization of 513 patients in 36 centers to CEA (n = 203), CAS (n = 197), or BMT (n = 113). The one-year rate of the major secondary endpoint did not significantly differ between groups (CEA 2.5%, CAS 3.0%, BMT 0.9%; p = 0.530) as well as rates of any stroke (CEA 3.9%, CAS 4.1%, BMT 0.9%; p = 0.256) and all-cause mortality (CEA 2.5%, CAS 1.0%, BMT 3.5%; p = 0.304). About half of all strokes occurred in the peri-interventional period. Higher albeit statistically non-significant rates of restenosis occurred in the stenting group (CEA 2.0% vs. CAS 5.6%; p = 0.068) without evidence of increased stroke rates. INTERPRETATION The low sample size of this prematurely stopped trial of 513 patients implies that its power is not sufficient to show that CEA or CAS is superior to a modern medical therapy (BMT) in the primary prevention of ischemic stroke in patients with an asymptomatic carotid stenosis up to one year after treatment. Also, no evidence for differences in safety between CAS and CEA during the first year after treatment could be derived. Follow-up will be performed up to five years. Data may be used for pooled analysis with ongoing trials.
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Affiliation(s)
- T Reiff
- Department of Neurology, University
Hospital of Heidelberg, Heidelberg, Germany
| | - HH Eckstein
- Department for Vascular and
Endovascular Surgery, Technical University of Munich, Munich, Germany
| | - U Mansmann
- Institute of Medical Informatics,
Biometry and Epidemiology, Ludwig Maximilian University Munich, Munich,
Germany
| | - O Jansen
- Department of Radiology and
Neuroradiology, UKSH Campus Kiel, Kiel, Germany
| | - G Fraedrich
- Department of Vascular Surgery,
University Hospital of Innsbruck, Innsbruck, Austria
| | - H Mudra
- Department of Internal Medicine,
Städtisches Klinikum München-Neuperlach, Munich, Germany
| | - D Böckler
- Department of Vascular Surgery,
University Hospital of Heidelberg, Heidelberg, Germany
| | - M Böhm
- Department of Internal Medicine,
University Hospital of Homburg/Saar, Homburg, Germany
| | - H Brückmann
- Department of Neuroradiology,
Ludwig-Maximilians-Universität, Munich, Germany
| | - ES Debus
- Department of Vascular Surgery,
University Hospital of Hamburg, Hamburg, Germany
| | - J Fiehler
- Department of Neuroradiology,
University Hospital of Hamburg, Hamburg, Germany
| | - W Lang
- Department of Vascular Surgery,
University Hospital Erlangen, Erlangen, Germany
| | - K Mathias
- Department of Radiology, Klinikum
Dortmund, Dortmund, Germany
| | - EB Ringelstein
- Department of Neurology,
University Hospital of Münster, Münster, Germany
| | - J Schmidli
- Department of Vascular Surgery,
University Hospital of Bern, Bern, Switzerland
| | - R Stingele
- Department of Neurology,
University of Kiel, Kiel, Germany
| | - R Zahn
- Department of Internal Medicine,
Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - T Zeller
- Department of Angiology,
University Hospital Freiburg, Bad Krozingen, Germany
| | - A Hetzel
- Department of Neurology,
University Hospital Freiburg, Freiburg, Germany
| | - U Bodechtel
- Department of Neurology,
University Hospital of Dresden, Dresden, Germany
| | - A Binder
- Department of Neurology, UKSH
Campus Kiel, Kiel, Germany
| | - J Glahn
- Department of Neurology, Johannes
Wesling Klinikum, Minden, Germany
| | - W Hacke
- Department of Neurology, University
Hospital of Heidelberg, Heidelberg, Germany
| | - PA Ringleb
- Department of Neurology, University
Hospital of Heidelberg, Heidelberg, Germany
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Gaba K, Bulbulia R. Identifying asymptomatic patients at high-risk for stroke. