2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery

Considerations in screening for asymptomatic carotid artery stenosis in irradiated head and neck cancer survivors

Carpenter et al. add to the body of evidence demonstrating that irradiated head and neck cancer survivors are at high risk for carotid artery stenosis. In this editorial, the concept of screening for asymptomatic carotid artery stenosis in this subpopulation is explored.

Prevalence of carotid ultrasound screening in survivors of childhood cancer: A report from the Childhood Cancer Survivor Study

INTRODUCTION

Many childhood cancer survivors are at risk for cardiovascular disease and stroke. The North American Children's Oncology Group long-term follow-up guidelines recommend carotid ultrasound in cancer survivors 10 years after neck radiation therapy (RT) ≥40 Gy. The use of carotid ultrasound in this population has not been described.

METHODS

Survivors of childhood cancer diagnosed 1970-1999 (N = 8693) and siblings (N = 1989) enrolled in the Childhood Cancer Survivor Study were asked if they had ever had a carotid ultrasound. Prevalence of carotid ultrasound was evaluated. Prevalence ratios (PR) and 95% confidence intervals (CIs) were evaluated in multivariate Poisson regression models.

RESULTS

Among participants with no reported cardiovascular condition, prevalence of carotid ultrasound among survivors with RT ≥40 Gy to the neck (N = 172) was 29.7% (95% CI, 22.5-36.8), significantly higher than those with <40 Gy (prevalence 10.7%; 95% CI, 9.9%-11.4%). Siblings without a cardiovascular condition (N = 1621) had the lowest prevalence of carotid ultrasound (4.7%; 95% CI, 3.6%-5.7%). In a multivariable models among survivors with no reported cardiovascular condition and RT ≥40 Gy to the neck, those who were over age 50 (vs. 18-49) at follow-up (PR = 1.82; 95% CI, 1.09-3.05), with a history of seeing a cancer specialist in the last 2 years (PR = 2.58; 95% CI, 1.53-4.33), or having a colonoscopy (PR = 2.02; 95% CI, 1.17-3.48) or echocardiogram (PR = 6.42; 95% CI, 1.54-26.85) were more likely to have had a carotid ultrasound.

CONCLUSION

Many survivors do not undergo carotid ultrasound despite meeting existing guidelines. Health care delivery features such as having seen a cancer specialist or having other testing are relevant.

Real-time carotid plaque recognition from dynamic ultrasound videos based on artificial neural network

PURPOSE

Carotid ultrasound allows noninvasive assessment of vascular anatomy and function with real-time display. Based on the transfer learning method, a series of research results have been obtained on the optimal image recognition and analysis of static images. However, for carotid plaque recognition, there are high requirements for self-developed algorithms in real-time ultrasound detection. This study aims to establish an automatic recognition system, Be Easy to Use (BETU), for the real-time and synchronous diagnosis of carotid plaque from ultrasound videos based on an artificial neural network.

MATERIALS AND METHODS

445 participants (mean age, 54.6±7.8 years; 227 men) were evaluated. Radiologists labeled a total of 3259 segmented ultrasound images from 445 videos with the diagnosis of carotid plaque, 2725 images were collected as a training dataset, and 554 images as a testing dataset. The automatic plaque recognition system BETU was established based on an artificial neural network, and remote application on a 5G environment was performed to test its diagnostic performance.

RESULTS

The diagnostic accuracy of BETU (98.5%) was consistent with the radiologist's (Kappa = 0.967, P < 0.001). Remote diagnostic feedback based on BETU-processed ultrasound videos could be obtained in 150ms across a distance of 1023 km between the ultrasound/BETU station and the consultation workstation.

CONCLUSION

Based on the good performance of BETU in real-time plaque recognition from ultrasound videos, 5G plus Artificial intelligence (AI)-assisted ultrasound real-time carotid plaque screening was achieved, and the diagnosis was made.

Peak systolic velocity ratio for evaluation of internal carotid artery stenosis correlated with plaque morphology: substudy results of the ANTIQUE study

Background

Accurate assessment of carotid stenosis severity is important for proper patient management. The present study aimed to compare the evaluation of carotid stenosis severity using four duplex sonography (DUS) measurements, including peak systolic velocity (PSV), PSV ratio in stenosis and distal to stenosis (PSVICA/ICA ratio), end-diastolic velocity (EDV), and B-mode, with computed tomography angiography (CTA), and to evaluate the impact of plaque morphology on correlation between DUS and CTA.

Methods

Consecutive patients with carotid stenosis of ≥40% examined using DUS and CTA were included. Plaque morphology was also determined using magnetic resonance imaging. Spearman's correlation and Kendall's rank correlation were used to evaluate the results.

Results

A total of 143 cases of internal carotid artery stenosis of ≥40% based on DUS were analyzed. The PSVICA/ICA ratio showed the highest correlation [Spearman's correlation r = 0.576) with CTA, followed by PSV (r = 0.526), B-mode measurement (r = 0.482), and EDV (r = 0.441; p < 0.001 in all cases]. The worst correlation was found for PSV when the plaque was calcified (r = 0.238), whereas EDV showed a higher correlation (r = 0.523). Correlations of B-mode measurement were superior for plaques with smooth surface (r = 0.677), while the PSVICA/ICA ratio showed the highest correlation in stenoses with irregular (r = 0.373) or ulcerated (r = 0.382) surfaces, as well as lipid (r = 0.406), fibrous (r = 0.461), and mixed (r = 0.403; p < 0.01 in all cases) plaques. Nevertheless, differences between the mentioned correlations were not statistically significant (p > 0.05 in all cases).

Conclusion

PSV, PSVICA/ICA ratio, EDV, and B-mode measurements showed comparable correlations with CTA in evaluation of carotid artery stenosis based on their correlation with CTA results. Heavy calcifications and plaque surface irregularity or ulceration negatively influenced the measurement accuracy.

Heart Team Intervention for Calcified Left Main Coronary Disease and Jeopardized Left Internal Mammary Artery Graft

It is sometimes difficult to identify the culprit lesion and treatment strategy in patients with acute coronary syndrome who have complex coronary lesions and jeopardized left internal mammary artery graft. This report describes a heart team approach for a non-ST-segment elevation myocardial infarction case with complex coronary vasculature. A 73-year-old man presented to the emergency department with crescendo angina. He had a history of total aortic arch replacement with concomitant coronary artery bypass graft using left internal mammary artery. Emergent coronary angiography demonstrated severe stenosis at left main trunk bifurcation caused by calcified nodule. While the bypass graft to left anterior descending coronary artery was patent, the proximal segment of left subclavian artery was occluded. Following the prompt discussion with our heart team, we performed percutaneous coronary intervention in the first step for treating the left main stenosis using rotational atherectomy into the unprotected left circumflex artery. After clinical recovery, stress myocardial scintigraphy identified the presence of anteroseptal ischemia, which indicated coronary subclavian steal syndrome due to left subclavian artery occlusion. Contrast-enhanced CT visualized that the occlusion originated from the anastomosis, suggesting the potential procedural risk of endovascular treatment by dilatation. Our heart team discussed again and decided to undergo axillo-axillary artery bypass surgery. He was discharged 8 days after the surgery without any sequelae. This is the rare case report of non-ST-segment elevation myocardial infarction who had similar condition to coronary subclavian steal syndrome after total aortic arch replacement. This case highlights the importance of a collaborative approach of the heart team to identify the best therapeutic strategy in a patient with complex coronary vasculature.

Carotid Artery Stenting: Applications and Technical Considerations

PURPOSE OF THE REVIEW

To examine current understanding of diverse etiologies of extracranial carotid disease, including clinical and imaging manifestations as well as treatment approaches.

