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Sanchez S, Mossa-Basha M, Anagnostakou V, Liebeskind DS, Samaniego EA. Comprehensive imaging analysis of intracranial atherosclerosis. J Neurointerv Surg 2025; 17:311-320. [PMID: 38719445 DOI: 10.1136/jnis-2023-020622] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/20/2024] [Indexed: 01/26/2025]
Abstract
Intracranial atherosclerotic disease (ICAD) involves the build-up of atherosclerotic plaques in cerebral arteries, significantly contributing to stroke worldwide. Diagnosing ICAD entails various techniques that measure arterial stenosis severity. Digital subtraction angiography, CT angiography, and magnetic resonance angiography are established methods for assessing stenosis. High-resolution MRI offers additional insights into plaque morphology including plaque burden, hemorrhage, remodeling, and contrast enhancement. These metrics and plaque traits help identify symptomatic plaques. Techniques like transcranial Doppler, CT perfusion, computational fluid dynamics, and quantitative MRA analyze blood flow restrictions due to ICAD. Intravascular ultrasound or optical coherence tomography have a very high spatial resolution and can assess the structure of the arterial wall and the plaque from the lumen of the target vascular territory. Positron emission tomography could further detect inflammation markers. This review aims to provide a comprehensive overview of the spectrum of current modalities for atherosclerotic plaque analysis and risk stratification.
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Affiliation(s)
| | | | - Vania Anagnostakou
- Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - David S Liebeskind
- Department of Neurology, University of California Los Angeles, Los Angeles, California, USA
| | - Edgar A Samaniego
- Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Kurosaki Y, Kinosada M, Ikeda H, Yamashita H, Yoshida K, Chin M. Progressive T1 high-intensity plaques in carotid stenosis: Comparative MRI analyses in asymptomatic and symptomatic phases of low-grade stenosis. J Neuroradiol 2024; 51:101223. [PMID: 39424099 DOI: 10.1016/j.neurad.2024.101223] [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: 09/07/2024] [Revised: 10/12/2024] [Accepted: 10/12/2024] [Indexed: 10/21/2024]
Abstract
BACKGROUND AND PURPOSE Carotid artery stenosis, particularly the progression from asymptomatic to symptomatic lesions, is a key factor in cerebrovascular events. This study identifies predictors of symptom development in low-grade carotid stenosis (<50%), focusing on intraplaque hemorrhage (IPH) and dynamic plaque changes. MATERIALS AND METHODS We conducted a retrospective study analyzing 30 cases of symptomatic low-grade carotid stenosis, using carotid MRI before and after symptom onset. Key measures included relative plaque signal intensity (rSI) and high-intensity plaque (HI plaque) volume. Stepwise regression analysis examined the influence of these factors on Symptomatic rSI, Symptomatic plaque volume, and NIHSS scores. RESULTS Significant increases were observed in rSI (1.32 ± 0.32 to 1.69 ± 0.25, p < 0.001) and HI plaque volume (296.4 ± 362.7 mm³ to 717.5 ± 554.9 mm³, p < 0.001) from asymptomatic to symptomatic phases. Past smoking (p = 0.008) and statin use (p = 0.04) were associated with higher Symptomatic rSI, while poor risk factor control (p = 0.03) was negatively associated. Female sex (p = 0.007) and current smoking (p = 0.009) were linked to smaller Symptomatic plaque volumes, while ischemic heart disease (p = 0.0002) and poor risk factor control (p = 0.002) predicted larger plaque volumes. Larger plaques were correlated with higher NIHSS scores (p = 0.002). CONCLUSIONS IPH and plaque volume are key markers of progression in low-grade carotid stenosis. Poor control of cardiovascular risk factors and a history of ischemic heart disease contribute to plaque burden and stroke severity. Continuous monitoring and strict risk management are essential in reducing stroke severity in these patients.
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Affiliation(s)
- Yoshitaka Kurosaki
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, 710-8602, Japan.
| | - Masanori Kinosada
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, 710-8602, Japan
| | - Hiroyuki Ikeda
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, 710-8602, Japan
| | - Haruki Yamashita
- Department of Neurosurgery, Kyoto University School of Medicine, Kyoto, 606-8501, Japan
| | - Kazumichi Yoshida
- Department of Neurosurgery, Shiga University School of Medicine, 520-2192, Otsu, Japan
| | - Masaki Chin
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, 710-8602, Japan
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Galyfos G, Charalampopoulos G, Karagiannis G, Liasis N, Koncar I, Siogkas P, Fotiadis D, Filis K, Sigala F. Factors Associated with High-Risk Plaque Characteristics Among Patients with Medium to Severe Carotid Artery Stenosis. Ann Vasc Surg 2024; 108:325-332. [PMID: 39009116 DOI: 10.1016/j.avsg.2024.05.017] [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: 03/23/2024] [Revised: 04/29/2024] [Accepted: 05/14/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND There has been a large discussion in literature regarding the proper management of asymptomatic patients with significant carotid artery stenosis. This study aims to identify potential risk factors associated with high-risk carotid plaques. METHODS This is a retrospective study based on a prospective database. Eligible patients had medium to severe symptomatic or asymptomatic carotid stenosis (≥50%, North American Symptomatic Carotid Endarterectomy Trial criteria). This study will analyze patients recruited by our institution as part of the multicenter TAXINOMISIS project (NCT03495830). According to protocol, all patients underwent a colored Duplex ultrasound examination and a magnetic resonance angiography at baseline. Carotid plaques were classified according to Gray-Weale ultrasonographic criteria (types I-V). Main outcomes included the occurrence of symptoms, the high/low echogenicity of the plaque, the existence of intraplaque hemorrhage and the existence of lipidic/necrotic core. Secondary, risk factors associated with the aforementioned outcomes were evaluated. RESULTS A total of 62 patients (mean age: 68.7 ± 9.3 years, 66.1% males, 24.2% symptomatic) were recruited by our department. Mean carotid stenosis was 70.81% ± 13.53%. In multivariate regression analysis, C-reactive protein > 2 mg/l was strongly associated with symptomatic stenosis (odds ratio [OR] = 9.92 [1.12-88.178]; P = 0.039), and low high-density lipoprotein levels (<1200 mmol/l) were associated with lipidic/necrotic plaque core (OR = 16.88 [1.10-259.30]; P = 0.043). Low high-density lipoprotein levels (OR = 7.22 [1.00-51.95], P = 0.049) and HbA1c >7% (OR = 0.08 [0.01-0.93], P = 0.044) were associated with type III/IV plaques whereas HgAbc1 >7% (OR = 14.26 [1.21-168.34], P = 0.035) was associated with type V plaques. CONCLUSIONS This preliminary study has revealed some potential risk factors associated with unstable carotid plaques. These data could help the future development of prognostic models for early detection patients that could benefit from further intervention.
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Affiliation(s)
- George Galyfos
- Vascular Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Athens, Greece.
| | - Georgios Charalampopoulos
- Vascular Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Karagiannis
- Vascular Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Liasis
- Vascular Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Igor Koncar
- Clinic of Vascular and Endovascular Surgery, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Panagiotis Siogkas
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, Ioannina, Greece
| | - Dimitrios Fotiadis
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, Ioannina, Greece
| | - Konstantinos Filis
- Vascular Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Frangeska Sigala
- Vascular Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Athens, Greece
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Jumah A, Aboul Nour H, Fana M, Choudhury O, Eltous L, Zoghoul S, Jumah F, Alsrouji OK, Alhajala H, Intikhab O, Marin H, Chebl A, Miller D. The role of non-stenosing carotid artery plaques in embolic stroke of undetermined source, is it a silent offender? A review of literature. Interv Neuroradiol 2024; 30:759-767. [PMID: 36451548 PMCID: PMC11569466 DOI: 10.1177/15910199221143172] [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: 10/25/2022] [Accepted: 11/17/2022] [Indexed: 02/17/2024] Open
Abstract
PURPOSE Atherosclerotic cervical internal carotid artery disease is one of the major causes of ischemic stroke and transient ischemic attacks. The risk of stroke from mild to moderate stenoses (i.e. <50% stenosis) might be underestimated. There is increasing evidence that plaque morphological features reflect plaque instability that may harbor high risk for embolization. In this narrative review, we will review the literature on plaque features that predict vulnerability beyond the degree of stenosis, discuss the clinical association with stroke, and evaluate the evidence that these lesions serve as a source for embolic stroke of unknown source (ESUS). METHODS We performed a literature search using PubMed, EMBASE, and Web of Science. The terms "embolic stroke of undetermined source" and "plaque morphology" were used either alone or in combination with "non-flow limiting stenosis," "non-stenosing plaques," "high-risk plaque features" or "internal carotid artery plaque." Data on plaque morphology and ESUS were mainly taken from review articles, observational studies including retrospective cohort and cross-sectional studies, meta-analyses, and systematic reviews. CONCLUSION Nonstenosing carotid artery plaques with high-risk features carry a remarkable risk for stroke occurrence and randomized clinical trials are warranted for further evaluation of using carotid artery stenting or carotid endarterectomy to mitigate the risk of stroke.
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Affiliation(s)
- Ammar Jumah
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Hassan Aboul Nour
- Department of Vascular Neurology, Emory University Hospital, Atlanta, GA, USA
| | - Michael Fana
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Omar Choudhury
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Lara Eltous
- Jordan University of Science and Technology, Irbid, Jordan
| | - Sohaib Zoghoul
- Department of Radiology, Hamad Medical Corporation, Doha, Qatar
| | - Fareed Jumah
- Department of Neurosurgery, University of Missouri Hospital, Columbia, MO, USA
| | | | - Hisham Alhajala
- Department of Vascular Neurology, University of Toledo, Toledo, OH, USA
| | - Osama Intikhab
- Department of Interventional Neuroradiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Horia Marin
- Department of Neuroradiology, Henry Ford Hospital, Detroit, MI, USA
| | - Alex Chebl
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Daniel Miller
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
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Jumah A, Albanna AJ, Elfaham A, Eltous L, Zoghoul S, Miller D. High-Risk Plaque Features in the Non-stenosing Carotid Artery, How Frequently is This Reported? A Retrospective Study. Neurohospitalist 2024:19418744241283858. [PMID: 39544266 PMCID: PMC11559455 DOI: 10.1177/19418744241283858] [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: 11/17/2024] Open
Abstract
Background High-risk features of non-stenosing (ie, <50%) carotid plaques are emerging as a possible source of embolism in patients with embolic stroke of undetermined source (ESUS). However, in the absence of hemodynamically significant stenosis, neuroradiology reports rarely describe these morphological features. Our aim was to determine how often high-risk features of non-stenosing plaques are included in diagnostic imaging reports. Methods In this retrospective study, we evaluated computed tomography angiography (CTA) reports associated with the CTA imaging results for a previously published cohort study. Plaque features reporting frequencies were calculated and defined as the number of times specific plaque features were included in the CTA reports (Thickness, ulceration, length, soft component and calcification) divided by the number of occurrences of high-risk plaque features (Thickness >0.3 cm; ulceration; length >1.0 cm), soft component, or calcification identified in the CTA results. We used Fisher exact test to compare the reporting frequencies of the 5 plaque features. Results We analyzed 152 CTA reports. The frequency of reporting plaque thickness (0/40; 0%), ulceration (3/37; 8.1%), and length (7/29; 24.1%) was significantly lower than the reporting of plaque calcification (122/122; 100%) and presence of soft component (31/34; 72.1%) when these features were present in CTA imaging results (all P < 0.001). Conclusion When carotid plaques are not causing hemodynamically significant stenosis, neuroradiology reports frequency mention plaque density but often exclude other characteristics. Neuroradiologists and neurologists should collaborate to create algorithms, scoring systems and prediction models to accurately determine which plaque features are highly associated with embolism.
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Affiliation(s)
- Ammar Jumah
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | | | | | - Lara Eltous
- Jordan University of Science and Technology, Irbid, Jordan
| | - Sohaib Zoghoul
- Department of Radiology, Hamad Medical Center, Doha, Qatar
| | - Daniel Miller
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
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Maes L, Versweyveld L, Evans NR, McCabe JJ, Kelly P, Van Laere K, Lemmens R. Novel Targets for Molecular Imaging of Inflammatory Processes of Carotid Atherosclerosis: A Systematic Review. Semin Nucl Med 2024; 54:658-673. [PMID: 37996309 DOI: 10.1053/j.semnuclmed.2023.10.004] [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: 10/03/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 11/25/2023]
Abstract
Computed tomography angiography (CTA), magnetic resonance angiography (MRA) and 18F-FDG-PET have proven clinical value when evaluating patients with carotid atherosclerosis. In this systematic review, we will focus on the role of novel molecular imaging tracers in that assessment and their potential strengths to stratify stroke risk. We systematically searched PubMed, Embase, the Web of Science Core Collection, and Cochrane Library for articles reporting on molecular imaging to noninvasively detect or characterize inflammation in carotid atherosclerosis. As our focus was on nonclassical novel targets, we omitted reports solely on 18F-FDG and 18F-NaF. We summarized and mapped the selected studies to provide an overview of the current clinical development in molecular imaging in relation to risk factors, imaging and histological findings, diagnostic and prognostic performance. We identified 20 articles in which the utilized tracers to visualize carotid wall inflammation were somatostatin subtype-2- (SST2-) (n = 5), CXC-motif chemokine receptor 4- (CXCR4-) (n = 3), translocator protein- (TSPO-) (n = 2) and aVβ3 integrin-ligands (n = 2) and choline-tracers (n = 2). Tracer uptake correlated with traditional cardiovascular risk factors, that is, age, gender, diabetes, hypercholesterolemia, and hypertension as well as prior cardiovascular disease. We identified discrepancies between tracer uptake and grade of stenosis, plaque calcification, and 18F-FDG uptake, suggesting the importance of alternative characterization of atherosclerosis beyond classical neuroimaging features. Immunohistochemical analysis linked tracer uptake to markers of macrophage infiltration and neovascularization. Symptomatic carotid arteries showed higher uptake compared to asymptomatic (including contralateral, nonculprit) arteries. Some studies demonstrated a potential role of these novel molecular imaging as a specific intermediary (bio)marker for outcome. Several novel tracers show promise for identification of high-risk plaque inflammation. Based on the current evidence we cautiously propose the SST2-ligands and the choline radiotracers as viable candidates for larger prospective longitudinal outcome studies to evaluate their predictive use in clinical practice.
