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Shimonaga K, Ikedo T, Yamada N, Niwa A, Kushi Y, Hamano E, Yamada K, Imamura H, Mori H, Hatakeyama K, Iihara K, Kataoka H. Plaque Ulcerations are Associated with Recurrence in Symptomatic Low-Grade Carotid Stenosis. World Neurosurg 2024; 183:e886-e891. [PMID: 38218448 DOI: 10.1016/j.wneu.2024.01.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 01/08/2024] [Indexed: 01/15/2024]
Abstract
OBJECTIVE Surgical indications for low-grade carotid stenosis have not yet been established. This study aimed to clarify the characteristics of low-grade carotid stenosis refractory to medical treatment. METHODS We retrospectively analyzed 48 patients with symptomatic low-grade carotid stenosis (<50%). Recurrence was defined as an ipsilateral ischemic event in the symptomatic lesions during the follow-up period. Patient demographics and imaging findings were compared between the recurrence and nonrecurrence groups to investigate risk factors associated with medical treatment. RESULTS The mean age was 74.1 (58-90 years), and the mean follow-up period was 35.4 months (2.0-97 months). Recurrence occurred in 15 of the symptomatic patients. Ulceration was significantly associated with recurrence under medical treatment (P = 0.001). The median time to recurrence was 26.1 months in patients with ulcers and 54.3 months in those without ulcers (P = 0.04). Pathological study with recurrence showed plaque rupture with multilayered lesions, indicating lesions refractory to medical treatment. CONCLUSIONS In cases of low-grade carotid stenosis, lesions with ulcerations are likely refractory to medical therapy. Consideration of the indications for surgical treatment may be warranted for lesions with ulceration, even if the degree of stenosis is low.
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Affiliation(s)
- Koji Shimonaga
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan.
| | - Taichi Ikedo
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Naoto Yamada
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akihiro Niwa
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuji Kushi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Eika Hamano
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kiyofumi Yamada
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hisae Mori
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kinta Hatakeyama
- Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Koji Iihara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
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2
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Nardi V, Benson JC, Larson AS, Brinjikji W, Saba L, Meyer FB, Lanzino G, Lerman A, Savastano LE. Carotid artery endarterectomy in patients with symptomatic non-stenotic carotid artery disease. Stroke Vasc Neurol 2022; 7:251-257. [PMID: 35241631 PMCID: PMC9240461 DOI: 10.1136/svn-2021-000939] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 04/08/2021] [Indexed: 11/09/2022] Open
Abstract
Object We sought to determine the safety and efficacy in secondary stroke prevention of carotid endarterectomy (CEA) in patients with symptomatic non-stenotic carotid artery disease (SyNC). Methods This was a single-centre retrospective case series. All patients who underwent CEA for unilateral anterior circulation cerebrovascular events with ipsilateral <50% carotid stenosis from 2002 to 2020 were included. Imaging hallmarks including the degree of luminal stenosis and the presence of various vulnerable plaque characteristics (eg, intraplaque haemorrhage (IPH) on MR angiography, ulceration or low-density plaque on CT angiography) were assessed. The presence of vulnerable plaque characteristics was compared between arteries ipsilateral to the ischaemic event and contralateral arteries. The prevalence of perioperative/intraoperative complications, as well as recurrent ischaemic events at follow-up was determined. Results Thirty-two patients were included in the analysis, of which 25.0% were female. Carotid arteries ipsilateral to an ischaemic event had a significantly higher prevalence of IPH when compared with contralateral arteries (80.0% vs 0.0%; p<0.001). There were no intraoperative complications. One patient (3.1%) developed symptoms of transient ipsilateral ischaemia 1 day following CEA which resolved without treatment. In a median follow-up of 18.0 months (IQR 5.0–36.0), only one patient (3.1%) experienced a transient neurologic deficit with complete resolution (annualised rate of recurrent stroke after CEA of 1.5% for a total follow-up of 788 patient-months following CEA). All other patients (31/32, 96.9%) were free of recurrent ischaemic events. Conclusion CEA appears to be safe and well-tolerated in patients with SyNC. Additional studies with larger cohorts and longer follow-up intervals are needed in order to determine the role of CEA in this patient population.
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Affiliation(s)
- Valentina Nardi
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Luca Saba
- Radiology, Azienda Ospedaliero Universitaria, Cagliari, Italy
| | | | | | - Amir Lerman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
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3
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Larson A, Nardi V, Brinjikji W, Benson JC, Lanzino G, Savastano L. Endarterectomy for symptomatic non-stenotic carotids: a systematic review and descriptive analysis. Stroke Vasc Neurol 2022; 7:6-12. [PMID: 34244446 PMCID: PMC8899633 DOI: 10.1136/svn-2021-001122] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/22/2021] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To systematically analyse prior reports of carotid endarterectomy (CEA) performed in cases of ≤50% carotid stenosis in order to understand patient tolerance and potential benefit. METHODS A systematic review and descriptive analysis was performed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An English-language search was performed of online databases using librarian-selected search terms. Abstracts were reviewed for relevance which included mention of carotid endarterectomy and stenosis. Prospective or retrospective observational cohort studies that reported series of patients who underwent endarterectomy for minimal (≤50%) luminal stenosis with reported outcomes were included. RESULTS Six studies (which included our institutional series) with a total of 143 patients met the inclusion criteria. The weighted mean age at the time of CEA was 72.3 years; 113 (79.0%) were male. 55.8% of patients with available data had recurrent ipsilateral ischaemic events despite medical therapy. Two patients out of 129 with available perioperative data (1.6%) had perioperative MRI findings of acute ischaemic stroke, both within the hemisphere contralateral to the side of CEA. Of the 138 patients with available follow-up (mean, 36 months), none had recurrent ipsilateral ischaemic events. CONCLUSIONS Endarterectomy for symptomatic carotid disease causing ≤50% stenosis may be a potentially beneficial strategy to prevent stroke recurrence. Studies with robust methodology are needed to draw more definitive conclusions in terms of the safety and efficacy of endarterectomy for minimal stenosis with vulnerable features relative to intensive medical therapy.
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Affiliation(s)
- Anthony Larson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Valentina Nardi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
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4
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Nardi V, Benson J, Bois MC, Saba L, Larson AS, Özcan I, Ahmad A, Morse DW, Meyer FB, Brinjikji W, Lanzino G, Lerman LO, Savastano LE, Lerman A. Carotid Plaques From Symptomatic Patients With Mild Stenosis Is Associated With Intraplaque Hemorrhage. Hypertension 2022; 79:271-282. [PMID: 34878895 DOI: 10.1161/hypertensionaha.121.18128] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Carotid plaque vulnerability features beyond the degree of stenosis may play a key role in the pathogenesis and recurrence of ischemic cerebrovascular events. This study sought to compare intraplaque hemorrhage (IPH) as a marker of plaque vulnerability in symptomatic patients with mild (<50%), moderate (50%-69%), and severe (≥70%) carotid artery stenosis. We included patients who experienced ischemic cerebrovascular events with no other identifiable sources and underwent carotid endarterectomy for mild (n=32), moderate (n=47), and severe (n=58) carotid artery stenosis. The degree of stenosis and imaging hallmarks were assessed by computed tomography angiography or magnetic resonance angiography. Plaque specimens were stained with hematoxylin and eosin and Movat pentachrome staining. Carotid plaques of patients with mild stenosis had a higher extent of IPH (%) on tissue analysis compared with patients with moderate (mild, 15.7% [interquartile range, 7.8%-26.7%]; moderate, 3.9% [0.0%-9.2%]; P<0.001) and severe carotid artery stenosis (mild, 15.7% [interquartile range, 7.8%-26.7%]; severe, 2.5% [interquartile range, 0.0%-11.2%]; P<0.001). When considering the degree of carotid artery stenosis as a continuous variable, a lower lumen narrowing was associated with higher extent of IPH (P<0.001; R, -0.329). Our major finding is the association of IPH with mild carotid artery stenosis based on histological analysis. The current study may suggest that IPH potentially plays a role in the mechanism of stroke in patients with nonobstructive carotid stenosis.
