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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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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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Nordanstig A, Gu T, Henze A, Wester P, Fox AJ, Johansson E. Risk of Stroke Recurrence After Intravenous Thrombolysis in Patients with Symptomatic Carotid Stenosis. Can J Neurol Sci 2023:1-8. [PMID: 37681233 DOI: 10.1017/cjn.2023.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVE To assess if intravenous thrombolysis (IVT) affects the risk of recurrent preoperative cerebrovascular events before carotid surgery or stenting in patients with symptomatic ≥ 50% carotid stenosis. METHODS Three cohorts of symptomatic ≥ 50% carotid stenosis patients were merged. To make the control group relevant, we excluded patients not presenting with stroke on the day of symptom onset. The risk of preoperative cerebrovascular events up to 30 days was compared between the IVT-treated and non-IVT-treated. RESULTS In total, 316 patients were included, 64 (20%) treated with IVT. Those treated with IVT had similar risk of recurrent ipsilateral ischemic stroke or retinal artery occlusion (12% at day 7, 12% at day 30) as those not treated (9% at day 7, 15% at day 30; adjusted HR 0.9, 95% CI 0.4-2.2). There was a tendency (p = 0.09) towards time-dependency in the data where the recurrence risk was higher in IVT-treated at day 0 (6% in IVT-treated, 1% in non-IVT-treated, OR 5.5, 95% CI 1.2-25.4, p = 0.03). This was not significant when adjusting for co-factors (adjusted OR 4.4, 95% CI 0.9-21.8, p = 0.07) and was offset by a later risk decrease, with no remaining risk difference between IVT-treated and non-IVT-treated at day 7. CONCLUSIONS Intravenous thrombolysis treatment does not seem to affect the risk of recurrent ipsilateral ischemic stroke in patients with symptomatic ≥50% carotid stenosis: The risk is high in both IVT-treated and non-IVT-treated. However, there might be a risk increase on the day of IVT treatment that is offset by a risk decrease during the first week.
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Affiliation(s)
- Annika Nordanstig
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Thomas Gu
- Department of Neurosciences, Institution of Clinical Science, Umea University, Umea, Sweden
| | - Alexander Henze
- Department of Diagnostic Radiology, Institution of Radiation Sciences, Umea University, Umea, Sweden
| | - Per Wester
- Institution of Public Health and Clinical Medicine, Umea University, Umea, Sweden
- Department of Clinical Sciences, Danderyds hospital Karolinska Institute, Stockholm, Sweden
| | - Allan J Fox
- Department of Medical Imaging, Sunnybrook health Science Center, University of Toronto, Toronto, ON, Canada
| | - Elias Johansson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Neurosciences, Institution of Clinical Science, Umea University, Umea, Sweden
- Wallenberg Center of Molecular Medicine, Umea University, Umea, Sweden
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Kargiotis O, Psychogios K, Safouris A, Spiliopoulos S, Karapanayiotides T, Bakola E, Mantatzis M, Dardiotis E, Ellul J, Giannopoulos S, Magoufis G, Tsivgoulis G. Diagnosis and treatment of acute isolated proximal internal carotid artery occlusions: a narrative review. Ther Adv Neurol Disord 2022; 15:17562864221136335. [PMID: 36437850 PMCID: PMC9685148 DOI: 10.1177/17562864221136335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/16/2022] [Indexed: 07/27/2023] Open
Abstract
The clinical manifestations of proximal (extracranial) internal carotid artery occlusions (pICAOs) may range from asymptomatic to acute, large, and devastating ischemic strokes. The etiology and pathophysiology of the occlusion, intracranial collateral status and patient's premorbid status are among the factors determining the clinical presentation and outcome of pICAOs. Rapid and accurate diagnosis is crucial and may be assisted by the combination of carotid and transcranial duplex sonography, or a computed tomography/magnetic resonance angiography (CTA/MRA). It should be noted that with either imaging modalities, the discrimination of a pseudo-occlusion of the extracranial internal carotid artery (ICA) from a true pICAO may not be straightforward. In the absence of randomized data, the management of acute, symptomatic pICAOs remains individualized and relies largely on expert opinion. Administration of intravenous thrombolysis is reasonable and probably beneficial in the settings of acute ischemic stroke with early presentation. Unfortunately, rates of recanalization are rather low and acute interventional reperfusion therapies emerge as a potentially powerful therapeutic option for patients with persistent and severe symptoms. However, none of the pivotal clinical trials on mechanical thrombectomy for acute ischemic stroke randomized patients with isolated extracranial large vessel occlusions. On the contrary, several lines of evidence from non-randomized studies have shown that acute carotid endarterectomy, or endovascular thrombectomy/stenting of the ICA are feasible and safe, and pοtentially beneficial. The heterogeneity in the pathophysiology and clinical presentation of acute pICAOs renders patient selection for an acute interventional treatment a complicated decision-making process. The present narrative review will outline the pathophysiology, clinical presentation, diagnostic challenges, and possible treatment options for pICAOs.
