Increased Angiogenesis and Angiogenic Gene Expression in Carotid Artery Plaques from Symptomatic Stroke Patients

Pathophysiology, cellular and molecular mechanisms of large and small vessel diseases

Cerebrovascular disease (CVD) is the second most common cause of cognitive impairment and dementia in aged population. CVD presents in a myriad number of clinical ways based on the functional location of pathology. While primary clinical emphasis has been placed on motor, speech and visual deficits, vascular cognitive decline is a vastly under recognized and devastating condition afflicting millions of Americans. CVD, a disease of the blood vessels that supply blood to brain involves an integration between small and large vessels. Cerebral large vessel diseases (LVD) are associated with atherosclerosis, artery-to-artery embolism, intracardiac embolism and a large vessel stroke leading to substantial functional disability. Cerebral small vessel disease (SVD) is critically involved in stroke, brain hemorrhages, cognitive decline and functional loss in elderly patients. An evolving understanding of cellular and molecular mechanisms emphasizes that inflammatory vascular changes contribute to systemic pathologic conditions of the central nervous systems (CNS), with specific clinical presentations including, cognitive decline. Advances in an understanding of pathophysiology of disease processes and therapeutic interventions may help improve outcomes. This review will focus on large and small vessels diseases and their relationship to vascular cognitive decline, atherosclerosis, stroke, and inflammatory neurodegeneration. We will also emphasize the molecular and cellular mechanisms, as well as genetic and epigenetic factors associated with LVD and SVD.

Attenuation Coefficient Parameter Computations for Tissue Composition Assessment of Carotid Atherosclerotic Plaque in Vivo

Quantitative ultrasound has been used to assess carotid plaque tissue composition. Here, we compute the attenuation coefficient (AC) in vivo with the optimum power spectral shift estimator (OPSSE) and reference phantom method (RPM), extract AC parameters and form parametric maps. Differences between OPSSE and RPM AC parameters are computed. Relationships between AC parameters, surgical scores and histopathology assessments are examined. Kendall's τ correlations between OPSSE AC and surgical scores are significant, including those between cholesterol and Standard Deviation (adjusted p = 0.038); thrombus and Minimum (adjusted p = 0.002), Maximum (adjusted p = 0.021) and Standard Deviation (adjusted p = 0.001); ulceration and Average (adjusted p = 0.033), Median (unadjusted p = 0.013), Maximum (unadjusted p = 0.039) and Mode (adjusted p = 0.009). The strongest correlations with histopathology are percentage cholesterol and Median OPSSE (unadjusted p = 0.007); percentage hemorrhage and Minimum OPSSE (adjusted p < 0.001); hemosiderin score and Median OPSSE (adjusted p = 0.010); and percentage calcium and Percentage Non-physical RPM Pixels (unadjusted p = 0.014). Kruskal-Wallis H and Dunn's post hoc tests have the ability to distinguish between groups (p < 0.05). Results suggest AC parameters may assist in vivo evaluation of carotid plaque vulnerability.

The Preservation of Cognition 1 Year After Carotid Endarterectomy in Patients With Prior Cognitive Decline

BACKGROUND

Vascular cognitive decline is critically important in the course of atherosclerosis and stroke.

OBJECTIVE

To explore the hypothesis that carotid endarterectomy (CEA) by removing an unstable plaque may slow the course of vascular cognitive decline in both symptomatic and asymptomatic patients.

METHODS

Patients with clinically significant (>60%) carotid stenosis were studied preop and 1 yr post-CEA for clinical symptoms, vascular cognitive decline, instability of carotid plaque-presence of microemboli, brain white matter changes, and medical risk factors.

RESULTS

Forty-six percent were classically symptomatic. All patients showed vascular cognitive decline at presentation which correlated with degree of plaque instability. Significant white matter hyperintensity changes (48.7%) and cerebral emboli (25%) were also seen at baseline in both classically symptomatic and asymptomatic. One year after CEA, both groups showed no decline in cognitive function and significant improvement in 2 tests (P = .028 and P = .013). Brain white matter hyperintensities were unchanged. Microemboli were reduced but remained present (17.86%). Improvement was predicted by the presence of hypertension (P = .001), or less advanced cognitive decline preoperatively (P = .009).

CONCLUSION

This study demonstrates the importance of vascular cognitive decline in atherosclerotic disease. This is a function of the degree of instability of the atherosclerotic plaque more than the presence of stroke symptoms. It further suggests that atherosclerotic vascular cognitive decline need not be inevitable, and may be modified by treating hypertension and removal of the unstable plaque. This highlights the need for continued research on the cognitive effects of cerebrovascular disease and the synergistic benefits of intensive medical and surgical therapy.

