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Liu M, Chang N, Zhang S, Du Y, Zhang X, Ren W, Sun J, Bai J, Wang L, Zhang G. Identification of vulnerable carotid plaque with CT-based radiomics nomogram. Clin Radiol 2023; 78:e856-e863. [PMID: 37633746 DOI: 10.1016/j.crad.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 07/08/2023] [Accepted: 07/26/2023] [Indexed: 08/28/2023]
Abstract
AIM To develop and validate a radiomics nomogram for identifying high-risk carotid plaques on computed tomography (CT) angiography (CTA). MATERIALS AND METHODS A total of 280 patients with symptomatic (n=131) and asymptomatic (n=139) carotid plaques were divided into a training set (n=135), validation set (n=58), and external test set (n=87). Radiomic features were extracted from CTA images. A radiomics model was constructed based on selected features and a radiomics score (rad-score) was calculated. A clinical factor model was constructed by demographics and CT findings. A radiomics nomogram combining independent clinical factors and the rad-score was constructed. The diagnostic performance of three models was evaluated and validated by region of characteristic curves. RESULTS Calcification and maximum plaque thickness were the independent clinical factors. Twenty-four features were used to build the radiomics signature. In the validation set, the nomogram (area under the curve [AUC], 0.977; 95% CI, 0.899-0.999) performed better (p=0.017 and p=0.031) than the clinical factor model (AUC, 0.862; 95% CI, 0.746-0.938) and radiomics signature (AUC, 0.944; 95% CI, 0.850-0.987). In external test set, the nomogram (AUC, 0.952; 95% CI, 0.884-0.987) and radiomics signature (AUC, 0.932; 95% CI, 0.857-0.975) showed better discrimination capability (p=0.002 and p=0.037) than clinical factor model (AUC, 0.818; 95% CI, 0.721-0.892). CONCLUSION The CT-based nomogram showed satisfactory performance in identification of high-risk plaques in carotid arteries, and it may serve as a potential non-invasive tool to identify carotid plaque vulnerability and risk stratification.
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Affiliation(s)
- M Liu
- Department of Health Management, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - N Chang
- Department of Medical Technology, Jinan Nursing Vocational College, No. 3636 Gangxi Road, Jinan 250021, Shandong, China
| | - S Zhang
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan China; Postgraduate Department, Shandong First Medical University (Shandong Academy of Medical Sciences), Jinan, China
| | - Y Du
- Department of Health Management, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - X Zhang
- Postgraduate Department, Shandong First Medical University (Shandong Academy of Medical Sciences), Jinan, China
| | - W Ren
- Postgraduate Department, Shandong First Medical University (Shandong Academy of Medical Sciences), Jinan, China
| | - J Sun
- Postgraduate Department, Shandong First Medical University (Shandong Academy of Medical Sciences), Jinan, China
| | - J Bai
- Department of Computed Tomography, Liaocheng Traditional Chinese Medicine Hospital, Liaocheng, China
| | - L Wang
- Physical Examination Centre, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.
| | - G Zhang
- Department of Health Management, The First Affiliated Hospital of Shandong First Medical University, Jinan, China.
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Homssi M, Saha A, Delgado D, RoyChoudhury A, Thomas C, Lin M, Baradaran H, Kamel H, Gupta A. Extracranial Carotid Plaque Calcification and Cerebrovascular Ischemia: A Systematic Review and Meta-Analysis. Stroke 2023; 54:2621-2628. [PMID: 37638399 PMCID: PMC10530110 DOI: 10.1161/strokeaha.123.042807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/17/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Although coronary calcification quantification is an established approach for cardiovascular risk assessment, the value of quantifying carotid calcification is less clear. As a result, we performed a systematic review and meta-analysis to evaluate the association between extracranial carotid artery plaque calcification burden and ipsilateral cerebrovascular ischemic events. METHODS A comprehensive literature search was performed in the following databases: Ovid MEDLINE(R) 1946 to July 6, 2022; OVID Embase 1974 to July 6, 2022; and The Cochrane Library (Wiley). We performed meta-analyses including studies in which investigators performed a computed tomography assessment of calcification volume, percentage, or other total calcium burden summarizable in a single continuous imaging biomarker and determined the association of these features with the occurrence of ipsilateral stroke or transient ischemic attack. RESULTS Our overall meta-analysis consisted of 2239 carotid arteries and 9 studies. The presence of calcification in carotid arteries ipsilateral to ischemic stroke or in stroke patients compared with asymptomatic patients did not demonstrate a significant association with ischemic cerebrovascular events (relative risk of 0.75 [95% CI, 0.44-1.28]; P=0.29). When restricted to studies of significant carotid artery stenosis (>50%), the presence of calcification was associated with a reduced risk of ischemic stroke (relative risk of 0.56 [95% CI, 0.38-0.85]; P=0.006). When the analysis was limited to studies of patients with mainly nonstenotic plaques, there was an increased relative risk of ipsilateral ischemic stroke of 1.72 ([95% CI, 1.01-2.91]; P=0.04). Subgroup meta-analyses of total calcium burden and morphological features of calcium showed wide variability in their strength of association with ischemic stroke and demonstrated significant heterogeneity. CONCLUSIONS The presence of calcification in carotid plaque confers a reduced association with ipsilateral ischemic events, although these results seem to be limited among carotid arteries with higher degrees of stenosis. Adoption of carotid calcification measures in clinical decision-making will require additional studies providing more reproducible and standardized methods of calcium characterization and testing these imaging strategies in prospective studies.