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:332-344. [PMID: 30785251 DOI: 10.23736/s0021-9509.19.10912-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Carotid endarterectomy and carotid artery stenting, in addition to good medical therapy, halve long-term stroke risk in asymptomatic patients with carotid artery stenosis. Since the absolute benefits following successful intervention are moderate, identification of asymptomatic patients at high-risk of future stroke could maximize the effectiveness of carotid interventions. The aim of this paper is to summarize the evidence for high-risk features associated with increased long-term stroke risk in asymptomatic patients. There is a paucity of reliable data describing the effect of clinical features, imaging findings and plaque characteristics on increased long-term stroke risk. Clinical and imaging features such as contralateral symptoms, silent brain infarcts/embolic signals, progression of stenosis and impaired cerebrovascular reactivity may be associated with increased future risk of stroke. Plaque characteristics such as echolucency, large plaque size (≥80 mm), intra-plaque hemorrhage, lipid-rich necrotic core and thinned/ruptured fibrous cap may also increase future risk of stroke. Whilst these form the basis for European guidelines targeting carotid intervention in asymptomatic patients with tight stenosis, conclusive evidence of their utility is lacking. Results from ongoing large, multicenter randomized clinical trials comparing carotid endarterectomy and carotid artery stenting with good medical therapy may be consistent with earlier trials, showing a halving of the long-term risk of stroke following successful carotid revascularization. However, they may well lack sufficient statistical power to identify higher-risk subgroups in whom the absolute gains of treatment are significantly higher. Large contemporary cohort studies are needed to provide further clarity regarding high-risk features associated with increased long-term stroke risk in asymptomatic patients with carotid artery stenosis.
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Affiliation(s)
- Kamran Gaba
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Richard Bulbulia
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK - .,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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44
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Paraskevas KI, Veith FJ, Ricco JB. Best medical treatment alone may not be adequate for all patients with asymptomatic carotid artery stenosis. J Vasc Surg 2018; 68:572-575. [DOI: 10.1016/j.jvs.2018.02.046] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 02/27/2018] [Indexed: 12/20/2022]
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45
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Paraskevas KI, Veith FJ, Spence JD. How to identify which patients with asymptomatic carotid stenosis could benefit from endarterectomy or stenting. Stroke Vasc Neurol 2018; 3:92-100. [PMID: 30022795 PMCID: PMC6047337 DOI: 10.1136/svn-2017-000129] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 02/06/2018] [Accepted: 02/07/2018] [Indexed: 11/23/2022] Open
Abstract
Offering routine carotid endarterectomy (CEA) or carotid artery stenting (CAS) to patients with asymptomatic carotid artery stenosis (ACS) is no longer considered as the optimal management of these patients. Equally suboptimal, however, is the policy of offering only best medical treatment (BMT) to all patients with ACS and not considering any of them for prophylactic CEA. In the last few years, there have been many studies aiming to identify reliable predictors of future cerebrovascular events that would allow the identification of patients with high-risk ACS and offer a prophylactic carotid intervention only to these patients to prevent them from becoming symptomatic. All patients with ACS should receive BMT. The present article will summarise the evidence suggesting ways to identify these high-risk asymptomatic individuals, namely: (1) microemboli detection on transcranial Doppler, (2) plaque echolucency on Duplex ultrasound, (3) progression in the severity of ACS, (4) silent embolic infarcts on brain CT/MRI, (5) reduced cerebrovascular reserve, (6) increased size of juxtaluminal hypoechoic area, (7) identification of intraplaque haemorrhage using MRI and (8) carotid ulceration. The evidence suggests that approximately 10%-15% of patents with asymptomatic stenosis might benefit from intervention; this will become more clear after publication of ongoing studies comparing stenting or endarterectomy with best medical therapy. In the meantime, no patient should be offered intervention unless there is evidence of high risk of ipsilateral stroke, from modalities such as those discussed here.