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Affiliation(s)
- Louise Maes
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium; Department of Neurosciences, Experimental Neurology, KULeuven - University of Leuven, Leuven, Belgium.
| | - Louis Versweyveld
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium; Department of Neurosciences, Experimental Neurology, KULeuven - University of Leuven, Leuven, Belgium
| | - Nicholas R Evans
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - John J McCabe
- Health Research Board (HRB), Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland; School of Medicine, University College Dublin (UCD), Dublin, Ireland; Department of Geriatric Medicine, Mater Misericordiae University Hospital Dublin, Dublin, Ireland
| | - Peter Kelly
- Health Research Board (HRB), Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland; School of Medicine, University College Dublin (UCD), Dublin, Ireland; Mater Misericordiae University Hospital Dublin, Stroke Service, Dublin, Ireland
| | - Koen Van Laere
- Division of Nuclear Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Imaging and Pathology, KULeuven - University of Leuven - Nuclear Medicine and Molecular Imaging, Leuven, Belgium
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium; Department of Neurosciences, Experimental Neurology, KULeuven - University of Leuven, Leuven, Belgium
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Kashiwazaki D, Yamamoto S, Akioka N, Hori E, Noguchi K, Kuroda S. Association between Pericarotid Fat Density and Positive Remodeling in Patients with Carotid Artery Stenosis. J Clin Med 2024; 13:3892. [PMID: 38999456 PMCID: PMC11242836 DOI: 10.3390/jcm13133892] [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: 03/20/2024] [Revised: 06/29/2024] [Accepted: 06/30/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: The underlying mechanism of the potential involvement of inflammatory crosstalk between pericarotid fat and vascular layers in atherosclerosis pathogenesis is unclear. We investigated the association between pericarotid fat density and positive remodeling and inflammatory markers in carotid stenosis. We hypothesized that pericarotid fat density might serve as a marker of plaque inflammation in a clinical setting. Methods: We evaluated the stenosis degree and pericarotid fat density in 258 patients with carotid plaques. Plaque composition was examined, and the correlation between pericarotid fat density and expansive remodeling was investigated. Pearson's product-moment correlation coefficient was used to examine the relationship between pericarotid fat density and the expansive remodeling ratio. We also evaluated the relationship of pericarotid fat density with plaque composition, degree of stenosis, and macrophage and microvessel counts by. The subgroup analysis compared these factors between symptomatic mild carotid stenosis. Results: The pericarotid fat density was -63.0 ± 11.1 HU. The carotid fat densities were -56.8 ± 10.4 HU in symptomatic and -69.2 ± 11.4 HU in asymptomatic lesions. The pericarotid fat density values in intraplaque hemorrhage, lipid-rich necrotic core, and fibrous plaque were -51.6 ± 10.4, -59.4 ± 12.8, and -74.2 ± 8.4 HU, respectively. Therefore, the expansive remodeling ratio was 1.64 ± 0.4. Carotid fat density and expansive remodeling ratio were correlated. Immunohistochemistry showed high macrophage and microvessel levels (143.5 ± 61.3/field and 121.2 ± 27.7/field, respectively). In symptomatic mild carotid stenosis, pericarotid fat density was correlated with other inflammatory factors. The pericarotid fat density and expansive remodeling ratio (2.08 ± 0.21) were high in mild stenosis (-50.1 ± 8.4 HU). Conclusions: Pericarotid fat and intraplaque components were well correlated. Carotid fat density may be a marker of plaque inflammation in carotid plaques.
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Affiliation(s)
- Daina Kashiwazaki
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama 930-0194, Japan; (S.Y.); (N.A.); (E.H.); (S.K.)
| | - Shusuke Yamamoto
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama 930-0194, Japan; (S.Y.); (N.A.); (E.H.); (S.K.)
| | - Naoki Akioka
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama 930-0194, Japan; (S.Y.); (N.A.); (E.H.); (S.K.)
| | - Emiko Hori
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama 930-0194, Japan; (S.Y.); (N.A.); (E.H.); (S.K.)
| | - Kyo Noguchi
- Department of Radiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama 930-0194, Japan;
| | - Satoshi Kuroda
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama 930-0194, Japan; (S.Y.); (N.A.); (E.H.); (S.K.)
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Takai H, Matsubara S, Minami-Ogawa Y, Hirai S, Shikata E, Yagi K, Oyama N, Yagita Y, Uno M. Association between Carotid Bifurcation Angle and Vulnerable Plaque Volume Using Black Blood Magnetic Resonance Imaging. Neurol Med Chir (Tokyo) 2023; 63:437-442. [PMID: 37495520 PMCID: PMC10687671 DOI: 10.2176/jns-nmc.2023-0034] [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: 03/09/2023] [Accepted: 05/24/2023] [Indexed: 07/28/2023] Open
Abstract
The morphology of the internal carotid artery (ICA) bifurcation is increasingly being recognized as the cause of atherosclerosis and vulnerable plaque leading to cerebral infarction. In this study, we investigated the relationship between carotid bifurcation angle and carotid plaque volume evaluated using black blood magnetic resonance imaging (BB-MRI). Among the 90 patients who underwent revascularization for atherosclerotic symptomatic carotid stenosis between April 2016 and October 2022 using BB-MRI, carotid plaque was evaluated in 57 patients. Relative overall signal intensity (roSI) was defined as the signal intensity of the plaque on T1-weighted images relative to the signal intensity of the sternocleidomastoid muscle in the same slice as the common carotid bifurcation. Regions showing roSI ≥ 1.0 were defined as plaque, and the plaque volume and relative plaque volume were measured from roSI ≥1.0 to ≥2.0 in 0.1 increments. We calculated the angles between the common carotid artery (CCA) and the ICA and between the CCA and the external carotid artery (ECA) on magnetic resonance angiography. We classified two groups according to carotid bifurcation angles based on the ICA angle: Group A = <35° and Group B = ≥35°. Compared with Group A (n = 42), Group B (n = 15) showed a greater relative plaque volume between roSI ≥ 1.3 and roSI ≥ 1.5. A significant correlation was identified between relative plaque volume with roSI ≥ 1.4 and ICA angle (p = 0.049). Vulnerable plaque was significantly more frequent in the group with an ICA angle of ≥35. Moreover, the ICA angle was significantly greater in patients with a roSI of ≥1.4.
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Affiliation(s)
- Hiroki Takai
- Department of Neurosurgery, Kawasaki Medical School
| | | | | | | | - Eiji Shikata
- Department of Neurosurgery, Kawasaki Medical School
| | - Kenji Yagi
- Department of Neurosurgery, Kawasaki Medical School
| | - Naoki Oyama
- Department of Stroke Medicine, Kawasaki Medical School
| | | | - Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School
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Wang D, Shang ZY, Cui Y, Yang BQ, Ntaios G, Chen HS. Characteristics of intracranial plaque in patients with non-cardioembolic stroke and intracranial large vessel occlusion. Stroke Vasc Neurol 2023; 8:387-398. [PMID: 36914215 PMCID: PMC10648047 DOI: 10.1136/svn-2022-002071] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 02/26/2023] [Indexed: 03/14/2023] Open
Abstract
OBJECTIVE To determine the characteristics of intracranial plaque proximal to large vessel occlusion (LVO) in stroke patients without major-risk cardioembolic source using 3.0 T high-resolution MRI (HR-MRI). METHODS We retrospectively enrolled eligible patients from January 2015 to July 2021. The multidimensional parameters of plaque such as remodelling index (RI), plaque burden (PB), percentage lipid-rich necrotic core (%LRNC), presence of discontinuity of plaque surface (DPS), fibrous cap rupture, intraplaque haemorrhage and complicated plaque were evaluated by HR-MRI. RESULTS Among 279 stroke patients, intracranial plaque proximal to LVO was more prevalent in the ipsilateral versus contralateral side to stroke (75.6% vs 58.8%, p<0.001). The larger PB (p<0.001), RI (p<0.001) and %LRNC (p=0.001), the higher prevalence of DPS (61.1% vs 50.6%, p=0.041) and complicated plaque (63.0% vs 50.6%, p=0.016) were observed in the plaque ipsilateral versus contralateral to stroke. Logistic analysis showed that RI and PB were positively associated with an ischaemic stroke (RI: crude OR: 1.303, 95% CI 1.072 to 1.584, p=0.008; PB: crude OR: 1.677, 95% CI 1.381 to 2.037, p<0.001). In subgroup with <50% stenotic plaque, the greater PB, RI, %LRNC and the presence of complicated plaque were more closely related to stroke, which was not evident in subgroup with ≥50% stenotic plaque. CONCLUSION This is the first study to report the characteristics of intracranial plaque proximal to LVO in non-cardioembolic stroke. It provides potential evidence to support different aetiological roles of <50% stenotic vs ≥50% stenotic intracranial plaque in this population.
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Affiliation(s)
- Dan Wang
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, Liaoning, China
| | - Zi-Yang Shang
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, Liaoning, China
| | - Yu Cui
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, Liaoning, China
| | - Ben-Qiang Yang
- Radiology, General Hospital of Northern Theatre Command, Shenyang, Liaoning, China
| | - George Ntaios
- Department of Medicine, University of Thessaly, Larissa, Greece
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, Liaoning, China
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10
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Peret A, Romero-Sanchez G, Dabiri M, McNally JS, Johnson KM, Mossa-Basha M, Eisenmenger LB. MR Angiography of Extracranial Carotid Disease. Magn Reson Imaging Clin N Am 2023; 31:395-411. [PMID: 37414468 DOI: 10.1016/j.mric.2023.04.003] [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: 07/08/2023]
Abstract
Magnetic resonance angiography sequences, such as time-of-flight and contrast-enhanced angiography, provide clear depiction of vessel lumen, traditionally used to evaluate carotid pathologic conditions such as stenosis, dissection, and occlusion; however, atherosclerotic plaques with a similar degree of stenosis may vary tremendously from a histopathological standpoint. MR vessel wall imaging is a promising noninvasive method to evaluate the content of the vessel wall at high spatial resolution. This is particularly interesting in the case of atherosclerosis as vessel wall imaging can identify higher risk, vulnerable plaques as well as has potential applications in the evaluation of other carotid pathologic conditions.
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Affiliation(s)
- Anthony Peret
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI 53705, USA
| | - Griselda Romero-Sanchez
- Department of Radiology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Avenida Vasco de Quiroga No.15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan C.P.14080, Ciudad de México, Mexico City, Mexico
| | - Mona Dabiri
- Radiology Department, Children's Medical Center, Tehran University of Medical Science, No 63, Gharib Avenue, Keshavarz Blv, Tehran 1419733151, Iran
| | - Joseph Scott McNally
- Department of Radiology, University of Utah, 50 N Medical Dr, Salt Lake City, UT 84132, USA
| | - Kevin M Johnson
- Department of Medical Physics, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI 53705, USA
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Laura B Eisenmenger
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI 53705, USA.
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Li X, Liu C, Zhu L, Wang M, Liu Y, Li S, Deng Q, Zhou J. The Role of High-Resolution Magnetic Resonance Imaging in Cerebrovascular Disease: A Narrative Review. Brain Sci 2023; 13:brainsci13040677. [PMID: 37190642 DOI: 10.3390/brainsci13040677] [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: 03/07/2023] [Revised: 04/07/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
High-resolution magnetic resonance imaging (HRMRI) is the most important and popular vessel wall imaging technique for the direct assessment of vessel wall and cerebral arterial disease. It can identify the cause of stroke in high-risk plaques and differentiate the diagnosis of head and carotid artery dissection, including inflammation, Moya Moya disease, cerebral aneurysm, vasospasm after subarachnoid hemorrhage, reversible cerebral vasoconstriction syndrome, blunt cerebrovascular injury, cerebral arteriovenous malformations, and other stenosis or occlusion conditions. Through noninvasive visualization of the vessel wall in vitro, quantified assessment of luminal stenosis and pathological features of the vessel wall can provide clinicians with further disease information. In this report, technical considerations of HRMRI are discussed, and current clinical applications of HRMRI are reviewed.
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Affiliation(s)
- Xiaohui Li
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
| | - Chengfang Liu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
| | - Lin Zhu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
| | - Meng Wang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
| | - Yukai Liu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
| | - Shuo Li
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
| | - Qiwen Deng
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Junshan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
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12
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van Dam-Nolen DH, van Egmond NC, Koudstaal PJ, van der Lugt A, Bos D. Sex Differences in Carotid Atherosclerosis: A Systematic Review and Meta-Analysis. Stroke 2023; 54:315-326. [PMID: 36444718 PMCID: PMC9855762 DOI: 10.1161/strokeaha.122.041046] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Over the last decades, several individual studies on sex differences in carotid atherosclerosis have been performed covering a wide range of plaque characteristics and including different populations. This systematic review and meta-analysis aims to summarize previously reported results on sex differences in carotid atherosclerosis and present a roadmap explaining next steps needed for implementing this knowledge in clinical practice. METHODS We systematically searched PubMed, Embase, Web of Science, Cochrane Central, and Google Scholar for eligible studies including both male and female participants reporting prevalence of imaging characteristics of carotid atherosclerosis and meta-analyzed these studies. Studies had to report at least the following: (1) calcifications; (2) lipid-rich necrotic core; (3) intraplaque hemorrhage; (4) thin-or-ruptured fibrous cap; (5) plaque ulceration; (6) degree of stenosis; (7) plaque size; or (8) plaque inflammation. We prespecified which imaging modalities had to be used per plaque characteristic and excluded ultrasonography. RESULTS We included 42 articles in our meta-analyses (ranging from 2 through 23 articles per plaque characteristic). Men had more frequently a larger plaque compared to women and, moreover, had more often plaques with calcifications (odds ratio=1.57 [95% CI, 1.23-2.02]), lipid-rich necrotic core (odds ratio=1.87 [95% CI, 1.36-2.57]), and intraplaque hemorrhage (odds ratio=2.52 [95% CI, 1.74-3.66]), or an ulcerated plaque (1.81 [95% CI, 1.30-2.51]). Furthermore, we found more pronounced sex differences for lipid-rich necrotic core in symptomatic opposed to asymptomatic participants. CONCLUSIONS In this systematic review and meta-analysis, we demonstrate convincing evidence for sex differences in carotid atherosclerosis. All kinds of plaque features-plaque size, composition, and morphology-were more common or larger in men compared to women. Our results highlight that sex is an important variable to include in both study design and clinical-decision making. Further investigation of sex-specific stroke risks with regard to plaque composition is warranted.