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Affiliation(s)
- Moayad Homssi
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Atin Saha
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Diana Delgado
- Samuel J. Wood Library and C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY, USA
| | - Arindam RoyChoudhury
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Charlene Thomas
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Matthew Lin
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Hediyeh Baradaran
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
- Feil Family Brain Mind Institute, Weill Cornell Medicine, New York, NY, USA
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
- Feil Family Brain Mind Institute, Weill Cornell Medicine, New York, NY, USA
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Chen C, Tang W, Chen Y, Xu W, Yu N, Liu C, Li Z, Tang Z, Zhang X. Computed tomography angiography-based radiomics model to identify high-risk carotid plaques. Quant Imaging Med Surg 2023; 13:6089-6104. [PMID: 37711840 PMCID: PMC10498225 DOI: 10.21037/qims-23-158] [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: 02/10/2023] [Accepted: 07/17/2023] [Indexed: 09/16/2023]
Abstract
Background Extracranial atherosclerosis is one of the major causes of stroke. Carotid computed tomography angiography (CTA) is a widely used imaging modality that allows detailed assessments of plaque characteristics. This study aimed to develop and test radiomics models of carotid plaques and perivascular adipose tissue (PVAT) to distinguish symptomatic from asymptomatic plaques and compare the diagnostic value between radiomics models and traditional CTA model. Methods A total of 144 patients with carotid plaques were divided into symptomatic and asymptomatic groups. The traditional CTA model was built by the traditional radiological features of carotid plaques measured on CTA images which were screened by univariate analysis and multivariable logistic regression. We extracted and screened radiomics features from carotid plaques and PVAT. Then, a support vector machine was used for building plaque and PVAT radiomics models, as well as a combined model using traditional CTA features and radiomics features. The diagnostic value between radiomics models and traditional CTA model was compared in identifying symptomatic carotid plaques by Delong method. Results The area under curve (AUC) values of traditional CTA model were 0.624 and 0.624 for the training and validation groups, respectively. The plaque radiomics model and PVAT radiomics model achieved AUC values of 0.766, 0.740 and 0.759, 0.618 in the two groups, respectively. Meanwhile, the combined model of plaque and PVAT radiomics features and traditional CTA features had AUC values of 0.883 and 0.840 for the training and validation groups, respectively, and the receiver operating characteristic curves of combined model were significantly better than those of traditional CTA model in the training group (P<0.001) and validation group (P=0.029). Conclusions The combined model of the radiomics features of carotid plaques and PVAT and the traditional CTA features significantly contributes to identifying high-risk carotid plaques compared with traditional CTA model.
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Affiliation(s)
- Chao Chen
- Medical Imaging Key Laboratory of Sichuan Province and Department of Radiology, Affiliated Hospital, North Sichuan Medical College, Nanchong, China
| | - Wei Tang
- Medical Imaging Key Laboratory of Sichuan Province and Department of Radiology, Affiliated Hospital, North Sichuan Medical College, Nanchong, China
| | - Yong Chen
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenhan Xu
- Medical Imaging Key Laboratory of Sichuan Province and Department of Radiology, Affiliated Hospital, North Sichuan Medical College, Nanchong, China
| | - Ningjun Yu
- Medical Imaging Key Laboratory of Sichuan Province and Department of Radiology, Affiliated Hospital, North Sichuan Medical College, Nanchong, China
| | - Chao Liu
- Medical Imaging Key Laboratory of Sichuan Province and Department of Radiology, Affiliated Hospital, North Sichuan Medical College, Nanchong, China
| | - Zenghui Li
- Medical Imaging Key Laboratory of Sichuan Province and Department of Radiology, Affiliated Hospital, North Sichuan Medical College, Nanchong, China
| | - Zhao Tang
- Medical Imaging Key Laboratory of Sichuan Province and Department of Radiology, Affiliated Hospital, North Sichuan Medical College, Nanchong, China
| | - Xiaoming Zhang
- Medical Imaging Key Laboratory of Sichuan Province and Department of Radiology, Affiliated Hospital, North Sichuan Medical College, Nanchong, China
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Homssi M, Vora A, Zhang C, Baradaran H, Kamel H, Gupta A. Association Between Spotty Calcification in Nonstenosing Extracranial Carotid Artery Plaque and Ipsilateral Ischemic Stroke. J Am Heart Assoc 2023; 12:e028525. [PMID: 37183863 PMCID: PMC10227294 DOI: 10.1161/jaha.122.028525] [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: 10/17/2022] [Accepted: 04/04/2023] [Indexed: 05/16/2023]
Abstract
Background Small spotty calcifications in the coronary arteries are associated with an increased risk of myocardial infarction. We examined the association between spotty calcifications near the carotid bifurcations and ipsilateral ischemic stroke in patients with <50% luminal stenosis of the extracranial carotid arteries. Methods and Results We used data from the CAESAR (Cornell Acute Stroke Academic Registry), a prospective registry of all patients with acute ischemic stroke admitted to our institution. We included patients who met criteria for cryptogenic stroke and underwent computed tomography angiography and brain magnetic resonance imaging. Patients with extracranial carotid artery stenosis ≥50% and patients with posterior or bilateral anterior circulation infarcts were excluded. We examined the carotid bifurcations for spotty calcifications, defined as ≥1 contiguous regions of luminal calcification ≤3 mm along the long axis of the vessel. We also measured low-density plaque and maximum plaque thickness. The eligible cohort consisted of 117 patients with a mean age of 66.7±1.65 years with a median National Institute of Health Stroke Scale stroke at the time of arrival of 6 (range, 3-13). The number of spotty calcifications present within a low-density plaque was significantly associated with ipsilateral infarction (0.3±0.8 versus 0.1±0.4, P=0.02). Maximum plaque thickness was also significantly associated with ipsilateral infarction (1.4 mm ±1.5 versus 1.0 mm ±1.1, P=0.004). Conclusions Spotty calcifications associated with low-density plaque and maximum plaque thickness were associated with ipsilateral ischemic stroke in patients with nonstenotic carotid atherosclerosis, suggesting a role as imaging markers of high-risk plaque.