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Affiliation(s)
- Valentina Nardi
- Department of Cardiovascular Medicine (V.N., I.Ö., A.A., D.W.M., A.L.), Mayo Clinic, Rochester, MN
| | - John Benson
- Department of Radiology (J.C.B., A.S.L., W.B.), Mayo Clinic, Rochester, MN
| | - Melanie C Bois
- Department of Laboratory Medicine and Pathology (M.C.B.), Mayo Clinic, Rochester, MN
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria, Cagliari, Italy (L.S.)
| | - Anthony S Larson
- Department of Radiology (J.C.B., A.S.L., W.B.), Mayo Clinic, Rochester, MN
| | - Ilke Özcan
- Department of Cardiovascular Medicine (V.N., I.Ö., A.A., D.W.M., A.L.), Mayo Clinic, Rochester, MN
| | - Ali Ahmad
- Department of Cardiovascular Medicine (V.N., I.Ö., A.A., D.W.M., A.L.), Mayo Clinic, Rochester, MN
| | - David W Morse
- Department of Cardiovascular Medicine (V.N., I.Ö., A.A., D.W.M., A.L.), Mayo Clinic, Rochester, MN
| | - Fredric B Meyer
- Department of Neurologic Surgery (F.B.M., G.L., L.E.S.), Mayo Clinic, Rochester, MN
| | - Waleed Brinjikji
- Department of Radiology (J.C.B., A.S.L., W.B.), Mayo Clinic, Rochester, MN
| | - Giuseppe Lanzino
- Department of Neurologic Surgery (F.B.M., G.L., L.E.S.), Mayo Clinic, Rochester, MN
| | - Lilach O Lerman
- Department of Nephrology and Hypertension (L.O.L.), Mayo Clinic, Rochester, MN
| | - Luis E Savastano
- Department of Neurologic Surgery (F.B.M., G.L., L.E.S.), Mayo Clinic, Rochester, MN
| | - Amir Lerman
- Department of Cardiovascular Medicine (V.N., I.Ö., A.A., D.W.M., A.L.), Mayo Clinic, Rochester, MN
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5
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Truong M, Håkansson C, HaileMichael M, Svensson J, Lätt J, Markenroth Bloch K, Siemund R, Gonçalves I, Wassélius J. The potential role of T2*-weighted multi-echo data image combination as an imaging marker for intraplaque hemorrhage in carotid plaque imaging. BMC Med Imaging 2021; 21:121. [PMID: 34380454 PMCID: PMC8356411 DOI: 10.1186/s12880-021-00652-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/14/2021] [Indexed: 01/14/2023] Open
Abstract
Background Carotid atherosclerotic plaques with intraplaque hemorrhage (IPH) are associated with elevated stroke risk. IPH is predominantly imaged based on paramagnetic properties of the upstream hemoglobin degradation product methemoglobin. This is an explorative observational study to test the feasibility of a spoiled gradient echo based T2* weighted MRI sequence (3D MEDIC) for carotid plaque imaging, and to compare signs suggestive of the downstream degradation product hemosiderin on 3D MEDIC with signs of methemoglobin on a T1wBB sequence.
Methods Patients with recent TIA or stroke were selected based on the presence on non-calcified plaque components on CTA to promote an enriched prevalence of IPH in the material. Patients (n = 42) underwent 3T MRI with 3D MEDIC and 2D turbo spin echo T1w black blood (T1wBB). Images were independently evaluated by two neuroradiologists and Cohens Kappa was used for inter-reader agreement for each sequence. Results The technical feasibility for 3D MEDIC, was 34/42 patients (81%). Non-calcified plaque components with susceptibility effect without simultaneous T1-shortening—a combination suggestive of hemosiderin, was seen in 13/34 of the plaques. An equally large group display elevated T1w signal in combination with signal loss on 3D MEDIC, a combination suggestive of both hemosiderin and methemoglobin. Cohen’s kappa for inter-reader agreement was 0.64 (CI 0.345–0.925) for 3D MEDIC and 0.94 (CI 0.81–1.00) for T1wBB. Conclusions 3D MEDIC shows signal loss, without elevated T1w signal on T1wBB, in non-calcified tissue in many plaques in this group of patients. If further studies, including histological verification, confirm that the 3D MEDIC susceptibility effect is indeed caused by hemosiderin, 3D MEDIC could aid in the detection of IPH, beyond elevation of T1w signal.
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Affiliation(s)
- My Truong
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Claes Håkansson
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Makda HaileMichael
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
| | - Jonas Svensson
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden.,Medical Radiation Physics, Department of Translational Medicine, Lund University , Lund, Sweden
| | - Jimmy Lätt
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
| | | | - Roger Siemund
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Isabel Gonçalves
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö , Sweden
| | - Johan Wassélius
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden. .,Department of Clinical Sciences, Lund University, Lund, Sweden. .,Department of Radiology, Skåne University Hospital, 221 85, Lund, Sweden.
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Fülesdi B, Farkas S, Gyöngyösi Z, Siró P, Bereczki D, Bacsó J, Csiba L. Correlation between calcium, water contents and ultrasonographic appearance of atherosclerotic lesions of carotid artery lesions. Transl Neurosci 2020; 11:269-276. [PMID: 33335767 PMCID: PMC7712159 DOI: 10.1515/tnsci-2020-0115] [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: 04/20/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 11/23/2022] Open
Abstract
Background We tested the hypothesis whether there is a correlation between the echogenicity and calcium and water contents of carotid plaques. Patients and methods Ninety carotid befurcations from 45 deceased patients were removed during autopsy. Thirty-four plaques were categorized as homogenous echolucent (HEL), homogenous echogenic (HEG) and heterogenous (HE) plaques based on premortem B-mode image. Water content was expressed in % of wet weight. Ca was determined by proton-induced X-ray emission and expressed in ppm. Relative optical density of the B-mode images was analyzed offline using a computer program. Results HEL plaques had lower Ca content (medians and IQRs: 6,145 [4,465–6,536 ppm]) compared to HEG (74,100 [15,300–1,44,500−ppm]), P ≤ 0.001). HE plaques showed an intermediate calcium content (7,310 [4,840–9,920 ppm]) that was statistically not different from echolucent plaques. Water content of HEG plaques was statistically not different from HEL and HE (HEG:53.5 [35.5–64%], HEL: 73.5 [69.7–78.5%], HE: 70.6 [67.4–73.9%]). HEG plaques had the highest relative optical densities (196 [188–217%]). HEL and HE had similar relative optical densities (HEL: 176 [164–187%], HE: 164 [144–188%], respectively). A significant positive correlation was found between the Ca content and relative optical density of plaques. Conclusions Echogenicity of carotid plaques increases along with their calcium content. Water content may be an important factor in differentiation of different plaques.
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Affiliation(s)
- Béla Fülesdi
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Division of Neurointensive Care and Neuroanesthesia, University of Debrecen, H_4032 Debrecen, Nagyerdei krt. 98, Hungary
| | - Szabolcs Farkas
- Department of Neurology, University of Debrecen, Debrecen, Hungary
| | - Zoltán Gyöngyösi
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Division of Neurointensive Care and Neuroanesthesia, University of Debrecen, H_4032 Debrecen, Nagyerdei krt. 98, Hungary
| | - Péter Siró
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Division of Neurointensive Care and Neuroanesthesia, University of Debrecen, H_4032 Debrecen, Nagyerdei krt. 98, Hungary
| | - Dániel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Budapest, Hungary
| | - József Bacsó
- Insitute of Nuclear Research, Hungarian Academy of Sciences, Debrecen, Hungary
| | - László Csiba
- Department of Neurology, University of Debrecen, Debrecen, Hungary
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7
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Yoshida K, Yang T, Yamamoto Y, Kurosaki Y, Funaki T, Kikuchi T, Ishii A, Kataoka H, Miyamoto S. Expansive carotid artery remodeling: possible marker of vulnerable plaque. J Neurosurg 2020; 133:1435-1440. [PMID: 31585432 DOI: 10.3171/2019.7.jns19727] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 07/12/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Accumulated findings in the pathophysiology of atherosclerosis have demonstrated that not only luminal narrowing but also plaque characteristics influence the risk of future ischemic events. The morphology of the carotid artery (CA) changes in response to atherosclerotic development by expansive remodeling (ER), the clinical significance of which remains unclear. This study aimed to define associations between ER and local risk factors, including CA geometry and traditional systemic risk factors for ischemic events, to determine whether ER could serve as a clinical marker of carotid vulnerable plaque. METHODS The authors retrospectively analyzed 66 patients with CA stenosis who were scheduled to undergo carotid endarterectomy or CA stenting. They calculated ER ratios in the internal CA (ICA) from long-axis MR images and as the maximal distance between the lumen and the outer borders of the plaque perpendicular to the axis of the ICA/the maximal luminal diameter of the distal ICA at a region unaffected by atherosclerosis. Relative overall signal intensity (roSI) was calculated to assess intraplaque hemorrhage and defined as the signal intensity of plaque on an axial T1-weighted image with maximal stenosis relative to that of the adjacent sternocleidomastoid muscle. The authors evaluated CA geometry by calculating the angles between the common CA (CCA) and ICA, and between the CCA and external CA (ECA) using digital subtraction angiography. The ER ratios, age, sex, percentage of stenosis, roSI, hypertension, hyperlipidemia, low-density lipoprotein, statin medication, diabetes, smoking habit, and ischemic heart disease were compared between 33 symptomatic and 33 asymptomatic patients. The authors also compared symptomatic status, age, sex, percentage of stenosis, ICA angle, ECA angle, roSI, and other traditional atherosclerotic risk factors between groups with extensive and slight ER. RESULTS The ER ratio was significantly greater in symptomatic than in asymptomatic patients (1.91 ± 0.46 vs 1.68 ± 0.40, p < 0.05). The ICA angle was significantly larger in the group with extensive ER than in those with slight ER (33.9° ± 20.2° vs 21.7° ± 13.8°, p < 0.01). The roSI, ECA angle, percentage stenosis, or any other traditional vascular risk factors were not associated with ER. CONCLUSIONS Carotid ER might be an independent indicator of carotid vulnerable plaque, which should be validated in a longitudinal study of patients with carotid atherosclerosis, including those with nonstenotic to moderate stenosis.