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Affiliation(s)
- Dianne H.K. van Dam-Nolen
- Department of Radiology and Nuclear Medicine (D.H.K.v.D.-N., N.C.M.v.E., A.v.d.L., D.B.), Erasmus University Medical Center Rotterdam, the Netherlands.,Department of Neurology (D.H.K.v.D.-N., P.J.K.), Erasmus University Medical Center Rotterdam, the Netherlands
| | - Nina C.M. van Egmond
- Department of Radiology and Nuclear Medicine (D.H.K.v.D.-N., N.C.M.v.E., A.v.d.L., D.B.), Erasmus University Medical Center Rotterdam, the Netherlands
| | - Peter J. Koudstaal
- Department of Neurology (D.H.K.v.D.-N., P.J.K.), Erasmus University Medical Center Rotterdam, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine (D.H.K.v.D.-N., N.C.M.v.E., A.v.d.L., D.B.), Erasmus University Medical Center Rotterdam, the Netherlands
| | - Daniel Bos
- Department of Radiology and Nuclear Medicine (D.H.K.v.D.-N., N.C.M.v.E., A.v.d.L., D.B.), Erasmus University Medical Center Rotterdam, the Netherlands.,the Department of Epidemiology (D.B.), Erasmus University Medical Center Rotterdam, the Netherlands
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13
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Catalano O, Bendotti G, Aloi TL, Bardile AF, Memmi M, Gambelli P, Zanaboni D, Gualco A, Cattaneo E, Mazza A, Frascaroli M, Eshja E, Bellazzi R, Poggi P, Forni G, La Rovere MT. Evidence of Carotid Atherosclerosis Vulnerability Regression in Real Life From Magnetic Resonance Imaging: Results of the MAGNETIC Prospective Study. J Am Heart Assoc 2023; 12:e026469. [PMID: 36628977 PMCID: PMC9939062 DOI: 10.1161/jaha.122.026469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background Atherosclerosis vulnerability regression has been evidenced mostly in randomized clinical trials with intensive lipid-lowering therapy. We aimed to demonstrate vulnerability regression in real life, with a comprehensive quantitative method, in patients with asymptomatic mild to moderate carotid atherosclerosis on a secondary prevention program. Methods and Results We conducted a single-center prospective observational study (MAGNETIC [Magnetic Resonance Imaging as a Gold Standard for Noninvasive Evaluation of Atherosclerotic Involvement of Carotid Arteries]): 260 patients enrolled at a cardiac rehabilitation center were followed for 3 years with serial magnetic resonance imaging. Per section cutoffs (95th/5th percentiles) were derived from a sample of 20 consecutive magnetic resonance imaging scans: (1) lipid-rich necrotic core: 26% of vessel wall area; (2) intraplaque hemorrhage: 12% of vessel wall area; and (3) fibrous cap: (a) minimum thickness: 0.06 mm, (b) mean thickness: 0.4 mm, (c) projection length: 11 mm. Patients with baseline magnetic resonance imaging of adequate quality (n=247) were classified as high (n=63, 26%), intermediate (n=65, 26%), or low risk (n=119, 48%), if vulnerability criteria were fulfilled in ≥2 contiguous sections, in 1 or multiple noncontiguous sections, or in any section, respectively. Among high-risk patients, a conversion to any lower-risk status was found in 11 (17%; P=0.614) at 6 months, in 16 (25%; P=0.197) at 1 year, and in 19 (30%; P=0.009) at 3 years. Among patients showing any degree of carotid plaque vulnerability, 21 (16%; P=0.014) were diagnosed at low risk at 3 years. Conclusions This study demonstrates with a quantitative approach that vulnerability regression is common in real life. A secondary prevention program can promote vulnerability regression in asymptomatic patients in the mid to long term.
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Affiliation(s)
- Oronzo Catalano
- Division of CardiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Giulia Bendotti
- Division of CardiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Teresa L. Aloi
- Angiology UnitIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | | | - Mirella Memmi
- Molecular CardiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Patrick Gambelli
- Molecular CardiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Daniela Zanaboni
- Division of RadiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Alessandra Gualco
- Division of CardiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Emanuela Cattaneo
- Division of CardiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Antonio Mazza
- Division of CardiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Mauro Frascaroli
- Division of RadiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Esmeralda Eshja
- Division of RadiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Riccardo Bellazzi
- Department of Electrical, Computer and Biomedical EngineeringUniversity of PaviaPaviaItaly
| | - Paolo Poggi
- Division of RadiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Giovanni Forni
- Division of CardiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
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Jumah A, Aboul Nour H, Intikhab O, Choudhury O, Gagi K, Fana M, Alhajala H, Alkhoujah M, Alsrouji OK, Eltous L, Schultz L, Latack K, Brady M, Chebl A, Marin H, Miller D. Non-stenosing carotid artery plaques in embolic stroke of undetermined source: a retrospective analysis. Neurol Sci 2023; 44:247-252. [PMID: 36166175 DOI: 10.1007/s10072-022-06425-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/21/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND We aim to identify the association between high-risk carotid plaques and their laterality to stroke in ESUS patient population. We also discuss recurrent stroke events and their laterality to the index stroke. METHODS This was a retrospective study. We reviewed data for patients with ESUS between June 20, 2016, and June 20, 2021. Using computed tomography angiography, we analyzed plaque features that are associated with ESUS, and then, we identified the recurrent stroke events and characterized lateralization to the index stroke. RESULTS Out of 1779 patients with cryptogenic ischemic stroke, we included 152 patients who met the criteria for ESUS. High-risk plaque features were found more often ipsilateral to the stroke side when compared contralaterally: plaque ulceration (19.08% vs 5.26%, p < .0001), plaque thickness > 3 mm (19.08% vs 7.24%, p = 0.001), and plaque length > 1 cm (13.16% vs 5.92%, p = 0.0218). There was also a significant difference in plaque component in which both components (soft and calcified) and only soft plaques were more prevalent ipsilaterally (42.76% vs 23.68% and 17.76% vs 9.21%, respectively, p < .0001). Of the 152 patients, 17 patients were found to have a recurrent stroke event, and 47% (n = 8) had an ipsilateral stroke to the index event. Moreover, stroke was bilateral in 41% of the patients (n = 7), and contralateral in 12% (n = 2). CONCLUSION High-risk plaque features studied here were more prevalent ipsilaterally to the stroke side in ESUS than contralaterally. Multicenter studies are needed to form precise prediction models and scoring systems to help guide treatment, i.e., choice of medical therapy and/or revascularization.
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Affiliation(s)
- Ammar Jumah
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA.
| | - Hassan Aboul Nour
- Department of Vascular Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Osama Intikhab
- Department of Neuroradiology, Henry Ford Hospital, Detroit, MI, USA
| | - Omar Choudhury
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Karam Gagi
- Department of Neurology, Sparrow Hospital, Lansing, MI, USA
| | - Michael Fana
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Hisham Alhajala
- Department of Vascular Neurology, University of Toledo, Toledo, OH, USA
| | | | | | - Lara Eltous
- Jordan University of Science and Technology, Amman, Jordan
| | - Lonni Schultz
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI, USA
| | - Katie Latack
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI, USA
| | - Megan Brady
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Alex Chebl
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Horia Marin
- Department of Neuroradiology, Henry Ford Hospital, Detroit, MI, USA
| | - Daniel Miller
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
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15
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Zhang S, Gao L, Kang B, Yu X, Zhang R, Wang X. Radiomics assessment of carotid intraplaque hemorrhage: detecting the vulnerable patients. Insights Imaging 2022; 13:200. [PMID: 36538100 PMCID: PMC9768061 DOI: 10.1186/s13244-022-01324-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 10/31/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Intraplaque hemorrhage (IPH), one of the key features of vulnerable plaques, has been shown to be associated with increased risk of stroke. The aim is to develop and validate a CT-based radiomics nomogram incorporating clinical factors and radiomics signature for the detection of IPH in carotid arteries. METHODS This retrospective study analyzed the patients with carotid plaques on CTA from January 2013 to January 2021 at two different institutions. Radiomics features were extracted from CTA images. Demographics and CT characteristics were evaluated to build a clinical factor model. A radiomics signature was constructed by the least absolute shrinkage and selection operator method. A radiomics nomogram combining the radiomics signature and independent clinical factors was constructed. The area under curves of three models were calculated by receiver operating characteristic analysis. RESULTS A total of 46 patients (mean age, 60.7 years ± 10.4 [standard deviation]; 36 men) with 106 carotid plaques were in the training set, and 18 patients (mean age, 61.4 years ± 10.1; 13 men) with 38 carotid plaques were in the external test sets. Stenosis was the independent clinical factor. Eight features were used to build the radiomics signature. The area under the curve (AUC) of the radiomics nomogram was significantly higher than that of the clinical factor model in both the training (p = 0.032) and external test (p = 0.039) sets. CONCLUSIONS A CT-based radiomics nomogram showed satisfactory performance in distinguishing carotid plaques with and without intraplaque hemorrhage.
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Affiliation(s)
- Shuai Zhang
- grid.410638.80000 0000 8910 6733The School of Medicine, Shandong First Medical University, No. 6699, Qingdao Road, Huaiyin District, Jinan, China
| | - Lin Gao
- grid.410638.80000 0000 8910 6733The School of Medicine, Shandong First Medical University, No. 6699, Qingdao Road, Huaiyin District, Jinan, China
| | - Bing Kang
- grid.460018.b0000 0004 1769 9639Department of Radiology, Shandong Provincial Hospital Affliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, 250021 China
| | - Xinxin Yu
- grid.460018.b0000 0004 1769 9639Department of Radiology, Shandong Provincial Hospital Affliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, 250021 China
| | - Ran Zhang
- Huiying Medical Technology Co. Ltd., 66 Xixiaokou Road, Haidian District, Beijing, China
| | - Ximing Wang
- grid.460018.b0000 0004 1769 9639Department of Radiology, Shandong Provincial Hospital Affliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, 250021 China
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16
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Luo N, Shang Z, Tao L, Yang B, Chen H. Atherosclerosis as a Potential Cause of Deep Embolic Stroke of Undetermined Source: A 3T High‐Resolution Magnetic Resonance Imaging Study. J Am Heart Assoc 2022; 11:e026737. [DOI: 10.1161/jaha.122.026737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
The potential causes or sources of embolic stroke of undetermined source (ESUS) vary. This study aimed to investigate the main cause of deep ESUS by evaluating nonstenotic intracranial atherosclerotic plaque.
Methods and Results
We retrospectively screened consecutive patients with unilateral anterior circulation ESUS. After excluding the patients with possible embolism from an extracranial artery such as aortic arch plaque, carotid plaque, and so on, the enrolled patients with ESUS were categorized into 2 groups: deep ESUS and cortical with/without deep ESUS. All patients underwent intracranial high‐resolution magnetic resonance imaging to assess the characteristics of nonstenotic intracranial atherosclerotic plaque. Biomarkers of atrial cardiopathy (ie, P‐wave terminal force in lead V1 on ECG, NT‐proBNP [N‐terminal pro–brain natriuretic peptide] and left atrial diameter) were collected. A total of 155 patients with ipsilateral nonstenotic intracranial atherosclerotic plaque were found, with 76 (49.0%) in deep ESUS and 79 (51.0%) in cortical with/without deep ESUS. We found more prevalent plaque in the M1 segment of the middle cerebral artery and the ostia of the perforator, with a smaller remodeling index plaque burden, and less frequent occurrence of complicated plaque in deep ESUS versus cortical with/without deep ESUS. Higher BNP (brain natriuretic peptide) levels and a higher prevalence of atrial cardiopathy in cortical with/without deep ESUS versus deep ESUS. Moreover, the discrimination of vulnerable plaque for predicting ESUS was significantly enhanced after adjusting for or further excluding patients with deep ESUS.
Conclusions
The current study provides the first high‐resolution magnetic resonance imaging evidence that cortical with/without deep ESUS and deep ESUS should be 2 distinct entities and that atherosclerosis, not embolism, might be the main cause of deep ESUS.
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Affiliation(s)
- Na Luo
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | - Zi‐Yang Shang
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | - Lin Tao
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | - Ben‐Qiang Yang
- Department of Radiology General Hospital of Northern Theater Command Shenyang China
| | - Hui‐Sheng Chen
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
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17
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Bomben MA, Moody AR, Drake JM, Matsuura N. Fabrication of Customizable Intraplaque Hemorrhage Phantoms for Magnetic Resonance Imaging. Mol Imaging Biol 2022; 24:732-739. [PMID: 35486294 PMCID: PMC9581813 DOI: 10.1007/s11307-022-01722-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 03/04/2022] [Accepted: 03/16/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Magnetic resonance (MR) imaging detection of methemoglobin, a molecular marker of intraplaque hemorrhage (IPH), in atherosclerotic plaque is a promising method of assessing stroke risk. However, the multicenter imaging studies required to further validate this technique necessitate the development of IPH phantoms to standardize images acquired across different scanners. This study developed a set of phantoms that modeled methemoglobin-laden IPH for use in MR image standardization. PROCEDURES A time-stable material mimicking the MR properties of methemoglobin in IPH was created by doping agarose hydrogel with gadolinium and sodium alginate. This material was used to create a phantom that consisted of 9 cylindrical IPH sites (with sizes from 1 to 8 mm). Anatomical replicas of IPH-positive atherosclerosis were also created using 3D printed molds. These plaque replicas also modeled other common plaque components including a lipid core and atheroma cap. T1 mapping and a magnetization-prepared rapid acquisition gradient echo (MPRAGE) carotid imaging protocol were used to assess phantom realism and long-term stability. RESULTS Cylindrical phantom IPH sites possessed a T1 time of 335 ± 51 ms and exhibited little change in size or MPRAGE signal intensity over 31 days; the mean (SD) magnitude of changes in size and signal were 6.4 % (2.7 %) and 7.3 % (6.7 %), respectively. IPH sites incorporated into complex anatomical plaque phantoms exhibited contrast comparable to clinical images. CONCLUSIONS The cylindrical IPH phantom accurately modeled the short T1 time characteristic of methemoglobin-laden IPH, with the IPH sites exhibiting little variation in imaging properties over 31 days. Furthermore, MPRAGE images of the anatomical atherosclerosis replicas closely matched those of clinical plaques. In combination, these phantoms will allow for IPH imaging protocol standardization and thus facilitate future multicenter IPH imaging.