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Affiliation(s)
- Moayad Homssi
- Department of Radiology, Weill Cornell MedicineNew YorkNYUSA
| | - Amar Vora
- Department of Radiology, Weill Cornell MedicineNew YorkNYUSA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell MedicineNew YorkNYUSA
| | - Hediyeh Baradaran
- Department of Radiology and Imaging SciencesUniversity of UtahSalt Lake CityUTUSA
| | - Hooman Kamel
- Brain Mind Institute, Weill Cornell MedicineNew YorkNYUSA
- Department of Neurology, Weill Cornell MedicineNew YorkNYUSA
| | - Ajay Gupta
- Department of Radiology, Weill Cornell MedicineNew YorkNYUSA
- Brain Mind Institute, Weill Cornell MedicineNew YorkNYUSA
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Imaging the Carotid Artery: Point-Why It's Time to Go Beyond the Lumen. AJR Am J Roentgenol 2023; 220:343-344. [PMID: 36169543 DOI: 10.2214/ajr.22.28417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Jumah A, Aboul Nour H, Intikhab O, Choudhury O, Gagi K, Fana M, Alhajala H, Alkhoujah M, Alsrouji OK, Eltous L, Schultz L, Latack K, Brady M, Chebl A, Marin H, Miller D. Non-stenosing carotid artery plaques in embolic stroke of undetermined source: a retrospective analysis. Neurol Sci 2023; 44:247-252. [PMID: 36166175 DOI: 10.1007/s10072-022-06425-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/21/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND We aim to identify the association between high-risk carotid plaques and their laterality to stroke in ESUS patient population. We also discuss recurrent stroke events and their laterality to the index stroke. METHODS This was a retrospective study. We reviewed data for patients with ESUS between June 20, 2016, and June 20, 2021. Using computed tomography angiography, we analyzed plaque features that are associated with ESUS, and then, we identified the recurrent stroke events and characterized lateralization to the index stroke. RESULTS Out of 1779 patients with cryptogenic ischemic stroke, we included 152 patients who met the criteria for ESUS. High-risk plaque features were found more often ipsilateral to the stroke side when compared contralaterally: plaque ulceration (19.08% vs 5.26%, p < .0001), plaque thickness > 3 mm (19.08% vs 7.24%, p = 0.001), and plaque length > 1 cm (13.16% vs 5.92%, p = 0.0218). There was also a significant difference in plaque component in which both components (soft and calcified) and only soft plaques were more prevalent ipsilaterally (42.76% vs 23.68% and 17.76% vs 9.21%, respectively, p < .0001). Of the 152 patients, 17 patients were found to have a recurrent stroke event, and 47% (n = 8) had an ipsilateral stroke to the index event. Moreover, stroke was bilateral in 41% of the patients (n = 7), and contralateral in 12% (n = 2). CONCLUSION High-risk plaque features studied here were more prevalent ipsilaterally to the stroke side in ESUS than contralaterally. Multicenter studies are needed to form precise prediction models and scoring systems to help guide treatment, i.e., choice of medical therapy and/or revascularization.
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Affiliation(s)
- Ammar Jumah
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA.
| | - Hassan Aboul Nour
- Department of Vascular Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Osama Intikhab
- Department of Neuroradiology, Henry Ford Hospital, Detroit, MI, USA
| | - Omar Choudhury
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Karam Gagi
- Department of Neurology, Sparrow Hospital, Lansing, MI, USA
| | - Michael Fana
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Hisham Alhajala
- Department of Vascular Neurology, University of Toledo, Toledo, OH, USA
| | | | | | - Lara Eltous
- Jordan University of Science and Technology, Amman, Jordan
| | - Lonni Schultz
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI, USA
| | - Katie Latack
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI, USA
| | - Megan Brady
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Alex Chebl
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Horia Marin
- Department of Neuroradiology, Henry Ford Hospital, Detroit, MI, USA
| | - Daniel Miller
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
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Jumah A, Aboul Nour H, Fana M, Choudhury O, Eltous L, Zoghoul S, Jumah F, Alsrouji OK, Alhajala H, Intikhab O, Marin H, Chebl A, Miller D. The role of non-stenosing carotid artery plaques in embolic stroke of undetermined source, is it a silent offender? A review of literature. Interv Neuroradiol 2022:15910199221143172. [PMID: 36451548 DOI: 10.1177/15910199221143172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
PURPOSE Atherosclerotic cervical internal carotid artery disease is one of the major causes of ischemic stroke and transient ischemic attacks. The risk of stroke from mild to moderate stenoses (i.e. <50% stenosis) might be underestimated. There is increasing evidence that plaque morphological features reflect plaque instability that may harbor high risk for embolization. In this narrative review, we will review the literature on plaque features that predict vulnerability beyond the degree of stenosis, discuss the clinical association with stroke, and evaluate the evidence that these lesions serve as a source for embolic stroke of unknown source (ESUS). METHODS We performed a literature search using PubMed, EMBASE, and Web of Science. The terms "embolic stroke of undetermined source" and "plaque morphology" were used either alone or in combination with "non-flow limiting stenosis," "non-stenosing plaques," "high-risk plaque features" or "internal carotid artery plaque." Data on plaque morphology and ESUS were mainly taken from review articles, observational studies including retrospective cohort and cross-sectional studies, meta-analyses, and systematic reviews. CONCLUSION Nonstenosing carotid artery plaques with high-risk features carry a remarkable risk for stroke occurrence and randomized clinical trials are warranted for further evaluation of using carotid artery stenting or carotid endarterectomy to mitigate the risk of stroke.