RECENT FINDINGS

Increasing availability of advanced cerebrovascular imaging modalities continues to elucidate atherosclerotic and nonatherosclerotic carotid steno-occlusive disease as a common culprit of cerebral ischemia. Individualized treatment strategies targeting each etiologic subset would optimize preventive measures and minimize recurrence of cerebral ischemia.

SUMMARY

Ischemic stroke is a prominent cause of mortality and long-term disability worldwide. The magnified effect of carotid disease warrants constant and close inspection.

Diagnosing Carotid Near-Occlusion with Phase-Contrast MRI

Carotid near-occlusion is a frequently overlooked diagnosis when CTA examinations are assessed in routine practice. To evaluate the potential value of phase-contrast MR imaging in identifying near-occlusion, we examined 9 carotid near-occlusions and 20 cases of conventional ≥50% carotid stenosis (mean stenosis degree, 65%) with phase-contrast MR imaging. Mean ICA flow was lower in near-occlusions (52 mL/min) than in conventional ≥50% stenosis (198 mL/min, P < .001). ICA flow of ≤110 mL/min was 100% sensitive and specific for near-occlusion. Phase-contrast MR imaging is a promising tool for diagnosing carotid near-occlusion.

Near-occlusion is difficult to diagnose with common carotid ultrasound methods

Purpose

To assess the sensitivity and specificity of common carotid ultrasound method for carotid near-occlusion diagnosis.

Methods

Five hundred forty-eight patients examined with both ultrasound and CTA within 30 days of each other were analyzed. CTA graded by near-occlusion experts was used as reference standard. Low flow velocity, unusual findings, and commonly used flow velocity parameters were analyzed.

Results

One hundred three near-occlusions, 272 conventional ≥50% stenosis, 162 <50% stenosis, and 11 occlusions were included. Carotid ultrasound was 22% (95%CI 14–30%; 23/103) sensitive and 99% (95%CI 99–100%; 442/445) specific for near-occlusion diagnosis. Near-occlusions overlooked on ultrasound were found misdiagnosed as occlusions (n = 13, 13%), conventional ≥50% stenosis (n = 65, 63%) and < 50% stenosis (n = 2, 2%). No velocity parameter or combination of parameters could identify the 65 near-occlusions mistaken for conventional ≥50% stenoses with >75% sensitivity and specificity.

Conclusion

Near-occlusion is difficult to diagnose with commonly used carotid ultrasound methods. Improved carotid ultrasound methods are needed if ultrasound is to retain its position as sole preoperative modality.

Combined risk modelling approach to identify the optimal carotid revascularisation approach

BACKGROUND

Carotid endarterectomy (CEA) results in fewer perioperative strokes, but more myocardial infarctions (MI) than carotid artery stenting (CAS). We explored a combined modelling approach that stratifies patients by baseline stroke and MI.

METHODS

Baseline registry-based risk models for perioperative stroke and MI were identified via literature search. We then selected treatment risk models in the Carotid Revascularisation Stenting versus Endarterectomy (CREST) trial by serially adding covariates (baseline risk, treatment (CEA vs CAS), treatment-risk interaction and age-treatment interaction terms). Treatment risk models were externally validated using data from the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) CEA and carotid stenting registries and treatment models were recalibrated to the SVS-VQI population. Predicted net benefit was estimated by summing the predicted stroke and MI risk differences with CEA versus CAS.

RESULTS

Perioperative treatment models had moderate predictiveness (c-statistic 0.69 for stroke and 0.68 for MI) and reasonable calibration across the risk spectrum for both stroke and MI within CREST. On external validation in SVS-VQI, predictiveness was substantially reduced (c-statistic 0.61 for stroke and 0.54 for MI) and models substantially overpredicted risk.Most patients (86.7%) were predicted to have net benefit from CEA in CREST (97.0% of symptomatic patients vs 75% of asymptomatic patients).

DISCUSSION

A combined modelling approach that separates risk elements has potential to inform optimal treatment. However, our current approach is not ready for clinical application. These data support guidelines that suggest that CEA should be the preferred revascularisation modality in most patients with symptomatic carotid stenosis.

Carotid Endarterectomy Versus Carotid Artery Stenting: Survey of the Quality, Readability, and Treatment Preference of Carotid Artery Disease Websites

Background

The internet is becoming increasingly more important in the new era of patient self-education. Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are recognized interventions to treat patients with carotid artery stenosis. Using the Google search platform, patients encounter many websites with conflicting information, which are sometimes difficult to understand. This lack of accessibility creates uncertainty or bias toward interventions for carotid artery disease. The quality, readability, and treatment preference of carotid artery disease (CAD) websites have not yet been evaluated.

Objective

This study aimed to explore the quality, readability, and treatment preference of CAD websites.

Methods

We searched Google Canada for 10 CAD-related keywords. Returned links were assessed for publication date, medical specialty and industry affiliation, presence of randomized controlled trial data, differentiation by symptomatic status, and favored treatment. Website quality and readability were rated by the DISCERN instrument and Gunning Fog Index.

Results

We identified 54 unique sites: 18 (33.3%) by medical societies or individual physicians, 11 (20.4%) by government organizations, 9 (16.7%) by laypersons, and 1 (1.9%) that was industry-sponsored. Of these sites, 26 (48.1%) distinguished symptomatic from asymptomatic CAD. A majority of sites overall (57.4%) and vascular-affiliated (72.7%) favored CEA. In contrast, radiology- and cardiology-affiliated sites demonstrated the highest proportion of sites favoring CAS, though they were equally likely to favor CEA. A large proportion (21/54, 38.9%) of sites received poor quality ratings (total DISCERN score <48), and the majority (41/54, 75.9%) required a reading level greater than a high school senior.

Conclusions

CAD websites are often produced by government organizations, medical societies, or physicians, especially vascular surgeons. Sites ranged in quality, readability, and differentiation by symptomatic status. Google searches of CAD-related terms are more likely to yield sites favoring CEA. Future research should determine the extent of website influence on CAD patients’ treatment decisions.

Antithrombotic treatment of asymptomatic carotid atherosclerosis: a medical dilemma

Carotid artery atherosclerosis (CAAS) is a common finding in asymptomatic subjects evaluated for cardiovascular (CV)-risk stratification. Besides the careful control of CV-risk factors, antithrombotic agents, and in particular aspirin, may be considered for primary prevention in patients at CV-risk. However, there is strong controversy on the use of aspirin in primary prevention. Even if several studies confirmed the association between CAAS and CV-events, CAAS is not universally recognized as an independent risk factor and the choice to use aspirin as primary prevention in these patients remains a medical dilemma. Here we review the available evidence on the prognostic value of asymptomatic CAAS for major CV-events and on the utility of antithrombotic agents in this population. We conclude that the detection of asymptomatic CAAS can not be considered as a direct indication to carry out primary prophylaxis with antithrombotic drugs, and the choice to use aspirin should be made only after the careful estimate of the individual's CV-and hemorrhagic risk.

The conundrum of asymptomatic carotid stenosis-determinants of decision and evidence

Management of asymptomatic carotid disease continues to challenge medical practice and present evidence is often conflicting. Stroke is a significant burden in Public Health and 11% to 15% appear as first neurologic event associated with asymptomatic carotid stenosis. Randomized trials provided support for Guidelines and Recommendations to intervene on asymptomatic stenosis, but at a known cost of a high number of unnecessary operations. Conflicting evidence from natural history studies and the widespread use of proper medical management including risk factors control, lowering-lipid drugs and strict control of arterial hypertension have reduced the incidence of strokes associated to asymptomatic carotid disease challenging established practice. Need to identify vulnerable lesions prone to develop thromboembolic brain events and also vulnerable patients at a higher risk of stroke is necessary and essential to further improve effectiveness of our interventions. After review of published literature on natural history of asymptomatic carotid stenosis, diagnostic methods to identify plaque vulnerability and present-day results of both endarterectomy and stenting, a strategy for management of asymptomatic carotid stenosis is suggested aiming to reduce unnecessary interventions and effectively contribute to stroke prevention.