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Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular and Endovascular Surgery, Royal Free Hospital, London, UK
| | - Frank J Veith
- Department of Vascular Surgery, New York University Langone Medical Center, New York, USA
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Canada
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46
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Abstract
Transcranial Doppler (TCD) is useful in stroke prevention for at least three purposes: diagnosis of intracranial stenosis, detection of right-to-left shunt in patients with suspected paradoxical embolism, and detection of microemboli in patients with carotid stenosis. Other uses may include assessment of cerebral blood flow, which is not discussed in this review. TCD saline studies are more sensitive than transesophageal echocardiography, and more strongly predictive of risk of recurrent events. TCD embolus detection is the best-validated method for identifying among patients with asymptomatic carotid stenosis the few who could benefit from carotid endarterectomy or stenting.
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Affiliation(s)
- J. David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
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47
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Mattia A, Azarpazhooh MR, Munoz C, Bogiatzi C, Quantz MA, Spence JD. Association of homocysteine and smoking with cerebral microemboli in patients with mechanical heart valves: a transcranial Doppler study. Stroke Vasc Neurol 2018; 2:198-203. [PMID: 29507780 PMCID: PMC5829912 DOI: 10.1136/svn-2017-000117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 10/31/2017] [Accepted: 11/01/2017] [Indexed: 11/03/2022] Open
Abstract
Objectives Microembolic signals (MES) on transcranial Doppler (TCD) predict stroke and cognitive decline. Plasma levels of total homocysteine (tHcy), a prothrombotic factor, are higher in patients with microemboli in carotid stenosis and in patients with paradoxical embolism. In this study we assessed the association between the level of tHcy and the number of MES in patients with mechanical heart valves (MHVs). Methods TCD monitoring was performed to detect MES before and after breathing 100% oxygen and repeated every 2-4 weeks up to six times. Results Twenty-five patients with MHVs (mean age: 63.60±10.15 years) participated in this study; 15 were men (66.47±7.25 years) and 10 were women (59.30±12.60 years). In total, there were 126 study visits. In multiple regression, higher tHcy was associated with more MES in both preoxygenation (OR 1.34 (95% CI 1.07 to 1.68, P=0.009)) and postoxygenation (OR 1.40 (95% CI 1.07 to 1.83, P=0.01)) phases. Current smoking and the length of time between the operation and monitoring also correlated with a higher number of MES before and after breathing oxygen, particularly in women. Conclusions Higher tHcy and smoking were associated with a higher MES count in both preoxygenation and postoxygenation phases. Because smoking can be stopped and hyperhomocysteinaemia is treatable, these are clinically important findings.
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Affiliation(s)
- Alicia Mattia
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada.,Department of Neurology, McMaster University, Hamilton, Ontario, Canada
| | - M Reza Azarpazhooh
- Division of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Division of Neurology, Western University, London, Ontario, Canada
| | - Claudio Munoz
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
| | - Chrysi Bogiatzi
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada.,Department of Neurology, McMaster University, Hamilton, Ontario, Canada
| | - Mackenzie A Quantz
- Division of Cardiac Surgery, Western University, London, Ontario, Canada
| | - J David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada.,Division of Neurology, Western University, London, Ontario, Canada.,Division of Clinical Pharmacology, Western University, London, Ontario, Canada
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48