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Affiliation(s)
- Ammar Jumah
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Hassan Aboul Nour
- Department of Vascular Neurology, Emory University Hospital, Atlanta, GA, USA
| | - Michael Fana
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Omar Choudhury
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Lara Eltous
- 37251Jordan University of Science and Technology, Irbid, Jordan
| | - Sohaib Zoghoul
- Department of Radiology, 36977Hamad Medical Corporation, Doha, Qatar
| | - Fareed Jumah
- Department of Neurosurgery, University of Missouri Hospital, Columbia, MO, USA
| | - Owais K Alsrouji
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Hisham Alhajala
- Department of Vascular Neurology, University of Toledo, Toledo, OH, USA
| | - Osama Intikhab
- Department of Interventional Neuroradiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Horia Marin
- Department of Neuroradiology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Alex Chebl
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Daniel Miller
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
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Prevalence of Symptomatic Nonstenotic Carotid Disease Using Simultaneous Non-Contrast Angiography and Intraplaque Hemorrhage Imaging for MR Screen Protocol. Diagnostics (Basel) 2022; 12:diagnostics12102321. [PMID: 36292010 PMCID: PMC9600452 DOI: 10.3390/diagnostics12102321] [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: 08/05/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 11/26/2022] Open
Abstract
Background: To determine the prevalence of symptomatic nonstenotic carotid disease (SyNC) using simultaneous non-contrast angiography and intraplaque hemorrhage (SNAP) imaging for patients with acute stroke as an MR screen protocol and to assess imaging findings of carotid plaques. Patients and Methods: From May 2020 to October 2021, 2459 patients with suspected acute neurological symptoms were evaluated with brain diffusion-weighted imaging (DWI) and carotid SNAP imaging. We analyzed the degree of stenosis and intraplaque hemorrhage (IPH) using SNAP imaging. Prevalence of SyNC and risk factors for stroke in patients with SyNC were determined. We performed subgroup multivariate analysis between SyNC and other etiologies of stroke (non-SyNC). Results: Of 4608 carotid arteries in 2304 patients enrolled in this study, 454 (9.9%) plaques (both lesions in 128 patients) were found on SNAP imaging. Of these plaques, 353 (77.8%) showed stenosis of <50%. Of plaques with <50% stenosis, 47 (13.3%) patients had a territorial acute focal infarction. Seventeen (36.2%) were classified with embolic stroke of undetermined source (ESUS) and SyNC. High maximal wall thickness and carotid IPH were identified as influencing factors for SyNC. Conclusion: For patients with <50% stenosis and territorial infarction, SyNC is a relatively important source of stroke. Especially, high maximal wall thickness and carotid IPH are important risk factors for SyNC.
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Baradaran H, Kamel H, Gupta A. The role of cross-sectional imaging of the extracranial and intracranial vasculature in embolic stroke of undetermined source. Front Neurol 2022; 13:982896. [PMID: 36090870 PMCID: PMC9459011 DOI: 10.3389/fneur.2022.982896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
Despite an extensive workup, nearly one third of ischemic strokes are defined as Embolic Stroke of Undetermined Source (ESUS), indicating that no clear etiologic cause has been identified. Since large vessel atherosclerotic disease is a major cause of ischemic stroke, we focus on imaging of large vessel atherosclerosis to identify further sources of potential emboli which may be contributing to ESUS. For a stroke to be considered ESUS, both the extracranial and intracranial vessels must have <50% stenosis. Given the recent paradigm shift in our understanding of the role of plaque vulnerability in ischemic stroke risk, we evaluate the role of imaging specific high-risk extracranial plaque features in non-stenosing plaque and their potential contributions to ESUS. Further, intracranial vessel-wall MR is another potential tool to identify non-stenosing atherosclerotic plaques which may also contribute to ESUS. In this review, we discuss the role of cross-sectional imaging of the extracranial and intracranial arteries and how imaging may potentially uncover high risk plaque features which may be contributing to ischemic strokes.