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Affiliation(s)
- Matteo A Bomben
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, ON, Canada
- The Wilfred and Joyce Posluns Centre for Image Guided Innovation and Therapeutic Intervention, The Hospital for Sick Children, Toronto, ON, Canada
| | - Alan R Moody
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
- Sunnybrook Hospital, Toronto, ON, Canada
| | - James M Drake
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, ON, Canada
- The Wilfred and Joyce Posluns Centre for Image Guided Innovation and Therapeutic Intervention, The Hospital for Sick Children, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, 184 College Street, Room 140, Toronto, ON, M5S 3E4, Canada
| | - Naomi Matsuura
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada.
- Institute of Biomedical Engineering, University of Toronto, 184 College Street, Room 140, Toronto, ON, M5S 3E4, Canada.
- Department of Materials Science and Engineering, University of Toronto, Toronto, ON, Canada.
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Kurosaki Y, Kinosada M, Ikeda H, Yamashita H, Yoshida K, Chin M. Clinical features and long-term outcomes of symptomatic low-grade carotid stenosis. J Stroke Cerebrovasc Dis 2022; 31:106779. [PMID: 36179612 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE In symptomatic low-grade stenosis, most of the reports did not clarify the long-term outcome. This study aims to clarify the clinical features and long-term outcomes of symptomatic low-grade stenosis cases. MATERIALS AND METHODS We included 123 symptomatic patients with low-grade (<50%) carotid stenosis. The relative plaque signal intensity (rSI) and expansive remodeling rate (ERR) were measured using carotid magnetic resonance imaging (MRI). Antiplatelet therapy and treatment for atherosclerosis risk factors were administered in all cases. Carotid endarterectomy (CEA) was performed when ischemic symptoms appeared, or the percent stenosis progressed despite medical treatment. RESULTS The mean percent stenosis, rSI, and ERR on admission were 22.3, 1.70, and 2.01, respectively. The mean volume of the hyperintense plaque on carotid MRI was 641.4± 540 mm3. Sixty percent of cases involved intraplaque hemorrhage and expansive remodeling. During a mean follow-up of 52 months, recurrence of ischemic events was confirmed in 45 cases (36.6%). Of the 67 cases performed follow-up MRI, 34 cases (50%) had an increased volume of T1-hyperintense plaque. CEA or carotid artery stenting was performed in 49 cases. During a mean follow-up of 57.8 months after CEA, two cases of death (fatal intracerebral hemorrhage and asphyxia) and one case of brain stem lacunar infarction were observed, but ipsilateral ischemic events were not. CONCLUSION Most of the symptomatic patients with low-grade stenosis had both intraplaque hemorrhage and expansive remodeling and presented a high risk of recurrence and stenosis progression. CEA may have preventive effects against ischemic events in low-grade stenosis.
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Affiliation(s)
| | - Masanori Kinosada
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Hiroyuki Ikeda
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Haruki Yamashita
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Kazumichi Yoshida
- Department of Neurosurgery, Kyoto University School of Medicine, 54 Shogoin Kawahara-Cho Sakyo-ku, Kyoto 606-8507, Japan.
| | - Masaki Chin
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
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19
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Sakai Y, Lehman VT, Eisenmenger LB, Obusez EC, Kharal GA, Xiao J, Wang GJ, Fan Z, Cucchiara BL, Song JW. Vessel wall MR imaging of aortic arch, cervical carotid and intracranial arteries in patients with embolic stroke of undetermined source: A narrative review. Front Neurol 2022; 13:968390. [PMID: 35968273 PMCID: PMC9366886 DOI: 10.3389/fneur.2022.968390] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/01/2022] [Indexed: 11/13/2022] Open
Abstract
Despite advancements in multi-modal imaging techniques, a substantial portion of ischemic stroke patients today remain without a diagnosed etiology after conventional workup. Based on existing diagnostic criteria, these ischemic stroke patients are subcategorized into having cryptogenic stroke (CS) or embolic stroke of undetermined source (ESUS). There is growing evidence that in these patients, non-cardiogenic embolic sources, in particular non-stenosing atherosclerotic plaque, may have significant contributory roles in their ischemic strokes. Recent advancements in vessel wall MRI (VW-MRI) have enabled imaging of vessel walls beyond the degree of luminal stenosis, and allows further characterization of atherosclerotic plaque components. Using this imaging technique, we are able to identify potential imaging biomarkers of vulnerable atherosclerotic plaques such as intraplaque hemorrhage, lipid rich necrotic core, and thin or ruptured fibrous caps. This review focuses on the existing evidence on the advantages of utilizing VW-MRI in ischemic stroke patients to identify culprit plaques in key anatomical areas, namely the cervical carotid arteries, intracranial arteries, and the aortic arch. For each anatomical area, the literature on potential imaging biomarkers of vulnerable plaques on VW-MRI as well as the VW-MRI literature in ESUS and CS patients are reviewed. Future directions on further elucidating ESUS and CS by the use of VW-MRI as well as exciting emerging techniques are reviewed.
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Affiliation(s)
- Yu Sakai
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Vance T. Lehman
- Department of Radiology, The Mayo Clinic, Rochester, MN, United States
| | - Laura B. Eisenmenger
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States
| | | | - G. Abbas Kharal
- Department of Neurology, Cerebrovascular Center, Neurological Institute, Cleveland, OH, United States
| | - Jiayu Xiao
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Grace J. Wang
- Department of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Zhaoyang Fan
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Brett L. Cucchiara
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Jae W. Song
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
- *Correspondence: Jae W. Song
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20
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Lu X, Calabretta R, Wadsak W, Haug AR, Mayerhöfer M, Raderer M, Zhang X, Li J, Hacker M, Li X. Imaging Inflammation in Atherosclerosis with CXCR4-Directed [ 68Ga]PentixaFor PET/MRI-Compared with [ 18F]FDG PET/MRI. Life (Basel) 2022; 12:1039. [PMID: 35888127 PMCID: PMC9320215 DOI: 10.3390/life12071039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/18/2022] [Accepted: 07/06/2022] [Indexed: 01/24/2023] Open
Abstract
(1) This study compared [68Ga]PentixaFor uptake in active arterial segments with corresponding [18F]FDG arterial uptake as well as the relationship with cardiac [68Ga]PentixaFor uptake. (2) Method: Tracer uptake on atherosclerotic lesions in the large arteries was measured and target-to-background ratios (TBR) were calculated to adjust background signals with two investigators blinded to the other PET scan. On a patient-based and lesion-to-lesion analysis, TBR values of two tracers were compared and the relationship with cardiac inflammation was further explored. Furthermore, two cardiovascular risk-related groups were divided to explore the value of risk stratification of the two tracers in atherosclerosis. (3) Results: [68Ga]PentixaFor PET/MRI identified more lesions (88% vs. 48%; p < 0.001) and showed higher uptake than [18F]FDG PET/MRI (TBR, 1.90 ± 0.36 vs. 1.63 ± 0.29; p < 0.001). In the patient-based analysis, the TBR of [68Ga]PentixaFor uptake was also significantly higher than [18F]FDG uptake (1.85 ± 0.20 vs. 1.42 ± 0.19; p < 0.001). The TBR of active lesions for [68Ga]PentixaFor was significantly increased in the high-risk group (n = 9), as compared to the low-risk group (n = 10) (2.02 ± 0.15 vs. 1.86 ± 0.10, p = 0.015), but not for [18F]FDG (1.85 ± 0.10 vs. 1.80 ± 0.07, p = 0.149). (4) Conclusion: [68Ga]PentixaFor PET/MRI identified many more lesions than [18F]FDG PET/MRI. Patients with high-risk cardiovascular factors illustrated an increased uptake of [68Ga]PentixaFor. There was a correlation between the elevated uptake of [68Ga]PentixaFor in the active arterial segments and heart.
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Affiliation(s)
- Xia Lu
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (X.L.); (R.C.); (W.W.); (A.R.H.); (J.L.); (M.H.)
- Department of Nuclear Medicine, Northern Jiangsu People’s Hospital, Yangzhou 225001, China
- Department of Nuclear Medicine, Laboratory for Molecular Imaging, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China;
| | - Raffaella Calabretta
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (X.L.); (R.C.); (W.W.); (A.R.H.); (J.L.); (M.H.)
| | - Wolfgang Wadsak
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (X.L.); (R.C.); (W.W.); (A.R.H.); (J.L.); (M.H.)
- Center for Biomarker Research in Medicine, CBmed, 8036 Graz, Austria
| | - Alexander R. Haug
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (X.L.); (R.C.); (W.W.); (A.R.H.); (J.L.); (M.H.)
| | - Marius Mayerhöfer
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA;
- Division of General and Pediatric, Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria
| | - Markus Raderer
- Department of Medicine I, Division of Oncology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Xiaoli Zhang
- Department of Nuclear Medicine, Laboratory for Molecular Imaging, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China;
| | - Jingle Li
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (X.L.); (R.C.); (W.W.); (A.R.H.); (J.L.); (M.H.)
| | - Marcus Hacker
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (X.L.); (R.C.); (W.W.); (A.R.H.); (J.L.); (M.H.)
| | - Xiang Li
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (X.L.); (R.C.); (W.W.); (A.R.H.); (J.L.); (M.H.)
- Department of Nuclear Medicine, Laboratory for Molecular Imaging, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China;
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21
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Shang ZY, Tao L, Li XQ, Yang BQ, Ntaios G, Chen HS. The characteristics of intracranial plaques of unilateral, anterior circulation embolic stroke of undetermined source: an analysis of different subtypes based on high-resolution imaging. Eur J Neurol 2022; 29:2654-2663. [PMID: 35593148 DOI: 10.1111/ene.15409] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE To investigate the characteristics of non-stenotic intracranial plaque (NSIP) among embolic stroke of undetermined source (ESUS) subtypes by high-resolution magnetic resonance imaging (HR-MRI). METHODS we retrospectively enrolled consecutive patients with ESUS who were mandatory for HR-MRI. Based the location and arterial supply of the infarct, ESUS were categorized into three types: cortical ESUS, subcortical ESUS and mixed ESUS. The NSIP parameters including plaque location, morphology (plaque distribution, remodeling index and plaque burden) and composition (thick fibrous cap, discontinuity of plaque surface, intraplaque hemorrhage and complicated plaque) were evaluated among subtypes. RESULTS Among 243 patients, there were 87 (35.8%) cortical ESUS, 127 (52.3%) subcortical ESUS and 29 (11.9%) mixed ESUS. We found significant differences in plaque location (P < 0.001), plaque quadrant (P < 0.001), remodeling index (P < 0.001), plaque burden (P < 0.001), discontinuity of plaque surface (P < 0.001), intraplaque hemorrhage (P = 0.001) and complicated plaque (P < 0.001) of ipsilateral NISP among different ESUS subtypes, except for fibrous cap (P = 0.135). But we found no differences among contralateral NISP. In addition, the clinical characteristics of the differences among ESUS subtypes were striking, including age (P = 0.004), initial National Institute of Health Stroke Scale (P < 0.001), coronary artery disease (P = 0.039), serum urea (P = 0.011) and creatinine (P = 0.002). CONCLUSION This is the first report of significantly heterogeneous characteristics of ipsilateral NSIP and clinical findings among ESUS subtypes, which may suggest their different underlying mechanisms.
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Affiliation(s)
- Zi-Yang Shang
- Department of Neurology, General Hospital of Northern Theater Command, China
| | - Lin Tao
- Department of Neurology, General Hospital of Northern Theater Command, China
| | - Xiao-Qiu Li
- Department of Neurology, General Hospital of Northern Theater Command, China
| | - Ben-Qiang Yang
- Radiology, General Hospital of Northern Theater Command, China
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, China
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22
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Geiger MA, Flumignan RLG, Sobreira ML, Avelar WM, Fingerhut C, Stein S, Guillaumon AT. Carotid Plaque Composition and the Importance of Non-Invasive in Imaging Stroke Prevention. Front Cardiovasc Med 2022; 9:885483. [PMID: 35651908 PMCID: PMC9149096 DOI: 10.3389/fcvm.2022.885483] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/27/2022] [Indexed: 12/24/2022] Open
Abstract
Luminal stenosis has been the standard feature for the current management strategies in patients with atherosclerotic carotid disease. Histological and imaging studies show considerable differences between plaques with identical degrees of stenosis. They indicate that specific plaque characteristics like Intraplaque hemorrhage, Lipid Rich Necrotic Core, Plaque Inflammation, Thickness and Ulceration are responsible for the increased risk of ischemic events. Intraplaque hemorrhage is defined by the accumulation of blood components within the plaque, Lipid Rich Necrotic Core is composed of macrophages loaded with lipid, Plaque Inflammation is defined as the process of atherosclerosis itself and Plaque thickness and Ulceration are defined as morphological features. Advances in imaging methods like Magnetic Resonance Imaging, Ultrasound, Computed Tomography and Positron Emission Tomography have enabled a more detailed characterization of the plaque, and its vulnerability is linked to these characteristics, changing the management of these patients based only on the degree of plaque stenosis. Studies like Rotterdam, ARIC, PARISK, CAPIAS and BIOVASC were essential to evaluate and prove the relevance of these characteristics with cerebrovascular symptoms. A better approach for the prevention of stroke is needed. This review summarizes the more frequent carotid plaque features and the available validation from recent studies with the latest evidence.
