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Pagliariccio G, Di Sario I, Capoccia L, D'Elia M, Bafile G, Leopardi M, Fiore F, Palmieri A, Antico L, Antico A. Carotid Near-Occlusion: Surgical or Conservative Management? Retrospective Multicenter Study. Ann Vasc Surg 2024; 102:133-139. [PMID: 38408393 DOI: 10.1016/j.avsg.2023.11.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/14/2023] [Accepted: 11/26/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Carotid near-occlusion (CNO) represents an anatomical-functional condition characterized by severe (more than 90%) internal carotid artery stenosis which can lead to a distal lumen diameter greater or less than 2 mm. CNO can be divided into a less severe subgroup (without lumen full collapse: diameter >2 mm) and a more severe subgroup (with lumen full collapse: diameter <2 mm). The decision for revascularization is still highly debated in Literature. The aim of the present multicenter retrospective study is to analyze the incidence of perioperative (30 days) and follow-up complications in 2 groups of patients with or without distal internal carotid lumen full collapse. METHODS Between January 2011 and March 2023, in 5 Vascular Surgery Units, 67 patients (49 male, 73% and 18 females, 27%) with CNO underwent carotid endarterectomy: 28 (41.7%) with lumen diameter <2 mm and 39 (58.3%) with diameter >2 mm. 19 patients were symptomatic and 48 asymptomatic. The outcomes considered for comparative analysis were: perioperative neurological and cardiac complications, carotid restenosis or occlusion at follow-up. Both groups were homogeneous in terms of risk factors, morphological features and pharmacological treatments. RESULTS In the group with lumen <2 mm, 3 perioperative major events (10.7%) occurred (1 ischemic stroke, 1 hemorrhagic stroke, 1 myocardial infarction) and 2 (7.1%) at follow-up (average 11 ± 14.5 months; 1 asymptomatic carotid occlusion, 1 hemodynamic restenosis treated with stenting). No event was recorded in the group with lumen >2 mm. CONCLUSIONS According to our results CNO patients show different complication risk according to the presence or not of distal lumen collapse. The later seems to play a significant role in perioperative and follow-up complication rate. These results therefore support a surgical treatment only in patients with CNO without lumen full collapse.
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Affiliation(s)
| | | | - Laura Capoccia
- Vascular Surgery Department, Avezzano Hospital, Avezzano, Italy
| | - Marcello D'Elia
- Vascular Surgery Department, Avezzano Hospital, Avezzano, Italy
| | - Gennaro Bafile
- Vascular Surgery Department, L'Aquila Hospital, L'Aquila, Italy
| | - Marco Leopardi
- Vascular Surgery Department, L'Aquila Hospital, L'Aquila, Italy
| | - Franco Fiore
- Vascular Surgery Department, Chieti Hospital, Chieti, Italy
| | | | - Lorenzo Antico
- Vascular Surgery Department, Pescara Hospital, Pescara, Italy
| | - Antonio Antico
- Vascular Surgery Department, Pescara Hospital, Pescara, Italy
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Holmgren M, Henze A, Wåhlin A, Eklund A, Fox AJ, Johansson E. Phase-contrast magnetic resonance imaging of intracranial and extracranial blood flow in carotid near-occlusion. Neuroradiology 2024; 66:589-599. [PMID: 38400954 PMCID: PMC10937755 DOI: 10.1007/s00234-024-03309-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 02/08/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE Compare extracranial internal carotid artery flow rates and intracranial collateral use between conventional ≥ 50% carotid stenosis and carotid near-occlusion, and between symptomatic and asymptomatic carotid near-occlusion. METHODS We included patients with ≥ 50% carotid stenosis. Degree of stenosis was diagnosed on CTA. Mean blood flow rates were assessed with four-dimensional phase-contrast MRI. RESULTS We included 110 patients of which 83% were symptomatic, and 38% had near-occlusion. Near-occlusions had lower mean internal carotid artery flow (70 ml/min) than conventional ≥ 50% stenoses (203 ml/min, P < .001). Definite use of ≥ 1 collateral was found in 83% (35/42) of near-occlusions and 10% (7/68) of conventional stenoses (P < .001). However, there were no differences in total cerebral blood flow (514 ml/min vs. 519 ml/min, P = .78) or ipsilateral hemispheric blood flow (234 vs. 227 ml/min, P = .52), between near-occlusions and conventional ≥ 50% stenoses, based on phase-contrast MRI flow rates. There were no differences in total cerebral or hemispheric blood flow, or collateral use, between symptomatic and asymptomatic near-occlusions. CONCLUSION Near-occlusions have lower internal carotid artery flow rates and more collateral use, but similar total cerebral blood flow and hemispheric blood flow, compared to conventional ≥ 50% carotid stenosis.
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Affiliation(s)
- Madelene Holmgren
- Department of Clinical Sciences, Neurosciences, Umeå University, Umeå, Sweden
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Alexander Henze
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Anders Wåhlin
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
- Umeå Center for Functional Brain Imaging, Umeå University, Umeå, Sweden
- Department of Applied Physics and Electronics, Umeå University, Umeå, Sweden
| | - Anders Eklund
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
- Umeå Center for Functional Brain Imaging, Umeå University, Umeå, Sweden
| | - Allan J Fox
- Sunnybrook Health Science Center, University of Toronto, Toronto, Canada
| | - Elias Johansson
- Department of Clinical Sciences, Neurosciences, Umeå University, Umeå, Sweden.
- Wallenberg Center for Molecular Medicine, Umeå University, Umeå, Sweden.
- Neuroscience and Physiology, Gothenburg University, Göteborg, Sweden.
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Henze A, Fox AJ, Johansson E. High risk of early recurrent stroke in patients with near-occlusion with full collapse of the internal carotid artery. Neuroradiology 2024; 66:349-352. [PMID: 38191868 PMCID: PMC10859336 DOI: 10.1007/s00234-024-03283-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 01/02/2024] [Indexed: 01/10/2024]
Abstract
We aimed to validate the prognostic ability and assess interrater reliability of a recently suggested measurement-based definition of near-occlusion with full collapse (distal ICA diameter ≤ 2.0 mm and/or ICA ratio ≤ 0.42). 118 consecutive patients with symptomatic near-occlusion were prospectively included and assessed on computed tomography angiography by 2 blinded observers, 26 (22%) had full collapse. At 2 days after presenting event, the risk of preoperative stroke was 3% for without full collapse and 16% for with full collapse (p = 0.01). At 28 days, this risk was 16% for without full collapse and 22% for with full collapse (p = 0.22). Interrater reliability was perfect (kappa 1.0). Thus, near-occlusion with full collapse should be defined as distal ICA ≤ 2.0 mm and/or ICA ratio ≤ 0.42 in order to detect cases with very high risk of early stroke recurrence.