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Affiliation(s)
- Hediyeh Baradaran
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, United States
- *Correspondence: Hediyeh Baradaran
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, NY, United States
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, United States
| | - Ajay Gupta
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, United States
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
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10
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Characteristics of non-stenotic carotid plaque in embolic stroke of undetermined source compared with cardiogenic embolism: a retrospective cross-sectional observational study. BMC Neurol 2022; 22:315. [PMID: 36008791 PMCID: PMC9404624 DOI: 10.1186/s12883-022-02846-4] [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: 05/13/2022] [Accepted: 08/16/2022] [Indexed: 12/03/2022] Open
Abstract
Background Non-stenotic carotid plaque is considered an important etiology of embolic stroke of undetermined source (ESUS). However, only a few previous studies included a negative control group, and the characteristics of non-stenotic carotid plaque in ESUS have yet to be investigated. The objective of this study is to explore the clinical characteristics of ESUS and the correlation between non-stenotic carotid plaque and ESUS. Methods This is a single-center, retrospective cross-sectional observational study conducted to compare differences in clinical information among ESUS, CE, and large-artery atherosclerosis (LAA), as well as the prevalence of non-stenotic carotid plaque and non-stenotic carotid plaque with low echo between patients with ESUS and CE in Changzhou No.2 People’s Hospital from January 2020 to January 2022. Ultrasound was used to evaluate the characteristics of non-stenotic carotid plaque and vulnerable carotid plaque was defined as plaque with low echo. The binary logistic regression model was used to analyze the relationship between the characteristics of non-stenotic carotid plaque and ESUS. The receiver-operating characteristic curve was used to evaluate the diagnostic efficiency of the characteristics of non-stenotic carotid plaque for ESUS. Results We had a final studying population of 280 patients including 81 with ESUS, 37 with CE, and 162 with LAA. There were no differences in clinical features between ESUS and LAA, but in the comparison of CE and ESUS, there were differences in age, smoking, hypertension, levels of triglyceride, total cholesterol, and low density lipoprotein cholesterol. In ESUS, the prevalence of non-stenotic carotid plaque was more common on the ipsilateral side of stroke than in CE [55 (67.90%) vs. 18 (48.65%), p = 0.046], so was the prevalence of non-stenotic carotid plaque with low echo [38 (46.91%) vs. 5 (13.51%), p < 0.001]. Logistic regression analysis showed that the prevalence of non-stenotic carotid plaque (OR: 4.19; 95% CI: 1.45–12.11; p = 0.008) and the prevalence of non-stenotic carotid plaque with low echo (OR: 5.12; 95% CI: 1.55–16.93; p = 0.007) were, respectively, the independent predictors of ESUS. The results receiver-operating characteristic (ROC) curve showed that the combination of age, hypertension, and ipsilateral non-stenotic carotid plaque with low echo had the best diagnostic efficiency for ESUS (0.811; 95%CI: 0.727–0.896; p < 0.001). Conclusion Our results suggest that ipsilateral vulnerable non-stenotic carotid plaque is associated with ESUS in anterior circulation infarction.
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Singh N, Ospel J, Mayank A, Marko M, Zaidat OO, Mueller-Kronast NH, Liebeskind DS, Goyal M. Nonstenotic Carotid Plaques in Ischemic Stroke: Analysis of the STRATIS Registry. AJNR Am J Neuroradiol 2021; 42:1645-1652. [PMID: 34326103 DOI: 10.3174/ajnr.a7218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/27/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Few studies assess nonstenotic carotid plaques on CTA, and the causative role of these plaques in stroke is not entirely clear. We used CTA to determine the prevalence of nonstenotic carotid plaques (<50%), plaque features, and their association with ipsilateral strokes in patients with cardioembolic and cryptogenic strokes. MATERIALS AND METHODS Data were from the Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke (STRATIS) registry, a prospective, nonrandomized registry of patients undergoing thrombectomy with the Solitaire device. The prevalence of nonstenotic carotid plaques ipsilateral and contralateral to the stroke was compared in patients with cryptogenic and cardioembolic strokes. Plaque features were further compared within both subgroups between patients with and without ipsilateral stroke. Adjusted associations among nonstenotic carotid plaque, plaque characteristics, and ipsilateral stroke in both subgroups were determined with logistic regression. RESULTS Of the 946 patients in the data base, 226 patients with cardioembolic stroke (median age, 72 years) and 141 patients with cryptogenic stroke (median age, 69 years) were included in the analysis. The prevalence of nonstenotic carotid plaque in the cardioembolic and cryptogenic subgroups was 33/226 (14.6%) and 32/141 (22.7%), respectively. Bilateral nonstenotic carotid plaques were seen in 10/226 (4.4%) patients with cardioembolic and 13/141 (9.2%) with cryptogenic strokes. Nonstenotic carotid plaques were significantly associated with ipsilateral strokes in the cardioembolic stroke (adjusted OR = 1.91; 95% CI, 1.15-3.18) and the cryptogenic stroke (adjusted OR = 1.69; 95% CI, 1.05-2.73) groups. Plaque irregularity, hypodensity, and per-millimeter increase in plaque thickness were significantly associated with ipsilateral stroke in the cryptogenic subgroup. CONCLUSIONS Nonstenotic carotid plaques were significantly associated with ipsilateral stroke in cardioembolic and cryptogenic stroke groups, and there was an association of plaque irregularity and hypodense plaque with ipsilateral stroke in the cryptogenic group, suggesting these plaques could be a potential cause of stroke in these patient subgroups.