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Affiliation(s)
- Martin Andreas Geiger
- Division of Vascular Surgery, Department of Surgery, Universidade Estadual de Campinas—UNICAMP, São Paulo, Brazil
| | - Ronald Luiz Gomes Flumignan
- Division of Vascular and Endovascular Surgery, Department of Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Marcone Lima Sobreira
- Division of Vascular and Endovascular Surgery, Department of Surgery and Orthopedics, Botucatu Medical School, Universidade Estadual Paulista (UNESP), São Paulo, Brazil
| | - Wagner Mauad Avelar
- Department of Neurology, Universidade Estadual de Campinas—UNICAMP, São Paulo, Brazil
| | - Carla Fingerhut
- Division of Radiology, Department of Anesthesiology and Radiology, Universidade Estadual de Campinas—UNICAMP, São Paulo, Brazil
| | - Sokrates Stein
- Division of Vascular Surgery, Department of Surgery, Universidade Estadual de Campinas—UNICAMP, São Paulo, Brazil
| | - Ana Terezinha Guillaumon
- Division of Vascular Surgery, Department of Surgery, Universidade Estadual de Campinas—UNICAMP, São Paulo, Brazil
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23
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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: 1.3] [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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24
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van der Toorn JE, Bos D, Ikram MK, Verwoert GC, van der Lugt A, Ikram MA, Vernooij MW, Kavousi M. Carotid Plaque Composition and Prediction of Incident Atherosclerotic Cardiovascular Disease. Circ Cardiovasc Imaging 2022; 15:e013602. [PMID: 35196868 DOI: 10.1161/circimaging.121.013602] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Whether information on carotid plaque composition contributes to prediction of incident atherosclerotic cardiovascular disease (ASCVD) remains to be investigated. We determined the sex-specific added value of carotid plaque components for predicting incident ASCVD events, beyond traditional cardiovascular risk factors. METHODS Between 2007 and 2012, participants from the population-based Rotterdam Study with asymptomatic carotid wall thickening >2.5 mm on ultrasonography were invited for carotid magnetic resonance imaging. Among 1349 participants (mean age: 72 years [SD±9.3], 49.5% women) without cardiovascular disease, we assessed plaque thickness, luminal stenosis (>30%), presence of intraplaque hemorrhage, lipid-rich necrotic core, and calcification. Follow-up for ASCVD was complete until January 1, 2015. Using Cox proportional hazards models, we fitted sex-specific prediction models including traditional cardiovascular risk factors (base model). We extended the base model by single and simultaneous additions of plaque characteristics and calculated improvement of model performance by the C statistics. RESULTS During a median follow-up of 4.8 years, 60 men and 48 women developed ASCVD. In women, presence of intraplaque hemorrhage was associated with incident ASCVD (adjusted hazard ratio, 3.37 [95% CI, 1.81-6.25]). The C statistic (95% CI) improved from 0.73 (0.66-0.79) to 0.76 (0.70-0.83) after single addition of intraplaque hemorrhage to the base model. Simultaneous addition of plaque components, plaque thickness, and stenosis did not change the results. In men, only carotid stenosis was statistically significantly associated with incident ASCVD (adjusted hazard ratio, 1.75 [95% CI, 1.00-3.08]); yet, the association diminished after the addition of other plaque characteristics, and no improvements were observed in C statistics. CONCLUSIONS Presence of intraplaque hemorrhage contributes to the prediction of incident ASCVD in women, beyond traditional cardiovascular risk factors, other plaque components, plaque size, and stenosis.
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Affiliation(s)
- Janine E van der Toorn
- Department of Epidemiology (J.E.v.d.T., D.B., M.K.I., M.A.I., M.W.V., M.K.), Erasmus MC, University Medical Centre Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine (J.E.v.d.T., D.B., A.v.d.L., M.W.V.), Erasmus MC, University Medical Centre Rotterdam, The Netherlands
| | - Daniel Bos
- Department of Epidemiology (J.E.v.d.T., D.B., M.K.I., M.A.I., M.W.V., M.K.), Erasmus MC, University Medical Centre Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine (J.E.v.d.T., D.B., A.v.d.L., M.W.V.), Erasmus MC, University Medical Centre Rotterdam, The Netherlands
| | - M Kamran Ikram
- Department of Epidemiology (J.E.v.d.T., D.B., M.K.I., M.A.I., M.W.V., M.K.), Erasmus MC, University Medical Centre Rotterdam, The Netherlands.,Department of Neurology (M.K.I.), Erasmus MC, University Medical Centre Rotterdam, The Netherlands
| | - Germaine C Verwoert
- Department of Cardiology (G.C.V.), Erasmus MC, University Medical Centre Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Epidemiology (J.E.v.d.T., D.B., M.K.I., M.A.I., M.W.V., M.K.), Erasmus MC, University Medical Centre Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine (J.E.v.d.T., D.B., A.v.d.L., M.W.V.), Erasmus MC, University Medical Centre Rotterdam, The Netherlands
| | - M Arfan Ikram
- Department of Epidemiology (J.E.v.d.T., D.B., M.K.I., M.A.I., M.W.V., M.K.), Erasmus MC, University Medical Centre Rotterdam, The Netherlands
| | - Meike W Vernooij
- Department of Epidemiology (J.E.v.d.T., D.B., M.K.I., M.A.I., M.W.V., M.K.), Erasmus MC, University Medical Centre Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine (J.E.v.d.T., D.B., A.v.d.L., M.W.V.), Erasmus MC, University Medical Centre Rotterdam, The Netherlands
| | - Maryam Kavousi
- Department of Epidemiology (J.E.v.d.T., D.B., M.K.I., M.A.I., M.W.V., M.K.), Erasmus MC, University Medical Centre Rotterdam, The Netherlands
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25
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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: 2.7] [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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26
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Larson AS, Brinjikji W, Kroll NJ, Savastano L, Huston J, Benson JC. Normalized intraplaque hemorrhage signal on MP-RAGE as a marker for acute ischemic neurological events. Neuroradiol J 2022; 35:112-118. [PMID: 34224247 PMCID: PMC8826295 DOI: 10.1177/19714009211029263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE This study sought to validate whether the signal intensity ratio (SIR) of carotid intraplaque hemorrhage (IPH) was associated with acute ischemic neurologic events. METHODS A retrospective review was completed of consecutive patients that underwent neck magnetic resonance angiography using magnetization prepared-rapid gradient echo (MP-RAGE) and T1-CUBE sequences between 2017 and 2020. Patients with magnetic resonance evidence of IPH were included. SIRs were measured by comparing the maximum IPH signal with the mean intramuscular signal from the adjacent sternocleidomastoid. Patients were stratified into ischemic or non-ischemic groups based on the presence of acute ipsilateral ischemic events (stroke, retinal artery occlusion). Logistic regression analysis was performed to determine if increasing IPH SIR was associated with an increased risk of ipsilateral ischemic events. RESULTS Of 85 included patients (85 arteries), 66 were male (77.6%). Mean age was 71.0 (SD ± 11.1). There were 70 arteries with IPH that were ipsilateral to an ischemic event, and 15 that belonged to patients without an ischemic event. No association was found between increasing IPH SIR seen on MP-RAGE (odds ratio (OR): 0.82; 95% confidence interval (CI): 0.58-1.4; P = 0.43) or T1-CUBE sequences (OR: 0.85; 95% CI: 0.53-1.5; P = 0.56). CONCLUSIONS There was no association between the SIR of IPH and acute ischemia on either MP-RAGE or T1-CUBE sequences. Further investigation is required prior to widespread acceptance of SIR as a predictive imaging marker of symptomatic carotid plaque.
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Affiliation(s)
- Anthony S Larson
- Department of Radiology, Mayo
Clinic, USA,Department of Neurosurgery, Mayo
Clinic, USA,Anthony S Larson, Department of Radiology,
Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Waleed Brinjikji
- Department of Radiology, Mayo
Clinic, USA,Department of Neurosurgery, Mayo
Clinic, USA
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27
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Nakamura M, Yaku H, Ako J, Arai H, Asai T, Chikamori T, Daida H, Doi K, Fukui T, Ito T, Kadota K, Kobayashi J, Komiya T, Kozuma K, Nakagawa Y, Nakao K, Niinami H, Ohno T, Ozaki Y, Sata M, Takanashi S, Takemura H, Ueno T, Yasuda S, Yokoyama H, Fujita T, Kasai T, Kohsaka S, Kubo T, Manabe S, Matsumoto N, Miyagawa S, Mizuno T, Motomura N, Numata S, Nakajima H, Oda H, Otake H, Otsuka F, Sasaki KI, Shimada K, Shimokawa T, Shinke T, Suzuki T, Takahashi M, Tanaka N, Tsuneyoshi H, Tojo T, Une D, Wakasa S, Yamaguchi K, Akasaka T, Hirayama A, Kimura K, Kimura T, Matsui Y, Miyazaki S, Okamura Y, Ono M, Shiomi H, Tanemoto K. JCS 2018 Guideline on Revascularization of Stable Coronary Artery Disease. Circ J 2022; 86:477-588. [DOI: 10.1253/circj.cj-20-1282] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University Graduate School of Medical Sciences
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Tohru Asai
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Kiyoshi Doi
- General and Cardiothoracic Surgery, Gifu University Graduate School of Medicine
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kumamoto University
| | - Toshiaki Ito
- Department of Cardiovascular Surgery, Japanese Red Cross Nagoya Daiichi Hospital
| | | | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Ken Kozuma
- Department of Internal Medicine, Teikyo University Faculty of Medicine
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Tokyo Women’s Medical University
| | - Takayuki Ohno
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University Hospital
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | | | - Hirofumi Takemura
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kanazawa University
| | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Yokoyama
- Department of Cardiovascular Surgery, Fukushima Medical University
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Institute of Community Medicine, Niigata University Uonuma Kikan Hospital
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, Tsuchiura Kyodo General Hospital
| | | | - Shigeru Miyagawa
- Frontier of Regenerative Medicine, Graduate School of Medicine, Osaka University
| | - Tomohiro Mizuno
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Noboru Motomura
- Department of Cardiovascular Surgery, Graduate School of Medicine, Toho University
| | - Satoshi Numata
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Hiroyuki Nakajima
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center
| | - Hirotaka Oda
- Department of Cardiology, Niigata City General Hospital
| | - Hiromasa Otake
- Department of Cardiovascular Medicine, Kobe University Graduate School of Medicine
| | - Fumiyuki Otsuka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Ken-ichiro Sasaki
- Division of Cardiovascular Medicine, Kurume University School of Medicine
| | - Kazunori Shimada
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Tomoki Shimokawa
- Department of Cardiovascular Surgery, Sakakibara Heart Institute
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Tomoaki Suzuki
- Department of Cardiovascular Surgery, Shiga University of Medical Science
| | - Masao Takahashi
- Department of Cardiovascular Surgery, Hiratsuka Kyosai Hospital
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | | | - Taiki Tojo
- Department of Cardiovascular Medicine, Kitasato University Graduate School of Medical Sciences
| | - Dai Une
- Department of Cardiovascular Surgery, Okayama Medical Center
| | - Satoru Wakasa
- Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine
| | - Koji Yamaguchi
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | | | - Kazuo Kimura
- Cardiovascular Center, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Yoshiro Matsui
- Department of Cardiovascular and Thoracic Surgery, Graduate School of Medicine, Hokkaido University
| | - Shunichi Miyazaki
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Kindai University
| | | | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
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Gradual Expansion of a Stent to Prevent Periprocedural Complications after Carotid Artery Stenting for Vulnerable Severe Stenotic Lesions with Intraplaque Hemorrhages: A Retrospective Observational Study. Life (Basel) 2022; 12:life12010131. [PMID: 35054523 PMCID: PMC8781376 DOI: 10.3390/life12010131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/15/2022] [Accepted: 01/16/2022] [Indexed: 11/17/2022] Open
Abstract
Vulnerable lesions with intraplaque hemorrhages are associated with a high incidence of complications following carotid artery stenting (CAS). CAS for vulnerable lesions has not been established; therefore, we gradually expand stents in such patients. This study aimed to compare the incidences of complications between gradual-expansion CAS for vulnerable lesions and standard CAS for non-vulnerable lesions. For gradual-expansion CAS, we used 3.0 or 4.0 mm balloons for minimal luminal diameters (MLDs) <2.0 or ≥2.0 mm, respectively, for pre-stenting angioplasty (SA) and did not overinflate them. By contrast, for standard CAS, we used a 4.0 mm balloon and overinflated it to 4.23 mm. A closed-cell stent was deployed, and post-SA was not performed in both groups. We evaluated the MLD before and minimal stent diameter (MSD) immediately after CAS, as well as periprocedural complications of combined stroke, death, and myocardial infarction within 30 days after CAS. In the vulnerable and non-vulnerable groups, 30 and 38 patients were analyzed, the MLDs were 0.76 and 0.96 mm before CAS, the MSDs were 2.97 mm and 3.58 mm after CAS, and the numbers of complications were 0 and 1, respectively. Gradual-expansion CAS for vulnerable lesions was as safe as standard CAS for non-vulnerable lesions.
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Rockman C, Jacobowitz GR. Role of Duplex Ultrasound in Carotid Screening. NONINVASIVE VASCULAR DIAGNOSIS 2022:211-230. [DOI: 10.1007/978-3-030-60626-8_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
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30
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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: 3.3] [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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Mishra SC, Singh V, Gupta A, Sharma S, Tyagi L. Blocked Filter of Anti-Embolic Device During Carotid Artery Stenting: A Rare Occurrence Posing Challenging Diagnostic Dilemma. Cureus 2021; 13:e19219. [PMID: 34873545 PMCID: PMC8639398 DOI: 10.7759/cureus.19219] [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] [Accepted: 11/02/2021] [Indexed: 11/22/2022] Open
Abstract
The use of anti-embolic devices (AED’s) is a common practice in carotid artery stenting (CAS). It prevents the passage of blood clots and thrombi generated during the procedure from embolizing into the intracranial circulation. Disadvantages include the passage of small particles and complications related to advancement, deployment, and recovery of the filters. The filter of the AED can get clogged due to the high load of the emboli generated during CAS causing a slowing of the intracranial blood flow which normalizes once the filter is removed. Here, we are presenting a case of the filter of AED getting blocked due to entrapped thrombi or blood clots and mimicking dissection and, sharing our experiences associated with the event.