The management of carotid restenosis: a comprehensive review

Carotid artery stenosis (CS) is a major medical problem affecting approximately 10% of the general population 80 years or older and causes stroke in approximately 10% of all ischemic events. In patients with symptomatic, moderate-to-severe CS, carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS), has been used to lower the risk of stroke. In primary CS, CEA was found to be superior to best medical therapy (BMT) according to 3 large randomized controlled trials (RCT). Following CEA and CAS, restenosis remains an unsolved problem involving a large number of patients as the current treatment recommendations are not as clear as those for primary stenosis. Several studies have evaluated the risk of restenosis, reporting an incidence ranging from 5% to 22% after CEA and an in-stent restenosis (ISR) rate ranging from 2.7% to 33%. Treatment and optimal management of this disease process, however, is a matter of ongoing debate, and, given the dearth of level 1evidence for the management of these conditions, the relevant guidelines lack clarity. Moreover, the incidence rates of stroke and complications in patients with carotid stenosis are derived from studies that did not use contemporary techniques and materials. Rapidly changing guidelines, updated techniques, and materials, and modern medical treatments make actual incidence rates barely comparable to previous ones. For these reasons, RCTs are critical for determining whether these patients should be treated with more aggressive treatments additional to BMT and identifying those patients indicated for surgical or endovascular treatments. This review summarizes the current evidence and controversies concerning the risks, causes, current treatment options, and prognoses in patients with restenosis after CEA or CAS.

Carotid endarterectomy versus conservative management of the asymptomatic carotid stenosis before coronary artery bypass grafting: a retrospective study

Background

Our retrospective single-center study aimed to evaluate the safety of the carotid endarterectomy (CEA) in comparison to patients with untreated asymptomatic carotid stenosis ≥60% before CABG.

Methods

This single-center retrospective study included 174 patients with asymptomatic unilateral carotid stenosis treated between 2004 and 2017 with CABG. Thereof 106 patients had CEA before cardiac surgery either by a simultaneous (n = 62) or staged (n = 44) approach. Patients with untreated carotid stenosis served as control (no-CEA group; n = 68).

Results

The mean stenosis grade was higher in the CEA group (CEA 83% (±1), no-CEA 71% (±1) p < 0.0001). The overall stroke rate was 5/174 (3%) and was due to a high incidence of stroke in the no-CEA group (CEA: 0/106 (0%); No-CEA 5/68 (7%) p = 0.0083). The overall mortality was 1% and comparable between the groups (CEA: 2/106 (2%); No-CEA 0/68 (0%) p = 0.5211). Stroke related mortality was not observed. The groups were similar regarding the incidence of myocardial infarction (p = 1.0), atrial fibrillation (p = 0.1931), delirium (p = 0.2106) and IMC/ICU stay (p = 0.1542). No significant difference in the subgroup analysis was found between the simultaneous and staged approach regarding the myocardial infarction (simultaneous: 1/62 (1%); staged: 1/44 (1%); p = 1.0).

Conclusions

CEA performed as a staged procedure in local anesthesia or a simultaneous procedure in general anesthesia, may reduce the stroke risk prior to CABG.

Occurrence and prognostic effect of cervical spine injuries and cervical artery injuries with concomitant severe head injury

BACKGROUND

Blunt cerebrovascular injuries (BCVIs) and cervical spinal injuries (CSIs) are not uncommon injuries in patients with severe head injury and may affect patient recovery. We aimed to assess the independent relationship between BCVI, CSI, and outcome in patients with severe head injury.

METHODS

We identified patients with severe head injury from the Helsinki Trauma Registry treated during 2015-2017 in a large level 1 trauma hospital. We assessed the association between BCVI and SCI using multivariable logistic regression, adjusting for injury severity. Our primary outcome was functional outcome at 6 months, and our secondary outcome was 6-month mortality.

RESULTS

Of 255 patients with a cervical spine CT, 26 patients (10%) had a CSI, and of 194 patients with cervical CT angiography, 16 patients (8%) had a BCVI. Four of the 16 BCVI patients had a BCVI-related brain infarction, and four of the CSI patients had some form of spinal cord injury. After adjusting for injury severity in multivariable logistic regression analysis, BCVI associated with poor functional outcome (odds ratio [OR] = 6.0, 95% CI [confidence intervals] = 1.4-26.5) and mortality (OR = 7.9, 95% CI 2.0-31.4). We did not find any association between CSI and outcome.

CONCLUSIONS

We found that BCVI with concomitant head injury was an independent predictor of poor outcome in patients with severe head injury, but we found no association between CSI and outcome after severe head injury. Whether the association between BCVI and poor outcome is an indirect marker of a more severe injury or a result of treatment needs further investigations.

An Alternative Approach to Carotid Endarterectomy in the High Carotid Bifurcation

BACKGROUND

Surgical exposure of a high carotid bifurcation (HCB) for carotid endarterectomy (CEA) can be technically challenging due to the presence of bony structures in the most cranial portion of the neck and is associated with significant morbidity making carotid artery stenting (CAS) a common alternative. However, a high transverse neck incision with subplatysmal flaps facilitates CEA in these patients without additional exposure techniques. We present a high transverse neck incision with subplatysmal flaps as an alternative to the standard surgical exposure of the carotid bifurcation to facilitate CEA in patients with HCB.

METHODS

Four patients with carotid bifurcations located cranial to the C3-4 vertebral interspace (identified on preoperative imaging) requiring intervention underwent CEA using a high transverse neck incision through an existing skin crease with subplatysmal flap elevation. CEA was performed in a standard fashion with bovine pericardial patch.

RESULTS

Two male and 2 female patients with an average age of 65 years successfully underwent CEA using this incision. One patient underwent concurrent carotid body tumor excision. None of the patients required mandibulotomy or hyoid bone resection. Two patients required division of the posterior belly of the digastric muscle. There were no perioperative complications. Primary patency was 100% in the 4 patients with surveillance studies, and mean follow-up of 160 days (range 54-369 days). There were no significant cranial nerve injuries. No patient required conversion to an endovascular procedure due to inaccessibility of the lesion or subsequent interventions for incomplete endarterectomy.

CONCLUSIONS

A high transverse incision with subplatysmal flaps is a safe, effective, and cosmetically preferable surgical approach in patients with HCB requiring carotid artery intervention and may be an alternative to CAS.

Changes in Cognition, Depression and Quality of Life after Carotid Stenosis Treatment

BACKGROUND

Although several studies have evaluated the change of cognitive performance after severe carotid artery stenosis, the results still remain elusive. The objective of this study was to assess changes in cognitive function, depressive symptoms and Health Related Quality of Life (HRQoL) after carotid stenosis revascularisation and Best Medical Treatment (BMT).

METHODS

Study involved 213 patients with ≥70% carotid stenosis who underwent assessment of cognitive function using Montreal Cognitive Assessment scale (MoCA), depressive symptoms - using Patient Health Questionnaire-9 (PHQ-9) and HRQoL - using Medical Outcome Survey Short Form version 2 (SF-36v2). The assessment was performed before and at 6 and 12 months followup periods in patients who had Carotid Endarterectomy (CEA), Carotid Artery Stenting (CAS) or received BMT only.

RESULTS

Improvement in the total MoCA scores was observed after 6 and 12 months (p<0.001, Kendall's W=0.28) in the CEA group. In the CAS group - after 12 months (p=0.01, Kendall's W=0.261) whereas in the BMT group - no significant changes (p=0.295, Kendall's W=0.081) were observed. Reduction of depressive symptoms was not found in any of the study groups. Comparing mean SF-36v2 scores in the CEA group, there was no significant difference in any of 10 subscales. Likewise in the CAS group - no significant difference in 9 of 10 subscales (p=0.028, η2=0.343) was observed. Three subscales worsened in the BMT group during the 1-year follow-up period.