Carotid atherosclerotic plaque instability and cognition determined by ultrasound-measured plaque strain in asymptomatic patients with significant stenosis

OBJECTIVE This article describes the use of ultrasound measurements of physical strain within carotid atherosclerotic plaques as a measure of instability and the potential for vascular cognitive decline, microemboli, and white matter changes. METHODS Asymptomatic patients with significant (> 60%) carotid artery stenosis were studied for dynamic measures of plaque instability, presence of microemboli, white matter changes, and vascular cognitive decline in comparison with normative controls and premorbid state. RESULTS Although classically asymptomatic, these patients showed vascular cognitive decline. The degree of strain instability measured within the atherosclerotic plaque directly predicted vascular cognitive decline in these patients thought previously to be asymptomatic according to classic criteria. Furthermore, 26% of patients showed microemboli, and patients had twice as much white matter hyperintensity as controls. CONCLUSIONS These data show that physical measures of plaque instability are possible through interpretation of ultrasound strain data during pulsation, which may be more clinically relevant than solely measuring degree of stenosis. The data also highlight the importance of understanding that the definition of symptoms should not be limited to motor, speech, and vision function but underscore the role of vascular cognitive decline in the pathophysiology of carotid atherosclerotic disease. Clinical trial registration no.: NCT02476396 (clinicaltrials.gov).

Transcranial Doppler and Microemboli Detection: Relationships to Symptomatic Status and Histopathology Findings

The purpose of this study was to determine the relationship between symptomatic status, transcranial Doppler (TCD) microemboli presence and plaque histopathology findings. TCD was performed on 60 patients (37 symptomatic, 23 asymptomatic) before undergoing clinically indicated carotid endarterectomy. The frequency of microemboli signals was not significantly different between symptomatic and asymptomatic subject groups (p = 0.88) and there were no differences observed in the macroscopic or histopathology scoring of these plaques (p-values all > 0.05). The presence of microemboli was associated with an ulceration score (regardless of symptomatic or asymptomatic status, p = 0.034), with a one-level increase in ulceration rating associated with an odds ratio of 5.86 (95% [CI] 1.55, 43.4). These findings suggest that both symptomatic and asymptomatic patients may have plaque with similar features of instability and ability to create emboli. Thus, identifying new ways to measure plaque instability may provide important information for optimizing treatment to prevent future stroke.

Histopathologic Validation of Grayscale Carotid Plaque Characteristics Related to Plaque Vulnerability

Inflammation and angiogenesis play major roles in carotid plaque vulnerability. The purpose of this study was to determine whether gray-scale features of carotid plaques are associated with histologic markers for inflammation. Thirty-eight individuals completed a dedicated research carotid ultrasound exam before carotid endarterectomy. Gray-scale analysis was performed on plaque images to measure plaque echogenicity (gray-scale median [GSM] pixel brightness), plaque area, presence of discrete white areas (DWAs) and the percent of black area near the lumen on any one component of the plaque. Plaques with higher ultrasound GSM had greater percent calcification (p = 0.013) on histopathology. Presence of an ultrasound DWA was associated with more plaque hemosiderin (p = 0.0005) and inflammation (p = 0.019) on histopathology examination. The percent of plaque black area in any one component was associated with a higher score for macroscopic ulceration (p = 0.028). Ultrasound plaque characteristics (GSM, DWAs and black areas) represent histopathologic markers associated with plaque vulnerability. ClinicalTrials.gov identifier: NCT02476396.

[Immunohistochemical study of the role of mast cells and macrophages in the process of angiogenesis in the atherosclerotic plaques in patients with metabolic syndrome]

OBJECTIVE

to analyze the histotopographic distribution of neogenic vessels, the degree of mast cell degranulation, the expression of markers of macrophages in different types of plaques in different stages and in different arterial vessels in patients with atherosclerosis and in those with metabolic syndrome associated with atherosclerosis and to establish the role of mast cells and macrophages in the development of stages of atherosclerosis along with their diagnostic and prognostic value.

MATERIAL AND METHODS

Fragments of the thoracic and abdominal aorta, middle cerebral, carotid, renal, and iliac, and vertebral arteries from 34 persons who had died from atherosclerosis (n=17) and atherosclerotic complications due to metabolic syndrome (n=17) were examined. The investigators employed standard techniques, such as hematoxylin-eosin or orcein staining; silver impregnation. They used immunohistochemical staining with anti-mast cell tryptase (anti-MCT) for the determination of mast cells, the specific markers CD68 for macrophages, and CD105 (endoglin) for neogenic vessels.

RESULTS

The immunohistochemical technique is effective in identifying mast cells, macrophages, and neogenic vessels in atherosclerotic plaques. They were found in many types of atherosclerotic plaques, advantium, and subendothelial layers in the immediate vicinity of the plaques. There was a statistical correlation between the types of plaques and clinical data, which is of importance in elucidating the specific features of the pathogenesis of atherosclerosis in patients with metabolic syndrome.

CONCLUSION

CD105 is a sensitive marker for neogenic endothelial cells, an effective indicator of microvascular activation and proliferation in the atherosclerotic plaques. Neovascularization in the plaques frequently begins in the intima, progresses, and gives rise to their further destabilization. Anti-MCT staining used to reveal mast cells and CD68 for macrophages can elucidate the important patterns of development of atherosclerosis and its complications in patients with metabolic disturbances.

Intraplaque neovascularization as a novel therapeutic target in advanced atherosclerosis

INTRODUCTION

Atherosclerosis is a lipid-driven inflammatory process with a tremendously high mortality due to acute cardiac events. There is an emerging need for new therapies to stabilize atherosclerotic lesions. Growing evidence suggests that intraplaque (IP) neovascularisation and IP hemorrhages are important contributors to plaque instability.