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Affiliation(s)
- Sarvesh C Mishra
- Radio-Diagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, IND
| | - Vivek Singh
- Radio-Diagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, IND
| | - Aviral Gupta
- Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, IND
| | - Srishti Sharma
- Radio-Diagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, IND
| | - Lavanya Tyagi
- Obstetrics and Gynecology, Javitri Hospital and Test Tube Baby Centre, Lucknow, IND
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Dilba K, van Dam-Nolen DHK, Korteland SA, van der Kolk AG, Kassem M, Bos D, Koudstaal PJ, Nederkoorn PJ, Hendrikse J, Kooi ME, Gijsen FJH, van der Steen AFW, van der Lugt A, Wentzel JJ. The Association Between Time-Varying Wall Shear Stress and the Development of Plaque Ulcerations in Carotid Arteries From the Plaque at Risk Study. Front Cardiovasc Med 2021; 8:732646. [PMID: 34869634 PMCID: PMC8636734 DOI: 10.3389/fcvm.2021.732646] [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: 06/29/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Abstract
Background and Purpose: Shear stress (WSS) is involved in the pathophysiology of atherosclerotic disease and might affect plaque ulceration. In this case-control study, we compared carotid plaques that developed a new ulcer during follow-up and plaques that remained silent for their exposure to time-dependent oscillatory shear stress parameters at baseline. Materials and Methods: Eighteen patients who underwent CTA and MRI of their carotid arteries at baseline and 2 years follow-up were included. These 18 patients consisted of six patients who demonstrated a new ulcer and 12 control patients selected from a larger cohort with similar MRI-based plaque characteristics as the ulcer group. (Oscillatory) WSS parameters [time average WSS, oscillatory shear index (OSI), and relative residence time (RRT)] were calculated using computational fluid dynamics applying the MRI-based geometry of the carotid arteries and compared among plaques (wall thickness>2 mm) with and without ulceration (Mann–Whitney U test) and ulcer-site vs. non-ulcer-site within the plaque (Wilcoxon signed rank test). More detailed analysis on ulcer cases was performed and the predictive value of oscillatory WSS parameters was calculated using linear and logistic mixed-effect regression models. Results: The ulcer group demonstrated no difference in maximum WSS [9.9 (6.6–18.5) vs. 13.6 (9.7–17.7) Pa, p = 0.349], a lower maximum OSI [0.04 (0.01–0.10) vs. 0.12 (0.06–0.20) p = 0.019] and lower maximum RRT [1.25 (0.78–2.03) Pa−1 vs. 2.93 (2.03–5.28) Pa−1, p = 0.011] compared to controls. The location of the ulcer (ulcer-site) within the plaque was not always at the maximal WSS, but demonstrated higher average WSS, lower average RRT and OSI at the ulcer-site compared to the non-ulcer-sites. High WSS (WSS>4.3 Pa) and low RRT (RRT < 0.25 Pa) were associated with ulceration with an odds ratio of 3.6 [CI 2.1–6.3] and 2.6 [CI 1.54–4.44] respectively, which remained significant after adjustment for wall thickness. Conclusion: In this explorative study, ulcers were not exclusively located at plaque regions exposed to the highest WSS, OSI, or RRT, but high WSS and low RRT regions had a significantly higher odds to present ulceration within the plaque even after adjustment for wall thickness.
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Affiliation(s)
- Kristine Dilba
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Dianne H K van Dam-Nolen
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suze-Anne Korteland
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Anja G van der Kolk
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Mohamed Kassem
- Department of Radiology and Nuclear Medicine, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Daniel Bos
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Peter J Koudstaal
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, University Medical Centers Amsterdam, Amsterdam, Netherlands
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - M Eline Kooi
- Department of Radiology and Nuclear Medicine, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Frank J H Gijsen
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Anton F W van der Steen
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jolanda J Wentzel
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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Larson AS, Chen JJ, Bhatti MT, Klaas JP, Lanzino G, Huston J, Brinjikji W. The Frequency of Carotid Intraplaque Hemorrhage on Vessel Wall Imaging in Patients With Retinal Artery Occlusion: A Cross-Sectional Prevalence Study. J Neuroophthalmol 2021; 41:e572-e577. [PMID: 33417414 DOI: 10.1097/wno.0000000000001156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intraplaque hemorrhage (IPH) in a carotid artery plaque viewed on vessel wall imaging has been shown to be associated with ischemic stroke. Whether such an association between carotid IPH and retinal artery occlusion (RAO) exists remains unknown. METHODS This was a cross-sectional prevalence study. Medical and imaging records of all patients who underwent neck MRA with plaque imaging sequences at our institution from 2015 to 2020 were retrospectively reviewed. Fourteen patients with confirmed RAO and plaque imaging performed within 6 weeks of presentation were included. A group of 211 patients without a prior ischemic event (RAO, stroke, etc.) with plaque imaging were used as controls. A single artery from control patients was randomly selected. The prevalence of IPH and degree of ipsilateral carotid stenosis were compared between RAO and control patients. Multiple regression analysis was performed to determine independent associations between variables and RAO. RESULTS Five patients (35.7%) with RAO had imaging evidence of ipsilateral IPH in contrast to 7 of 211 (3.3%) patients in the control group (odds ratio [OR]: 16.2, 95% confidence interval [95% CI]: 4.3-61.1, P = 0.0002). Of the 5 patients with RAO and ipsilateral IPH, only one (20.0%) was found to ipsilateral carotid stenosis greater than 70%. Carotid IPH was the only variable that was independently associated with RAO (OR: 12.6, 95% CI = 2.2-73.6, P = 0.005). CONCLUSIONS Carotid IPH is independently associated with RAO. The use of plaque imaging in the evaluation of patients with acute RAO is therefore supported.
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Affiliation(s)
- Anthony S Larson
- Departments of Radiology (ASL, GL, JH, WB), Neurosurgery (GL, WB), Neurology (JJC, MTB, JPK), Ophthalmology (JJC, MTB), Mayo Clinic, Rochester, Minnesota
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34
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Larson AS, Brinjikji W, Savastano L, Scharf E, Huston J, Benson JC. Left-sided carotid arteries have a higher prevalence of intraplaque hemorrhage than right-sided: An asymmetric conundrum. Neuroradiol J 2021; 33:494-500. [PMID: 33283672 DOI: 10.1177/1971400920970920] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To assess whether an asymmetry exists in the prevalence of carotid artery intraplaque hemorrhage (IPH) between right- and left-sided arteries. MATERIALS AND METHODS The records of all patients with atherosclerotic carotid artery disease that underwent neck magnetic resonance angiography imaging with high-resolution plaque sequences between 2017 and 2020 at our institution were retrospectively reviewed. The prevalence of stenosis and IPH was determined for all patients and compared between the left and right carotid arteries of those with unilateral anterior circulation ischemic strokes. Multiple regression analysis was performed to determine potential independent associations of IPH laterality with ischemic strokes. RESULTS A total of 368 patients were included overall and 241 were male (65.4%). There were a total of 125 asymptomatic patients and 211 patients with unilateral anterior circulation ischemic strokes. Of patients with ischemic strokes, 55.5% had left-sided strokes compared with 44.5% who had right-sided strokes (p = 0.03). Patients with left-sided strokes had a higher prevalence of ipsilateral IPH than those with right-sided strokes (64.1% versus 36.2%, p < 0.0001), despite similar degrees of stenosis. Both age (odds ratio (OR): 1.0; 95% confidence interval (CI): 1.0-1.1; p = 0.007) and the presence of left-sided IPH (OR: 3.2; 95% CI: 1.5-6.8; p = 0.003) were independently associated with unilateral ischemic strokes. CONCLUSIONS Left-sided plaques more frequently have IPH and may be more likely to result in ipsilateral ischemic strokes compared with right-sided plaques. The underlying mechanism of asymmetric distribution of IPH between right and left carotids remains unclear.
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Affiliation(s)
- Anthony S Larson
- Department of Radiology, Mayo Clinic, USA.,Department of Neurosurgery, Mayo Clinic, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, USA.,Department of Neurosurgery, Mayo Clinic, USA
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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36
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SOCIETY FOR VASCULAR SURGERY CLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF EXTRACRANIAL CEREBROVASCULAR DISEASE. J Vasc Surg 2021; 75:4S-22S. [PMID: 34153348 DOI: 10.1016/j.jvs.2021.04.073] [Citation(s) in RCA: 266] [Impact Index Per Article: 66.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 11/22/2022]
Abstract
Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were published. Since that publication, several studies and a few systematic reviews comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2011 guidelines with specific emphasis on five areas: is carotid endarterectomy recommended over maximal medical therapy in low risk patients; is carotid endarterectomy recommended over trans-femoral carotid artery stenting in low surgical risk patients with symptomatic carotid artery stenosis of >50%; timing of carotid Intervention in patients presenting with acute stroke; screening for carotid artery stenosis in asymptomatic patients; and optimal sequence for intervention in patients with combined carotid and coronary artery disease. A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) approach, as has been done with other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin 0-2), carotid revascularization is considered appropriate in symptomatic patients with greater than 50% stenosis and is recommended and performed as soon as the patient is neurologically stable after 48 hours but definitely before 14 days of onset of symptoms. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients who are at increased risk for carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis as long as the patients would potentially be fit for and willing to consider carotid intervention if significant stenosis is discovered. In patients with symptomatic carotid stenosis 50-99%, who require both CEA and CABG, we suggest CEA before or concomitant with CABG to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on clinical presentation and institutional experience.
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Kim MJ, Kwak HS, Hwang SB, Chung GH. One-step evaluation of intraplaque hemorrhage in the carotid artery and vertebrobasilar artery using simultaneous non-contrast angiography and intraplaque hemorrhage. Eur J Radiol 2021; 141:109824. [PMID: 34126430 DOI: 10.1016/j.ejrad.2021.109824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 05/23/2021] [Accepted: 06/08/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate the one-step detection of intraplaque hemorrhage (IPH) in the carotid artery (CA) and vertebrobasilar artery (VBA) using simultaneous non-contrast angiography and intraplaque hemorrhage (SNAP). METHODS From January 2019 to March 2020, 1820 consecutive patients who visited our emergency room for evaluation of neurologic symptoms underwent brain MR imaging, including the SNAP sequence. SNAP imaging examined the coronal section from the CA to the VBA. IPH was defined as plaque in the CA and VBA with 200 % higher signal intensity on SNAP than in adjacent muscle in at least two consecutive slices. RESULTS Of these patients, 360 (19.8 %) had carotid plaque (both sides = 141, 39.2 %; single side = 219, 61.8 %). Of patients with carotid plaque, 185 (51.4 %) had IPH. Of 141 patients with plaques on both sides, 35 (24.8 %) had bilateral IPH. In total, 73 (4.0 %) patients had VBA IPH (30 with carotid plaque, 43 without carotid plaque). In addition, 18 (1.0 %) patients had carotid IPH and VBA IPH. Maximal wall thickness was significantly higher in the carotid IPH groups (4.5 ± 0.1 vs. 4.1 ± 0.1, p = 0.009). Prevalence of high grade stenosis (>70 %) was significantly higher in the carotid IPH group (17.5 % vs. 6.2 %, p < 0.001). CONCLUSIONS SNAP imaging can be evaluated with a one-step examination of CA and VBA IPH.
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Affiliation(s)
- Min Jee Kim
- Department of Radiology and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Republic of Korea
| | - Hyo Sung Kwak
- Department of Radiology and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Republic of Korea.
| | - Seung Bae Hwang
- Department of Radiology and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Republic of Korea
| | - Gyung Ho Chung
- Department of Radiology and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Republic of Korea
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Kim JH, Kwak HS, Hwang SB, Chung GH. Differential Diagnosis of Intraplaque Hemorrhage and Dissection on High-Resolution MR Imaging in Patients with Focal High Signal of the Vertebrobasilar Artery on TOF Imaging. Diagnostics (Basel) 2021; 11:1024. [PMID: 34204962 PMCID: PMC8230252 DOI: 10.3390/diagnostics11061024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 12/02/2022] Open
Abstract
PURPOSE Intraplaque hemorrhage (IPH) and dissection in the vertebrobasilar artery (VBA) on time of flight (TOF) source imaging are seen as focal eccentric high-signal intensity. The purpose of this study is to identify IPH and dissection in the VBA using high-resolution magnetic resonance imaging (HR-MRI). METHODS A total of 78 patients (VBA IPH: 55; dissection: 23) with focal high-signal intensity in the VBA on simultaneous non-contrast angiography and intraplaque hemorrhage (SNAP) of HR-MRI were included in this study. The focal high-signal intensity in the VBA on SNAP was defined as >200% than that of the adjacent muscle. We analyzed the signal intensity ratio (area of focal high signal intensity area/lumen) on TOF imaging and black blood (BB) T2-weighted imaging. RESULTS The VBA IPH group was older than the dissection group and had more hypertension. Signal intensity of a false lumen in patients with dissection on TOF imaging was significantly higher than that of VBA IPH (p < 0.001). The signal intensity ratio between lumen and lesion on TOF imaging was significantly higher in the dissection group (p < 0.001). The signal intensity of a false lumen in patients with dissection on BB T2-weighted imaging was significantly lower than that of VBA IPH (p < 0.001). The signal intensity ratio between lumen and lesion on BB T2-weighted imaging was significantly higher in the VBA IPH group (p < 0.001). CONCLUSIONS TOF imaging and BB T2-weighted imaging on HR-MRI in patients with focal eccentric high-signal intensity on TOF imaging can distinguish between VBA IPH and dissection.
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Affiliation(s)
| | - Hyo Sung Kwak
- Department of Radiology and Research Institute of Clinical Medicine of Jeonbuk National University, Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 54896, Korea; (J.H.K.); (S.B.H.); (G.H.C.)
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Tonetti DA, Desai SM, Nayar G, Jankowitz BT, Jovin TG, Jadhav AP. Symptomatic nonstenotic carotid disease: Evaluation of a proposed classification scheme in a prospective cohort. J Clin Neurosci 2021; 90:21-25. [PMID: 34275551 DOI: 10.1016/j.jocn.2021.04.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/21/2021] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Unraveling symptomatic nonstenotic carotid disease (SyNC) as a stroke etiology from other cryptogenic stroke may have important implications for defining natural history and for tailoring secondary prevention strategies. We aim to describe the characteristics of the plaques in a prospectively-collected cohort of patients with non-invasive imaging suggesting symptomatic carotid stenosis but whose DSA demonstrated nonstenotic atheromatous disease, and to evaluate the recurrence rate depending on the type of SyNC. METHODS We reviewed prospectively-collected data for patients presenting with new neurologic events and non-invasive imaging suggestive of moderate or severe (≥50%) carotid stenosis between July 2016 and October 2018. Patients were included in the present study if the degree of stenosis on DSA was < 50%. We assigned these patients into groups based on a previously-proposed working definition of SyNC, and analyzed the rate of recurrent stroke in the following 6 months. RESULTS 28 patients had DSA-confirmed < 50% stenosis and constituted the study cohort. The median age was 73 years and 64% were male; median presenting NIHSS was 1 (IQR 0-3). The great majority (86%) of carotid plaques had high-risk features including ulcerated plaque (n = 21, 75%) and plaque > 3 mm thick (n = 18, 64%). 17 of 28 patients (61%) met classification criteria for "definite" or "probable" SyNC. Three of five patients in the "definite SyNC" group experienced recurrent neurologic events. CONCLUSION The majority of patients with non-invasive imaging suggesting carotid stenosis harbor symptomatic carotid disease per current classifications despite DSA stenosis < 50%. Current classification schema may allow for risk stratification of SyNC patients and these findings warrant further study.