CONCLUSION

Patients with severe carotid stenosis who underwent revascularisation enhanced their cognitive performance without exerting significant change of depressive symptoms. Preoperative HRQoL may be maintained for at least one year in the CEA group.

Carotid near-occlusion is often overlooked when CT angiography is assessed in routine practice

Objective

Assess the sensitivity and specificity of computed tomography angiography (CTA) for carotid near-occlusion diagnosis interpreted in clinical practice against expert assessment.

Methods

CTAs were graded by two expert interpreters for near-occlusion. Findings were compared with clinical reports in 383 consecutive cases with symptomatic ≥ 50% carotid stenosis. In addition, 14 selected CTA exams (8 near-occlusions and 6 controls) were analyzed in a national effort by 13 radiologists experienced with carotid CTA.

Results

In clinical practice, imaging reports were 20% (95% CI 12–28%) sensitive for near-occlusion, ranging 0–58% between different radiologists; specificity was 99%. Among the 13 radiologists reviewing the same 8 near-occlusions, the average sensitivity was 8%, ranging 0–75%; specificity was 100%.

Conclusions

Carotid near-occlusion is systematically under-reported in clinical routine practice, caused by limited application of grading criteria when assessing CTA.

Key Points

• Carotid near-occlusion is severe stenosis with distal artery collapse; this collapse is often subtle.

• A fifth of near-occlusions were detected in routine practice. Many readers mistake near-occlusion for stenosis without distal artery collapse, either by not actively searching for subtle collapses or by not interpreting the collapse correctly when noticed.

• On the other hand, the novice diagnostician should be cautioned to not over-diagnose near-occlusion; other causes of extracranial ICA asymmetry also exist such as distal disease and Circle of Willis anatomical variants.

Analysis of young ischemic stroke patients in northeast China

Background

Limited research has been conducted to address stroke etiology in young patients in developing countries. We aimed to analyze risk factors and etiology of ischemic stroke (IS) in young patients of northeast China.

Methods

We retrospectively analyzed ischemic stroke patients aged 15-49 years in a single-center study from January 2013 to December 2017. Demographics and clinical information, including imaging studies, were retrieved for all patients. Patients were first compared according to sex and age. They were then divided into the first-ever and recurrent stroke groups; risk factors and stroke etiology between the two groups were compared.

Results

Of the 956 patients (median age 45 years) included, 78.9% were males. The most frequent risk factors were hypertension (60.0%), dyslipidemia (55.3%), smoking (54.1%), and alcohol consumption (49.6%). The most common etiology of stroke was large-artery atherosclerosis (LAA, 43.7%). In total, 789 patients experienced first-ever stroke and 167 patients experienced recurrent stroke. Recurrent stroke patients more often suffered from hypertension (70.7% versus 57.8%, P=0.002), diabetes (35.3% versus 24.8%, P=0.005), and coronary heart disease (10.2% versus 5.1%, P=0.011), and were less likely to be smokers (44.3% versus 56.1%, P=0.005) and consume alcohol (38.3% versus 52.0%, P=0.001). Recurrent strokes were more frequently caused by LAA (42.1% versus 52.5%, P=0.026) and less often by small-vessel disease (40.9% versus 29.9%, P=0.008).

Conclusions

LAA is the most common etiology in Chinese young stroke patients, especially in those with recurrent stroke. Our data highlight the need of screening of LAA and prevention and management of conventional stroke risk factors in young people of China.

Sonographic features of carotid artery dissection due to extension of aortic dissection: a case report

BACKGROUND

Carotid artery dissection due to extension of aortic dissection (CAEAD) is a severe complication of acute aortic dissection. The risk of ischemic stroke is increased. Early sonographic detection and repeat evaluation are necessary to guide clinical management.

CASE PRESENTATION

A 58-year-old male patient presents with sudden, tearing retrosternal pain. Point-of-care carotid ultrasound is used to establish the diagnosis of CAEAD. We describe a number of sonographic features and compare ultrasound to other imaging modalities.

CONCLUSIONS

Bedside carotid ultrasound enables rapid, sensitive and safe hemodynamic assessment, especially in critically ill patients.

Update in the treatment of extracranial atherosclerotic disease for stroke prevention

Stroke is a leading cause of adult mortality and disability worldwide. Extracranial atherosclerotic disease (ECAD), primarily, carotid artery stenosis, accounts for approximately 18%–25% of ischaemic stroke. Recent advances in neuroimaging, medical therapy and interventional management have led to A significant reduction of stroke from carotid artery stenosis. The current treatment of ECAD includes optimal medical therapy, carotid endarterectomy (CEA) and carotid artery stenting (CAS). The selection of treatments depends on symptomatic status, severity of stenosis, individual factors, efficacy and risk of complications. The aim of this paper is to review current evidence and guidelines on the management of carotid artery stenosis, including the comparison of medical and interventional therapy (CAS and CEA), as well as future directions.

Symptomatic carotid near-occlusion causes a high risk of recurrent ipsilateral ischemic stroke

Objective

To assess the risk of recurrent ipsilateral ischemic stroke in patients with symptomatic near-occlusion with and without full collapse.

Methods

Included were consecutive patients eligible for revascularization, grouped into symptomatic conventional ≥ 50% carotid stenosis (n = 266), near-occlusion without full collapse (n = 57) and near-occlusion with full collapse (n = 42). The risk of preoperative recurrent ipsilateral ischemic stroke was analyzed, or, for cases not revascularized within 90 days, 90-day risk was analyzed.

Results

The risk of a preoperative recurrent ipsilateral ischemic stroke or ipsilateral retinal artery occlusion was 15% (95% CI 9–20%) for conventional ≥ 50% stenosis, 22% (95% CI 6–38%) among near-occlusion without full collapse and 30% (95% CI 16–44%) among near-occlusion with full collapse (p = 0.01, log rank test). In multivariate analysis, near-occlusion with full collapse had a higher risk of recurrent ipsilateral ischemic stroke (adjusted HR 2.6, 95% CI 1.3–5.3) and near-occlusion without full collapse tended to have a higher risk (adjusted HR 2.0, 95% CI 0.9–4.5) than conventional ≥ 50% stenosis. Only 24% of near-occlusion with full collapse underwent revascularization, common causes for abstaining were misdiagnosis as occlusion (31%), deemed surgically unfeasible (21%) and low perceived benefit (10%).

Conclusions

Symptomatic carotid near-occlusion has a high short-term risk of recurrent ipsilateral ischemic stroke, especially near-occlusion with full collapse.

The dimension of preventable stroke in a large representative patient cohort

Objective

To analyze the frequency of inadequately treated risk factors in a large representative cohort of patients with acute ischemic stroke or TIA and to estimate the proportion of events potentially avertable by guideline-compliant preventive therapy compared to the status quo.

Methods

A total of 1,730 patients from the Poststroke Disease Management STROKE-CARD trial (NCT02156778) were recruited between 2014 and 2017. We focused on 8 risk conditions amenable to drug therapy and 3 lifestyle risk behaviors and assessed pre-event risk factor control in retrospect.

Results

The proportion of patients with at least 1 inadequately treated risk condition was 79.5% (95% confidence interval [CI] 77.6%–81.4%) and increased to 95.1% (95% CI 94.1%–96.1%) upon consideration of the lifestyle risk behaviors. Risk factor control was worse in patients with recurrent vs first-ever events (p < 0.001), men vs women (p = 0.003), and patients ≤75 vs >75 years of age (p < 0.001). The estimated degree of stroke preventability ranged from 0.4% (95% CI 0.2%–0.6%) to 13.7% (95% CI 12.2%–15.2%) for the individual risk factors. Adequate control of the 5 most relevant risk factors combined (hypertension, hypercholesterolemia, atrial fibrillation, smoking, and overweight) would have averted ≈1 of 2 events or 1 in 4 with a highly conservative computation approach.