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Affiliation(s)
- Alexander Henze
- Institution of Radiation Sciences, Department of Diagnostic Radiology, Umeå University, Umeå, Sweden
| | - Allan J Fox
- Sunnybrook Health Science Center, Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Elias Johansson
- Institution of Clinical Science, Department of Neurosciences, Umeå University, Umeå, Sweden.
- Wallenberg Center of Molecular Medicine, Umeå University, Umeå, Sweden.
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, Gothenburg, Sweden.
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Zarrinkoob L, Myrnäs S, Wåhlin A, Eklund A, Malm J. Cerebral Blood Flow Patterns in Patients With Low-Flow Carotid Artery Stenosis, a 4D-PCMRI Assessment. J Magn Reson Imaging 2024. [PMID: 38168876 DOI: 10.1002/jmri.29216] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/16/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Compromised cerebral blood flow can contribute to future ischemic events in patients with symptomatic carotid artery disease. However, there is limited knowledge of the effects on cerebral hemodynamics resulting from a reduced internal carotid artery (ICA) blood flow rate (BFR). PURPOSE Investigate how reduced ICA-BFR, relates to BFR in the cerebral arteries. STUDY TYPE Prospective. SUBJECTS Thirty-eight patients, age 72 ± 6 years (11 female). FIELD STRENGTH/SEQUENCE 3-Tesla, four-dimensional phase-contrast magnetic resonance imaging (4D-PCMRI). ASSESSMENT Patients with ischemic stroke or transient ischemic attack were evaluated regarding the degree of stenosis. 4D-PCMRI was used to measure cerebral BFR in 38 patients with symptomatic carotid stenosis (≥50%). BFR in the cerebral arteries was assessed in two subgroups based on symptomatic ICA-BFR: reduced ICA-flow (<160 mL/minutes) and preserved ICA-flow (≥160 mL/minutes). BFR laterality was defined as a difference in the paired ipsilateral-contralateral arteries. STATISTICAL TESTS Patients were grouped based on ICA-BFR (reduced vs. preserved). Statistical tests (independent sample t-test/paired t-test) were used to compare groups and hemispheres. Significance was determined at P < 0.05. RESULTS The degree of stenosis was not significantly different, 80% (95% confidence interval [CI] = 73%-87%) in the reduced ICA-flow vs. 72% (CI = 66%-76%) in the preserved ICA-flow; P = 0.09. In the reduced ICA-flow group, a significantly reduced BFR was found in the ipsilateral middle cerebral artery and anterior cerebral artery (A1), while significantly increased in the contralateral A1. Retrograde BFR was found in the posterior communicating artery and ophthalmic artery. Significant BFR laterality was present in all paired arteries in the reduced ICA-flow group, contrasting the preserved ICA-flow group (P = 0.14-0.93). DATA CONCLUSIONS 4D-PCMRI revealed compromised cerebral BFR due to carotid stenosis, not possible to detect by solely analyzing the degree of stenosis. In patients with reduced ICA-flow, collaterals were not sufficient to maintain symmetrical BFR distribution to the two hemispheres. EVIDENCE LEVEL 2 TECHNICAL EFFICACY: Stage 3.
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Affiliation(s)
- Laleh Zarrinkoob
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine Unit, Umeå University, Umeå, Sweden
| | - Sanne Myrnäs
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine Unit, Umeå University, Umeå, Sweden
| | - Anders Wåhlin
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
- Centre for Biomedical Engineering and Physics, Umeå University, Umeå, Sweden
- Umeå Center for Functional Brain Imaging, Umeå University, Umeå, Sweden
| | - Anders Eklund
- Centre for Biomedical Engineering and Physics, Umeå University, Umeå, Sweden
- Umeå Center for Functional Brain Imaging, Umeå University, Umeå, Sweden
| | - Jan Malm
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
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Saba L, Scicolone R, Johansson E, Nardi V, Lanzino G, Kakkos SK, Pontone G, Annoni AD, Paraskevas KI, Fox AJ. Quantifying Carotid Stenosis: History, Current Applications, Limitations, and Potential: How Imaging Is Changing the Scenario. Life (Basel) 2024; 14:73. [PMID: 38255688 PMCID: PMC10821425 DOI: 10.3390/life14010073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/24/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024] Open
Abstract
Carotid artery stenosis is a major cause of morbidity and mortality. The journey to understanding carotid disease has developed over time and radiology has a pivotal role in diagnosis, risk stratification and therapeutic management. This paper reviews the history of diagnostic imaging in carotid disease, its evolution towards its current applications in the clinical and research fields, and the potential of new technologies to aid clinicians in identifying the disease and tailoring medical and surgical treatment.
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Affiliation(s)
- Luca Saba
- Department of Radiology, University of Cagliari, 09042 Cagliari, Italy;
| | - Roberta Scicolone
- Department of Radiology, University of Cagliari, 09042 Cagliari, Italy;
| | - Elias Johansson
- Neuroscience and Physiology, Sahlgrenska Academy, 41390 Gothenburg, Sweden;
| | - Valentina Nardi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| | - Stavros K. Kakkos
- Department of Vascular Surgery, University of Patras, 26504 Patras, Greece;
| | - Gianluca Pontone
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy; (G.P.); (A.D.A.)
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20122 Milan, Italy
| | - Andrea D. Annoni
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy; (G.P.); (A.D.A.)
| | | | - Allan J. Fox
- Department of Medical Imaging, Neuroradiology Section, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada;
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Kellomäki E, Gu T, Fox AJ, Johansson E. Symptomatic and asymptomatic carotid near-occlusions have very similar angiographic appearance on CT-angiography. Neuroradiology 2022; 64:2203-2206. [PMID: 36129513 PMCID: PMC9576665 DOI: 10.1007/s00234-022-03054-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/13/2022] [Indexed: 10/25/2022]
Abstract
The aim of this study was to compare the angiographic appearance of symptomatic and asymptomatic carotid near-occlusion. We have found no such previous study. The study hypothesis was that among symptomatic patients with ≥ 50% carotid stenosis, near-occlusion is more common and near-occlusions are more severe than among asymptomatic persons with ≥ 50% carotid stenosis. We reassessed consecutive CTAs from 4042 persons, 645 had ≥ 50% carotid stenosis, and 385 (60%) symptomatic. Near-occlusion was similarly common in symptomatic (105, 27%) and asymptomatic (56, 24%) cases. Among near-occlusions, the angiographic appearance was very similar between symptomatic and asymptomatic cases: mean stenosis lumen diameter (0.7 mm), distal ICA diameter (2.1 mm), and ECA ratio (0.79) were the same in both groups. Mean ICA ratio (0.46 and 0.48) and share of full collapse was very similar (45% and 42%). These findings add to the pathophysiological understanding of carotid near-occlusion.