AREAS COVERED

Neovascularization is a complex process that involves different growth factors and inflammatory mediators of which their individual significance in atherosclerosis remains poorly understood. This review discusses different aspects of IP neovascularization in atherosclerosis including the potential treatment opportunities to stabilize advanced plaques. Furthermore, we highlight the development of accurate and feasible in vivo imaging modalities for IP neovascularization to prevent acute events.

EXPERT OPINION

Although lack of a valuable animal model of IP neovascularization impeded the investigation of a causal and straightforward link between neovascularization and atherosclerosis, recent evidence shows that vein grafts in ApoE*3 Leiden mice as well as plaques in ApoE(-/-) Fbn1(C1039G+/-) mice are useful models for intraplaque neovessel research. Even though interference with vascular endothelial growth factor (VEGF) signalling has been widely investigated, new therapeutic opportunities have emerged. Cell metabolism, in particular glycolysis and fatty acid oxidation, appears to perform a crucial role in the development of IP neovessels and thereby serves as a promising target.

Improved Correlation of Strain Indices with Cognitive Dysfunction with Inclusion of Adventitial Layer with Carotid Plaque

Plaque instability may lead to chronic embolization, which in turn may contribute to progressive cognitive decline. Accumulated strain tensor indices over a cardiac cycle within a pulsating carotid plaque may be viable biomarkers for the diagnosis of plaque instability. Using plaque-only carotid artery segmentations, we recently demonstrated that impaired cognitive function correlated significantly with maximum axial and lateral strain indices within a localized region of interest in plaque. Inclusion of the adventitial layer focuses our strain or instability measures on the vessel wall-plaque interface hypothesized to be a region with increased shearing forces and measureable instability. A hierarchical block-matching motion tracking algorithm developed in our laboratory was used to estimate accumulated axial, lateral, and shear strain distribution in plaques identified with the plaque-with-adventitia segmentation. Correlations of strain indices to the Repeatable Battery for the Assessment of Neuropsychological Status Total score were performed and compared with previous results. Overall, correlation coefficients (r) and significance (p) values improved for axial, lateral, and shear strain indices. Shear strain indices, however, demonstrated the largest improvement. The Pearson correlation coefficients for maximum shear strain and cognition improved from the previous plaque-only analyses of -0.432 and -0.345 to -0.795 and -0.717 with the plaque-with-adventitia segmentation for the symptomatic group and for all patients combined, respectively. Our results demonstrate the advantage of including adventitia for ultrasound carotid strain imaging providing improved association to parameters assessing cognitive impairment in patients. This supports theories of the importance of the vessel wall plaque interface in the pathophysiology of embolic disease.

Cognitive Deficits in Symptomatic and Asymptomatic Carotid Endarterectomy Surgical Candidates

The role played by vessel disease in stroke-related cognition dysfunction is unclear. We assessed the impact of significant atherosclerotic disease on cognition-even in patients asymptomatic for stroke. We hypothesized that patients would perform poorly relative to controls, but that symptomatic/asymptomatic status (history of stroke/transient ischemic attack) would have no effect. Fifty-two carotid endarterectomy candidates with >60% carotid stenosis and 17 controls underwent a 60-min neuropsychological test protocol. Symptomatic and asymptomatic patients showed deficits in executive function, delayed verbal recall, and general knowledge. Patients symptomatic for stroke also performed worse on tests of language and motor/visuomotor ability. Symptomatic and asymptomatic patients differed in working memory and language task performance. Although all patients showed deficits in executive function and memory, only symptomatic patients showed additional deficits in language and motor function. Cognitive abnormalities in patients viewed as "asymptomatic" for stroke underscore the need for early identification and treatment.

The relationship between carotid artery plaque stability and white matter ischemic injury

Higher local carotid artery strain has previously been shown to be a characteristic of unstable carotid plaques. These plaques may be characterized by microvascular changes that predispose to intraplaque hemorrhage, increasing the likelihood of embolization. Little is known however, about how these strain indices correspond with imaging markers of brain health and metrics of brain structure. White matter hyperintensities (WMHs), which are bright regions seen on T2-weighted brain MRI imaging, are postulated to result from cumulative ischemic vascular injury. Consequently, we hypothesized that plaques that are more prone to microvascular changes and embolization, represented by higher strain indices on ultrasound, would be associated with an increased amount of WMH lesion volume. This relationship would suggest not only emboli as a cause for the brain degenerative changes, but more importantly, a common microvascular etiology for large and small vessel contributions to this process. Subjects scheduled to undergo a carotid endarterectomy were recruited from a neurosurgery clinic. Prior to surgery, participating subjects underwent both ultrasound strain imaging and brain MRI scans as part of a larger clinical study on vascular health and cognition. A linear regression found that maximum absolute strain and peak to peak strain in the surgical side carotid artery were predictive of WMH burden. Furthermore, the occurrence of microembolic signals monitored using transcranial Doppler (TCD) ultrasound examinations also correlated with increasing lesion burden. It is becoming increasingly recognized that cognitive decline is often multifactorial in nature. One contributing extra-brain factor may be changes in the microvasculature that produce unstable carotid artery plaques. In this study, we have shown that higher strain indices in carotid artery plaques are significantly associated with an increased WMH burden, a marker of vascular mediated brain damage.

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We examine how carotid artery plaque strain indices correspond with MRI metrics.

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Strain in the ICA predicts increased white matter hyperintensity lesion burden.

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Subjects with embolizing plaques have greater white matter lesion burden.