Conclusions

Our study confirms the existence of a considerable gap between risk factor control recommended by guidelines and real-world stroke prevention. Our study intends to increase awareness among physicians about stroke preventability and provides a quantitative basis for the emerging discussion on how to best tackle this challenge.

Imaging of Carotid Dissection

PURPOSE OF REVIEW

Here, we describe the four primary imaging modalities for identification of carotid artery dissection, advantages, limitations, and clinical considerations. In addition, imaging characteristics of carotid dissection associated with each modality will be described.

RECENT FINDINGS

Recent advances in etiopathogenesis describe the genetic factors implicated in cervical artery dissection. MRI/MRA (magnetic resonance angiography) with fat suppression is regarded as the best initial screening test to detect dissection. Advances in magnetic resonance imaging for the diagnosis of dissection include the use of susceptibility-weighted imaging (SWI) for the detection of intramural hematoma and multisection motion-sensitized driven equilibrium (MSDE), which causes phase dispersion of blood spin using a magnetic field to suppress blood flow signal and obtain 3D T1- or T2*-weighted images. Digital subtraction angiography (DSA) remains the gold standard for identifying and characterizing carotid artery dissections. Carotid artery dissection is the result of a tear in the intimal layer of the carotid artery. This leads to a "double lumen" sign comprised of the true vessel lumen and the false lumen created by the tear. The most common presentation of carotid artery dissection is cranial and/or cervical pain ipsilateral to the dissection. However, severe neurological sequelae such as embolic ischemic stroke, intracranial hemorrhage, and subarachnoid hemorrhage can also result from carotid artery dissection. Carotid artery dissection can be identified by a variety of different imaging modalities including computed tomographic angiography (CTA), MRI, carotid duplex imaging (CDI), and digital subtraction angiography (DSA).

Carotid Near-Occlusion Stent Experiences

Introduction

Treatment strategy for near-occlusions (NO) of the internal carotid artery (ICA) is still controversial. In this study, we aimed to present the clinical results of stent placement in 50 patients with carotid artery (NO) stenosis that presented to our center, and upon which revascularization will be performed.

Methods

Between 2014 and 2017, 50 patients with (NO) from 180 patients who had stents in the Interventional Vascular Neurology clinic were retrospectively studied. All the patients whether using or not using the proximal and distal protection device during the procedure were included. Patients had clinical neurologic evaluation, and underwent carotid artery radiologic imaging before the carotid artery stent (CAS) procedure. Balloon dilatation was applied before the stent procedure for patients that had advanced stenosis. Post-dilatation was applied with a balloon of appropriate size in case of residual narrowing. Findings such as bradycardia, hypotension, reperfusion hemorrhage during and after the stent placement procedure, as well as patients that developed restenosis within 12 months were recorded.

Results

This study includes 50 (30 males, 20 females) patients that underwent carotid stent placement. The mean age of patients was 65 (28-81). Reperfusion hemorrhage was seen in 1 (2%) patient and the patient died in week 3. Ten (20%) patients complained of chills and tremor lasting less than 3 hours after the procedure. One (2%) patient had encephalopathy and agitation for less than 24 hours. Two (4%) patients had hypotension, and 15 (30%) patients had a headache for less than 24 hours. Three patients developed local hematoma at the site of the sheath, and were treated by applying compression. Restenosis signs in the stent site was observed in 6 patients (12%) in color Doppler ultrasonography of the carotid performed in the 6th and 12th months.

Conclusion

Although the innate process of ICA NO is not well known, it might be more frequent than currently considered. Especially after the diagnosis of ICA stenosis, it is important to make the right diagnosis in patients that have new ipsilateral symptoms. After the diagnosis is made, CAS, when performed by an experienced neuro-interventional team, seems beneficial with low complication rates.

Antiplatelet Agents in Secondary Stroke Prevention: Selection, Timing, and Dose

PURPOSE OF REVIEW

This narrative review critically evaluated the published studies regarding the systematic use of antiplatelet agents for secondary stroke prevention.

RECENT FINDINGS

Stroke is a leading cause of morbidity and mortality around the world. Multimodal prevention is the most viable strategy for reducing the societal burden of stroke recurrence. For secondary stroke prevention, antiplatelet therapy is at the core of effective long-term vascular risk reduction among survivors of an ischemic stroke or transient ischemic attack (TIA). In addition to aspirin, there are several antiplatelet agents proven to be efficacious in averting recurrent vascular events after an index ischemic stroke or TIA. However, beyond the challenges of keeping up with recent advances in antiplatelet drug options for secondary stroke prevention, questions linger about the most appropriate selection, timing, and dosing of antiplatelet treatment for a given patient. We narratively summarized the pharmacological properties of key antiplatelet drugs; discussed the evidence regarding efficacy, selection, timing, and dosing of various antiplatelet treatment regimens; and highlighted ongoing clinical trials identifying novel therapies with more favorable risk-benefit profiles than currently available antiplatelet agents for patients with a recent history of ischemic or TIA stroke. Finally, we reviewed published data on antiplatelet therapies that could potentially be applied in the management of commonly encountered challenging clinical scenarios.

Pierre S, Newman WP, Rae G, Perlman ES, Rosol M, Keith JC, Buckler AJ. Atherosclerotic Plaque Tissue: Noninvasive Quantitative Assessment of Characteristics with Software-aided Measurements from Conventional CT Angiography

Purpose To (a) evaluate whether plaque tissue characteristics determined with conventional computed tomographic (CT) angiography could be quantitated at higher levels of accuracy by using image processing algorithms that take characteristics of the image formation process coupled with biologic insights on tissue distributions into account by comparing in vivo results and ex vivo histologic findings and (b) assess reader variability. Materials and Methods Thirty-one consecutive patients aged 43-85 years (average age, 64 years) known to have or suspected of having atherosclerosis who underwent CT angiography and were referred for endarterectomy were enrolled. Surgical specimens were evaluated with histopathologic examination to serve as standard of reference. Two readers used lumen boundary to determine scanner blur and then optimized component densities and subvoxel boundaries to best fit the observed image by using semiautomatic software. The accuracy of the resulting in vivo quantitation of calcification, lipid-rich necrotic core (LRNC), and matrix was assessed with statistical estimates of bias and linearity relative to ex vivo histologic findings. Reader variability was assessed with statistical estimates of repeatability and reproducibility. Results A total of 239 cross sections obtained with CT angiography and histologic examination were matched. Performance on held-out data showed low levels of bias and high Pearson correlation coefficients for calcification (-0.096 mm2 and 0.973, respectively), LRNC (1.26 mm2 and 0.856), and matrix (-2.44 mm2 and 0.885). Intrareader variability was low (repeatability coefficient ranged from 1.50 mm2 to 1.83 mm2 among tissue characteristics), as was interreader variability (reproducibility coefficient ranged from 2.09 mm2 to 4.43 mm2). Conclusion There was high correlation and low bias between the in vivo software image analysis and ex vivo histopathologic quantitative measures of atherosclerotic plaque tissue characteristics, as well as low reader variability. Software algorithms can mitigate the blurring and partial volume effects of routine CT angiography acquisitions to produce accurate quantification to enhance current clinical practice. Clinical trial registration no. NCT02143102 © RSNA, 2017 Online supplemental material is available for this article. An earlier incorrect version of this article appeared online. This article was corrected on September 15, 2017.