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Affiliation(s)
- Kazumichi Yoshida
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto; and
| | - Tao Yang
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto; and
| | - Yu Yamamoto
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto; and
| | | | - Takeshi Funaki
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto; and
| | - Takayuki Kikuchi
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto; and
| | - Akira Ishii
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto; and
| | - Hiroharu Kataoka
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto; and
| | - Susumu Miyamoto
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto; and
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8
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Abstract
OBJECTIVES Embolic ischemic strokes cause significant mortality and morbidity worldwide. It has been proposed that some of these strokes are due to unstable carotid plaques with intraplaque hemorrhage (IPH) but a low overall degree of stenosis. Our aim was to test a fat-saturated T1-weighted (T1WI) black-blood sequence on MRI for the detection of IPH in symptomatic individuals and to quantify the relation between IPH, severity of stenoses, and ischemic brain lesions. MATERIALS AND METHODS Sixty-two patients were examined by 3T MRI. Sequences included brain diffusion-weighted imaging (DWI) as well as 3D turbo spin echo (TSE) fat-saturated black-blood T1 of the carotid bifurcations, to detect IPH as a focal intraplaque hyperintensity. Both carotid arteries were analyzed in each patient. The North American Symptomatic Carotid Endarterectomy Trial scale was used for quantification of stenosis degree. RESULTS Thirty-six out of 62 patients (mean age, 74) showed brain ischemia on DWI. Fifteen of these 36 patients (42%) had associated ipsilateral IPH at the carotid bifurcation or the proximal internal carotid artery. Mean degree of stenosis in this group was 50%. In 21 patients with ischemia without IPH, the mean degree of stenosis was 44%. CONCLUSIONS MRI with 3D TSE fat-saturated black-blood T1 technique is a safe, reliable, and noninvasive tool for the detection of IPH. A high percentage (42%) of ischemic events in patients with low- to moderate-degree stenosis were associated with IPH, an easily detectable imaging biomarker of plaque vulnerability. The ability to confirm IPH by MRI may help stratify patients into different risk and treatment groups in the future.
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9
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Singh N, Marko M, Ospel JM, Goyal M, Almekhlafi M. The Risk of Stroke and TIA in Nonstenotic Carotid Plaques: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2020; 41:1453-1459. [PMID: 32646945 DOI: 10.3174/ajnr.a6613] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 04/29/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Severe carotid stenosis carries a high risk of stroke. However, the risk of stroke with nonstenotic carotid plaques (<50%) is increasingly recognized. PURPOSE We aimed to summarize the risk of TIA or stroke in patients with nonstenotic carotid plaques. DATA SOURCES We performed a comprehensive systematic review and meta-analysis in patients with acute ischemic stroke in whom carotid imaging was performed using MEDLINE and the Cochrane Database, including studies published up to December 2019. STUDY SELECTION Included studies had >10 patients with <50% carotid plaques on any imaging technique and reported the incidence or recurrence of ischemic stroke/TIA. High-risk plaque features and the risk of progression to stenosis >50% were extracted if reported. DATA SYNTHESIS We identified 31 studies reporting on the risk of ipsilateral stroke/TIA in patients with nonstenotic carotid plaques. Twenty-five studies (n = 13,428 participants) reported on first-ever stroke/TIA and 6 studies (n = 122 participants) reported on the recurrence of stroke/TIA. DATA ANALYSIS The incidence of first-ever ipsilateral stroke/TIA was 0.5/100 person-years. The risk of recurrent stroke/TIA was 2.6/100 person-years and increased to 4.9/100 person-years if intraplaque hemorrhage was present. The risk of progression to severe stenosis (>50%) was 2.9/100 person-years (8 studies, n = 448 participants). LIMITATIONS Included studies showed heterogeneity in reporting stroke etiology, the extent of stroke work-up, imaging modalities, and classification systems used for characterizing carotid stenosis. CONCLUSIONS The risk of recurrent stroke/TIA in nonstenotic carotid plaques is not negligible, especially in the presence of high-risk plaque features. Further research is needed to better define the significance of nonstenotic carotid plaques for stroke etiology.
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Affiliation(s)
- N Singh
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - M Marko
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada.,Department of Neurology (M.M.), Medical University of Vienna, Vienna, Austria
| | - J M Ospel
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology (J.M.O.), University Hospital of Basel, Basel, Switzerland
| | - M Goyal
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - M Almekhlafi
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
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10
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Schindler A, Schinner R, Altaf N, Hosseini AA, Simpson RJ, Esposito-Bauer L, Singh N, Kwee RM, Kurosaki Y, Yamagata S, Yoshida K, Miyamoto S, Maggisano R, Moody AR, Poppert H, Kooi ME, Auer DP, Bonati LH, Saam T. Prediction of Stroke Risk by Detection of Hemorrhage in Carotid Plaques: Meta-Analysis of Individual Patient Data. JACC Cardiovasc Imaging 2020; 13:395-406. [PMID: 31202755 DOI: 10.1016/j.jcmg.2019.03.028] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 03/20/2019] [Accepted: 03/24/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The goal of this study was to compare the risk of stroke between patients with carotid artery disease with and without the presence of intraplaque hemorrhage (IPH) on magnetic resonance imaging. BACKGROUND IPH in carotid stenosis increases the risk of cerebrovascular events. Uncertainty remains whether risk of stroke alone is increased and whether stroke is predicted independently of known risk factors. METHODS Data were pooled from 7 cohort studies including 560 patients with symptomatic carotid stenosis and 136 patients with asymptomatic carotid stenosis. Hazards of ipsilateral ischemic stroke (primary outcome) were compared between patients with and without IPH, adjusted for clinical risk factors. RESULTS IPH was present in 51.6% of patients with symptomatic carotid stenosis and 29.4% of patients with asymptomatic carotid stenosis. During 1,121 observed person-years, 66 ipsilateral strokes occurred. Presence of IPH at baseline increased the risk of ipsilateral stroke both in symptomatic (hazard ratio [HR]: 10.2; 95% confidence interval [CI]: 4.6 to 22.5) and asymptomatic (HR: 7.9; 95% CI: 1.3 to 47.6) patients. Among patients with symptomatic carotid stenosis, annualized event rates of ipsilateral stroke in those with IPH versus those without IPH were 9.0% versus 0.7% (<50% stenosis), 18.1% versus 2.1% (50% to 69% stenosis), and 29.3% versus 1.5% (70% to 99% stenosis). Annualized event rates among patients with asymptomatic carotid stenosis were 5.4% in those with IPH versus 0.8% in those without IPH. Multivariate analysis identified IPH (HR: 11.0; 95% CI: 4.8 to 25.1) and severe degree of stenosis (HR: 3.3; 95% CI: 1.4 to 7.8) as independent predictors of ipsilateral stroke. CONCLUSIONS IPH is common in patients with symptomatic and asymptomatic carotid stenosis and is a stronger predictor of stroke than any known clinical risk factors. Magnetic resonance imaging might help identify patients with carotid disease who would benefit from revascularization.