Carotid Revascularization: An Update

Symptomatic extracranial internal carotid artery stenosis poses a high short-time risk of ischemic cerebral stroke, as high as 20% to 30% in the first three months. Timely performed carotid endarterectomy (CEA) has been shown to be highly effective in reducing this risk although, in recent years, there has been great interest in replacing this procedure with less invasive carotid angioplasty and stenting (CAS). In this update we review recent studies and provide recommendations regarding the indications, methods and timing of surgical intervention as well as the anaesthetic management of CEA, and we report on recently published randomized controlled trials comparing CEA to CAS. We also provide recommendations regarding the sometime neglected but important medical management of patients undergoing carotid intervention, including antithrombotic and antihypertension therapy, lipid lowering agents, assistance with smoking cessation, and diabetes control.

All's well that transcribes well: non-coding RNAs and post-stroke brain damage

The mammalian genome is replete with various classes of non-coding (nc) RNA genes. Many of them actively transcribe, and their relevance to CNS diseases is just beginning to be understood. CNS is one of the organs in the body that shows very high ncRNAs activity. Recent studies demonstrated that cerebral ischemia rapidly changes the expression profiles of different classes of ncRNAs: including microRNA, long noncoding RNA and piwi-interacting RNA. Several studies further showed that post-ischemic neuronal death and/or plasticity/regeneration can be altered by modulating specific microRNAs. These studies are of interest for therapeutic development as they may contribute to identifying new ncRNA targets that can be modulated to prevent secondary brain damage after stroke.

Upregulation of ANGPTL4 messenger RNA and protein in severely calcified carotid plaques

BACKGROUND

In carotid atherosclerotic lesions, calcified plaques are thought to be stable and to evoke very few symptoms. However, the molecular activity in calcified plaques and their clinical significance have not been fully clarified yet.

METHODS

Carotid plaques from 18 endarterectomy patients were classified into high- and low-calcified plaques on the basis of Agatston calcium score. Twelve plaques were investigated for the alteration of gene expression by microarray analysis and real-time polymerase chain reaction (PCR) and 6 other plaques underwent protein assessment to elucidate the difference in molecular biological activity between the groups.

RESULTS

Microarray analysis demonstrated 93 angiogenesis or growth factor-related transcripts that are reliably expressed (175 probe sets). Among them, angiopoietin-like protein 4 (ANGPTL4) expression was significantly elevated, whereas fibroblast growth factor receptor 2 (FGFR2) expression was significantly suppressed. Quantitative messenger RNA analysis was performed with real-time PCR. Augmented or decreased protein expression of each gene was confirmed by Western blotting analysis and immunohistochemistry.

CONCLUSIONS

In high-calcified plaques, ANGPTL4 might be upregulated for antiangiogenic modulating function together with the downregulation of FGFR2, contributing to the stability of the plaques.

Profiling of atherosclerotic lesions by gene and tissue microarrays reveals PCSK6 as a novel protease in unstable carotid atherosclerosis

OBJECTIVE

Carotid plaque instability is a major cause of ischemic stroke, but detailed knowledge about underlying molecular pathways is still lacking. Here, we evaluated large-scale transcriptomic and protein expression profiling in a biobank of carotid endarterectomies followed by characterization of identified candidates, as a platform for discovery of novel proteins differentially regulated in unstable carotid lesions.

APPROACH AND RESULTS

Genes highly upregulated in symptomatic versus asymptomatic plaques were selected from Affymetrix microarray analyses (n=127 plaques), and tissue microarrays constructed from 34 lesions were assayed for 21 corresponding proteins by immunohistochemistry. Quantification of stainings demonstrated differential expression of CD36, CD137, and DOCK7 (P<0.05) in unstable versus stable lesions and the most significant upregulation of a proprotein convertase, PCSK6 (P<0.0001). Increased expression of PCSK6 in symptomatic lesions was verified by quantitative real-time polymerase chain reaction (n=233), and the protein was localized to smooth muscle α-actin positive cells and extracellular matrix of the fibrous cap by immunohistochemistry. PCSK6 expression positively correlated to genes associated with inflammation, matrix degradation, and mitogens in microarrays. Stimulation of human carotid smooth muscle cells in vitro with cytokines caused rapid induction of PCSK6 mRNA.

CONCLUSIONS

Using a combination of transcriptomic and tissue microarray profiling, we demonstrate a novel approach to identify proteins differentially expressed in unstable carotid atherosclerosis. The proprotein convertase PCSK6 was detected at increased levels in the fibrous cap of symptomatic carotid plaques, possibly associated with key processes in plaque rupture such as inflammation and extracellular matrix remodeling. Further studies are needed to clarify the role of PCSK6 in atherosclerosis.

Histologically unstable asymptomatic carotid plaques have altered expression of genes involved in chemokine signalling leading to localised plaque inflammation and rupture

BACKGROUND

Many studies have evaluated histological and gene expression profiles in TIA/stroke patients after onset of symptoms, but there is limited understanding as to how these plaque related features interact before symptom onset. In particular, no studies have evaluated differential gene expression in histologically unstable (vs stable plaques) in neurologically asymptomatic patients.

METHODS

Nine asymptomatic patients had their plaques scored blindly by two independent Histopathologists using the AHA plaque scoring system. RNA extracted from the plaques was hybridised onto a whole genome microarray. Analysis was performed using GenomeStudio (v1.0) and the DAVID bioinformatics resource (v6.7).