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Increased platelet count and reticulated platelets in recently symptomatic versus asymptomatic carotid artery stenosis and in cerebral microembolic signal-negative patient subgroups: results from the HaEmostasis In carotid STenosis (HEIST) study. J Neurol 2018; 265:1037-1049. [PMID: 29476243 DOI: 10.1007/s00415-018-8797-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 02/10/2018] [Accepted: 02/12/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND The pathophysiological mechanisms responsible for the disparity in stroke risk between asymptomatic and symptomatic carotid stenosis patients are not fully understood. The functionally important reticulated platelet fraction and reticulocytes could play a role. OBJECTIVES We performed a prospective, multi-centre, observational analytical study comparing full blood count parameters and platelet production/turnover/activation markers in patients with asymptomatic versus recently symptomatic moderate (≥ 50-69%) or severe (≥ 70-99%) carotid stenosis. PATIENTS/METHODS Data from 34 asymptomatic patients were compared with 43 symptomatic patients in the 'early phase' (≤ 4 weeks) and 37 of these patients in the 'late phase' (≥ 3 months) after TIA/ischaemic stroke. Reticulated platelets were quantified by whole blood flow cytometry and reticulated platelets and red cell reticulocytes by 'automated assays' (Sysmex XE-2100™). Bilateral simultaneous transcranial Doppler ultrasound monitoring classified patients as micro-embolic signal (MES)+ve or MES-ve. RESULTS Mean platelet count was higher in early (216 × 109/L; P = 0.04) and late symptomatic (219 × 109/L; P = 0.044) than asymptomatic patients (194 × 109/L). Mean platelet volume was higher in early symptomatic than asymptomatic patients (10.8 vs. 10.45 fl; P = 0.045). Automated assays revealed higher % reticulated platelet fractions in early (5.78%; P < 0.001) and late symptomatic (5.11%; P = 0.01) than asymptomatic patients (3.48%). Red cell reticulocyte counts were lower in early (0.92%; P = 0.035) and late symptomatic (0.93%; P = 0.036) than asymptomatic patients (1.07%). The automated % reticulated platelet fraction was also higher in early symptomatic than asymptomatic MES-ve patients (5.7 vs. 3.55%; P = 0.001). DISCUSSION The combination of increased platelet counts and a shift towards production of an increased population of larger, young, reticulated platelets could contribute to a higher risk of first or recurrent cerebrovascular events in recently symptomatic versus asymptomatic carotid stenosis, including those who are MES-ve.
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49
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Lal BK, Dux MC, Sikdar S, Goldstein C, Khan AA, Yokemick J, Zhao L. Asymptomatic carotid stenosis is associated with cognitive impairment. J Vasc Surg 2017; 66:1083-1092. [DOI: 10.1016/j.jvs.2017.04.038] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
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50
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Spence JD, Yi Q, Hankey GJ. B vitamins in stroke prevention: time to reconsider. Lancet Neurol 2017; 16:750-760. [PMID: 28816120 DOI: 10.1016/s1474-4422(17)30180-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 03/11/2017] [Accepted: 05/19/2017] [Indexed: 12/09/2022]
Abstract
B vitamin therapy lowers plasma total homocysteine concentrations, and might be a beneficial intervention for stroke prevention; however, cyanocobalamin (a form of vitamin B12) can accelerate decline in renal function and increase the risk of cardiovascular events in patients with impaired renal function. Although early trials did not show benefit in reduction of stroke, these results might have been due to harm in participants with impaired renal function. In patients with diabetic nephropathy, cyanocobalamin is harmful, whereas B vitamins appear to reduce cardiovascular events in study participants with normal renal function. Our meta-analysis of individual patient data from two large trials of B vitamin therapy (VISP and VITATOPS) indicates that patients with impaired renal function who are exposed to high-dose cyanocobalamin do not benefit from therapy with B vitamins for the prevention of stroke (risk ratio 1·04, 95% CI 0·84-1·27), however, patients with normal renal function who are not exposed to high-dose cyanocobalamin benefit significantly from this treatment (0.78, 0·67-0·90; interaction p=0·03). The potential benefits of B vitamin therapy with folic acid and methylcobalamin or hydroxycobalamin, instead of cyanocobalamin, to lower homocysteine concentrations in people at high risk of stroke warrant further investigation.
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Affiliation(s)
- J David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada.
| | - Qilong Yi
- Canadian Blood Services, Epidemiology and Surveillance, Ottawa, ON, Canada
| | - Graeme J Hankey
- School of Medicine, The University of Western Australia, Harry Perkins Institute of Medical Research, Perth, WA, Australia
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