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Affiliation(s)
- Andreas Schindler
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany; Department of Radiology, Trauma Center Murnau, Murnau, Germany
| | - Regina Schinner
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Nishaf Altaf
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom; Department of Vascular Surgery, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Akram A Hosseini
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom; Department of Neurology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Richard J Simpson
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom; Department of Vascular Surgery, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | | | - Navneet Singh
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Robert M Kwee
- Department of Radiology and Nuclear Medicine, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Radiology, Zuyderland Medical Center, Heerlen, the Netherlands
| | | | - Sen Yamagata
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Kazumichi Yoshida
- Department of Neurosurgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Robert Maggisano
- Department of Vascular Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Alan R Moody
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Holger Poppert
- Department of Neurology, Technische Universität München, Munich, Germany
| | - M Eline Kooi
- Department of Radiology and Nuclear Medicine, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Dorothee P Auer
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom; NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, United Kingdom
| | - Leo H Bonati
- Department of Neurology and Stroke Center, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Tobias Saam
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
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11
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Elhfnawy AM, Heuschmann PU, Pham M, Volkmann J, Fluri F. Stenosis Length and Degree Interact With the Risk of Cerebrovascular Events Related to Internal Carotid Artery Stenosis. Front Neurol 2019; 10:317. [PMID: 31024420 PMCID: PMC6465418 DOI: 10.3389/fneur.2019.00317] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/13/2019] [Indexed: 12/23/2022] Open
Abstract
Background and Purpose: Internal carotid artery stenosis (ICAS)≥70% is a leading cause of ischemic cerebrovascular events (ICVEs). However, a considerable percentage of stroke survivors with symptomatic ICAS (sICAS) have <70% stenosis with a vulnerable plaque. Whether the length of ICAS is associated with high risk of ICVEs is poorly investigated. Our main aim was to investigate the relation between the length of ICAS and the development of ICVEs. Methods: In a retrospective cross-sectional study, we identified 95 arteries with sICAS and another 64 with asymptomatic internal carotid artery stenosis (aICAS) among 121 patients with ICVEs. The degree and length of ICAS as well as plaque echolucency were assessed on ultrasound scans. Results: A statistically significant inverse correlation between the ultrasound-measured length and degree of ICAS was detected for sICAS≥70% (Spearman correlation coefficient ρ = -0.57, p < 0.001, n = 51) but neither for sICAS<70% (ρ = 0.15, p = 0.45, n = 27) nor for aICAS (ρ = 0.07, p = 0.64, n = 54). The median (IQR) length for sICAS<70% and ≥70% was 17 (15-20) and 15 (12-19) mm (p = 0.06), respectively, while that for sICAS<90% and sICAS 90% was 18 (15-21) and 13 (10-16) mm, respectively (p < 0.001). Among patients with ICAS <70%, a cut-off length of ≥16 mm was found for sICAS rather than aICAS with a sensitivity and specificity of 74.1% and 51.1%, respectively. Irrespective of the stenotic degree, plaques of the sICAS compared to aICAS were significantly more often echolucent (43.2 vs. 24.6%, p = 0.02). Conclusion: We found a statistically insignificant tendency for the ultrasound-measured length of sICAS<70% to be longer than that of sICAS≥70%. Moreover, the ultrasound-measured length of sICAS<90% was significantly longer than that of sICAS 90%. Among patients with sICAS≥70%, the degree and length of stenosis were inversely correlated. Larger studies are needed before a clinical implication can be drawn from these results.
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Affiliation(s)
| | - Peter U. Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Mirko Pham
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital of Würzburg, Würzburg, Germany
| | - Jens Volkmann
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Felix Fluri
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
- Department of Neurology, Kantonssptial St. Gallen, St. Gallen, Switzerland
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12
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Yoshida K, Fukumitsu R, Kurosaki Y, Nagata M, Tao Y, Suzuki M, Yamamoto Y, Funaki T, Kikuchi T, Ishii A, Miyamoto S. Carotid Endarterectomy for Medical Therapy-Resistant Symptomatic Low-Grade Stenosis. World Neurosurg 2019; 123:e543-e548. [DOI: 10.1016/j.wneu.2018.11.208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 11/21/2018] [Accepted: 11/22/2018] [Indexed: 11/25/2022]
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13
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Kashiwazaki D, Shiraishi K, Yamamoto S, Kamo T, Uchino H, Saito H, Akioka N, Kuwayama N, Noguchi K, Kuroda S. Efficacy of Carotid Endarterectomy for Mild (<50%) Symptomatic Carotid Stenosis with Unstable Plaque. World Neurosurg 2019; 121:e60-e69. [DOI: 10.1016/j.wneu.2018.09.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/30/2018] [Accepted: 09/02/2018] [Indexed: 11/17/2022]
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14
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de Haro J, Rodriguez-Padilla J, Bleda S, Cañibano C, Michel I, Acin F. Carotid stenting with proximal cerebral protection in symptomatic low-grade vulnerable recurrent carotid stenosis. Ther Adv Chronic Dis 2018; 9:125-133. [PMID: 29854374 DOI: 10.1177/2040622318765727] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 02/05/2018] [Indexed: 11/16/2022] Open
Abstract
Background Although the management of carotid disease is well established for symptomatic lesions ⩾70%, carotid revascularization for symptomatic low-grade (⩽50%) stenosis is not actually supported by data from randomized clinical trials. Such patients may occasionally have recurrent neurological symptoms despite optimal medical treatment owing to vulnerable plaques. In such cases, carotid artery stenting (CAS) may represent an option for treatment but this has not been tested in clinical trials. This study analyzed early and long-term outcomes of CAS performed in patients with low-grade symptomatic recurrent carotid stenosis. Methods From a prospective registry of 322 carotid revascularization in symptomatic patients, 21 consecutive patients with low-grade symptomatic recurrent carotid stenosis who underwent CAS with proximal cerebral protection device Mo.Ma, after ruling out any other source of cerebral embolization, were involved in the study.All patients had suggestive evidence of unstable plaque or plaque ulceration. Results Procedural technical success rate was 100%. No 30-day stroke or death occurred, and no patients had recurrent neurological events related to the revascularized hemisphere during follow up. No 30-day local complications were reported. No late carotid occlusions were detected. There was one late death, and no stroke-related deaths. Survival rates were 100% at 1 year and 96% at 3 years. Conclusions This study shows that CAS is a well-tolerated, effective and durable treatment for patients with recurrent symptomatic low-grade carotid stenosis associated with a vulnerable plaque. Patients had excellent protection against further ischemic events and survived long enough.
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Affiliation(s)
- Joaquin de Haro
- Angiology and Vascular Surgery Department of Getafe University Hospital, Getafe, Madrid, Spain
| | | | - Silvia Bleda
- Vascular Surgery and Angiology Department, Hospital Universitario Getafe, Ctra Toledo Km 12,500, 28905 Madrid, Spain
| | - Cristina Cañibano
- Angiology and Vascular Surgery Department of Getafe University Hospital, Getafe, Madrid, Spain
| | - Ignacio Michel
- Angiology and Vascular Surgery Department of Getafe University Hospital, Getafe, Madrid, Spain
| | - Francisco Acin
- Angiology and Vascular Surgery Department of Getafe University Hospital, Getafe, Madrid, Spain
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15
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Yamada K, Yoshimura S, Shirakawa M, Uchida K, Maruyama F, Nakahara S, Nishida S, Iwamoto Y, Sato Y, Kawasaki M. High intensity signal in the plaque on routine 3D-TOF MRA is associated with ischemic stroke in the patients with low-grade carotid stenosis. J Neurol Sci 2018; 385:164-167. [DOI: 10.1016/j.jns.2017.12.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 12/02/2017] [Accepted: 12/18/2017] [Indexed: 10/18/2022]
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16
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17
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Fukumitsu R, Yoshida K, Kurosaki Y, Torihashi K, Sadamasa N, Koyanagi M, Narumi O, Sato T, Chin M, Handa A, Yamagata S, Miyamoto S. Short-Term Results of Carotid Endarterectomy and Stenting After the Introduction of Carotid Magnetic Resonance Imaging: A Single-Institution Retrospective Study. World Neurosurg 2017; 101:308-314. [PMID: 28214642 DOI: 10.1016/j.wneu.2017.02.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Although carotid artery stenting (CAS) has been gaining popularity as an alternative to carotid endarterectomy (CEA), perioperative stroke rate following contemporary CAS remains significantly higher than stroke rate after CEA. The purpose of this study was to assess perioperative (within 30 days) therapeutic results in patients with carotid stenosis (CS) after introduction of preoperative carotid magnetic resonance imaging plaque evaluation in a single center performing both CEA and CAS. METHODS Based on prospectively collected data for patients with CS who were scheduled for carotid revascularization, retrospective analysis was conducted of 295 consecutive patients with CS. An intervention was selected after consideration of periprocedural risks for both CEA and CAS. Concerning risk factors for CAS, results of magnetic resonance imaging plaque evaluation were emphasized with a view toward reducing embolic complications. RESULTS CAS was performed in 114 patients, and CEA was performed in 181 patients. Comparing baseline characteristics of the 295 patients, age, T1 signal intensity of plaque, symptomatic CS, urgent intervention, and diabetes mellitus differed significantly between CAS and CEA groups. Among patients who underwent CAS, new hyperintense lesions on diffusion-weighted imaging were confirmed in 47 patients. New hyperintense lesions on diffusion-weighted imaging were recognized in 21.4% of patients who underwent CEA (n = 39), significantly less frequent than in patients who underwent CAS. CONCLUSIONS The overall short-term outcome of CEA and CAS is acceptable. Preoperative carotid magnetic resonance imaging evaluation of plaque might contribute to low rates of ischemic complications in CAS.