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Affiliation(s)
- Daniel A Tonetti
- The Departments of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; The Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | | | - Gautam Nayar
- The Departments of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Larson AS, Brinjikji W, Savastano L, Rabinstein AA, Saba L, Huston J, Benson JC. Carotid Intraplaque Hemorrhage and Stenosis: At What Stage of Plaque Progression Does Intraplaque Hemorrhage Occur, and When is It Most Likely to Be Associated with Symptoms? AJNR Am J Neuroradiol 2021; 42:1285-1290. [PMID: 33888452 DOI: 10.3174/ajnr.a7133] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 02/08/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The relationship between carotid intraplaque hemorrhage and luminal stenosis severity is not well-established. We sought to determine whether intraplaque hemorrhage is related to carotid stenosis and at what degree of stenosis intraplaque hemorrhage most likely contributes to ischemic symptoms. MATERIALS AND METHODS Consecutive patients who underwent MR carotid plaque imaging with MPRAGE sequences to identify intraplaque hemorrhage were retrospectively reviewed. Degrees of stenoses were categorized as minimal (<30%), moderate (30%-69%), and severe (>70%). Arteries were categorized into 2 groups: symptomatic (ipsilateral to a cerebral ischemic event) and asymptomatic (from a patient without an ischemic event). Multiple regression analyses were used to determine independent associations between the degree of stenosis and intraplaque hemorrhage and the presence of intraplaque hemorrhage with symptoms among categories of stenosis. RESULTS We included 449 patients with 449 carotid arteries: Two hundred twenty-five (50.1%) were symptomatic, and 224 (49.9%) were asymptomatic. An increasing degree of stenosis was independently associated with the presence of intraplaque hemorrhage (OR = 1.02; 95% confidence interval, 1.01-1.03). Intraplaque hemorrhage was independently associated with ischemic events in arteries with <30% stenosis (OR = 5.68; 95% CI, 1.49-21.69). No such association was observed in arteries with >30% stenosis. Of symptomatic arteries with minimal stenosis, 8.7% had intraplaque hemorrhage versus 1.7% of asymptomatic arteries (P = .02). No differences in intraplaque hemorrhage prevalence were found between symptomatic and asymptomatic groups with moderate (P = .18) and severe stenoses (P = .99). CONCLUSIONS The presence of intraplaque hemorrhage on high-resolution plaque imaging is likely most useful in identifying symptomatic plaques in cases of minimal stenosis.
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Affiliation(s)
- A S Larson
- From the Departments of Radiology (A.S.L., W.B., J.H., J.C.B.) .,Neurosurgery (A.S.L., W.B., L. Savastano)
| | - W Brinjikji
- From the Departments of Radiology (A.S.L., W.B., J.H., J.C.B.).,Neurosurgery (A.S.L., W.B., L. Savastano)
| | | | | | - L Saba
- Department of Radiology (L. Saba), University of Cagliari, Cagliari, Italy
| | - J Huston
- From the Departments of Radiology (A.S.L., W.B., J.H., J.C.B.)
| | - J C Benson
- From the Departments of Radiology (A.S.L., W.B., J.H., J.C.B.)
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41
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Schenk WB, Brinjikji W, Larson AS, Nasr DM. Diagnostic Yield of Neck CT Angiography in Young Adults With Anterior Circulation Ischemic Stroke: A Community Based Study. Neurohospitalist 2021; 11:119-124. [PMID: 33791054 DOI: 10.1177/1941874420974542] [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: 11/17/2022] Open
Abstract
Background and Purpose Few community-based studies investigating young adult strokes exist. The aim of this study was to determine the diagnostic yield of head and neck CTA in evaluation of anterior circulation ischemic stroke in young adults. Materials and Methods This retrospective review is limited to patients between the ages of 18-50 presenting to the Mayo Clinic Rochester emergency department or referred from smaller institutions in adjacent counties. Patients with posterior circulation infarcts, amaurosis fugax, central retinal artery occlusion or transient ischemic attacks were excluded. The presence of carotid dissection, webs, plaque, or other high-risk lesions were recorded. Results A total of 136 patients met inclusion criteria. Mean degree of carotid stenosis ipsilateral to infarct was 14.1%, compared to 6.5% on the contralateral side (p = .006). Ipsilateral mean carotid wall thickness measured .79 mm, compared to contralateral thickness of .80 mm (p = .51). Ipsilateral low-density plaque was observed in 22 patients (16.2%), and 21 patients (15.4%) on the contralateral side (p = .87). Ipsilateral calcified plaque was observed in 37 patients (27.2%), and 29 patients (21.3%) on the contralateral side (p = .31). 20 (14.7%) ipsilateral dissections were noted, compared to 4 (2.9%) contralateral dissections (p = .001). 3 (2.2%) ipsilateral carotid webs were identified, compared to 0 contralateral webs (p = .25). Conclusion Carotid dissection was the most common cause of anterior circulation infarct identified on cervical CTA in this population. Carotid webs and atherosclerosis were not common findings.
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Affiliation(s)
| | | | | | - Deena M Nasr
- Mayo Clinic Department of Neurology, Rochester, MN, USA
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42
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Tao L, Li XQ, Hou XW, Yang BQ, Xia C, Ntaios G, Chen HS. Intracranial Atherosclerotic Plaque as a Potential Cause of Embolic Stroke of Undetermined Source. J Am Coll Cardiol 2021; 77:680-691. [PMID: 33573737 DOI: 10.1016/j.jacc.2020.12.015] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 12/08/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Previous studies investigated the potential mechanism of embolic stroke of undetermined source (ESUS) from extracranial artery plaque, but there has been no study other than a case report on high-risk intracranial plaque in ESUS. OBJECTIVES The aim of this study was to investigate the issue by evaluating the morphology and composition of intracranial plaque in patients with ESUS and small-vessel disease (SVD) using 3.0-T high-resolution magnetic resonance imaging. METHODS Two hundred forty-three consecutive patients with ESUS and 160 patients with SVD-associated stroke between January 2015 and December 2019 were retrospectively enrolled. Multidimensional parameters involving the presence of plaque on both sides, including remodeling index (RI), plaque burden, presence of discontinuity of plaque surface, thick fibrous cap, intraplaque hemorrhage, and complicated American Heart Association type VI plaque at the maximal luminal narrowing site, were evaluated using intracranial high-resolution magnetic resonance imaging. RESULTS Among 243 patients with ESUS, the prevalence of intracranial plaque was much higher in the ipsilateral than the contralateral side (63.8% vs. 42.8%; odds ratio [OR]: 5.25; 95% confidence interval [CI]: 2.83 to 9.73), a finding that was not evident in patients with SVD (35.6% vs. 30.6%; OR: 2.14; 95% CI: 0.87 to 5.26; p = 0.134). Logistic analysis showed that RI was independently associated with ESUS in model 1 (OR: 2.329; 95% CI: 1.686 to 3.217; p < 0.001) and model 2 (OR: 2.295; 95% CI: 1.661 to 3.172; p < 0.001). RI alone with an optimal cutoff of 1.162, corresponding to an area under the curve of 0.740, had good diagnostic efficiency for ESUS. CONCLUSIONS The present study supports an etiologic role of high-risk nonstenotic intracranial plaque in ESUS.
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Affiliation(s)
- Lin Tao
- Department of Neurology, General Hospital of Northern Theater Command, Shen Yang, China
| | - Xiao-Qiu Li
- Department of Neurology, General Hospital of Northern Theater Command, Shen Yang, China
| | - Xiao-Wen Hou
- Department of Neurology, General Hospital of Northern Theater Command, Shen Yang, China
| | - Ben-Qiang Yang
- Department of Radiology, General Hospital of Northern Theater Command, Shen Yang, China
| | - Cheng Xia
- Department of Neurology, General Hospital of Northern Theater Command, Shen Yang, China
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shen Yang, China.
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Catalano O, Bendotti G, Mori A, De Salvo M, Falconi M, Aloi TL, Tibollo V, Bellazzi R, Bardile AF, Montagna S, Pesarin C, Poggi P, Pedretti RFE, Priori SG. Evolving determinants of carotid atherosclerosis vulnerability in asymptomatic patients from the MAGNETIC observational study. Sci Rep 2021; 11:2327. [PMID: 33504842 PMCID: PMC7840938 DOI: 10.1038/s41598-021-81247-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 12/28/2020] [Indexed: 11/08/2022] Open
Abstract
MRI can assess plaque composition and has demonstrated an association between some atherosclerotic risk factors (RF) and markers of plaque vulnerability in naive patients. We aimed at investigating this association in medically treated asymptomatic patients. This is a cross-sectional interim analysis (August 2013-September 2016) of a single center prospective study on carotid plaque vulnerability (MAGNETIC study). We recruited patients with asymptomatic carotid atherosclerosis (US stenosis > 30%, ECST criteria), receiving medical treatments at a tertiary cardiac rehabilitation. Atherosclerotic burden and plaque composition were quantified with 3.0 T MRI. The association between baseline characteristics and extent of lipid-rich necrotic core (LRNC), fibrous cap (CAP) and intraplaque hemorrhage (IPH) was studied with multiple regression analysis. We enrolled 260 patients (198 male, 76%) with median age of 71-y (interquartile range: 65-76). Patients were on antiplatelet therapy, ACE-inhibitors/angiotensin receptor blockers and statins (196-229, 75-88%). Median LDL-cholesterol was 78 mg/dl (59-106), blood pressure 130/70 mmHg (111-140/65-80), glycosylated hemoglobin 46 mmol/mol (39-51) and BMI 25 kg/m2 (23-28); moreover, 125 out of 187 (67%) patients were ex-smokers. Multivariate analysis of a data-set of 487 (94%) carotid arteries showed that a history of hypercholesterolemia, diabetes, hypertension or smoking did not correlate with LRNC, CAP or IPH. Conversely, maximum stenosis was the strongest independent predictor of LRNC, CAP and IPH (p < 0.001). MRI assessment of plaque composition in patients on treatment for asymptomatic carotid atherosclerosis shows no correlation between plaque vulnerability and the most well-controlled modifiable RF. Conversely, maximum stenosis exhibits a strong correlation with vulnerable features despite treatment.
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Affiliation(s)
- Oronzo Catalano
- Division of Cardiology, Istituti Clinici Scientifici Maugeri, via Maugeri 6, Pavia, Italy.
| | - Giulia Bendotti
- Division of Cardiology, Istituti Clinici Scientifici Maugeri, via Maugeri 6, Pavia, Italy
| | - Alessia Mori
- Division of Cardiology, Istituti Clinici Scientifici Maugeri, via Maugeri 6, Pavia, Italy
| | - Maria De Salvo
- Division of Cardiology, Istituti Clinici Scientifici Maugeri, via Maugeri 6, Pavia, Italy
| | - Marialuisa Falconi
- Division of Cardiology, Istituti Clinici Scientifici Maugeri, via Maugeri 6, Pavia, Italy
| | - Teresa L Aloi
- Angiology Unit, Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Valentina Tibollo
- Bioinformatics Laboratory (LISRC Lab), Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Riccardo Bellazzi
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | | | - Stefano Montagna
- Division of Radiology, Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Clara Pesarin
- Division of Radiology, Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Paolo Poggi
- Division of Radiology, Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Roberto F E Pedretti
- Division of Cardiology, Istituti Clinici Scientifici Maugeri, via Maugeri 6, Pavia, Italy
| | - Silvia G Priori
- Molecular Cardiology, Istituti Clinici Scientifici Maugeri, Pavia, Italy
- University of Pavia, Pavia, Italy
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Advances in Multimodality Carotid Plaque Imaging: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 217:16-26. [PMID: 33438455 DOI: 10.2214/ajr.20.24869] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Contemporary imaging methods provide detailed visualization of carotid athero-sclerotic plaque, enabling a major evolution of in vivo carotid plaque imaging evaluation. The degree of luminal stenosis in the carotid artery bifurcation, as assessed by ultrasound, has historically served as the primary imaging feature for determining ischemic stroke risk and the potential need for surgery. However, stroke risk may be more strongly driven by the presence of specific characteristics of vulnerable plaque, as visualized on CT and MRI, than by traditional ultrasound-based assessment of luminal narrowing. This review highlights six promising imaging-based plaque characteristics that harbor unique information regarding plaque vulnerability: maximum plaque thickness and volume, calcification, ulceration, intraplaque hemorrhage, lipid-rich necrotic core, and thin or ruptured fibrous cap. Increasing evidence supports the association of these plaque characteristics with risk of ischemic stroke, although these characteristics have varying suitability for clinical implementation. Key aspects of CT and MRI protocols for carotid plaque imaging are also considered. Practical next steps and hurdles are explored for implementing routine imaging assessment of these plaque characteristics in addition to, or even as replacement for, traditional assessment of the degree of vascular stenosis on ultrasound, in the identification of individuals at high risk of ischemic stroke.