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Affiliation(s)
- N Singh
- From the Departments of Clinical Neurosciences (N.S., A.M., M.G.)
| | - J Ospel
- Department of Radiology (J.O.), University Hospital of Basel, Basel, Switzerland
| | - A Mayank
- From the Departments of Clinical Neurosciences (N.S., A.M., M.G.)
| | - M Marko
- Department of Neurology (M.M.), Medical University of Vienna, Vienna, Austria
| | - O O Zaidat
- Neuroscience Institute (O.O.Z.), Mercy Health St. Vincent Medical Center, Toledo, Ohio
| | - N H Mueller-Kronast
- Department of Neurology (N.H.M.-K.), Delray Medical Center, Delray Beach, Florida
| | - D S Liebeskind
- UCLA Comprehensive Stroke Center (D.S.L.), Los Angeles, California
| | - M Goyal
- From the Departments of Clinical Neurosciences (N.S., A.M., M.G.) .,Diagnostic Imaging (M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
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12
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Zhang DH, Jin JL, Zhu CF, Chen QY, He XW. Association between carotid artery perivascular fat density and cerebral small vessel disease. Aging (Albany NY) 2021; 13:18839-18851. [PMID: 34289452 PMCID: PMC8351687 DOI: 10.18632/aging.203327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 07/06/2021] [Indexed: 12/18/2022]
Abstract
Studies aiming to identify the significance of the carotid artery perivascular fat density are limited. The present study investigated the distribution pattern of pericarotid fat and its association with imaging markers of cerebral small vessel disease (CSVD). In total, 572 subjects who underwent both neck computed tomography angiography and cranial magnetic resonance imaging were analyzed. The pericarotid fat density near the origin of the internal carotid artery (ICA) and imaging markers of CSVD, such as lacunes, white matter hyperintensities (WMHs) and dilated perivascular spaces (PVSs), were assessed. We found that an increased pericarotid fat density was associated with the presence of lacunes and a higher WMH grade in all subjects, but in the patients with acute ischemic stroke, there was a difference only among the WMH grades. There was no significant difference in the pericarotid fat density in different grades of PVSs. The patients with acute ischemic stroke had a significantly higher mean pericarotid fat density than those without stroke. In conclusion, our study provides evidence suggesting that an increased pericarotid fat density is associated with the presence and degree of WMHs and lacunes. Our findings suggested that features that appear to extend beyond the vessel lumen of the ICA may be linked to CSVD.
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Affiliation(s)
- Dan-Hong Zhang
- Department of Neurology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou 317700, Zhejiang, China
| | - Jiao-Lei Jin
- Department of Neurology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou 317700, Zhejiang, China
| | - Cheng-Fei Zhu
- Department of Neurology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou 317700, Zhejiang, China
| | - Qiu-Yue Chen
- Department of Neurology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou 317700, Zhejiang, China
| | - Xin-Wei He
- Department of Neurology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou 317700, Zhejiang, China
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13
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Song JW, Cao Q, Siegler JE, Thon JM, Woo JH, Cucchiara BL. Sex Differences in Carotid Plaque Composition in Patients With Embolic Stroke of Undetermined Source. J Am Heart Assoc 2021; 10:e020143. [PMID: 33904317 PMCID: PMC8200747 DOI: 10.1161/jaha.120.020143] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background We examined sex differences in nonstenotic carotid plaque composition in patients with embolic stroke of undetermined source (ESUS). Methods and Results Patients with anterior circulation ischemic stroke imaged with neck computed tomographic angiography who met criteria for ESUS or had atrial fibrillation were identified. Patients with atrial fibrillation were included as a negative control. Semiautomated plaque quantification software analyzed carotid artery bifurcations. Plaque subcomponent (calcium, intraplaque hemorrhage [IPH], and lipid rich necrotic core) volumes were compared by sex and in paired analyses of plaque ipsilateral versus contralateral to stroke. Multivariate linear regressions tested for associations. Ninety‐four patients with ESUS (55% women) and 95 patients with atrial fibrillation (47% women) were identified. Men with ESUS showed significantly higher volumes of calcified plaque (63.9 versus 19.6 mm3, P<0.001), IPH (9.4 versus 3.3 mm3, P=0.008) and a IPH/lipid rich necrotic core ratio (0.17 versus 0.07, P=0.03) in carotid plaque ipsilateral to stroke side than women. The atrial fibrillation cohort showed no significant sex differences in plaque volumes ipsilateral to stroke. Multivariate analyses of the ESUS cohort showed male sex was associated with IPHipsi (β=0.49; 95% CI, 0.11–0.87) and calciumipsi (β=0.78; 95% CI, 0.33–1.23). Paired plaque analyses in men with ESUS showed significantly higher calcified plaque (63.9 versus 34.1 mm3, P=0.03) and a trend of higher IPHipsi (9.4 versus 7.5 mm3, P=0.73) and lipid rich necrotic coreipsi (59.0 versus 48.4 mm3, P=0.94) volumes. Conclusions Sex differences in carotid plaque composition in ESUS suggest the possibility of a differential contribution of nonstenosing carotid plaque as a stroke mechanism in men versus women.