RESULTS

Three plaques were histologically unstable (Grade 2/3), while six were stable (Grade 0/1). 346 differentially expressed genes (>1.3 fold, P < 0.05) were identified (293 down-regulated and 53 up-regulated) between stable and unstable plaques. Genes related to chemokine and protein signalling (pro-inflammatory/pro-apoptotic) were identified to have high enrichment scores (>1.3) and were significantly up-regulated in unstable (asymptomatic) plaques.

CONCLUSION

The findings confirm the intuitively held belief that changes in chemokine and protein signalling may be associated with acute plaque disruption and precede the onset of symptoms. Once validated, these genes could therefore become targets for innovative medical treatments in the future or could help identify asymptomatic patients with histologically unstable plaques that would benefit from surgical intervention.

Impaired cognitive function in patients with atherosclerotic carotid stenosis and correlation with ultrasound strain measurements

INTRODUCTION

It has been postulated that up to 11 million "silent" strokes occur annually. While these patients are without classic neurologic deficits, they may exhibit cognitive decline. In this study, we examine the cognitive function of patients with carotid stenosis. Additionally, we evaluate a noninvasive measure of strain in pulsating carotid artery plaques to determine its ability to predict cognitive decline.

METHODS

We administered the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) to 44 patients with carotid stenosis. All patients had stenosis meeting NASCET or ACAS criteria for endarterectomy, and were classified as symptomatic or asymptomatic as defined by these publications. Age-adjusted scores for each of the 5 RBANS domains (immediate memory, visuospatial ability, language, attention, and delayed memory) were compared between symptomatic and asymptomatic patients. Mean score for each of the 5 domains was then compared to all other domains, regardless of symptom status. From this cohort, 23 patients underwent assessment of carotid plaque strain by tracking displacements in ultrasound radiofrequency data to estimate axial and principal strains over the cardiac cycle.

RESULTS

Thirty symptomatic and 14 asymptomatic patients were studied. Visuospatial scores were significantly lower than any other domain regardless of symptoms (p<0.05 for all pairwise comparisons). No other domain score was significantly different from any other. In the language domain, asymptomatic patients scored significantly higher than symptomatic patients (p<0.05. For all other domains, no difference was found. Asymptomatic patients showed a relationship between plaque strain and immediate memory (r=-.61, p=ns). Left carotid disease was associated with poorer performance across multiple cognitive domains with increasing accumulated strain. This was not seen in right carotid disease.

CONCLUSION

Patients with large carotid plaques (>70% stenosis) exhibit significant difficulties in mental status whether classically symptomatic or asymptomatic. While language deficits may be a non-specific marker for stroke symptoms, visuospatial deficits are seen before classic symptoms, suggesting that carotid disease may become symptomatic earlier and more subtly than previously suspected. Abnormal strain distribution with pulsation may be related to cognition.

Neuropeptide Y receptors in carotid plaques of symptomatic and asymptomatic patients: effect of inflammatory cytokines

AIMS

Cytokines released by the immune cells at the site of plaque milieu induce smooth muscle cell apoptosis to promote plaque instability. But, neuropeptide Y (NPY), a pleotropic factor, may modulate the effects of cytokines in atherosclerotic plaques of patients with carotid stenosis. Our aim was to investigate the relative expression of NPY-Y1, NPY-Y2 and NPY-Y5 receptors on carotid plaque vascular smooth muscle cells (pVSMCs) of symptomatic (S) and asymptomatic (AS) patients and examine the effect of inflammatory cytokines on the expression of NPY receptors, that may attenuate plaque rupture.

METHODS AND RESULTS

In healthy carotid artery, there were significantly increased immunopositivity and increased mRNA transcripts of NPY-Y1 and NPY-Y5 receptors in thin sections and isolated VSMCs, respectively, compared to S and AS plaques. However, the NPY-Y2 expression was higher in S and AS pVSMCs than controls. Stimulation of the cells with TNF-α, IL-12 or IFN-γ (50 ng/ml) decreased mRNA transcripts of NPY-Y1 and NPY-Y5 and increased NPY-Y2 mRNAs in VSMCs of healthy carotid artery. The effect of the cytokines on mRNA transcripts of NPY-Y5 and NPY-Y2 in pVSMCs of S and AS patients was similar to healthy VSMCs, but with variable effect on NPY-Y1.

CONCLUSION

Increased expression of NPY-Y2 receptors in symptomatic pVSMCs than in healthy and asymptomatic subjects suggests a potential role of NPY-Y2 in plaque instability. This is further supported by the pronounced effect of atheroma-associated cytokines to increase NPY-Y2 mRNA transcripts in pVSMCs of patients with carotid stenosis.

A review of carotid atherosclerosis and vascular cognitive decline: a new understanding of the keys to symptomology

This review encourages the reader to consider cerebral vascular disease beyond the traditional clinical end points of major motor and speech strokes and to consider the possible impact of embolic cerebral vascular disease on vascular cognitive decline. This article examines the issue of "silent" strokes in the relationship between the structural stability of atherosclerotic carotid plaque and the development of nonmotor symptomatology, including cognitive decline. It addresses the question of the role of carotid emboli in silent stroke and their cognitive sequelae. In a study of endarterectomy patients, we relate plaque elasticity and its development of mechanical strain features and thinning of stabilizing fibrous cap at the point of these mechanical strain features. The possibility that microemboli from such mechanically unstable carotid plaques could contribute to silent strokes led to a study of cognitive function in such patients. A linear relationship between the process of mechanically unstable areas of carotid plaques and cognitive decline suggests a contributory role for such a process in silent strokes.