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Affiliation(s)
- Elisa Kellomäki
- Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Thomas Gu
- Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Allan J Fox
- Sunnybrook Health Science Centre, University of Toronto, Toronto, ON, Canada
| | - Elias Johansson
- Clinical Science, Neurosciences, Umeå University, Umeå, Sweden. .,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
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Johansson E, Holmgren M, Henze A, Fox AJ. Diagnosing carotid near-occlusion is a difficult task-but it might get easier. Neuroradiology 2022; 64:1709-1714. [PMID: 35829763 DOI: 10.1007/s00234-022-03007-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/02/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Elias Johansson
- Clinical Science, Umeå University, Neurosciences, Umeå, Sweden. .,Wallenberg Center for Molecular Medicine, Umeå University, Umeå, Sweden.
| | | | | | - Allan J Fox
- Sunnybrook Health Science Center, University of Toronto, Toronto, Canada
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Štěchovský C, Hulíková Tesárková K, Hájek P, Horváth M, Hansvenclová E, Veselka J. Comparison of 30-Day Outcomes after Carotid Artery Stenting in Patients with Near-Occlusion and Severe Stenosis: A Propensity Score Matching Analysis. AJNR Am J Neuroradiol 2022; 43:1311-1317. [PMID: 35981760 PMCID: PMC9451624 DOI: 10.3174/ajnr.a7598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/17/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Carotid artery near-occlusion is a type of severe stenosis with complete or partial distal luminal collapse and intracranial collaterals. This study aimed to compare 30-day outcomes and 10-year survival in patients undergoing carotid artery stenting for near-occlusion with a control group of patients with severe stenosis. MATERIALS AND METHODS We used data from a registry of 639 patients who underwent 789 carotid artery stenting procedures between 2005 and 2021. The primary end point was any stroke or death within 30 days after carotid artery stenting. Patients were matched using propensity scores based on 6 variables. RESULTS Propensity score matching yielded 84 subjects in the near-occlusion group matched with 168 subjects in the control group. In the matched cohort, the primary end point occurred in 7 (8.3%) and 11 (6.6%) patients in the near-occlusion and control groups, respectively (P = .611). In the unmatched cohort, the primary end point occurred in 7 (8.3%) and 19 (4.1%) patients (P = .101). Survival in the near-occlusion group versus the control group in the matched cohort at 5 and 10 years was 69.8% (95% CI, 58.0%-78.8%) versus 77.3% (95% CI, 70.0%-83.1%) and 53.3% (95% CI, 39.9%-65.0%) versus 53.3% (95% CI, 44.5%-61.4%) (log-rank, P = .798). CONCLUSIONS Carotid stent placement in patients with ICA near-occlusion was not associated with an increased 30-day risk of stroke or death compared with severe stenosis. Survival up to 10 years after carotid artery stenting was similar in both groups.
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Affiliation(s)
- C Štěchovský
- From the Department of Cardiology (C.Š., P,H., M.H., E.H., J.V.), Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
| | - K Hulíková Tesárková
- Department of Demography and Geodemography (K.H.T.), Faculty of Science, Charles University, Prague, Czech Republic
| | - P Hájek
- From the Department of Cardiology (C.Š., P,H., M.H., E.H., J.V.), Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
| | - M Horváth
- From the Department of Cardiology (C.Š., P,H., M.H., E.H., J.V.), Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
| | - E Hansvenclová
- From the Department of Cardiology (C.Š., P,H., M.H., E.H., J.V.), Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
| | - J Veselka
- From the Department of Cardiology (C.Š., P,H., M.H., E.H., J.V.), Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
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Omoto K, Takayama K, Myouchin K, Wada T, Nakagawa I, Tanaka T, Kurokawa S, Nakase H, Kichikawa K. Carotid Artery Stenting for Near Occlusion with Full Collapse. World Neurosurg 2022; 163:e215-e222. [PMID: 35342028 DOI: 10.1016/j.wneu.2022.03.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Carotid near occlusions show a lower risk of stroke than other types of severe stenosis. However, emerging evidence suggests that near occlusion with full collapse differs from that without full collapse. The results of treatment with carotid artery stenting for near occlusion with full collapse are presented. METHODS Between March 2007 and December 2020, 18 of 477 carotid artery stenting procedures were performed in patients with near occlusion with full collapse (3.8%). A total of 17 men and one woman with a mean age of 76.1 years were included. Eleven patients (61%) were symptomatic. The technical success rate, incidence of symptomatic stroke within 30 days, new ipsilateral ischemic lesions on diffusion tensor imaging within 48 hours after carotid artery stenting, and follow-up results (ipsilateral stroke rate and restenosis rate) were retrospectively assessed. RESULTS The technical success rate was 100%. All carotid artery stenting procedures were performed using embolic protection devices. No symptomatic stroke occurred within 30 days. New ipsilateral ischemic lesions on magnetic resonance imaging were observed in 16.7% (3/18) of patients. Asymptomatic minor cerebral hemorrhage occurred in 2 patients (11.1%) with cerebral hyperperfusion syndrome. The median follow-up period was 77 months. Asymptomatic restenosis of 50% occurred in one patient (5.5%), and asymptomatic occlusion occurred in one patient (5.5%). During follow-up, no patients experienced ipsilateral stroke. Three patients (16.7%) died from nonneurological causes. CONCLUSIONS Carotid artery stenting for near occlusion with full collapse seems to be a feasible and safe procedure that can be performed by an experienced neuro-interventional team.
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Affiliation(s)
- Koji Omoto
- Department of Neurosurgery, Ishinkai Yao General Hospital, Yao, Osaka, Japan.
| | - Katsutoshi Takayama
- Department of Interventional Neuroradiology/Radiology, Kouseikai Takai Hospital, Tenri, Nara, Japan
| | - Kaoru Myouchin
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
| | - Takeshi Wada
- Department of Interventional Neuroradiology/Radiology, Kouseikai Takai Hospital, Tenri, Nara, Japan
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Toshihiro Tanaka
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
| | - Shinichiro Kurokawa
- Department of Neurosurgery, Ishinkai Yao General Hospital, Yao, Osaka, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Kimihiko Kichikawa
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
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Johansson E, Gu T, Castillo S, Brunström M, Holsti M, Wanhainen A. Intracerebral Haemorrhage after Revascularisation of Carotid Near Occlusion with Full Collapse. Eur J Vasc Endovasc Surg 2022; 63:523-524. [DOI: 10.1016/j.ejvs.2021.10.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/18/2021] [Accepted: 10/31/2021] [Indexed: 11/03/2022]
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Zhou M, Chen L, Zheng H, He L. Pendulum Movement of Contrast Agent Indicating to-and-fro Blood Flow Stasis in a Patient with Carotid Near-Occlusion. J Stroke Cerebrovasc Dis 2021; 30:106002. [PMID: 34333224 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/03/2021] [Accepted: 07/07/2021] [Indexed: 02/05/2023] Open
Abstract
In the present case, we directly visualized the pendulum movement of the contrast agent downstream of a carotid near-occlusion during digital subtraction angiography, suggesting the existence of "to-and-fro" stagnant flow created by the significant flow reduction and high back pressure from visible ophthalmic collaterals with blood stagnation distal to the stenosis. The pendular movement phenomenon represents a stagnation of blood that could be associated with an increased risk of thrombus formation and subsequent embolization to more distal arterial territories. This case may partially explain not only the embolic mechanism for stroke in carotid near-occlusion but the recent observation that collateral circulation through the ipsilateral ophthalmic artery is associated independently with an increased risk of the progression of carotid near-occlusion to complete occlusion.