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Affiliation(s)
- Ryu Fukumitsu
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Kazumichi Yoshida
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan.
| | | | - Koichi Torihashi
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Nobutake Sadamasa
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Masaomi Koyanagi
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Osamu Narumi
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Tsukasa Sato
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Masaki Chin
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Akira Handa
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Sen Yamagata
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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18
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Mild Carotid Stenosis with Recurrent Symptoms Triggered by Eating. World Neurosurg 2017; 97:750.e11-750.e13. [DOI: 10.1016/j.wneu.2016.10.097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 10/18/2016] [Accepted: 10/20/2016] [Indexed: 11/21/2022]
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19
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Liem MI, Kennedy F, Bonati LH, van der Lugt A, Coolen BF, Nederveen AJ, Jager HR, Brown MM, Nederkoorn PJ. Investigations of Carotid Stenosis to Identify Vulnerable Atherosclerotic Plaque and Determine Individual Stroke Risk. Circ J 2017; 81:1246-1253. [DOI: 10.1253/circj.cj-16-1284] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Fiona Kennedy
- UCL Stroke Research Centre, Institute of Neurology, University College London
| | | | | | | | | | - Hans R. Jager
- UCL Stroke Research Centre, Institute of Neurology, University College London
| | - Martin M. Brown
- UCL Stroke Research Centre, Institute of Neurology, University College London
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20
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McNally JS, Burton TM, Aldred BW, Kim SE, McLaughlin MS, Eisenmenger LB, Stoddard GJ, Majersik JJ, Miller DV, Treiman GS, Parker DL. Vitamin D and Vulnerable Carotid Plaque. AJNR Am J Neuroradiol 2016; 37:2092-2099. [PMID: 27313129 DOI: 10.3174/ajnr.a4849] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 04/26/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE MR imaging-detected carotid intraplaque hemorrhage indicates vulnerable plaque with high stroke risk. Angiotensin II stimulates intraplaque hemorrhage in animal models, and the angiotensin system is highly regulated by vitamin D. Our purpose was to determine whether low vitamin D levels predict carotid intraplaque hemorrhage in humans. MATERIALS AND METHODS In this cross-sectional study, 65 patients with carotid disease underwent carotid MR imaging and blood draw. Systemic clinical confounders and local lumen imaging markers were recorded. To determine the association of low vitamin D levels with MR imaging detected intraplaque hemorrhage, we performed multivariable Poisson regression by using generalized estimating equations to account for up to 2 carotid arteries per patient and backward elimination of confounders. MR imaging detected intraplaque hemorrhage volume was also correlated with vitamin D levels and maximum plaque thickness. Thirty-five patients underwent carotid endarterectomy, and histology-detected intraplaque hemorrhage was correlated with vitamin D levels and total plaque area. RESULTS Low vitamin D levels (<30 ng/mL, prevalence ratio = 2.05, P = .03) were a significant predictor of MR imaging detected intraplaque hemorrhage, along with plaque thickness (prevalence ratio = 1.40, P < .001). MR imaging detected intraplaque hemorrhage volume linearly correlated with plaque thickness (partial r = 0.45, P < .001) and low vitamin D levels (partial r = 0.26, P = .003). Additionally, histology-detected intraplaque hemorrhage area linearly correlated with plaque area (partial r = 0.46, P < .001) and low vitamin D levels (partial r = 0.22, P = .03). The association of intraplaque hemorrhage volume with low vitamin D levels was also higher with ischemic stroke. CONCLUSIONS Low vitamin D levels and plaque thickness predict carotid intraplaque hemorrhage and outperform lumen markers of vulnerable plaque. This research demonstrates a significant link between low vitamin D levels and carotid intraplaque hemorrhage.
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Affiliation(s)
- J S McNally
- From the Department of Radiology and Imaging Sciences, Utah Center for Advanced Imaging Research (J.S.M., B.W.A., S.-E.K., M.S.M., L.B.E., D.L.P.)
| | - T M Burton
- Department of Neurology (T.M.B., J.J.M.)
| | - B W Aldred
- From the Department of Radiology and Imaging Sciences, Utah Center for Advanced Imaging Research (J.S.M., B.W.A., S.-E.K., M.S.M., L.B.E., D.L.P.)
| | - S-E Kim
- From the Department of Radiology and Imaging Sciences, Utah Center for Advanced Imaging Research (J.S.M., B.W.A., S.-E.K., M.S.M., L.B.E., D.L.P.)
| | - M S McLaughlin
- From the Department of Radiology and Imaging Sciences, Utah Center for Advanced Imaging Research (J.S.M., B.W.A., S.-E.K., M.S.M., L.B.E., D.L.P.)
| | - L B Eisenmenger
- From the Department of Radiology and Imaging Sciences, Utah Center for Advanced Imaging Research (J.S.M., B.W.A., S.-E.K., M.S.M., L.B.E., D.L.P.)
| | - G J Stoddard
- Department of Orthopedics, Study Design and Biostatistics Center (G.J.S)
| | | | | | - G S Treiman
- Department of Surgery at the University of Utah and VA Salt Lake City Health Care System, Salt Lake City, Utah (G.S.T.)
| | - D L Parker
- From the Department of Radiology and Imaging Sciences, Utah Center for Advanced Imaging Research (J.S.M., B.W.A., S.-E.K., M.S.M., L.B.E., D.L.P.)
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Kurosaki Y, Yoshida K, Fukumitsu R, Sadamasa N, Handa A, Chin M, Yamagata S. Carotid artery plaque assessment using quantitative expansive remodeling evaluation and MRI plaque signal intensity. J Neurosurg 2016; 124:736-42. [DOI: 10.3171/2015.2.jns142783] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Plaque characteristics and morphology are important indicators of plaque vulnerability. MRI-detected intraplaque hemorrhage has a great effect on plaque vulnerability. Expansive remodeling, which has been considered compensatory enlargement of the arterial wall in the progression of atherosclerosis, is one of the criteria of vulnerable plaque in the coronary circulation. The purpose of this study was risk stratification of carotid artery plaque through the evaluation of quantitative expansive remodeling and MRI plaque signal intensity.
METHODS
Both preoperative carotid artery T1-weighted axial and long-axis MR images of 70 patients who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) were studied. The expansive remodeling ratio (ERR) was calculated from the ratio of the linear diameter of the artery at the thickest segment of the plaque to the diameter of the artery on the long-axis image. Relative plaque signal intensity (rSI) was also calculated from the axial image, and the patients were grouped as follows: Group A = rSI ≥ 1.40 and ERR ≥ 1.66; Group B = rSI< 1.40 and ERR ≥ 1.66; Group C = rSI ≥ 1.40 and ERR < 1.66; and Group D = rSI < 1.40 and ERR < 1.66. Ischemic events within 6 months were retrospectively evaluated in each group.
RESULTS
Of the 70 patients, 17 (74%) in Group A, 6 (43%) in Group B, 7 (44%) in Group C, and 6 (35%) in Group D had ischemic events. Ischemic events were significantly more common in Group A than in Group D (p = 0.01).
CONCLUSIONS
In the present series of patients with carotid artery stenosis scheduled for CEA or CAS, patients with plaque with a high degree of expansion of the vessel and T1 high signal intensity were at higher risk of ischemic events. The combined assessment of plaque characterization with MRI and morphological evaluation using ERR might be useful in risk stratification for carotid lesions, which should be validated by a prospective, randomized study of asymptomatic patients.