Enhanced TLR4 endothelial cell immunohistochemical expression in symptomatic carotid atherosclerotic plaques

BACKGROUND AND PURPOSE

Toll-like receptor-4 (TLR4) has been linked to the pathogenesis of atherosclerosis. Carotid atheroma endothelial cells (ECs) express TLR4, nevertheless correlations with cerebrovascular symptomatology, epidemiological and clinical variables remain unresolved.

METHODS

Carotid atherosclerotic plaques were obtained by standard carotid endarterectomy from 157 patients with carotid artery disease (84 asymptomatic - Group A, 73 symptomatic - Group B). TLR4 expression was detected by immunohistochemistry and TLR4 positivity, overexpression and intensity of immunostaining in ECs were correlated with cerebrovascular symptomatology, epidemiological and clinical variables.

RESULTS

A significant association was found between TLR4 positivity in ECs and the occurrence of any cerebrovascular event (overall response (OR): 2.85, 95% CI 1.33 - 6.11, p = 0.009). TLR4 overexpression and staining intensity in ECs were both significantly enhanced in symptomatic patients (p < 0.0001 and p = 0.003, respectively). These associations were stronger for the occurrence of a major cerebrovascular accident (CVA) compared with a transient ischemic attack (TIA) or amaurosis fugax. TLR4 expression in ECs was less prominent in statin users (OR: 0.25, 95%CI 0.1 - 0.58, p = 0.001], while it was enhanced in restenotic plaques compared with primary atherosclerotic lesions (p = 0.012).

CONCLUSIONS

TLR4 expression in ECs of carotid atheroma was enhanced in symptomatic patients with most commonly 'unstable' - 'more prone to rupture' carotid plaques.

The use of contrast enhanced ultrasound in carotid arterial disease

Traditionally, stroke risk stratification has centred on the degree of internal carotid artery stenosis, and the presence of focal neurological symptoms. However, degree of stenosis alone is a relatively poor predictor of future stroke in asymptomatic patients; the Asymptomatic Carotid Surgery Trial highlighting the need to identify a subgroup of asymptomatics that may benefit from intervention. Attempting to define this subgroup has inspired imaging research to identify, in vivo, high-risk plaques. In addition to pre-operative risk stratification of carotid stenosis, contrast enhanced ultrasound (CEUS) may be employed in monitoring response to plaque-stabilising therapies. Unlike most contrast agents used for computed tomography and magnetic resonance imaging, microbubbles used in CEUS remain within the vascular space and can hence be used to study the vasculature. In addition to improving current carotid structural scans, CEUS has potential to add extra information on plaque characteristics. Furthermore, by targeting microbubbles to specific ligands expressed on vascular endothelium, CEUS may have the ability to probe plaque biology. This review describes the current carotid ultrasound examination and the need to improve it, rationale for imaging neovascularisation, use of CEUS to image neovascularisation, microbubbles in improving the structural imaging of plaque, potential problems with CEUS, and future directions.

In vivo attenuation and equivalent scatterer size parameters for atherosclerotic carotid plaque: preliminary results

We have previously reported on the equivalent scatterer size, attenuation coefficient, and axial strain properties of atherosclerotic plaque ex vivo. Since plaque structure and composition may be damaged during a carotid endarterectomy procedure, characterization of in vivo properties of atherosclerotic plaque is essential. The relatively shallow depth of the carotid artery and plaque enables non-invasive evaluation of carotid plaque utilizing high frequency linear-array transducers. We investigate the ability of the attenuation coefficient and equivalent scatterer size parameters to differentiate between calcified, and lipidic plaque tissue. Softer plaques especially lipid rich and those with a thin fibrous cap are more prone to rupture and can be classified as unstable or vulnerable plaque. Preliminary results were obtained from 10 human patients whose carotid artery was scanned in vivo to evaluate atherosclerotic plaque prior to a carotid endarterectomy procedure. Our results indicate that the equivalent scatterer size obtained using Faran's scattering theory for calcified regions are in the 120-180 microm range while softer regions have larger equivalent scatterer size distribution in the 280-470 microm range. The attenuation coefficient for calcified regions as expected is significantly higher than that for softer regions. In the frequency bandwidth ranging from 2.5 to 7.5 MHz, the attenuation coefficient for calcified regions lies between 1.4 and 2.5 dB/cm/MHz, while that for softer regions lies between 0.3 and 1.3 dB/cm/MHz.

CD105 positive neovessels are prevalent in early stage carotid lesions, and correlate with the grade in more advanced carotid and coronary plaques

Background

Previous studies have demonstrated that expression of CD105 is a sensitive marker and indicator of endothelial cell/microvessel activation and proliferation in aggressive solid tumour growth and atherosclerotic plaque lesions. Since intimal neovascularization contributes significantly to subsequent plaque instability, haemorrhage and rupture.