De-adoption and exnovation in the use of carotid revascularization: retrospective cohort study

Objective To determine physician characteristics associated with exnovation (scaling back on use) and de-adoption (abandoning use) of carotid revascularization.Design Retrospective longitudinal cohort study.Setting Medicare claims linked to the Doximity database provider registry, 2006-13.Participants 9158 physicians who performed carotid revascularization on Medicare patients between 2006 and 2013.Main outcome measures The primary outcomes were the number of carotid revascularization procedures for each physician per year at the end of the sample period, and the percentage change in the volume of carotid revascularization procedures.Results At baseline (2006-07), 9158 physicians performed carotid revascularization. By 2012-13 the use of revascularization in this cohort had declined by 37.7%, with two thirds attributable to scaling back (exnovation) rather than dropping the procedure entirely (de-adoption). Compared with physicians with fewer than 12 years of experience, those with more than 25 years of experience decreased use by an additional 23.0% (95% confidence interval -36.7% to -9.2%). The lowest rates of decline occurred in physicians specializing in vascular or thoracic surgery, for whom the procedures accounted for a large share of revenue. Physicians with high proportions of patients aged more than 80 years or with asymptomatic carotid stenosis were less likely to reduce their use of carotid revascularization.Conclusion Surgeons with more experience and the lowest share in carotid revascularization practice reduced their use of the procedure the most. These practice factors should be considered in quality improvement efforts when the evidence base evolves away from a specific treatment.

Neutrophil gelatinase associated lipocalin (NGAL) is elevated in type 2 diabetics with carotid artery stenosis and reduced under metformin treatment

Background

Neutrophil gelatinase-associated lipocalin (NGAL), an acute phase protein released by neutrophils, has been described as biomarker of inflammatory states. Type 2 diabetes mellitus (T2DM) is characterized by increased inflammation and an elevated risk for embolization of carotid artery stenosis (CAS). We aimed to explore the role of NGAL systemically and in plaques of diabetics undergoing carotid endarterectomy. Moreover, the potential anti-inflammatory effect of metformin on NGAL was addressed in diabetics.

Methods

Serum NGAL and matrix metalloproteinase (MMP)-9/NGAL levels were measured in 136 patients (67 with T2DM vs. 69 non-diabetics) by specific ELISA. Endarterectomy samples were graded histologically according to the American Heart Association´s classification. NGAL mRNA expression was detected using RealTime-PCR in carotid endarterectomy specimens.

Results

Serum NGAL [median 107.4 ng/ml (quartiles: 75.2–145.0) vs. 64.4 (50.4 –81.3), p < 0.0001] and MMP-9/NGAL [41.5 ng/ml (20.8–63.9) vs. 27.6 (16.0–42.4), p = 0.017] were significantly elevated in diabetics compared to non-diabetics, as were leukocytes, neutrophils, C-reactive protein and fibrinogen (all p < 0.05). In patients with symptomatic and asymptomatic CAS diabetics had higher NGAL levels compared to non-diabetics [128.8 ng/ml (100.8–195.6) vs. 64.8 (48.9–82.2] and [101.6 ng/ml (70.1–125.3) vs. 63.8 (51.0–81.3), respectively, both p < 0.0001]. Presence of T2DM and type VI plaques (with surface defect, hemorrhage or thrombus) had a profound impact on NGAL levels (both p < 0.01) in multiple linear regression analysis. NGAL mRNA was detectable in 95% of analyzed carotid artery lesions of diabetics compared to 5% of non-diabetics (p < 0.0001). Accordingly, cerebral embolization was more frequent in diabetics (52.2% vs. 29%, p = 0.006). Metformin treatment was associated with decreased NGAL [60.7 ng/ml (51.9–69.2) vs. 121.7 (103.7–169.9), p < 0.0001] and MMP-9/NGAL [20.8 ng/ml (12.1–26.5) vs. 53.7 (27.4–73.4), p = 0.007] in diabetics and reduced leukocyte infiltration in carotid lesions of diabetics.

Conclusions

Higher NGAL levels in serum and plaques are associated with T2DM in patients with CAS. Metformin significantly reduced the inflammatory burden including NGAL in diabetics. Early treatment of these patients may be recommended, as elevated NGAL levels were linked with vulnerable plaques prone for embolization.

Evaluation and Management of Atherosclerotic Carotid Stenosis

Medical therapies for the prevention of stroke have advanced considerably in the past several years. There can also be a role for mechanical restoration of the lumen by endarterectomy or stenting in selected patients with high-grade atherosclerotic stenosis of the extracranial carotid artery. Endarterectomy is generally recommended for patients with high-grade symptomatic carotid stenosis. Stenting is considered an option for patients at high risk of complications with endarterectomy. Whether revascularization is better than contemporary medical therapy for asymptomatic extracranial carotid stenosis is a subject of several ongoing randomized clinical trials in the United States and internationally.

Association between Carotid Intima Media Thickness and Heart Rate Variability in Adults at Increased Cardiovascular Risk

Background: Atherosclerotic carotid intima-media thickness (IMT) may be associated with alterations in the sensitivity of carotid baroreceptors. The aim of this study was to investigate the association between carotid IMT and the autonomic modulation of heart rate variability (HRV). Methods: A total of 101 subjects were enrolled in this prospective observational study. The carotid IMT was determined by duplex ultrasonography. The cardiac autonomic function was determined through HRV measures during the Deep Breathing Test. Linear regression models, adjusted for demographics, comorbidities, body mass index, waist-hip-ratio, and left ventricular ejection fraction were used to evaluate the association between HRV parameters and carotid IMT. Results: Participants had a mean age of 60.4 ± 13.4 years and an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk score (using the Pooled Cohort Equations) of 16.4 ± 17. The mean carotid media thickness was highest (0.90 ± 0.19 mm) in the first quartile of the standard deviation of all RR intervals (SDNN) (19.7 ± 5.1 ms) and progressively declined in each subsequent quartile to 0.82 ± 0.21 mm, 0.81 ± 0.16 mm, and 0.68 ± 0.19 in quartiles 2 (36.5 ± 5.9 ms), 3 (57.7 ± 6.2 ms) and 4 (100.9 ± 22.2 ms), respectively. In multivariable adjusted models, there was a statistical significant association between SDNN and carotid IMT (OR -0.002; 95%CI -0.003 to -0.001, p = 0.005). The same significant association was found between carotid IMT and other measures of HRV, including coefficient of variation of RR intervals (CV) and dispersion of points along the line of identity (SD2). Conclusions: In a cohort of individuals at increased cardiovascular risk, carotid IMT as a marker of subclinical atherosclerosis was associated with alterations of HRV indicating an impaired cardiac autonomic control, independently of other cardiovascular risk factors.

Endovascular treatment and morphology typing of chronic ostial occlusion of the subclavian artery

Chronic obstructive lesions of the subclavian artery (SCA) often result in subclavian steal syndrome, which leads to arm claudication, transient cerebral ischemia, and other serious complications. The lesions are classified as stenosis and occlusion, according to the degree of obstruction. Unlike totally occlusive lesions, including ostial occlusions, stenotic lesions have an excellent technical success rate. In the present study, ostial occlusions were classified into 4 types according to their angiographic appearance. A total of 8 patients (6 male, 2 female) with SCA occlusions were treated with percutaneous transluminal angioplasty and stenting over a 4-year period. Mean patient age was 65.6 years (range, 60-72 years). In total, 9 self-expanding and 1 balloon-expandable stent were implanted at the ostia of the SCA in 7 of the patients. One female patient did not undergo stenting. Bleeding at the access site was noted in 2 patients and was controlled by gauze pressure. The patient that did not undergo stenting was lost to follow-up with symptoms of a transient ischemic attack at 3 months. The mean follow-up time for the remaining 7 patients was 15.7 months (range, 1-36 months). No ischemic symptoms, neointimal hyperplasia, or restenosis was observed in these patients. The transfemoral artery operation approach is preferred for rat-tail and peak type occlusions, whereas the dual approach involving both femoral and radial arteries is preferred for hilly and plain type occlusions. The angiographic morphology typing used in the present study may serve as a reference to decide upon the interventional operation strategy to be used for improving the technical success rate.