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Affiliation(s)
| | - Kazumichi Yoshida
- 2Department of Neurosurgery, Kyoto University School of Medicine, Kyoto, Japan
| | - Ryu Fukumitsu
- 2Department of Neurosurgery, Kyoto University School of Medicine, Kyoto, Japan
| | - Nobutake Sadamasa
- 1Department of Neurosurgery, Kurashiki Central Hospital, Okayama; and
| | - Akira Handa
- 1Department of Neurosurgery, Kurashiki Central Hospital, Okayama; and
| | - Masaki Chin
- 1Department of Neurosurgery, Kurashiki Central Hospital, Okayama; and
| | - Sen Yamagata
- 1Department of Neurosurgery, Kurashiki Central Hospital, Okayama; and
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Brinjikji W, Huston J, Rabinstein AA, Kim GM, Lerman A, Lanzino G. Contemporary carotid imaging: from degree of stenosis to plaque vulnerability. J Neurosurg 2016. [DOI: 10.3171/2015.1.jns142452.test] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | | | | | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Brinjikji W, Huston J, Rabinstein AA, Kim GM, Lerman A, Lanzino G. Contemporary carotid imaging: from degree of stenosis to plaque vulnerability. J Neurosurg 2015; 124:27-42. [PMID: 26230478 DOI: 10.3171/2015.1.jns142452] [Citation(s) in RCA: 209] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Carotid artery stenosis is a well-established risk factor of ischemic stroke, contributing to up to 10%-20% of strokes or transient ischemic attacks. Many clinical trials over the last 20 years have used measurements of carotid artery stenosis as a means to risk stratify patients. However, with improvements in vascular imaging techniques such as CT angiography and MR angiography, ultrasonography, and PET/CT, it is now possible to risk stratify patients, not just on the degree of carotid artery stenosis but also on how vulnerable the plaque is to rupture, resulting in ischemic stroke. These imaging techniques are ushering in an emerging paradigm shift that allows for risk stratifications based on the presence of imaging features such as intraplaque hemorrhage (IPH), plaque ulceration, plaque neovascularity, fibrous cap thickness, and presence of a lipid-rich necrotic core (LRNC). It is important for the neurosurgeon to be aware of these new imaging techniques that allow for improved patient risk stratification and outcomes. For example, a patient with a low-grade stenosis but an ulcerated plaque may benefit more from a revascularization procedure than a patient with a stable 70% asymptomatic stenosis with a thick fibrous cap. This review summarizes the current state-of-the-art advances in carotid plaque imaging. Currently, MRI is the gold standard in carotid plaque imaging, with its high resolution and high sensitivity for identifying IPH, ulceration, LRNC, and inflammation. However, MRI is limited due to time constraints. CT also allows for high-resolution imaging and can accurately detect ulceration and calcification, but cannot reliably differentiate LRNC from IPH. PET/CT is an effective technique to identify active inflammation within the plaque, but it does not allow for assessment of anatomy, ulceration, IPH, or LRNC. Ultrasonography, with the aid of contrast enhancement, is a cost-effective technique to assess plaque morphology and characteristics, but it is limited in sensitivity and specificity for detecting LRNC, plaque hemorrhage, and ulceration compared with MRI. Also summarized is how these advanced imaging techniques are being used in clinical practice to risk stratify patients with low- and high-grade carotid artery stenosis. For example, identification of IPH on MRI in patients with low-grade carotid artery stenosis is a risk factor for failure of medical therapy, and studies have shown that such patients may fair better with carotid endarterectomy (CEA). MR plaque imaging has also been found to be useful in identifying revascularization candidates who would be better candidates for CEA than carotid artery stenting (CAS), as high intraplaque signal on time of flight imaging is associated with vulnerable plaque and increased rates of adverse events in patients undergoing CAS but not CEA.
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Affiliation(s)
| | | | | | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Affiliation(s)
- Jie Sun
- Department of Radiology, University of Washington, Seattle, WA (J.S., C.Y.)
| | - Chun Yuan
- Department of Radiology, University of Washington, Seattle, WA (J.S., C.Y.)
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Maruyama D, Fukuda K, Kataoka H, Morita Y, Nishimura K, Kawamura Y, Iihara K. Evaluation of carotid artery outward remodeling by T1-weighted magnetic resonance imaging in carotid endarterectomy and stenting. J Vasc Surg 2015; 61:1464-71.e1. [DOI: 10.1016/j.jvs.2015.01.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 01/13/2015] [Indexed: 11/30/2022]
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Orion KC, Ruppert J, Call D, Malas M, Piazza K, Perler BA. The role of advanced diagnostic technology in the selection of a patient with symptomatic but hemodynamically insignificant disease for carotid endarterectomy. J Vasc Surg Cases 2015; 1:90-93. [PMID: 31724619 PMCID: PMC6849974 DOI: 10.1016/j.jvsc.2015.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 03/01/2015] [Indexed: 11/24/2022] Open
Abstract
Current Level I evidence demonstrates no benefit for carotid endarterectomy in symptomatic patients with <50% carotid stenoses. However, unstable plaque morphology is increasingly recognized in the genesis of ischemic cerebral events. New advanced imaging technology, such as contrast-enhanced magnetic resonance angiography and ultrasound imaging, are emerging as important adjuncts in the evaluation of this patient population. We present a case where both modalities were beneficial in identifying plaque instability manifested by intraplaque hemorrhage and neovascularization in a patient with recurrent cerebral ischemic events and hemodynamically insignificant carotid disease.
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Affiliation(s)
- Kristine Clodfelter Orion
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, Md
| | - Jenna Ruppert
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, Md
| | - Diana Call
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, Md
| | - Mahmoud Malas
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, Md
| | - Kristen Piazza
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, Md
| | - Bruce A Perler
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, Md
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Kashiwazaki D, Akioka N, Kuwayama N, Noguchi K, Tanaka K, Kuroda S. Pathophysiology of Acute Cerebrovascular Syndrome in Patients With Carotid Artery Stenosis. Neurosurgery 2015; 76:427-33; discussion 433-4. [DOI: 10.1227/neu.0000000000000655] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Abstract
BACKGROUND:
The mechanisms underlying acute cerebrovascular syndrome in patients with carotid artery stenosis remain unclear.
OBJECTIVE:
To assess the relationships among infarct localization, hemodynamics, and plaque components.
METHODS:
This prospective study included 38 patients with acute cerebrovascular syndrome resulting from ipsilateral carotid artery stenosis. Cerebral infarct localization was categorized into 3 patterns (cortical, border zone, and mixed pattern). Carotid plaque components were evaluated with T1-weighted magnetic resonance imaging and time-of-flight imaging. Cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) were also quantified.
RESULTS:
Infarcts were identified in 38 patients with the use of diffusion-weighted magnetic resonance imaging. On the basis of the assessment of hemodynamics, the cortical pattern was seen in 18 of 21 patients with type 1 ischemia (normal CBF, normal CVR), whereas the mixed pattern was seen in 2 patients with type 2 ischemia (normal CBF, impaired CVR) and 12 of 15 patients with type 3 ischemia (impaired CBF, impaired CVR). The plaque components were categorized into fibrous (4 patients), lipid-rich (14 patients), and intraplaque hemorrhage (IPH; 20 patients). Of the patients with fibrous plaque, 2 had border-zone and 2 had mixed-pattern infarcts. Of the patients with lipid-rich plaque, 7 had cortical and 6 had mixed-pattern infarcts. Of patients with intraplaque hemorrhage, 11 had cortical and 9 had mixed-pattern infarcts.
CONCLUSION:
Cortical infarction occurs as a result of vulnerable plaque. Reduced cerebral perfusion induces border-zone infarction. Both factors are implicated in mixed-pattern infarction. Developments in noninvasive diagnostic modalities allow us to explore the mechanisms behind acute cerebrovascular syndrome in carotid artery stenosis and to determine the ideal therapies.
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Affiliation(s)
| | | | | | - Kyo Noguchi
- Radiology, Graduate School of Medicine and Pharmacological Science, University of Toyama, Toyama, Japan
| | - Kortaro Tanaka
- Department of Neurology, Toyama University Hospital, Toyama, Japan
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Yamada K, Kawasaki M, Yoshimura S, Sasaki Y, Nakahara S, Sato Y. Asymptomatic moderate carotid artery stenosis with intraplaque hemorrhage: onset of new ischemic stroke. J Neurointerv Surg 2014; 8:130-4. [DOI: 10.1136/neurintsurg-2014-011317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 11/24/2014] [Indexed: 01/16/2023]
Abstract
BackgroundThe degree of stenosis of carotid arteries is recognized as an important risk factor for ischemic stroke. However, high-grade stenosis does not always cause cerebrovascular events, whereas low- to moderate-grade stenosis may often cause strokes. It has been reported that there is an association between carotid intraplaque hemorrhage (IPH) and new brain ischemic events.Case presentationWe present three patients with asymptomatic moderate carotid artery stenosis and carotid IPH who underwent both neurological and MRI at baseline and after at least 1 year's follow-up. These patients were admitted to our hospital (after 15–35 months of follow-up) because of neurological deficits. Diffusion-weighted MRI of the brain showed ipsilateral new ischemic lesions due to carotid artery plaques. The patients were treated with carotid artery stenting and discharged uneventfully.ConclusionsWhether plaques with severe stenosis already had severe stenosis at the onset of events or plaques with moderate stenosis progressed owing to an acute change, such as growth of an IPH, remains unclear, because no carotid imaging was carried out just before the events. This is the first case report which presents neurological symptoms and MRI at both baseline and follow-up in patients with asymptomatic moderate carotid artery stenosis and carotid IPH.
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Alexander MD, Cooke DL, Meyers PM, Amans MR, Dowd CF, Halbach VV, Higashida RT, Hetts SW. Lesion stability characteristics outperform degree of stenosis in predicting outcomes following stenting for symptomatic intracranial atherosclerosis. J Neurointerv Surg 2014; 8:19-23. [PMID: 25416828 DOI: 10.1136/neurintsurg-2014-011482] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 11/01/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND Intracranial atherosclerotic disease (ICAD) causes substantial morbidity and mortality. Treatment decisions have most commonly been driven by the degree of luminal stenosis. This study compares ICAD lesion stability features with percentage stenosis for associations with adverse outcomes following treatment with stents. MATERIALS AND METHODS Retrospective analysis was performed of prospectively maintained procedure logs. Lesions were classified by symptom type as hypoperfusion, non-hypoperfusion, or indeterminate, and pretreatment asymptomatic intervals were noted. Hypoperfusion lesions and indeterminate or non-hypoperfusion lesions with ≥14 days of asymptomatic interval were classified as stable. Percentage stenosis was calculated and compared against these other symptom features for value in predicting technical complication, ischemic stroke, disability, or death at 90 days and 2 years using univariate and multivariate analysis. RESULTS 130 lesions were treated in 124 patients. The only statistically significant percent stenosis finding was lesions with 60-99% stenosis were less likely to have technical complications. In univariate analysis, stroke at 2 years was less common with hypoperfusion and stable lesions. In multivariate analysis, only hypoperfusion status was associated with lower stroke rates at 2 years. CONCLUSIONS Lesion stability features, particularly non-hypoperfusion symptomatology, outperform percentage stenosis in predicting outcomes following treatment of ICAD with stents. Further examination is needed to better classify the natural history of ICAD and more precisely classify lesion stability.