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Affiliation(s)
- Muke Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lizhang Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hongbo Zheng
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Abstract
BACKGROUND Symptomatic carotid near-occlusion is often described as rare. Recent studies have shown that near-occlusions are overlooked, especially near-occlusion without full collapse (with a small but normal-appearing distal internal carotid artery). OBJECTIVE To assess the prevalence of near-occlusion among symptomatic ≥50% carotid stenosis, incidence of symptomatic near-occlusion, and review the literature. METHODS Prospective controlled single-center cross-sectional study. Consecutive cases with symptomatic ≥50% carotid stenosis were examined with computed tomography angiography (CTA). The CTAs were assessed for near-occlusion by two observers. A systematic literature review was performed with emphasis on how study design affects prevalence estimate. RESULTS Totally, 186 patients with symptomatic ≥50% carotid stenosis were included, 34% (n = 63, 95% CI 27, 41) had near-occlusion. The incidence of symptomatic near-occlusion was 3.4 (95% CI 2.5, 4.2) per 100,000 person-years. Inter-rater κ was 0.71. The average prevalence of near-occlusion among symptomatic ≥50% carotid stenosis was higher in studies with good design (30%, range 27%-34%) than studies without good design (9%, range 2%-10%). CONCLUSIONS Near-occlusion is common variant of symptomatic ≥50% carotid stenosis, both in the current study and in all previous studies of good design. Studies that suggest that near-occlusion is rare have had methodological issues.
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Defining carotid near-occlusion with full collapse: a pooled analysis. Neuroradiology 2021; 64:59-67. [PMID: 33944975 PMCID: PMC8724220 DOI: 10.1007/s00234-021-02728-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/26/2021] [Indexed: 11/21/2022]
Abstract
Purpose Create a new definition of near-occlusion with full collapse to predicting recurrent stroke. Methods Pooled analysis of two studies. Patients with symptomatic ≥ 50% carotid stenoses were included. Outcome was preoperative recurrent ipsilateral ischemic stroke or retinal artery occlusion within 28 days of presenting event. We analyzed several artery diameters on computed tomography angiography and stenosis velocity on ultrasound. Results A total of 430 patients with symptomatic ≥ 50% carotid stenosis were included, 27% had near-occlusion. By traditional definition, 27% with full collapse and 11% without full collapse reached the outcome (p = 0.047). Distal internal carotid artery (ICA) diameter, ICA ratio, and ICA-to-external carotid artery ratio were associated with the outcome. Best new definition of full collapse was distal ICA diameter ≤ 2.0 mm and/or ICA ratio ≤ 0.42. With this new definition, 36% with full collapse and 4% without full collapse reached the outcome (p < 0.001). Conclusions Defining near-occlusion with full collapse as distal ICA diameter ≤ 2.0 mm and/or ICA ratio ≤ 0.42 seems to yield better prognostic discrimination than the traditional appearance-based definition. This novel definition can be used in prognostic and treatment studies of near-occlusion with full collapse.
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Johansson E, Zarrinkoob L, Wåhlin A, Eklund A, Malm J. Diagnosing Carotid Near-Occlusion with Phase-Contrast MRI. AJNR Am J Neuroradiol 2021; 42:927-929. [PMID: 33707277 DOI: 10.3174/ajnr.a7076] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/07/2020] [Indexed: 11/07/2022]
Abstract
Carotid near-occlusion is a frequently overlooked diagnosis when CTA examinations are assessed in routine practice. To evaluate the potential value of phase-contrast MR imaging in identifying near-occlusion, we examined 9 carotid near-occlusions and 20 cases of conventional ≥50% carotid stenosis (mean stenosis degree, 65%) with phase-contrast MR imaging. Mean ICA flow was lower in near-occlusions (52 mL/min) than in conventional ≥50% stenosis (198 mL/min, P < .001). ICA flow of ≤110 mL/min was 100% sensitive and specific for near-occlusion. Phase-contrast MR imaging is a promising tool for diagnosing carotid near-occlusion.
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Affiliation(s)
- E Johansson
- Department of Clinical Science (E.J., L.Z., J.M.), Neurosciences, Umeå University, Umeå, Sweden
- Wallenberg Center for Molecular Medicine (E.J.), Umeå University, Umeå, Sweden
| | - L Zarrinkoob
- Department of Clinical Science (E.J., L.Z., J.M.), Neurosciences, Umeå University, Umeå, Sweden
- Department of Perioperative Sciences (L.Z.), Umeå University, Umeå, Sweden
| | - A Wåhlin
- Department of Radiation Sciences (A.W., A.E.), Umeå University, Umeå, Sweden
- Umeå Center for Functional Brain Imaging (A.W., A.E.), Umeå University, Umeå, Sweden
| | - A Eklund
- Department of Radiation Sciences (A.W., A.E.), Umeå University, Umeå, Sweden
- Umeå Center for Functional Brain Imaging (A.W., A.E.), Umeå University, Umeå, Sweden
| | - J Malm
- Department of Clinical Science (E.J., L.Z., J.M.), Neurosciences, Umeå University, Umeå, Sweden
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15
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Near-occlusion is difficult to diagnose with common carotid ultrasound methods. Neuroradiology 2021; 63:721-730. [PMID: 33715027 PMCID: PMC8041670 DOI: 10.1007/s00234-021-02687-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/03/2021] [Indexed: 01/01/2023]
Abstract
Purpose To assess the sensitivity and specificity of common carotid ultrasound method for carotid near-occlusion diagnosis. Methods Five hundred forty-eight patients examined with both ultrasound and CTA within 30 days of each other were analyzed. CTA graded by near-occlusion experts was used as reference standard. Low flow velocity, unusual findings, and commonly used flow velocity parameters were analyzed. Results One hundred three near-occlusions, 272 conventional ≥50% stenosis, 162 <50% stenosis, and 11 occlusions were included. Carotid ultrasound was 22% (95%CI 14–30%; 23/103) sensitive and 99% (95%CI 99–100%; 442/445) specific for near-occlusion diagnosis. Near-occlusions overlooked on ultrasound were found misdiagnosed as occlusions (n = 13, 13%), conventional ≥50% stenosis (n = 65, 63%) and < 50% stenosis (n = 2, 2%). No velocity parameter or combination of parameters could identify the 65 near-occlusions mistaken for conventional ≥50% stenoses with >75% sensitivity and specificity. Conclusion Near-occlusion is difficult to diagnose with commonly used carotid ultrasound methods. Improved carotid ultrasound methods are needed if ultrasound is to retain its position as sole preoperative modality.