Methods

We have used immunohistochemical analysis to investigate the expression of CD105-positive vessels in both large (carotid) and medium calibre (coronary and middle cerebral artery, MCAs) diseased vessels in an attempt to identify any correlation with plaque growth, stage and complication/type.

Results

Here we show, that carotid arteries expressed intimal neovascularization associated with CD105-positive endothelial cells, concomitant with increased inflammation in early stage lesions, preatheroma (I-III) whilst they were not present in coronary plaques of the same grade. Some of these CD105-positive neovessels were immature, thin walled and without smooth muscle cell coverage making them more prone to haemorrhage and rupture. In high-grade lesions, neovessel proliferation was similar in both arterial types and significantly higher numbers of CD105-positive vasa vasorum were associated with plaque regions in coronary arteries. In contrast, although the MCAs exhibited expanded intimas and established plaques, there were very few CD105 positive neovessels.

Conclusion

Our results show that CD105 is a useful marker of angiogenesis within adventitial and intimal vessels and suggest the existence of significant differences in the pathological development of atherosclerosis in separate vascular beds which may have important consequences when considering management and treatment of this disease.

Identification of pro-angiogenic markers in blood vessels from stroked-affected brain tissue using laser-capture microdissection

Background

Angiogenesis correlates with patient survival following acute ischaemic stroke, and survival of neurons is greatest in tissue undergoing angiogenesis. Angiogenesis is critical for the development of new microvessels and leads to re-formation of collateral circulation, reperfusion, enhanced neuronal survival and improved recovery.

Results

Here, we have isolated active (CD105/Flt-1 positive) and inactive (CD105/Flt-1 minus (n=5) micro-vessel rich-regions from stroke-affected and contralateral tissue of patients using laser-capture micro-dissection. Areas were compared for pro- and anti-angiogenic gene expression using targeted TaqMan microfluidity cards containing 46 genes and real-time PCR. Further analysis of key gene de-regulation was performed by immunohistochemistry to define localization and expression patterns of identified markers and de novo synthesis by human brain microvessel endothelial cells (HBMEC) was examined following oxygen-glucose deprivation (OGD). Our data revealed that seven pro-angiogenic genes were notably up-regulated in CD105 positive microvessel rich regions. These were, beta-catenin, neural cell adhesion molecule (NRCAM), matrix metalloproteinase-2 (MMP-2), tissue inhibitor of matrix metalloproteinase-1 (TIMP-1), hepatocyte growth factor-alpha (HGF-alpha), monocyte chemottractant protein-1 (MCP-1) and and Tie-2 as well as c-kit. Immunohistochemistry demonstrated strong staining of MMP-2, HGF-alpha, MCP-1 and Tie-2 in stroke-associated regions of active remodeling in association with CD105 positive staining. In vitro, OGD stimulated production of Tie-2, MCP-1 and MMP-2 in HBMEC, demonstrated a de novo response to hypoxia.

Conclusion

In this work we have identified concurrent activation of key angiogenic molecules associated with endothelial cell migration, differentiation and tube-formation, vessel stabilization and stem cell homing mechanisms in areas of revascularization. Therapeutic stimulation of these processes in all areas of damaged tissue might improve morbidity and mortality from stroke.

Increased PrPC expression correlates with endoglin (CD105) positive microvessels in advanced carotid lesions

Normal cellular prion protein (PrP(C)) has multiple functions but its role in the development of atherosclerosis has not been studied. Our pilot microarray data showed increased expression of PrP(C) in tissue samples of complicated carotid lesions. Therefore in this study, we aimed to investigate its localisation within atherosclerotic arteries and its concentration in patient plasma. PrP(C) expression was examined using an enzyme immunometric assay (EIA) in plasma from patients undergoing endarterectomy. Carotid specimens and control vascular transplants were studied for PrP(C) and CD105 (endoglin, a marker of active vessels) expression by immunohistochemistry and real-time PCR. Patients with carotid disease had higher levels of plasma PrP(C) than the control group [4.35 ng/ml (n = 22; 3.1-5.3) vs. 1.95 ng/ml (n = 21; 1.1-2.5), P < 0.001]. Furthermore, CD105-positive plaques had higher PrP(C) expression which colocalized with CD105 in neovessels. There was a significant correlation between mRNA expression of PrP(C) and CD105 in tested plaques (P < 0.001; r = 0.7) supporting our immunohistochemical findings. We conclude that PrP(C) is expressed in carotid specimens and may be associated with neovessel growth or survival in these plaques. Our results suggest a role for PrP(C) in modulating neovessel formation in complicated plaques.

Relationship between ultrasonic attenuation, size and axial strain parameters for ex vivo atherosclerotic carotid plaque

Many ultrasonic parameters, primarily related to attenuation and scatterer size, have been used to characterize the composition of atherosclerotic plaque tissue. In this study, we combine elastographic (axial strain ratio) and ultrasonic tissue characterization parameters, namely the attenuation coefficient and a scattering parameter associated with an "equivalent" scatterer size to delineate between fibrous, calcified, and lipidic plaque tissue. We present results obtained from 44 ex vivo atherosclerotic plaque specimens obtained after carotid endarterectomy on human patients. Our results in the frequency range 2.5 - 7.5 MHz indicate that softer plaques (with higher values of the strain ratio) are usually associated with larger equivalent scatterer size estimates (200 - 500 microm) and lower values of the attenuation coefficient slope (<1 dB/cm/MHz). On the other hand, stiffer plaques (with lower strain ratio values) are associated with smaller equivalent scatterer size estimates (100 - 200 microm) and higher values of the attenuation coefficient slope (1 - 3 dB/cm/MHz). These results indicate that ultrasonic tissue characterization and strain parameters have the potential to differentiate between different plaque types. These parameters can be estimated from radio-frequency data acquired under in vivo conditions and may help the clinician decide on appropriate interventional techniques.