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Affiliation(s)
- Jae W Song
- Department of Radiology University of Pennsylvania Philadelphia PA
| | - Quy Cao
- Department of Biostatistics University of Pennsylvania Philadelphia PA
| | - James E Siegler
- Cooper Neurologic Institute Cooper University Hospital Camden NJ
| | - Jesse M Thon
- Cooper Neurologic Institute Cooper University Hospital Camden NJ
| | - John H Woo
- Department of Radiology University of Pennsylvania Philadelphia PA
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14
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Tic Movement of Thyroid Cartilage as a Cause for Localized Cerebral Embolism: Mimics of Embolic Stroke of Undetermined Source with Non-Stenotic Carotid Plaque. J Stroke Cerebrovasc Dis 2020; 29:105197. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/07/2020] [Accepted: 07/21/2020] [Indexed: 11/21/2022] Open
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15
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Grosse GM, Sieweke JT, Biber S, Ziegler NL, Gabriel MM, Schuppner R, Worthmann H, Bavendiek U, Weissenborn K. Nonstenotic Carotid Plaque in Embolic Stroke of Undetermined Source: Interplay of Arterial and Atrial Disease. Stroke 2020; 51:3737-3741. [PMID: 33040704 DOI: 10.1161/strokeaha.120.030537] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Approximately one-sixth of all ischemic strokes are attributable to embolic stroke of undetermined source (ESUS). Recent analyses suggest that atrial cardiopathy and nonstenotic carotid plaque (nsCP) may represent 2 distinct underlying causes in patients with ESUS, although both diseases share common risk factors and are pathophysiologically intertwined. In this study, we, therefore, aimed to search for associations between nsCP and markers of atrial remodeling and function in patients with embolic stroke. METHODS Sixty-eight patients with ESUS or atrial fibrillation (AF)-related stroke proven by imaging who underwent comprehensive echocardiographic studies, including measurements of left atrial function and remodeling, were considered. Patients with ESUS underwent a follow-up of at least 1 year after index stroke. For 20 patients with ESUS, NT-proBNP (N-terminal pro-B-type natriuretic peptide) values were available. Presence of nsCP was evaluated considering Duplex sonography and computed tomography angiography and was further categorized in possibly or probably symptomatic nsCP. RESULTS ESUS patients with nsCP tended to have higher values of septal and lateral total atrial conduction times (P=0.071 and P=0.072, respectively), left atrial volume index (P=0.077), and revealed significantly higher strain rates during early diastole (P=0.013) as well as higher NT-proBNP values (P=0.010) than ESUS patients without nsCP. Moreover, septal total atrial conduction time was significantly longer in ESUS patients with possibly symptomatic nsCP compared with those without (P=0.015). Comparison of ESUS with AF patients revealed significantly higher proportions of nsCP (P=0.010), possibly symptomatic nsCP (P=0.037), and probably symptomatic nsCP (P=0.036) in patients with atrial fibrillation-related stroke. In the regression analysis adjusted for vascular risk factors probably symptomatic nsCP remained significantly associated with AF (P=0.048, odds ratio: 4.46 [95% CI, 1.02-19.56]). CONCLUSIONS Presence of nsCP is associated with AF and markers of left atrial disease in patients with embolic stroke. Therefore, a thorough evaluation regarding atrial cardiopathy and AF in patients with ESUS should not be restricted if nsCP are found, even if high-risk plaque characteristics are evident.
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Affiliation(s)
- Gerrit M Grosse
- Department of Neurology (G.M.G., S.B., N.L.Z., M.M.G., R.S., H.W., K.W.), Hannover Medical School, Germany
| | - Jan-Thorben Sieweke
- Department of Cardiology and Angiology (J.-T.S., S.B., U.B.), Hannover Medical School, Germany
| | - Saskia Biber
- Department of Neurology (G.M.G., S.B., N.L.Z., M.M.G., R.S., H.W., K.W.), Hannover Medical School, Germany.,Department of Cardiology and Angiology (J.-T.S., S.B., U.B.), Hannover Medical School, Germany
| | - Nora L Ziegler
- Department of Neurology (G.M.G., S.B., N.L.Z., M.M.G., R.S., H.W., K.W.), Hannover Medical School, Germany
| | - Maria M Gabriel
- Department of Neurology (G.M.G., S.B., N.L.Z., M.M.G., R.S., H.W., K.W.), Hannover Medical School, Germany
| | - Ramona Schuppner
- Department of Neurology (G.M.G., S.B., N.L.Z., M.M.G., R.S., H.W., K.W.), Hannover Medical School, Germany
| | - Hans Worthmann
- Department of Neurology (G.M.G., S.B., N.L.Z., M.M.G., R.S., H.W., K.W.), Hannover Medical School, Germany
| | - Udo Bavendiek
- Department of Cardiology and Angiology (J.-T.S., S.B., U.B.), Hannover Medical School, Germany
| | - Karin Weissenborn
- Department of Neurology (G.M.G., S.B., N.L.Z., M.M.G., R.S., H.W., K.W.), Hannover Medical School, Germany
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16