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Vishnyakova MV, Pronin IN, Larkov RN, Vishnyakova MV. [Ct-angiography in assessment of critical occlusive carotid artery disease]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2021; 85:37-42. [PMID: 34951758 DOI: 10.17116/neiro20218506137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Occlusive carotid artery disease is still one of the major causes of ischemic stroke in the world. Progression of severe carotid stenosis may lead to critical stenosis and vascular occlusion. Nevertheless, there is still no pure definition of the concept of critical occlusive carotid artery disease. OBJECTIVE To define the role of CT-angiography in assessment of critical occlusive carotid artery disease. MATERIAL AND METHODS We analyzed data of 405 patients who underwent preoperative precise assessment of carotid arteries and subsequent surgical treatment for the period from 2016 to 2019. Contrast-enhanced CT-angiography (Philips Ict scanner, 256 slices) was made after previous ultrasound. Contrast agent injection rate was 4-5 ml/sec. CT angiography data were assessed according to a specialized protocol. RESULTS Critical occlusive carotid artery disease was observed in 128 (31.6%) cases including critical stenosis (24.94%), near-occlusion (5.92%) and local occlusion (0.74%). Critical stenosis was characterized by local narrowing ≥90% and normal diameter of distal arterial segment. In case of near-occlusion, local critical stenosis was accompanied by narrowing of distal arterial segment. In case of local occlusion, distal collateral supply of internal carotid artery occurred through atypically originating ascending pharyngeal artery. Patients with near-occlusion and local occlusion of internal carotid artery had no signs of ICA hypoplasia and intracranial stenoses. All elements of circle of Willis were observed in 70% of patients. CONCLUSION State of distal segment of internal carotid artery can be considered as a differential diagnostic criterion for critical occlusive carotid disease variants. CT-angiography provides all necessary data and can be recommended for precise preoperative assessment.
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Affiliation(s)
- M V Vishnyakova
- Vladimirskiy Moscow Regional Research Clinical Institute, Moscow, Russia
| | - I N Pronin
- Burdenko Neurosurgery Center, Moscow, Russia
| | - R N Larkov
- Vladimirskiy Moscow Regional Research Clinical Institute, Moscow, Russia
| | - M V Vishnyakova
- Vladimirskiy Moscow Regional Research Clinical Institute, Moscow, Russia
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Palacios-Mendoza MA, García-Pastor A, Gil-Núñez A, Ramírez-Moreno JM, González-Nafría N, Moniche F, Portilla-Cuenca JC, Fuentes B, Gamero-García MA, Alonso de Leciñana M, Masjuan J, Canovas-Verge D, Aladro Y, Lago A, de Arce-Borda AM, Usero-Ruiz M, Delgado-Mederos R, Pampliega A, Ximenez-Carrillo Á, Bártulos-Iglesias M, Castro-Reyes E. Ultrasonographic and hemodynamic characteristics of patients with symptomatic carotid near-occlusion: results from a multicenter registry study. Neuroradiology 2020; 63:705-711. [PMID: 33025041 DOI: 10.1007/s00234-020-02567-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/23/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE The ultrasonographic and hemodynamic features of patients with carotid near-occlusion (CNO) are still not well known. Our aim was to describe the ultrasonographic and hemodynamic characteristics of a cohort of patients with CNO. METHODS A prospective, observational, nationwide, and multicenter study was conducted from January/2010 to May/2016. Patients with digital subtraction angiography (DSA)-confirmed CNO were included. We collected information on clinical and demographic characteristics, carotid and transcranial ultrasonography and DSA findings, presence of full-collapse, collateral circulation, and cerebrovascular reactivity (CVR). RESULTS One hundred thirty-five patients were analyzed. Ultrasonographic and DSA diagnosis of CNO were concordant in only 44%. This disagreement was related to the presence/absence of full-collapse: 45% of patients with CNO with full-collapse were classified as a complete carotid occlusion, and 40% with a CNO without full-collapse were interpreted as severe stenosis (p < 0.001). Mean velocities (mV) and pulsatility indexes (PIs) were significantly lower in the ipsilateral middle cerebral artery compared with the contralateral (43 cm/s vs 58 cm/s, p < 0.001; 0.80 vs 1.00, p < 0.001). Collateral circulation was identified in 92% of patients, with the anterior communicating artery (73%) being the most frequent. CVR was decreased or exhausted in 66% of cases and was more frequent in patients with a poor or absent collateral network compared with patients with ≥ 2 collateral arteries (82% vs 56%, p = 0.051). CONCLUSION The accuracy of carotid ultrasonography in the diagnosis of CNO seems to be limited, with significant discrepancies with DSA. Decreased ipsilateral mV, PI, and CVR suggest a hemodynamic compromise in patients with CNO.
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Affiliation(s)
| | - A García-Pastor
- Hospital General Universitario Gregorio Marañón, Neurology, C/ Dr Esquerdo 46, 28007, Madrid, Spain
| | - A Gil-Núñez
- Hospital General Universitario Gregorio Marañón, Neurology, C/ Dr Esquerdo 46, 28007, Madrid, Spain
| | | | | | - F Moniche
- Hospital Universitario Virgen del Rocío, Sevilla, Neurology, Sevilla, Spain
| | | | - B Fuentes
- Hospital Universitario La Paz, Neurology, Madrid, Spain
| | | | | | - J Masjuan
- Hospital Universitario Ramón y Cajal, Neurology, Madrid, Spain
| | | | - Y Aladro
- Hospital Universitario de Getafe, Neurology, Getafe, Spain
| | - A Lago
- Hospital Universitari La Fe, Neurology, Valencia, Spain
| | | | - M Usero-Ruiz
- Hospital Universitario de Valladolid, Neurology, Valladolid, Spain
| | | | - A Pampliega
- Hospital General Univeristario de Alicante, Neurology, Alicante, Spain
| | | | | | - E Castro-Reyes
- Hospital General Universitario Gregorio Marañón, Neurology, C/ Dr Esquerdo 46, 28007, Madrid, Spain
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A Systematic Review and Updated Metaanalysis for Carotid Near-Occlusion. Ann Vasc Surg 2020; 66:636-645.e3. [DOI: 10.1016/j.avsg.2019.10.093] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/28/2019] [Accepted: 10/30/2019] [Indexed: 11/20/2022]
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Johansson E, Gu T, Aviv RI, Fox AJ. Carotid near-occlusion is often overlooked when CT angiography is assessed in routine practice. Eur Radiol 2020; 30:2543-2551. [PMID: 32006173 PMCID: PMC7160198 DOI: 10.1007/s00330-019-06636-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/20/2019] [Accepted: 12/16/2019] [Indexed: 11/26/2022]
Abstract
Objective Assess the sensitivity and specificity of computed tomography angiography (CTA) for carotid near-occlusion diagnosis interpreted in clinical practice against expert assessment. Methods CTAs were graded by two expert interpreters for near-occlusion. Findings were compared with clinical reports in 383 consecutive cases with symptomatic ≥ 50% carotid stenosis. In addition, 14 selected CTA exams (8 near-occlusions and 6 controls) were analyzed in a national effort by 13 radiologists experienced with carotid CTA. Results In clinical practice, imaging reports were 20% (95% CI 12–28%) sensitive for near-occlusion, ranging 0–58% between different radiologists; specificity was 99%. Among the 13 radiologists reviewing the same 8 near-occlusions, the average sensitivity was 8%, ranging 0–75%; specificity was 100%. Conclusions Carotid near-occlusion is systematically under-reported in clinical routine practice, caused by limited application of grading criteria when assessing CTA. Key Points • Carotid near-occlusion is severe stenosis with distal artery collapse; this collapse is often subtle. • A fifth of near-occlusions were detected in routine practice. Many readers mistake near-occlusion for stenosis without distal artery collapse, either by not actively searching for subtle collapses or by not interpreting the collapse correctly when noticed. • On the other hand, the novice diagnostician should be cautioned to not over-diagnose near-occlusion; other causes of extracranial ICA asymmetry also exist such as distal disease and Circle of Willis anatomical variants.