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Affiliation(s)
| | | | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus,
Greece
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
- Aktios Rehabilitation Center, Koropi,
Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional
Radiology Unit, ‘Attikon’ University General Hospital, Athens, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of
Medicine, Faculty of Health Sciences, AHEPA University General Hospital,
Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Bakola
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
| | - Michail Mantatzis
- Department of Radiology, Interventional
Neuroradiology Unit, AHEPA University General Hospital, Aristotle University
of Thessaloniki, Thessaloniki, Greece
| | - Efthimios Dardiotis
- Department of Neurology, University Hospital
of Larissa, School of Medicine, University of Thessaly, Larissa,
Greece
| | - John Ellul
- Department of Neurology, University General
Hospital of Patras, Patras, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
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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: 3] [Impact Index Per Article: 1.5] [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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Manrique-Zegarra M, García-Pastor A, Castro-Reyes E, Guzmán-De-Villoria JA, Herrera Herrera I, Garrido Morro I, Del Valle Diéguez M, Fortea Gil F, González Cantero J, Saura Lorente J. CT angiography for diagnosis of carotid near-occlusion: a digital subtraction angiography validation study. Neuroradiology 2022; 64:1729-1735. [PMID: 35729332 DOI: 10.1007/s00234-022-02995-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 06/07/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Carotid near-occlusion (CNO) is a variant of severe stenosis where there is a distal luminal collapse of the internal carotid artery (ICA) beyond a tight stenosis. This study aimed to validate new visual extracranial diagnostic CT angiography (CTA) criteria, for the diagnosis of CNO. The new criteria include distal ICA diameter smaller than contralateral ICA and distal ICA diameter less than or equal to the ipsilateral external carotid artery (ECA). We also assessed the previously described CTA criteria: stenosis ≤ 1.3 mm, ipsilateral distal ICA ≤ 3.5 mm, ipsilateral distal ICA/contralateral distal ICA ratio ≤ 0.87, ipsilateral distal ICA/ipsilateral ECA ≤ 1.27. METHODS Fifty-eight patients with ICA stenosis (including the near-occlusion variant) or occlusion on digital subtraction angiography (DSA) were included. These patients had DSA and CTA studies completed within 30 days of each other. DSA was considered the reference test. Two neuroradiologists blinded to the DSA results assessed the CTA images and evaluated the new and previously published CNO diagnostic criteria. RESULTS Twenty-eight CNO were identified with DSA. The "distal ICA diameter less than or equal to the ipsilateral ECA" criterion had 79% sensitivity and 83% specificity with excellent interobserver agreement (kappa = 0.80), while three or more of the previously published criteria reached 82% sensitivity and 90% specificity, with a good interobserver agreement (kappa = 0.64). CONCLUSIONS CT angiography may be useful for CNO diagnosis. The new visual diagnostic criteria provide acceptable results of sensitivity and specificity with an excellent interobserver agreement. However, false-negative and positive results persist.
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Affiliation(s)
| | | | - Enrique Castro-Reyes
- Interventional Neuroradiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Irene Garrido Morro
- Neuroradiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Fernando Fortea Gil
- Interventional Neuroradiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jorge González Cantero
- Interventional Neuroradiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Saura Lorente
- Interventional Neuroradiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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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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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: 10] [Impact Index Per Article: 3.3] [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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