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Affiliation(s)
- M D Alexander
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - D L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - P M Meyers
- Departments of Radiology and Neurological Surgery, Columbia University, New York, New York, USA
| | - M R Amans
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - C F Dowd
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Departments of Neurological Surgery, Neurology, Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - V V Halbach
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Departments of Neurological Surgery, Neurology, Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - R T Higashida
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Departments of Neurological Surgery, Neurology, Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - S W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
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Utility of 3-dimensional ultrasound imaging to evaluate carotid artery stenosis: comparison with magnetic resonance angiography. J Stroke Cerebrovasc Dis 2014; 24:148-53. [PMID: 25440325 DOI: 10.1016/j.jstrokecerebrovasdis.2014.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 07/23/2014] [Accepted: 08/05/2014] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND We evaluated the utility of 3-dimensional (3-D) ultrasound imaging for assessment of carotid artery stenosis, as compared with similar assessment via magnetic resonance angiography (MRA). METHODS Subjects comprised 58 patients with carotid stenosis who underwent both 3-D ultrasound imaging and MRA. We studied whether abnormal findings detected by ultrasound imaging could be diagnosed using MRA. Ultrasound images were generated using Voluson 730 Expert and Voluson E8. RESULTS The degree of stenosis was mild in 17, moderate in 16, and severe in 25 patients, according to ultrasound imaging. Stenosis could not be recognized using MRA in 4 of 17 patients diagnosed with mild stenosis using ultrasound imaging. Ultrasound imaging showed ulceration in 13 patients and mobile plaque in 6 patients. When assessing these patients, MRA showed ulceration in only 2 of 13 patients and did not detect mobile plaque in any of these 6 patients. Static 3-D B mode images demonstrated distributions of plaque, ulceration, and mobile plaque, and static 3-D flow images showed flow configuration as a total structure. Real-time 3-D B mode images demonstrated plaque and vessel movement. Carotid artery stenting was not selected for patients diagnosed with ulceration or mobile plaque. CONCLUSIONS Ultrasound imaging was necessary to detect mild stenosis, ulcerated plaque, or mobile plaque in comparison with MRA, and 3-D ultrasound imaging was useful to recognize carotid stenosis and flow pattern as a total structure by static and real-time 3-D demonstration. This information may contribute to surgical planning.
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Kiyofuji S, Inoue T, Hasegawa H, Tamura A, Saito I. Emergent surgical embolectomy for middle cerebral artery occlusion due to carotid plaque rupture followed by elective carotid endarterectomy. J Neurosurg 2014; 121:631-6. [DOI: 10.3171/2014.4.jns132441] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Embolic intracranial large artery occlusion with severe neurological deficit is associated with an extremely poor prognosis. The safest and most effective treatment strategy has not yet been determined when such emboli are associated with unstable proximal carotid plaque. The authors performed emergent surgical embolectomy for left middle cerebral artery (MCA) occlusion, and the patient experienced marked neurological recovery without focal deficit and regained premorbid activity. Postoperative investigation revealed “vulnerable plaque” of the left internal carotid artery without apparent evidence of cardiac embolism, such as would be seen with atrial fibrillation. Specimens from subsequent elective carotid endarterectomy (CEA) showed ruptured vulnerable plaque that was histologically consistent as a source of the intracranial embolic specimen. Surgical embolectomy for MCA occlusion due to carotid plaque rupture followed by CEA could be a safer and more effective alternative to endovascular treatment from the standpoint of obviating the risk of secondary embolism that could otherwise occur as a result of the manipulation of devices through an extremely unstable portion of plaque. Further, this strategy is associated with a high probability of complete recanalization with direct removal of hard and large, though fragile, emboli.
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Xu D, Hippe DS, Underhill HR, Oikawa-Wakayama M, Dong L, Yamada K, Yuan C, Hatsukami TS. Prediction of high-risk plaque development and plaque progression with the carotid atherosclerosis score. JACC Cardiovasc Imaging 2014; 7:366-73. [PMID: 24631510 DOI: 10.1016/j.jcmg.2013.09.022] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 09/13/2013] [Accepted: 09/19/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The goal of this prospective study was to evaluate the carotid atherosclerosis score (CAS) for predicting the development of high-risk plaque features and plaque burden progression. BACKGROUND Previous studies have shown that carotid intraplaque hemorrhage (IPH) and a disrupted luminal surface (DLS), as identified by using magnetic resonance imaging, are associated with greater risk for cerebrovascular events. On the basis of data from a large cross-sectional study, a scoring system was developed to determine which plaque features are associated with the presence of IPH and DLS. However, the predictive value of CAS has not been previously tested in a prospective, longitudinal study. METHODS A total of 120 asymptomatic subjects with 50% to 79% carotid stenosis underwent carotid magnetic resonance imaging scans at baseline and 3 years thereafter. Presence of IPH and DLS, wall volume, maximum wall thickness, and maximum percent lipid-rich necrotic core area were measured at both time-points. Baseline CAS values were calculated on the basis of previously published criteria. RESULTS Of the 73 subjects without IPH or DLS at baseline, 9 (12%) developed 1 or both of these features during follow-up. There was a significant increasing trend between CAS and the development of new DLS (p < 0.001) and with plaque burden progression (p = 0.03) but not with the development of new IPH (p = 0.3). Percent carotid stenosis was not significantly associated with new DLS (p = 0.2), new IPH (p = 0.1), or plaque progression (p = 0.6). CONCLUSIONS CAS was found to have a significant increasing relationship with incident DLS and plaque progression in this prospective study. CAS can potentially provide improved risk stratification beyond luminal stenosis.
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Affiliation(s)
- Dongxiang Xu
- Department of Radiology, University of Washington, Seattle, Washington
| | - Daniel S Hippe
- Department of Radiology, University of Washington, Seattle, Washington
| | - Hunter R Underhill
- Departments of Neurological Surgery and Medicine, University of Washington, Seattle, Washington
| | | | - Li Dong
- Department of Radiology, Anzhen Hospital, Beijing, China
| | - Kiyofumi Yamada
- Department of Radiology, University of Washington, Seattle, Washington
| | - Chun Yuan
- Department of Radiology, University of Washington, Seattle, Washington
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Fukuda K, Iihara K, Maruyama D, Yamada N, Ishibashi-Ueda H. Relationship between carotid artery remodeling and plaque vulnerability with T1-weighted magnetic resonance imaging. J Stroke Cerebrovasc Dis 2014; 23:1462-70. [PMID: 24582790 DOI: 10.1016/j.jstrokecerebrovasdis.2013.12.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 12/06/2013] [Accepted: 12/06/2013] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The aim of this study was to validate the relationship between carotid artery remodeling defined as the carotid remodeling index (CRI) and plaque vulnerability by comparing the degree of outward remodeling calculated using 3-dimensional inversion recovery-based T1-weighted imaging (magnetization-prepared rapid acquisition gradient echo [MPRAGE]) with the symptomatology and histology of plaques extracted during carotid endarterectomy. METHODS Sixty-one patients with 50% stenosis or more (North American Symptomatic Carotid Endarterectomy Trial criteria) were included. The average rate of stenosis was 79.8%. The CRI was determined by measuring the external cross-sectional vessel area (CSVA) at the maximum stenosis of the internal carotid artery (ICA) and dividing it by the external CSVA at the distal ICA (unaffected by atherosclerosis) using MPRAGE imaging. RESULTS The CRI was significantly higher in symptomatic patients compared with asymptomatic patients (1.98±.26 versus 1.68±.24, P<.0001). A higher CRI positively correlated with the necrotic core area (r=.57, P<.0001) and negatively correlated with the fibrous cap thickness (r=-.33, P=.01). It was also significantly associated with severe intraplaque hemorrhage (P<.0001) and the prevalence of cap inflammation with macrophage (P=.03) and lymphocyte (P=.01) infiltration. CONCLUSIONS The larger outward remodeling of the carotid artery on MPRAGE imaging had symptomatic carotid plaques and histologically vulnerable plaques. This study indicates that MPRAGE imaging is useful for the assessment of carotid artery remodeling.