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Dilba K, van Dam-Nolen DHK, van Dijk AC, Kassem M, van der Steen AFW, Koudstaal PJ, Nederkoorn PJ, Hendrikse J, Kooi ME, Wentzel JJ, van der Lugt A. Plaque Composition as a Predictor of Plaque Ulceration in Carotid Artery Atherosclerosis: The Plaque At RISK Study. AJNR Am J Neuroradiol 2021; 42:144-151. [PMID: 33214179 DOI: 10.3174/ajnr.a6868] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 08/09/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Plaque ulceration is a marker of previous plaque rupture. We studied the association between atherosclerotic plaque composition at baseline and plaque ulceration at baseline and follow-up. MATERIALS AND METHODS We included symptomatic patients with a carotid stenosis of <70% who underwent MDCTA and MR imaging at baseline (n = 180). MDCTA was repeated at 2 years (n = 73). We assessed the presence of ulceration using MDCTA. Baseline MR imaging was used to assess the vessel wall volume and the presence and volume of plaque components (intraplaque hemorrhage, lipid-rich necrotic core, and calcifications) and the fibrous cap status. Associations at baseline were evaluated with binary logistic regression and reported with an OR and its 95% CI. Simple statistical testing was performed in the follow-up analysis. RESULTS At baseline, the prevalence of plaque ulceration was 27% (49/180). Increased wall volume (OR = 12.1; 95% CI, 3.5-42.0), higher relative lipid-rich necrotic core (OR = 1.7; 95% CI, 1.3-2.2), higher relative intraplaque hemorrhage volume (OR = 1.7; 95% CI, 1.3-2.2), and a thin-or-ruptured fibrous cap (OR = 3.4; 95% CI, 1.7-6.7) were associated with the presence of ulcerations at baseline. In 8% (6/73) of the patients, a new ulcer developed. Plaques with a new ulceration at follow-up had at baseline a larger wall volume (1.04 cm3 [IQR, 0.97-1.16 cm3] versus 0.86 cm3 [IQR, 0.73-1.00 cm3]; P = .029), a larger relative lipid-rich necrotic core volume (23% [IQR, 13-31%] versus 2% [IQR, 0-14%]; P = .002), and a larger relative intraplaque hemorrhage volume (14% [IQR, 8-24%] versus 0% [IQR, 0-5%]; P < .001). CONCLUSIONS Large atherosclerotic plaques and plaques with intraplaque hemorrhage and lipid-rich necrotic cores were associated with plaque ulcerations at baseline and follow-up.
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Affiliation(s)
- K Dilba
- From the Departments of Radiology and Nuclear Medicine (K.D., D.H.K.v.D.-N., A.C.v.D., A.v.d.L.)
- Cardiology (K.D., A.F.W.v.d.S., J.J.W.)
| | - D H K van Dam-Nolen
- From the Departments of Radiology and Nuclear Medicine (K.D., D.H.K.v.D.-N., A.C.v.D., A.v.d.L.)
| | - A C van Dijk
- From the Departments of Radiology and Nuclear Medicine (K.D., D.H.K.v.D.-N., A.C.v.D., A.v.d.L.)
- Neurology (A.C.v.D., P.J.K.), Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - M Kassem
- Department of Radiology and Nuclear Medicine (M.K., M.E.K.), CARIM School for Cardiovascular Diseases, Maastricht University Medical Center+, Maastricht, the Netherlands
| | | | - P J Koudstaal
- Neurology (A.C.v.D., P.J.K.), Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - P J Nederkoorn
- Department of Neurology (P.J.N.), University Medical Center Amsterdam, Amsterdam, the Netherlands
| | - J Hendrikse
- Department of Radiology (J.H.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - M E Kooi
- Department of Radiology and Nuclear Medicine (M.K., M.E.K.), CARIM School for Cardiovascular Diseases, Maastricht University Medical Center+, Maastricht, the Netherlands
| | | | - A van der Lugt
- From the Departments of Radiology and Nuclear Medicine (K.D., D.H.K.v.D.-N., A.C.v.D., A.v.d.L.)
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Settecase F, Rayz VL. Advanced vascular imaging techniques. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:81-105. [DOI: 10.1016/b978-0-444-64034-5.00016-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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47
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Larson AS, Benson JC, Brinjikji W, Savastano L, Lanzino G, Huston J, Nasr D. Variations in the Presence of Carotid Intraplaque Hemorrhage Across Age Categories: What Age Groups Are Most Likely to Benefit From Plaque Imaging? Front Neurol 2021; 11:603055. [PMID: 33381079 PMCID: PMC7768076 DOI: 10.3389/fneur.2020.603055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/25/2020] [Indexed: 11/13/2022] Open
Abstract
Although carotid artery intraplaque hemorrhage (IPH) is a known risk-factor for cerebral ischemic events in patients of advanced age, its prevalence in younger cohorts is less certain. The purpose of this study was to assess the prevalence of carotid artery IPH across the age spectrum. A retrospective review was completed of all adult patients from our institution who underwent neck MRA with high-resolution carotid plaque imaging between 2017 and 2020. The mean ages of patients with and without IPH were calculated. The prevalence of IPH was compared between patients that were categorized into age groups. Patients with and without a cerebral ischemic event (e.g., stroke, retinal ischemia) were included. Unilateral anterior circulation ischemic events in patients without atrial fibrillation were presumed to be likely related to ipsilateral carotid artery disease. Multiple regression analysis was performed to determine independent associations with IPH. 634 patients were included (1,268 carotid arteries). Increasing age (OR: 1.04; 95% CI: 1.02-1.06; P = 0.001) was independently associated with IPH. 211 patients had unilateral anterior circulation ischemic events. The mean age of patients with carotid IPH was 71.4 years (SD = 9.9), compared to 62.8 years (SD = 15.8) of those without (P ≤ 0.0001). The prevalence of IPH increased with age in all patients (P = 0.0002). Among patients with ipsilateral anterior circulation ischemic events, each age category above 50 years had a significantly higher prevalence of IPH when compared to patients 18-50 years (P ≤ 0.05 for all comparisons). The prevalence of carotid IPH increases with age and is rare in patients under 50 years. The approximate threshold age for IPH development is likely around 50 years.
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Affiliation(s)
- Anthony S Larson
- Department of Radiology, Mayo Clinic, Rochester, MN, United States.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, United States.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Luis Savastano
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Giuseppe Lanzino
- Department of Radiology, Mayo Clinic, Rochester, MN, United States.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - John Huston
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Deena Nasr
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
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Dilba K, van Dijk AC, Crombag GAJC, van der Steen AFW, Daemen MJ, Koudstaal PJ, Nederkoorn PJ, Hendrikse J, Kooi ME, van der Lugt A, Wentzel JJ. Association between Intraplaque Hemorrhage and Vascular Remodeling in Carotid Arteries: The Plaque at RISK (PARISK) Study. Cerebrovasc Dis 2020; 50:94-99. [PMID: 33271533 DOI: 10.1159/000511935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 09/11/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Vascular remodeling is a compensatory enlargement of the vessel wall in response to atherosclerotic plaque growth. We aimed to investigate the association between intraplaque hemorrhage (IPH), vascular remodeling, and luminal dimensions in recently symptomatic patients with mild to moderate carotid artery stenosis in which the differences in plaque size were taken into account. MATERIALS AND METHODS We assessed vessel dimensions on MRI of the symptomatic carotid artery in 164 patients from the Plaque At RISK study. This study included patients with recent ischemic neurological event and ipsilateral carotid artery stenosis <70%. The cross section with the largest wall area (WA) in the internal carotid artery (ICA) was selected for analysis. On this cross section, the following parameters were determined: WA, total vessel area (TVA), and lumen area (LA). Vascular remodeling was quantified as the remodeling ratio (RR) and was calculated as TVA at this position divided by the TVA in an unaffected distal portion of the ipsilateral ICA. Adjustment for WA was performed to correct for plaque size. RESULTS Plaques with IPH had a larger WA (0.56 vs. 0.46 cm2; p < 0.001), a smaller LA (0.17 vs. 0.22 cm2; p = 0.03), and a higher RR (2.0 vs. 1.9; p = 0.03) than plaques without IPH. After adjustment for WA, plaques containing IPH had a smaller LA (B = -0.052, p = 0.01) than plaques without IPH, but the RR was not different. CONCLUSION After correcting for plaque size, plaques containing IPH had a smaller LA than plaques without IPH. However, RR was not different.
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Affiliation(s)
- Kristine Dilba
- Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Anouk C van Dijk
- Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Geneviève A J C Crombag
- Radiology and Nuclear Medicine, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Rotterdam, The Netherlands
| | | | - Mat J Daemen
- Amsterdam University Medical Center, University of Amsterdam, Pathology, Amsterdam, The Netherlands
| | - Peter J Koudstaal
- Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Paul J Nederkoorn
- Neurology, University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Jeroen Hendrikse
- Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Eline Kooi
- Radiology and Nuclear Medicine, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jolanda J Wentzel
- Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands,
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Cao X, Yang Q, Tang Y, Pan L, Lai M, Yu Z, Geng D, Zhang J. Normalized wall index, intraplaque hemorrhage and ulceration of carotid plaques correlate with the severity of ischemic stroke. Atherosclerosis 2020; 315:138-144. [PMID: 33183741 DOI: 10.1016/j.atherosclerosis.2020.10.896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/20/2020] [Accepted: 10/28/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIMS Carotid atherosclerosis is considered an important cause of ischemic stroke. Tthis study aimed to explore the relationship between plaque features and the severity of stroke, and to identify plaque risk factors for the assessment of the severity of ischemic stroke. METHODS Symptomatic patients with carotid atherosclerotic plaques were prospectively recruited and underwent high-resolution vessel wall magnetic resonance imaging (VW-MRI). Two trained MRI readers independently identified intraplaque hemorrhage (IPH), calcification (CA), surface CA, deep CA, and ulceration. They measured and calculated the maximum vessel diameter (Max VD), maximum wall thickness (Max WT), total vessel area, lumen area, normalized wall index (NWI), plaque volume, IPH volume, IPH proportion, CA volume, and CA proportion. Patients were divided into two groups according to their National Institutes of Health Stroke Scale (NIHSS) scores (NIHSS ≤1 vs. NIHSS >1). Clinical characteristics and carotid plaque features were compared using the Mann-Whitney U test or Chi-square test as appropriate. Odds ratio (OR) and corresponding 95% confidence interval (CI) of plaque features to distinguish patients with NIHSS >1 were calculated. Spearman's rank correlations or Pearson correlations were determined for plaque features and NIHSS scores. RESULTS Of the 97 included patients, 34 (35.05%) with NIHSS >1 had significantly greater NWI (p < 0.05), larger IPH volume (p < 0.01), and greater IPH proportion (p < 0.01), and higher prevalence of IPH (OR, 5.654; 95%CI, 2.272-14.070; p < 0.01) and ulceration (OR, 2.891; 95%CI, 1.090-7.667; p = 0.033) than patients with NIHSS ≤1. Max WT (r = 0.24, p = 0.018), NWI (r = 0.22, p = 0.032), IPH (r = 0.27, p = 0.007), IPH volume (r = 0.35, p < 0.01), IPH proportion (r = 0.28, p = 0.005), and ulceration (r = 0.35, p < 0.01) had positive correlations with NIHSS scores. CONCLUSIONS NWI, IPH, and ulceration of carotid atherosclerotic plaque based on high-resolution VW-MRI may be useful indicators for assessing the severity of ischemic stroke in patients with atherosclerosis. NIHSS score is related to max WT, NWI, IPH, IPH volume, IPH proportion, and ulceration.
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Affiliation(s)
- Xin Cao
- Department of Radiology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, 200040, China; Institute of Functional and Molecular Medical Imaging, Fudan University, 12 Wulumuqi Middle Road, Shanghai, 200040, China
| | - Qingluan Yang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, 200040, China
| | - Ye Tang
- Department of Radiology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, 200040, China
| | - Lei Pan
- Department of Radiology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, 200040, China
| | - Mao Lai
- Department of Medical Imaging, Jinghong First People's Hospital, 48 Galan Middle Road, Jinghong, 666100, Xishuangbanna Dai Autonomous Prefecture Yunnan Province, China
| | - Zekuan Yu
- Academy for Engineering and Technology, Fudan University, 20 Handan Road, Yangpu District, Shanghai, 200433, China
| | - Daoying Geng
- Department of Radiology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, 200040, China; Institute of Functional and Molecular Medical Imaging, Fudan University, 12 Wulumuqi Middle Road, Shanghai, 200040, China.
| | - Jun Zhang
- Department of Radiology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, 200040, China.
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Rizvi A, Seyedsaadat SM, Alzuabi M, Murad MH, Huston J, Lehman VT, Lanzino G, Saba L, Brinjikji W. Carotid plaque vulnerability on magnetic resonance imaging and risk of future ischemic events: a systematic review and meta-analysis. J Neurosurg Sci 2020; 64:480-486. [PMID: 33236863 DOI: 10.23736/s0390-5616.20.04959-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Magnetic resonance imaging (MRI) can characterize carotid plaque features, including intraplaque hemorrhage (IPH), lipid-rich necrotic core (LRNC), and thin/ruptured fibrous cap (TRFC), that have increased tendency to cause future cerebrovascular ischemic events. We performed a systematic review and meta-analysis of studies evaluating association of MRI-identified high-risk plaque features, including IPH, LRNC, and TRFC, with risks of subsequent ischemic events of stroke, transient ischemic attack (TIA), or amaurosis fugax (AF) over follow-up duration of ≥3 months. EVIDENCE ACQUISITION Multiple databases were searched for relevant publications between January 2000 and March 2020. Studies reporting outcomes of future ischemic events of stroke, TIA, or AF for individual MRI-identified high-risk carotid plaque features over follow-up duration of ≥3 months were included. Random effects meta-analysis was performed to estimate odds ratios (OR) and 95% confidence intervals (CI) comparing outcomes between MRI-positive and MRI-negative groups. EVIDENCE SYNTHESIS Fifteen studies including 2350 patients were included. The annual rate of future ischemic events was 11.9% for MRI-positive IPH, 5.4% for LRNC, and 5.7% for TRFC. IPH, LRNC, and TRFC were associated with increased risk of future ischemic events (OR 6.37; 95% CI, 3.96 to 10.24), (OR 4.34; 95% CI, 1.65 to 11.42), and (OR 10.60, 95% CI 3.56 to 31.58), respectively. CONCLUSIONS The current study findings strengthen the assertion that MRI-positive "high-risk" or "vulnerable" plaque features, including IPH, LRNC, and/or TRFC can predict risks of future ischemic events of stroke, TIA, or AF.
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Affiliation(s)
- Asim Rizvi
- Department of Radiology, Mayo Clinic, Rochester, MN, USA - .,Department of Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX, USA - .,-
| | | | - Muayad Alzuabi
- Evidence-based Practice Center, Mayo Clinic, Rochester, MN, USA
| | | | - John Huston
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Luca Saba
- Department of Radiology, University of Cagliari, Cagliari, Italy
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.,Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, ON, Canada
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