Cyclodextrin promotes atherosclerosis regression via macrophage reprogramming

Atherosclerosis is an inflammatory disease linked to elevated blood cholesterol concentrations. Despite ongoing advances in the prevention and treatment of atherosclerosis, cardiovascular disease remains the leading cause of death worldwide. Continuous retention of apolipoprotein B-containing lipoproteins in the subendothelial space causes a local overabundance of free cholesterol. Because cholesterol accumulation and deposition of cholesterol crystals (CCs) trigger a complex inflammatory response, we tested the efficacy of the cyclic oligosaccharide 2-hydroxypropyl-β-cyclodextrin (CD), a compound that increases cholesterol solubility in preventing and reversing atherosclerosis. We showed that CD treatment of murine atherosclerosis reduced atherosclerotic plaque size and CC load and promoted plaque regression even with a continued cholesterol-rich diet. Mechanistically, CD increased oxysterol production in both macrophages and human atherosclerotic plaques and promoted liver X receptor (LXR)-mediated transcriptional reprogramming to improve cholesterol efflux and exert anti-inflammatory effects. In vivo, this CD-mediated LXR agonism was required for the antiatherosclerotic and anti-inflammatory effects of CD as well as for augmented reverse cholesterol transport. Because CD treatment in humans is safe and CD beneficially affects key mechanisms of atherogenesis, it may therefore be used clinically to prevent or treat human atherosclerosis.

The Association between Ideal Cardiovascular Health Metrics and Extracranial Carotid Artery Stenosis in a Northern Chinese Population: A Cross-Sectional Study

Past epidemiologic studies have indicated that the ideal cardiovascular health (CVH) metrics are associated with a lower risk of cardiovascular diseases (CVDs) and stroke. Carotid artery stenosis (CAS) causes approximately 10% of ischemic strokes. The association between ideal CVH and extracranial CAS has not yet been assessed. In the current study, extracranial CAS was assessed by carotid duplex ultrasonography. Logistic regression was used to analyze the association between ideal CVH metrics and extracranial CAS. A total of 3297 participants (52.2% women) aged 40 years and older were selected from the Jidong community in China. After adjusting for sex, age and other potential confounds, the odds ratios (95% confidence intervals) for extracranial CAS were 0.57 (0.39–0.84), 0.46 (0.26–0.80) and 0.29 (0.15–0.54), and for those quartiles, quartile 2 (9–10), quartile 3 (11) and quartile 4 (12–14), respectively, compared with quartile 1 (≤8). This negative correlation was particularly evident in women and the elderly (≥60 years). This cross-sectional study showed a negative correlation between the ideal CVH metrics and the prevalence of extracranial CAS in northern Chinese adults.

Quality of Life in Carotid Atherosclerosis: The Role of Co-morbid Mood Disorders

INTRODUCTION/OBJECTIVE

To study in severe carotid atherosclerosis (CA): the frequency of mood disorders (MD); the impairment of quality of life (QoL); the role of co-morbid MD in such impairment.

METHODS

Case-control study.

CASES

consecutive in-patients with CA (stenosis ≥ 50%).

CONTROLS

subjects with no diagnosis of CA randomized from a database of a community survey. Psychiatric diagnosis according to DSM-IV made by clinicians and semi-structured interview, QoL measured by the Short Form Health Survey (SF-12).

RESULTS

This is the first study on comorbidity on CA disease and MD in which psychiatric diagnoses are conducted by clinicians according to DSM-IV diagnostic criteria. Major Depressive Disorder (MDD) (17.4% vs 2.72%, P <0.0001) but not Bipolar Disorders (BD) (4.3% vs 0.5%, P = 0.99) was higher in cases (N=46) than in controls (N= 184). SF-12 scores in cases were lower than in controls (30.56±8.12 vs 36.81±6:40; p <0.001) with QoL comparable to serious chronic diseases of the central nervous system. The burden of a concomitant MDD or BD amplifies QoL impairment.

CONCLUSION

Comorbid MD aggravates the impairment of QoL in CA. Unlike autoimmune diseases or degenerative diseases of the Central Nervous System, CA shows a strong risk of MDD than BD.

Evaluation of Endarterectomy Recanalization under Ultrasound Guidance in Symptomatic Patients with Carotid Artery Occlusion

Rigorous screening and good imaging would help perform surgery on carotid artery occlusion CAO safely and effectively. The purpose of this study was to retrospectively evaluate carotid endarterectomy (CEA) recanalization in patients with common carotid artery occlusion (CCAO) or internal carotid artery occlusion (ICAO) with color Doppler flow imaging (CDFI). A total of 59 patients undergoing CEA were enrolled. According to the results of CEA, the patients were divided into successful recanalization (group A) and unsuccessful recanalization (group B) groups. The original diameter, lesion length, proximal-to-distal diameter ratio and echo characteristics of the lesion within the lumen of the carotid artery were recorded before CEA and compared between the two groups. In regards to the achievement of repatency by CEA, the overall success rate was 74.6% (44/59), the success rate in CCAO patients was 75.9% (22/29) and the success rate in ICAO patients was 73.3% (22/30). There was no significant difference in the success rates between the CCAO and ICAO patients (χ2 = 0.050, P = 0.824). The overall rate of stroke and death within 30 postoperative days was 5.1% (3/59). For the CCAO patients, the lesion length in group A was shorter than that in group B (t = 3.221, P = 0.004). For the ICAO patients, the original diameter of the distal ICA was broader (t = 6.254, P = 0.000) and the proximal-to-distal ICA diameter ratio was smaller (t = 8.036, P = 0.000) in group A than in group B. The rate of recanalization for lumens with a homogeneous echo pattern (hypoecho or isoecho) was significantly higher than that for lumens with echo heterogeneity for both the CCAO and ICAO patients (χ2 = 14.477, P = 0.001; χ2 = 10.519, P = 0.003). However, for both the CCAO and ICAO patients, there was no difference in the rate of recanalization between patients with hypoecho and isoecho lesions (χ2 = 0.109, P = 0.742; χ2 = 0.836, P = 0.429). The original diameter, proximal-to-distal ICA diameter ratio, lesion length and echo characteristics may affect the success of CEA recanalization in patients with CCAO and ICAO. CDFI is helpful in screening patients with carotid artery occlusion and may improve the success rate of CEA.

Automatically finding relevant citations for clinical guideline development

OBJECTIVE

Literature database search is a crucial step in the development of clinical practice guidelines and systematic reviews. In the age of information technology, the process of literature search is still conducted manually, therefore it is costly, slow and subject to human errors. In this research, we sought to improve the traditional search approach using innovative query expansion and citation ranking approaches.

METHODS

We developed a citation retrieval system composed of query expansion and citation ranking methods. The methods are unsupervised and easily integrated over the PubMed search engine. To validate the system, we developed a gold standard consisting of citations that were systematically searched and screened to support the development of cardiovascular clinical practice guidelines. The expansion and ranking methods were evaluated separately and compared with baseline approaches.

RESULTS

Compared with the baseline PubMed expansion, the query expansion algorithm improved recall (80.2% vs. 51.5%) with small loss on precision (0.4% vs. 0.6%). The algorithm could find all citations used to support a larger number of guideline recommendations than the baseline approach (64.5% vs. 37.2%, p<0.001). In addition, the citation ranking approach performed better than PubMed's "most recent" ranking (average precision +6.5%, recall@k +21.1%, p<0.001), PubMed's rank by "relevance" (average precision +6.1%, recall@k +14.8%, p<0.001), and the machine learning classifier that identifies scientifically sound studies from MEDLINE citations (average precision +4.9%, recall@k +4.2%, p<0.001).