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Affiliation(s)
- Kenji Fukuda
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Koji Iihara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan.
| | - Daisuke Maruyama
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Naoaki Yamada
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
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Teng Z, Sadat U, Brown AJ, Gillard JH. Plaque hemorrhage in carotid artery disease: pathogenesis, clinical and biomechanical considerations. J Biomech 2014; 47:847-58. [PMID: 24485514 PMCID: PMC3994507 DOI: 10.1016/j.jbiomech.2014.01.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2014] [Indexed: 12/21/2022]
Abstract
Stroke remains the most prevalent disabling illness today, with internal carotid artery luminal stenosis due to atheroma formation responsible for the majority of ischemic cerebrovascular events. Severity of luminal stenosis continues to dictate both patient risk stratification and the likelihood of surgical intervention. But there is growing evidence to suggest that plaque morphology may help improve pre-existing risk stratification criteria. Plaque components such a fibrous tissue, lipid rich necrotic core and calcium have been well investigated but plaque hemorrhage (PH) has been somewhat overlooked. In this review we discuss the pathogenesis of PH, its role in dictating plaque vulnerability, PH imaging techniques, marterial properties of atherosclerotic tissues, in particular, those obtained based on in vivo measurements and effect of PH in modulating local biomechanics.
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Affiliation(s)
- Zhongzhao Teng
- University Department of Radiology, University of Cambridge, UK; Department of Engineering, University of Cambridge, UK.
| | - Umar Sadat
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Adam J Brown
- Department of Cardiovascular Medicine, University of Cambridge, UK
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Carotid endarterectomy for symptomatic low-grade carotid stenosis. J Vasc Surg 2014; 59:25-31. [DOI: 10.1016/j.jvs.2013.06.079] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 06/19/2013] [Accepted: 06/21/2013] [Indexed: 11/19/2022]
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Gupta A, Baradaran H, Schweitzer AD, Kamel H, Pandya A, Delgado D, Dunning A, Mushlin AI, Sanelli PC. Carotid Plaque MRI and Stroke Risk. Stroke 2013; 44:3071-7. [PMID: 23988640 DOI: 10.1161/strokeaha.113.002551] [Citation(s) in RCA: 368] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
MRI characterization of carotid plaque has been studied recently as a potential tool to predict stroke caused by carotid atherosclerosis. We performed a systematic review and meta-analysis to summarize the association of MRI-determined intraplaque hemorrhage, lipid-rich necrotic core, and thinning/rupture of the fibrous cap with subsequent ischemic events.
Methods—
We performed a comprehensive literature search evaluating the association of carotid plaque composition on MRI with ischemic outcomes. We included cohort studies examining intraplaque hemorrhage, lipid-rich necrotic core, or thinning/rupture of the fibrous cap with mean follow-up of ≥1 month and an outcome measure of ipsilateral stroke or transient ischemic attack. A meta-analysis using a random-effects model with assessment of study heterogeneity and publication bias was performed.
Results—
Of the 3436 articles screened, 9 studies with a total of 779 subjects met eligibility for systematic review. The hazard ratios for intraplaque hemorrhage, lipid-rich necrotic core, and thinning/rupture of the fibrous cap as predictors of subsequent stroke/transient ischemic attack were 4.59 (95% confidence interval, 2.91–7.24), 3.00 (95% confidence interval, 1.51–5.95), and 5.93 (95% confidence interval, 2.65–13.20), respectively. No statistically significant heterogeneity or publication bias was present in the 3 main meta-analyses performed.
Conclusions—
The presence of intraplaque hemorrhage, lipid-rich necrotic core, and thinning/rupture of the fibrous cap on MRI of carotid plaque is associated with increased risk of future stroke or transient ischemic attack in patients with carotid atherosclerotic disease. Dedicated MRI of plaque composition offers stroke risk information beyond measurement of luminal stenosis in carotid atherosclerotic disease.
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Affiliation(s)
- Ajay Gupta
- From the Departments of Radiology (A.G., H.B., A.D.S., P.C.S.), Neurology (H.K.), and Public Health (A.P., A.D., A.I.M., P.C.S.) and Samuel J. Wood Library & C.V. Starr Biomedical Information Center (D.D.), Weill Cornell Medical College, New York, NY
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Saba L, Anzidei M, Marincola BC, Piga M, Raz E, Bassareo PP, Napoli A, Mannelli L, Catalano C, Wintermark M. Imaging of the carotid artery vulnerable plaque. Cardiovasc Intervent Radiol 2013; 37:572-85. [PMID: 23912494 DOI: 10.1007/s00270-013-0711-2] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 07/03/2013] [Indexed: 11/28/2022]
Abstract
Atherosclerosis involving the carotid arteries has a high prevalence in the population worldwide. This condition is significant because accidents of the carotid artery plaque are associated with the development of cerebrovascular events. For this reason, carotid atherosclerotic disease needs to be diagnosed and those determinants that are associated to an increased risk of stroke need to be identified. The degree of stenosis typically has been considered the parameter of choice to determine the therapeutical approach, but several recently published investigations have demonstrated that the degree of luminal stenosis is only an indirect indicator of the atherosclerotic process and that direct assessment of the plaque structure and composition may be key to predict the development of future cerebrovascular ischemic events. The concept of "vulnerable plaque" was born, referring to those plaque's parameters that concur to the instability of the plaque making it more prone to the rupture and distal embolization. The purpose of this review is to describe the imaging characteristics of "vulnerable carotid plaques."
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Affiliation(s)
- Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato, s.s. 554, 09045, Monserrato, Cagliari, Italy,
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Hosseini AA, Kandiyil N, Macsweeney STS, Altaf N, Auer DP. Carotid plaque hemorrhage on magnetic resonance imaging strongly predicts recurrent ischemia and stroke. Ann Neurol 2013; 73:774-84. [PMID: 23463579 PMCID: PMC3824333 DOI: 10.1002/ana.23876] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 01/23/2013] [Accepted: 02/22/2013] [Indexed: 12/02/2022]
Abstract
Objective There is a recognized need to improve selection of patients with carotid artery stenosis for carotid endarterectomy (CEA). We assessed the value of magnetic resonance imaging (MRI)-defined carotid plaque hemorrhage (MRIPH) to predict recurrent ipsilateral cerebral ischemic events, and stroke in symptomatic carotid stenosis. Methods One hundred seventy-nine symptomatic patients with ≥50% stenosis were prospectively recruited, underwent carotid MRI, and were clinically followed up until CEA, death, or ischemic event. MRIPH was diagnosed if the plaque signal intensity was >150% that of the adjacent muscle. Event-free survival analysis was done using Kaplan–Meier plots and Cox regression models controlling for known vascular risk factors. We also undertook a meta-analysis of reported data on MRIPH and recurrent events. Results One hundred fourteen patients (63.7%) showed MRIPH, suffering 92% (57 of 62) of all recurrent ipsilateral events and all but 1 (25 of 26) future strokes. Patients without MRIPH had an estimated annual absolute stroke risk of only 0.6%. Cox multivariate regression analysis proved MRIPH as a strong predictor of recurrent ischemic events (hazard ratio [HR] = 12.0, 95% confidence interval [CI] = 4.8–30.1, p < 0.001) and stroke alone (HR = 35.0, 95% CI = 4.7–261.6, p = 0.001). Meta-analysis of published data confirmed this association between MRIPH and recurrent cerebral ischemic events in symptomatic carotid artery stenosis (odds ratio = 12.2, 95% CI = 5.5–27.1, p < 0.00001). Interpretation MRIPH independently and strongly predicts recurrent ipsilateral ischemic events, and stroke alone, in symptomatic ≥50% carotid artery stenosis. The very low stroke risk in patients without MRIPH puts into question current risk–benefit assessment for CEA in this subgroup. ANN NEUROL 2013;73:774–784
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Affiliation(s)
- Akram A Hosseini
- Division of Radiological and Imaging Sciences, University of Nottingham, Queen's Medical Campus, Nottingham, United Kingdom
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Identifying a high risk cardiovascular phenotype by carotid MRI-depicted intraplaque hemorrhage. Int J Cardiovasc Imaging 2013; 29:1477-83. [DOI: 10.1007/s10554-013-0229-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 04/19/2013] [Indexed: 10/26/2022]
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Saito H, Kuroda S, Hirata K, Magota K, Shiga T, Tamaki N, Yoshida D, Terae S, Nakayama N, Houkin K. Validity of Dual MRI and18F-FDG PET Imaging in Predicting Vulnerable and Inflamed Carotid Plaque. Cerebrovasc Dis 2013; 35:370-7. [DOI: 10.1159/000348846] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 02/04/2013] [Indexed: 11/19/2022] Open
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Magnetic Resonance Imaging of Carotid Atherosclerosis and the Risk of Stroke. CURRENT CARDIOVASCULAR IMAGING REPORTS 2012. [DOI: 10.1007/s12410-012-9178-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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