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Affiliation(s)
- Elias Johansson
- Department of Clinical Science, Umeå University, Umeå, Sweden.
- Wallenberg Center for Molecular Medicine (WCMM), Umeå University, Umeå, Sweden.
| | - Thomas Gu
- Department of Clinical Science, Umeå University, Umeå, Sweden
| | - Richard I Aviv
- Department of Radiology, Division of Neuroradiology, University of Ottawa, Ottawa, Canada
| | - Allan J Fox
- Department of Medical Imaging, Sunnybrook Health Science Center, University of Toronto, Toronto, Canada
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Johansson E, Aviv RI, Fox AJ. Atherosclerotic ICA stenosis coinciding with ICA asymmetry associated with Circle of Willis variations can mimic near-occlusion. Neuroradiology 2020; 62:101-104. [PMID: 31705180 PMCID: PMC6940316 DOI: 10.1007/s00234-019-02309-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/15/2019] [Indexed: 12/23/2022]
Abstract
Differentiating carotid near-occlusion (tight atherosclerotic stenosis causing distal artery size reduction) from conventional stenosis is the first step when grading carotid stenoses with NASCET method. The internal carotid artery (ICA) can be asymmetrically associated with Circle of Willis variations. When such ICA asymmetry coincides with stenosis, it may mimic near-occlusion. We studied ICA anatomical variant prevalence in 4042 consecutive CTA exams from all indications, 53 excluded due to carotid occlusion, 814 with any ≥ 50% steno-occlusive disease intra- or extracranially, 3228 without. Of the 3989 included cases, 568 (14%) had ICA asymmetry, of which 335 (59%) were from associated with Circle of Willis variations. Of 3228 patients without ≥ 50% stenosis or other steno-occlusive disease intra- and extracranially; 257 (8.0%) demonstrated ICA asymmetry associated with Circle of Willis variations, equally common among sexes and age unrelated and most frequently attributed to an ipsilateral A1 hypoplasia/aplasia, less often attributed to large contralateral posterior communicating artery. As ICA asymmetry associated with Circle of Willis variations are common, caution should be exercised diagnosing near-occlusion on asymmetry alone.
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Affiliation(s)
- Elias Johansson
- Department Clinical Science, and Wallenberg Center for Molecular Medicine (WCMM), Umeå University, Umeå, Sweden.
| | - Richard I Aviv
- Department of Medical Imaging, Sunnybrook Health Science Center, University of Toronto, Toronto, Canada
| | - Allan J Fox
- Department of Medical Imaging, Sunnybrook Health Science Center, University of Toronto, Toronto, Canada
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21
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Gu T, Aviv RI, Fox AJ, Johansson E. Symptomatic carotid near-occlusion causes a high risk of recurrent ipsilateral ischemic stroke. J Neurol 2019; 267:522-530. [PMID: 31701329 PMCID: PMC6989616 DOI: 10.1007/s00415-019-09605-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 01/06/2023]
Abstract
Objective To assess the risk of recurrent ipsilateral ischemic stroke in patients with symptomatic near-occlusion with and without full collapse. Methods Included were consecutive patients eligible for revascularization, grouped into symptomatic conventional ≥ 50% carotid stenosis (n = 266), near-occlusion without full collapse (n = 57) and near-occlusion with full collapse (n = 42). The risk of preoperative recurrent ipsilateral ischemic stroke was analyzed, or, for cases not revascularized within 90 days, 90-day risk was analyzed. Results The risk of a preoperative recurrent ipsilateral ischemic stroke or ipsilateral retinal artery occlusion was 15% (95% CI 9–20%) for conventional ≥ 50% stenosis, 22% (95% CI 6–38%) among near-occlusion without full collapse and 30% (95% CI 16–44%) among near-occlusion with full collapse (p = 0.01, log rank test). In multivariate analysis, near-occlusion with full collapse had a higher risk of recurrent ipsilateral ischemic stroke (adjusted HR 2.6, 95% CI 1.3–5.3) and near-occlusion without full collapse tended to have a higher risk (adjusted HR 2.0, 95% CI 0.9–4.5) than conventional ≥ 50% stenosis. Only 24% of near-occlusion with full collapse underwent revascularization, common causes for abstaining were misdiagnosis as occlusion (31%), deemed surgically unfeasible (21%) and low perceived benefit (10%). Conclusions Symptomatic carotid near-occlusion has a high short-term risk of recurrent ipsilateral ischemic stroke, especially near-occlusion with full collapse.