CONCLUSIONS

Our unsupervised query expansion and ranking techniques are more flexible and effective than PubMed's default search engine behavior and the machine learning classifier. Automated citation finding is promising to augment the traditional literature search.

Stroke associated with coronary artery bypass grafting

While coronary artery bypass grafting (CABG) has been playing a significant role in the revascularization for ischemic heart disease, neurological complications associated with CABG have been a primary concern. Stroke, although the incidence is low, is one of the most devastating complication of CABG. Many studies have identified the risk factors for stroke with CABG, such as prior stroke, carotid artery stenosis, aortic atherosclerosis, atrial fibrillation and cardiopulmonary bypass. Various rational approaches focusing on individual risk factor have been proposed for the stroke. Prophylactic carotid revascularization is an important strategy, and the diagnosis of carotid stenosis has to be established correctly. Prevention of emboli from aortic plaque is also an essential issue. Intraoperative monitoring with transesophageal or epiaortic ultrasound is useful to identify mobile atheromatous plaques and to select appropriate aortic manipulations. Maintenance of cerebral blood flow and blood pressure during cardiopulmonary bypass might be critical issues. Besides, there are conflicting two opinions regarding off-pump CABG; one supports an efficiency for the prevention of stroke while the other advocates no effect. This discrepancy might be explained by the difference of the risk of stroke in the population of the individual study and by the variation of the percentage of aortic clamping or aortic anastomosis in each study. Pharmaceutical therapies such as statin, preventive medication for atrial fibrillation, or antiplatelet are promising methods. Although it is hard to decrease the incidence of the stroke with any single countermeasure, sustained effort should be continued to overcome the stroke associated with CABG.

Risk Factors for Carotid Artery Stenosis in Chinese Patients Undergoing Coronary Artery Bypass Graft Interventions

Current guidelines established in the USA and Europe for coronary artery bypass graft (CABG) suggest that patients ≥65 and ≥70 years of age, or with certain atherosclerotic-risk factors, should be screened preoperatively for extracranial carotid artery stenosis (CAS) to assess their risk of perioperative stoke. We sought factors that should be taken into consideration when treating Chinese CABG patients using CABG guidelines based on an analysis of CAS in a large cohort of Chinese CABG patients. We analyzed data for 1558 Chinese CABG patients who were screened preoperatively for CAS using duplex ultrasonography at a single institution. We defined significant and severe CAS as ≥50% and ≥70% stenosis, respectively, in one or more common or internal carotid arteries. We investigated the prevalence of CAS, the incidence of perioperative stroke, and the risk factors for CAS in the CABG cohort. The prevalence of CAS in the CABG cohort was 21.2%. Multivariate stepwise logistic regression analysis showed that an age ≥50 years and a history of smoking (odds ratios = 8.36 and 1.83, respectively) were independent risk factors for CAS (P < 0.05 for both). The incidence of perioperative stroke among CABG patients with significant or severe CAS was significantly higher (2.4% and 2.9%, respectively) than in CABG patients with <50% stenosis (0.5%; P = 0.004 and 0.029, respectively). Chinese CABG patients with a history of smoking or ≥50 years of age should undergo preoperative screening for CAS to assess their risk of perioperative stroke.

Depression and cerebrovascular disease: could vortioxetine represent a valid treatment option?

INTRODUCTION

Depression and cerebrovascular atherosclerosis often occur in comorbidity showing neuropsychological impairment and poor response to antidepressant treatment. Objective is to evaluate if new antidepressant vortioxetine may be a potential treatment option. Mechanism of Action : Vortioxetine has 5-HT3, 5-HT7 and 5-HT1D antagonists, 5-HT1B partial agonist and a 5-HT1A agonist and serotonin transporter inhibitor property. Efficacy and safety in Major Depressive Disorders and in cognitive impairment : The majority of trials (one of them in older people) showed efficacy for vortioxetine against placebo and no differences against other active treatments. The Adverse Effects ranged from 15.8% more to 10.8% less than placebo. In the elderly, only nausea was found higher than placebo. Effects on arterial blood pressure and cardiac parameters including the ECG-QT segment were similar to placebo. Elderly depressive patients on vortioxetine showed improvement versus placebo and other active comparators in Auditory Verbal Learning Test and Digit Symbol Substitution Test scores. The inclusion criteria admitted cases with middle cerebrovascular disease. Conclusion : The mechanism of action, the efficacy on depression and safety profile and early data on cognitive impairment make Vortioxetine a strong candidate for use in depression associated with cerebrovascular disease. This information must be supported by future randomized controlled trials.

Evidence for management of carotid artery stenosis

In this review, we presented the evidence concerning carotid artery stenosis treatment in symptomatic stenosis and asymptomatic stenosis separately, and discussed the future challenges. The validity of carotid endarterectomy (CEA) to treat moderate or greater degree of symptomatic carotid artery stenosis appears to be established. Due to the additional option of carotid artery stenting (CAS), it is necessary to comprehensively determine whether CEA or CAS is more appropriate for each individual patient. Moreover, since there are rapid advancements in devices for CAS and improvements in treatment outcomes, continual learning of the latest treatment method is essential. For asymptomatic stenosis, due to improvements in the outcomes with best medical treatment (BMT), it is essential to re-evaluate the use of invasive CEA/CAS. Continual verification of the latest randomized clinical trial that compares CEA, CAS, and BMT, and establishment of a diagnostic method that can accurately extract the group of patients who have the highest future risk of developing ischemia, are desired.

Management of extracranial carotid artery disease

Stroke is the third leading cause of death in developed nations. Up to 88% of strokes are ischemic in nature. Extracranial carotid artery atherosclerotic disease is the third leading cause of ischemic stroke in the general population and the second most common nontraumatic cause among adults younger than 45 years. This article provides comprehensive, evidence-based recommendations for the management of extracranial atherosclerotic disease, including imaging for screening and diagnosis, medical management, and interventional management.

Carotid artery ultrasonographic assessment in patients from the Fremantle Diabetes Study Phase II with carotid bruits detected by electronic auscultation

BACKGROUND

Electronic auscultation appears superior to acoustic auscultation for identifying hemodynamic abnormalities. The aim of this study was to determine whether carotid bruits detected by electronic stethoscope in patients with diabetes are associated with stenoses and increased carotid intima-medial thickness (CIMT).

SUBJECTS AND METHODS

Fifty Fremantle Diabetes Study patients (mean±SD age, 73.7±10.0 years; 38.0% males) with a bruit found by electronic auscultation and 50 age- and sex-matched patients with normal carotid sounds were studied. The degree of stenosis and CIMT were assessed from duplex ultrasonography.

RESULTS

Patients with a bruit were more likely to have stenosis of ≥50% and CIMT of >1.0 mm than those without (odds ratios [95% confidence intervals]=14.0 [1.8-106.5] and 5.3 [1.8-15.3], respectively; both P=0.001). For the six patients with stenosis of ≥70%, five had a bruit, and one (with a known total occlusion) did not (odds ratio=5.0 [0.6-42.8]; P=0.22). The sensitivity and specificity of carotid bruit for stenoses of ≥50% were 88% and 58%, respectively; respective values for stenoses of ≥70% were 83% and 52%. The equivalent negative predictive values were 96% and 98%, and positive predictive values were 30% and 10%, respectively.

CONCLUSIONS

Electronic recording of carotid sounds for later interpretation is convenient and reliable. Most patients with stenoses had an overlying bruit. Most bruits were false positives, but ultrasonography is justified to document extent of disease; CIMT measurement will identify increased vascular risk in most of these patients. The absence of a bruit was rarely a false-negative finding, suggesting that these patients can usually be reassured that they do not have hemodynamically important stenosis.