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Bulwa Z, Saleh Velez FG, Brorson JR, Pinto CB. Ipsilateral Nonstenotic Carotid Disease in Minor Ischemic Stroke: an Exploratory Analysis of The POINT Randomized Clinical Trial. J Stroke Cerebrovasc Dis 2020; 29:105115. [PMID: 33066893 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 06/25/2020] [Accepted: 06/28/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND AND AIM Ipsilateral nonstenotic carotid disease is increasingly recognized as an etiology of ischemic stroke, however tailored treatment strategies are lacking. We aimed to examine clinical characteristics and treatment effects in patients with minor ischemic stroke associated with ipsilateral nonstenotic carotid disease in the Platelet Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial. METHODS We performed an exploratory analysis of the interaction of the treatment effects of aspirin plus clopidogrel versus aspirin monotherapy, stratified by presence of ipsilateral nonstenotic carotid disease in patients with minor ischemic stroke in the POINT trial. RESULTS For this exploratory analysis, 167 patients presenting with ischemic stroke and ipsilateral nonstenotic carotid disease, defined as 1%-49% carotid stenosis ipsilateral to the corresponding territory of ischemic stroke, and 833 patients no carotid disease were included. Compared to patients with no carotid disease, patients with ipsilateral nonstenotic carotid disease were older (68.5 ± 11.3 years versus 61.3 ± 12.8 years; P < 0.001), and had a higher prevalence of hypertension (76.6% versus 59.2%, P < 0.001), ischemic heart disease (13.8% versus 5.4%, P < 0.001), and tobacco use (past: 34.1% versus 25.2%, P = 0.005; present: 27.5% versus 22.8%, P = 0.005). 5.4% of patients with ipsilateral nonstenotic carotid disease had recurrent ischemic stroke within 14 days. Patients receiving dual antiplatelet therapy had a numerical reduction in recurrent ischemic stroke compared to patients receiving aspirin monotherapy, however the exploratory analysis was underpowered to detect a statistically significant difference in treatment effect (HR 0.50, 95% CI 0.18-1.40, P = 0.19). CONCLUSION Patients with minor ischemic stroke and ipsilateral nonstenotic carotid disease had a high risk of early stroke recurrence in the POINT trial. Dual antiplatelet therapy provided a non-statistically significant reduction in recurrent ischemic stroke with no difference in safety outcomes compared to aspirin monotherapy. Further study is needed to determine if early and short duration dual antiplatelet therapy is beneficial for all patients with ipsilateral nonstenotic carotid disease.
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Affiliation(s)
- Zachary Bulwa
- Department of Neurology, University of Chicago Medical Center, 5841 South Maryland Avenue MC 2030, Chicago, IL 60637, USA.
| | - Faddi G Saleh Velez
- Department of Neurology, University of Chicago Medical Center, 5841 South Maryland Avenue MC 2030, Chicago, IL 60637, USA.
| | - James R Brorson
- Department of Neurology, University of Chicago Medical Center, 5841 South Maryland Avenue MC 2030, Chicago, IL 60637, USA.
| | - Camila B Pinto
- University of Sao Paulo, Institute of Psychology, Sao Paulo, Brazil.
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17
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Knight-Greenfield A, Quitlong Nario JJ, Vora A, Baradaran H, Merkler A, Navi BB, Kamel H, Gupta A. Associations Between Features of Nonstenosing Carotid Plaque on Computed Tomographic Angiography and Ischemic Stroke Subtypes. J Am Heart Assoc 2019; 8:e014818. [PMID: 31818209 PMCID: PMC6951053 DOI: 10.1161/jaha.119.014818] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Thromboembolism from nonstenosing carotid plaques may be an underrecognized cause of embolic strokes of undetermined source (ESUS). We evaluated the association between features of nonstenosing atherosclerotic plaque on computed tomographic angiography and ESUS. Methods and Results We identified consecutive acute ischemic stroke patients from 2011 to 2015 who had unilateral anterior territory infarction on brain magnetic resonance imaging and a neck computed tomographic angiography. We included ESUS cases and as controls, cardioembolic strokes. Patients with ≥50% internal carotid artery atherosclerotic stenosis ipsilateral to the stroke were excluded from this analysis. Reviewers blinded to infarct location and stroke cause retrospectively evaluated computed tomographic angiography studies for specific plaque features including thickness of the total, soft, and calcified plaque; presence of ulceration; and perivascular fat attenuation. Paired t tests and McNemar's test for paired data were used to compare plaque features ipsilateral versus contralateral to the side of infarction. Ninety‐one patients with ESUS or cardioembolic stroke were included in this study. Total plaque thickness was greater on the infarcted side (2.1±2.0 mm) than the contralateral side (1.2±1.5 mm) (P=0.006) among ESUS cases, but not among cardioembolic cases (1.9±1.6 mm versus 1.8±1.6 mm) (P=0.32). Conclusions Among ESUS cases, total plaque thickness was greater ipsilateral to the side of infarction than on the contralateral, stroke‐free side. No such side‐to‐side differences were apparent in cardioembolic strokes. Our findings suggest that nonstenosing large‐artery atherosclerotic plaques represent one underlying mechanism of ESUS.
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Affiliation(s)
| | | | - Amar Vora
- Department of Radiology Weill Cornell Medicine New York NY
| | | | - Alex Merkler
- Department of Radiology Weill Cornell Medicine New York NY.,Feil Family Brain and Mind Research Institute New York NY
| | - Babak B Navi
- Department of Radiology Weill Cornell Medicine New York NY.,Feil Family Brain and Mind Research Institute New York NY
| | - Hooman Kamel
- Department of Radiology Weill Cornell Medicine New York NY.,Feil Family Brain and Mind Research Institute New York NY
| | - Ajay Gupta
- Department of Radiology Weill Cornell Medicine New York NY.,Feil Family Brain and Mind Research Institute New York NY
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