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Affiliation(s)
- Thomas Gu
- Department of Clinical Science, Umeå University, Norrlands Universitetssjukhus, 907 37, Umeå, Sweden.
| | - Richard I Aviv
- Department of Medical Imaging, Sunnybrook Health Science Center, University of Toronto, Toronto, Canada
| | - Allan J Fox
- Emeritus, Department of Medical Imaging, Sunnybrook Health Science Center, University of Toronto, Toronto, Canada
| | - Elias Johansson
- Department of Clinical Science, Umeå University, Norrlands Universitetssjukhus, 907 37, Umeå, Sweden.,Wallenberg Center for Molecular Medicine (WCMM), Umeå University, Umeå, Sweden
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Johansson E, Benhabib H, Herod W, Hopyan J, Machnowska M, Maggisano R, Aviv R, Fox AJ. Carotid near-occlusion can be identified with ultrasound by low flow velocity distal to the stenosis. Acta Radiol 2019; 60:396-404. [PMID: 29896980 DOI: 10.1177/0284185118780900] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Most carotid near-occlusions are indistinguishable from conventional ≥ 50% stenosis on ultrasound, demonstrating high peak systolic velocity (PSV) in the stenosis. PURPOSE To study whether the velocity distal to the stenosis can separate high PSV near-occlusion from conventional ≥ 50% stenosis. MATERIAL AND METHODS We included patients with ≥ 50% carotid stenosis with high PSV (≥125 cm/s), examined with both computed tomography angiography (CTA) and ultrasound within 30 days, and a distal velocity measurement was performed. Based on CTA, cases were divided into three groups: conventional stenosis; near-occlusion without full collapse (NwoC; normal-appearing albeit small distal artery); and near-occlusion with full collapse (NwC; threadlike distal artery). Distal Doppler ultrasound flow velocities were compared between these groups. RESULTS Sixty patients were included: 33 patients with conventional stenosis; 20 patients with NwoC; and seven patients with NwC. Mean distal PSV was 93, 63, and 21 cm/s ( P < 0.001) and mean distal end-diastolic velocity was 30, 24, and 5 cm/s ( P < 0.001), respectively. A distal PSV < 50 cm/s was 63% sensitive and 94% specific for separating both types of near-occlusion from conventional stenosis. CONCLUSION In high PSV carotid stenoses, the distal velocity was lower in near-occlusions than conventional carotid stenosis. Distal velocities warrant further investigation in diagnostic studies.
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Affiliation(s)
- Elias Johansson
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Hadas Benhabib
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Wendy Herod
- Vascular Lab, Sunnybrook Health Sciences Centre, Department of Surgery, University of Toronto, Canada
| | - Julia Hopyan
- Department of Neurology, Sunnybrook Health Sciences Centre, Department of Medicine, University of Toronto, Canada
| | - Matylda Machnowska
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Robert Maggisano
- Department of Vascular Surgery, Sunnybrook Health Sciences Centre, Department of Surgery, University of Toronto, Canada
| | - Richard Aviv
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Allan J Fox
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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Meershoek AJA, Vonken EPA, Nederkoorn PJ, Kappelle LJ, de Borst GJ. Carotid endarterectomy in patients with recurrent symptoms associated with an ipsilateral carotid artery near occlusion with full collapse. J Neurol 2018; 265:1900-1905. [PMID: 29916130 PMCID: PMC6060778 DOI: 10.1007/s00415-018-8939-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Near occlusion (NO) of the internal carotid artery (ICA) with full collapse (NOFC) is a rare condition, with a prevalence of around 1%. Guidelines on carotid stenosis recommend a conservative treatment in patients with a single-event ipsilateral to a NOFC, but the optimal treatment for patients with recurrent symptoms associated with NOFC remains uncertain. We describe a consecutive series of patients with recurrent symptoms associated with NOFC (RSNOFC) who underwent carotid endarterectomy (CEA). METHODS From 2008 to 2017, 17 consecutive patients with RSNOFC were treated according to our standardized multidisciplinary work-up and protocol and included for this single-center cohort study. NO was defined according to the angiographic North American Symptomatic Carotid Endarterectomy Trial criteria. Only patients with NOFC were included in this study. RESULTS Standard longitudinal CEA was performed in 15 patients, whereas in 2 patients the ICA was ligated with concomitant endarterectomy of the ECA. Within 30 postoperative days, one patient died from a hemorrhagic infarction. During follow-up (median 23 months) one patient died of unknown cause 90 days after CEA. No TIA, stroke, myocardial infarction or re-stenosis occurred in the remaining patients. CONCLUSION In patients with RSNOFC, CEA may be considered a potential treatment option. Although procedural risks in this small subgroup may be higher as compared to patients with low-to-moderate risk anatomy, this risk may outbalance the natural course.
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Affiliation(s)
- A J A Meershoek
- Department of Vascular Surgery, Room G04.129, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - E P A Vonken
- Department of Radiology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - P J Nederkoorn
- Department of Neurology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - L J Kappelle
- Department of Neurology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - G J de Borst
- Department of Vascular Surgery, Room G04.129, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
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Neves CRB, Casella IB, da Silva ES, Puech-Leão P. Medical Therapy for Asymptomatic Patients and Stent Placement for Symptomatic Patients Presenting with Carotid Artery Near-Occlusion with Full Collapse. J Vasc Interv Radiol 2018; 29:998-1005. [DOI: 10.1016/j.jvir.2018.01.779] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 01/16/2018] [Accepted: 01/19/2018] [Indexed: 11/29/2022] Open
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25
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Khangure SR, Benhabib H, Machnowska M, Fox AJ, Grönlund C, Herod W, Maggisano R, Sjöberg A, Wester P, Hojjat SP, Hopyan J, Aviv RI, Johansson E. Carotid near-occlusion frequently has high peak systolic velocity on Doppler ultrasound. Neuroradiology 2017; 60:17-25. [PMID: 29177789 DOI: 10.1007/s00234-017-1938-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 10/17/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Carotid near-occlusion is a tight atherosclerotic stenosis of the internal carotid artery (ICA) resulting in decrease in diameter of the vessel lumen distal to the stenosis. Near-occlusions can be classified as with or without full collapse, and may have high peak systolic velocity (PSV) across the stenosis, mimicking conventional > 50% carotid artery stenosis. We aimed to determine how frequently near-occlusions have high PSV in the stenosis and determine how accurately carotid Doppler ultrasound can distinguish high-velocity near-occlusion from conventional stenosis. METHODS Included patients had near-occlusion or conventional stenosis with carotid ultrasound and CT angiogram (CTA) performed within 30 days of each other. CTA examinations were analyzed by two blinded expert readers. Velocities in the internal and common carotid arteries were recorded. Mean velocity, pulsatility index, and ratios were calculated, giving 12 Doppler parameters for analysis. RESULTS Of 136 patients, 82 had conventional stenosis and 54 had near-occlusion on CTA. Of near-occlusions, 40 (74%) had high PSV (≥ 125 cm/s) across the stenosis. Ten Doppler parameters significantly differed between conventional stenosis and high-velocity near-occlusion groups. However, no parameter was highly sensitive and specific to separate the groups. CONCLUSION Near-occlusions frequently have high PSV across the stenosis, particularly those without full collapse. Carotid Doppler ultrasound does not seem able to distinguish conventional stenosis from high-velocity near-occlusion. These findings question the use of ultrasound alone for preoperative imaging evaluation.