Expression of hypoxia-inducible angiogenic proteins (hypoxia-inducible factor-1alpha, vascular endothelial growth factor, and E26 transformation-specific-1) and plaque hemorrhage in human carotid atherosclerosis

OBJECT

Plaque hemorrhage in carotid atherosclerosis promotes plaque progression, resulting in cerebrovascular disease. Hypoxia inducible factor-1alpha (HIF-1alpha) induces angiogenesis via the expression of vascular endothelial growth factor (VEGF) and E26 transformation-specific-1 (Ets-1). The authors investigated human carotid plaques to determine whether these hypoxia-inducible angiogenic proteins play a major role in intraplaque angiogenesis and hemorrhage.

METHODS

The expression of HIF-1alpha, VEGF, and Ets-1 was analyzed using immunohistochemistry and Western blotting in 29 human carotid plaques obtained at carotid endarterectomy. The authors investigated the relationship between plaque characteristics and clinical symptoms.

RESULTS

A higher incidence of plaque hemorrhage was observed in plaques associated with symptoms than in those without symptoms (p = 0.03). Hypoxia-inducible factor-1alpha, VEGF, and Ets-1 coexisted in the deep layer of plaque, where angiogenesis was remarkably developed; the expression levels of HIF-1alpha, VEGF, and Ets-1 were significantly enhanced in the main lesion of the plaque (p < 0.01). Symptomatic plaques showed higher expression of VEGF (p = 0.04) than asymptomatic plaques. Plaques with hemorrhage showed a higher incidence of plaque ulcer (p = 0.001) and higher expression of Ets-1 (p = 0.03) than those without hemorrhage. Moreover, significantly increased expressions of VEGF (p = 0.01) and Ets-1 (p = 0.006) were observed in plaques with not only hemorrhages but also ulcers and severe stenosis.

CONCLUSIONS

The findings in this study suggest that hypoxia-inducible angiogenic proteins in human carotid atherosclerosis promote intraplaque angiogenesis, which can induce plaque hemorrhage and progression.

The relationship between serum levels of vascular calcification inhibitors and carotid plaque vulnerability

OBJECTIVE

Osteopontin (OPN) and osteoprotegerin (OPG) are well-known vascular calcification inhibitors, which have been recently demonstrated to correlate with inflammation and cardiovascular events incidence. The aim of this cross-sectional study is to survey whether OPN and OPG are involved in carotid plaque vulnerability. For this reason, we assessed serum OPN and OPG levels in patients with carotid stenosis, and we explored their relationship with carotid plaque echogenicity and subsequent cerebrovascular ischemic events.

METHODS

A total of 164 Whites were selected from a large cohort of 297 subjects to participate. In particular, 114 patients (61 men, 53 women), aged 55 to 80, had recently-diagnosed ICA stenosis higher than 50%. A group of 50 age-, sex-, and body mass index (BMI)-matched healthy individuals served as healthy controls. Patients with renal failure, hypothyroidism, osteoporosis, and lipid-lowering therapy were excluded. Images of both carotids were obtained from all participants using a high-resolution color duplex ultrasound and the gray-scale median (GSM) score was calculated. Brain computed tomography (CT), and magnetic resonance imaging (MRI) scans when CT was questionable, were performed on all patients with carotid stenosis. Clinical parameters, lipid and glycemic indexes, hsCRP, fibrinogen, white blood cells (WBC) count, OPN, and OPG were measured. Independent t test, one-way ANOVA, Pearson correlation, and multiple regression analysis were used for statistical analysis.

RESULTS

Among patients with carotid stenosis, 60 had history of ipsilateral stroke or TIA and positive CT or MRI findings (group A), while 54 had no neurological symptoms and negative CT and MRI scan (group B). Overall, patients with carotid stenosis showed worse lipid profile and increased waist circumference, blood pressure, hsCRP, fibrinogen, WBC count, OPN, and OPG levels compared with healthy subjects (group C) (P <.05). Statistical analysis revealed that group A had significantly lower levels of GSM than group B (57.41 +/- 38.19 vs 76.32 +/- 36.72; P = .008) and higher levels of hsCRP, OPN, and OPG than groups B and C (P < .05). Concerning the latter, biochemical markers group B showed only elevated OPG levels compared with group C (P = .038). Notably, GSM was considerably associated with serum OPN and OPG and waist circumference in patients with carotid atherosclerosis in univariate (r = -0.333; P = .032, r = -0.575; P < .001, r = -0.590; P =.006, respectively) and multiple regression analysis (R(2) = 0.445; P =.006).

CONCLUSIONS

The present study demonstrated elevated serum OPN and OPG levels in patients with carotid stenosis and documented an independent association between these biochemical markers, GSM and carotid-induced symptomatology. Therefore bone-matrix proteins combined with GSM could be potential markers for vulnerable carotid plaques.