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Affiliation(s)
- Simon R Khangure
- Department of Medical Imaging, Neuroradiology Division, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. .,Department of Medical Imaging, Division of Neuroimaging, University of Toronto, Toronto, Canada.
| | - Hadas Benhabib
- Department of Medical Imaging, Neuroradiology Division, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Matylda Machnowska
- Department of Medical Imaging, Neuroradiology Division, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Medical Imaging, Division of Neuroimaging, University of Toronto, Toronto, Canada
| | - Allan J Fox
- Department of Medical Imaging, Neuroradiology Division, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Medical Imaging, Division of Neuroimaging, University of Toronto, Toronto, Canada
| | - Christer Grönlund
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Wendy Herod
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Robert Maggisano
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada.,Division of Vascular Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Anders Sjöberg
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden.,Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Per Wester
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.,Department of Clinical Sciences, Karolinska Institutet Danderyds Hospital, Stockholm, Sweden
| | - Seyed-Parsa Hojjat
- Department of Medical Imaging, Neuroradiology Division, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Medical Imaging, Division of Neuroimaging, University of Toronto, Toronto, Canada
| | - Julia Hopyan
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Richard I Aviv
- Department of Medical Imaging, Neuroradiology Division, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Medical Imaging, Division of Neuroimaging, University of Toronto, Toronto, Canada
| | - Elias Johansson
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden.,Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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García-Pastor A, Gil-Núñez A, Ramírez-Moreno JM, González-Nafría N, Tejada J, Moniche F, Portilla-Cuenca JC, Martínez-Sánchez P, Fuentes B, Gamero-García MÁ, Alonso de Leciñana M, Cánovas-Verge D, Aladro Y, Parkhutik V, Lago-Martín A, de Arce-Borda AM, Usero-Ruíz M, Delgado-Mederos R, Pampliega A, Ximenez-Carrillo Á, Bártulos-Iglesias M, Castro-Reyes E. Early risk of recurrent stroke in patients with symptomatic carotid near-occlusion: Results from CAOS, a multicenter registry study. Int J Stroke 2017; 12:713-719. [DOI: 10.1177/1747493017714177] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The risk of recurrent stroke among patients with symptomatic carotid near-occlusion is not well established, and management of the condition remains controversial. Symptomatic carotid near-occlusion with full collapse has been identified as a strong predictor of early recurrence. We aimed to analyze the 90-day risk of recurrent ipsilateral ischemic stroke in medically treated patients with symptomatic carotid near-occlusion. Methods We performed a multicenter, nationwide, prospective study from January 2010 to May 2016. Patients with angiography-confirmed symptomatic carotid near-occlusion were included. The primary endpoint was ipsilateral ischemic stroke or transient ischemic attack (TIA) within 90 days after the presenting event. For this analysis, patients who underwent revascularization within 90 days after stroke were excluded. Results The study population comprised 141 patients from 17 Spanish centers; 83 patients were treated medically. Primary endpoint occurred in eight patients, resulting in a cumulative rate of 10.6% (95% CI, 3.7–17.5). Previous history of stroke or transient ischemic attack was identified as an independent predictor for recurrence in the multivariate Cox regression analysis (HR, 4.37 [95% CI, 1.05–18.18]; p = 0.043), while the presence of full collapse was not associated with an increased risk (HR, 0.81 [95% CI, 0.17–3.92]; p = 0.793). The risk of recurrence was also not affected by the presence of significant stenosis or occlusion of the contralateral carotid artery, or by the collateral circulation. Conclusions Patients with symptomatic carotid near-occlusion seem to have an increased risk of early ipsilateral recurrent stroke. Our results contrast with the low risk of symptomatic carotid near-occlusion reported to date. Full collapse did not increase the risk of recurrent stroke in our study.
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Affiliation(s)
| | | | | | | | - Javier Tejada
- Complejo Asistencial Universitario de León, León, Spain
| | | | | | | | | | | | | | | | | | - Vera Parkhutik
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | | | | | | | - Ana Pampliega
- Hospital General Universitario de Alicante, Alicante, Spain
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Diagnosing carotid near-occlusion with 1 mm side-to-side asymmetry: a tough task made too easy. Neuroradiology 2017; 59:319-321. [PMID: 28303375 DOI: 10.1007/s00234-017-1792-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/27/2017] [Indexed: 12/28/2022]
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28
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Recognizing subtle near-occlusion in carotid stenosis patients: a computed tomography angiographic study. Neuroradiology 2017; 59:353-359. [DOI: 10.1007/s00234-017-1791-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 01/27/2017] [Indexed: 10/20/2022]
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Akkan K, Ilgit E, Onal B, Cindil E, Solak EP, Oncu F, Geylan DE. Endovascular Treatment for Near Occlusion of the Internal Carotid Artery : 30-Day Outcome and Long-Term Follow-Up. Clin Neuroradiol 2016; 28:245-252. [PMID: 27783127 DOI: 10.1007/s00062-016-0546-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 10/05/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The treatment strategy and the correct incidence of near occlusion (NO) of the internal carotid artery (ICA) is still controversial. In routine radiological imaging NO can easily be misdiagnosed as complete occlusion and there is no consensus on the standard treatment strategy. PURPOSE To present our perioperative and long-term follow-up results of ICA NO patients treated with carotid artery stenting (CAS). MATERIAL AND METHODS Between 2004-2014 a total of 182 patients with ICA NO were evaluated for CAS. The study included 132 male (72.5 %) and 50 female (27.5 %) patients with a mean age of 70.2 years. Patients underwent a clinical neurological evaluation and radiological imaging of the carotid arteries before the CAS procedure. Of the patients 80 (44 %) were asymptomatic. The median clinical and carotid Doppler ultrasound (DUS) follow-up period was 64 months (range 18-124 months). RESULTS In 182 patients CAS were performed, 4 patients (2.2 %) developed minor stroke, 2 patients (1.1 %) developed myocardial infarction but no major stroke or death occurred in the following 30-day period. Asymptomatic restenosis was detected in seven patients (3.8 %) in the follow-up period. CONCLUSION With sufficient neurological evaluation during pretreatment and posttreatment periods and when the procedure is performed with technologically developed products by an experienced interventional team, CAS is beneficial in patients with ICA NO.
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Affiliation(s)
- Koray Akkan
- Department of Radiology, Gazi University School of Medicine, 06510, Besevler/Ankara, Turkey.
| | - Erhan Ilgit
- Department of Radiology, Gazi University School of Medicine, 06510, Besevler/Ankara, Turkey
| | - Baran Onal
- Department of Radiology, Gazi University School of Medicine, 06510, Besevler/Ankara, Turkey
| | - Emetullah Cindil
- Department of Radiology, Gazi University School of Medicine, 06510, Besevler/Ankara, Turkey
| | - Evsen Polattas Solak
- Department of Radiology, Gazi University School of Medicine, 06510, Besevler/Ankara, Turkey
| | - Fatih Oncu
- Department of Radiology, Gazi University School of Medicine, 06510, Besevler/Ankara, Turkey
| | - Dilan Ece Geylan
- Department of Radiology, Gazi University School of Medicine, 06510, Besevler/Ankara, Turkey
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