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Saba L, Cau R, Spinato G, Suri JS, Melis M, De Rubeis G, Antignani P, Gupta A. Carotid stenosis and cryptogenic stroke. J Vasc Surg 2024; 79:1119-1131. [PMID: 38190926 DOI: 10.1016/j.jvs.2024.01.004] [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: 12/13/2023] [Revised: 12/30/2023] [Accepted: 01/04/2024] [Indexed: 01/10/2024]
Abstract
OBJECTIVES Cryptogenic stroke represents a type of ischemic stroke with an unknown origin, presenting a significant challenge in both stroke management and prevention. According to the Trial of Org 10,172 in Acute Stroke Treatment criteria, a stroke is categorized as being caused by large artery atherosclerosis only when there is >50% luminal narrowing of the ipsilateral internal carotid artery. However, nonstenosing carotid artery plaques can be an underlying cause of ischemic stroke. Indeed, emerging evidence documents that some features of plaque vulnerability may act as an independent risk factor, regardless of the degree of stenosis, in precipitating cerebrovascular events. This review, drawing from an array of imaging-based studies, explores the predictive values of carotid imaging modalities in the detection of nonstenosing carotid plaque (<50%), that could be the cause of a cerebrovascular event when some features of vulnerability are present. METHODS Google Scholar, Scopus, and PubMed were searched for articles on cryptogenic stroke and those reporting the association between cryptogenic stroke and imaging features of carotid plaque vulnerability. RESULTS Despite extensive diagnostic evaluations, the etiology of a considerable proportion of strokes remains undetermined, contributing to the recurrence rate and persistent morbidity in affected individuals. Advances in imaging modalities, such as magnetic resonance imaging, computed tomography scans, and ultrasound examination, facilitate more accurate detection of nonstenosing carotid artery plaque and allow better stratification of stroke risk, leading to a more tailored treatment strategy. CONCLUSIONS Early detection of nonstenosing carotid plaque with features of vulnerability through carotid imaging techniques impacts the clinical management of cryptogenic stroke, resulting in refined stroke subtype classification and improved patient management. Additional research is required to validate these findings and recommend the integration of these state-of-the-art imaging methodologies into standard diagnostic protocols to improve stroke management and prevention.
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Affiliation(s)
- Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), Cagliari, Italy.
| | - Riccardo Cau
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), Cagliari, Italy
| | - Giacomo Spinato
- Department of Neurosciences, Section of Otolaryngology and Regional Centre for Head and Neck Cancer, University of Padova, Treviso, Italy
| | - Jasjit S Suri
- Stroke Monitoring and Diagnostic Division, AtheroPoint™, Roseville, CA
| | - Marta Melis
- Department of Neurology, Azienda Ospedaliero Universitaria (A.O.U.), Cagliari, Italy
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Carotid Artery Disease in the Era of Biomarkers: A Pilot Study. Diagnostics (Basel) 2023; 13:diagnostics13040644. [PMID: 36832132 PMCID: PMC9954896 DOI: 10.3390/diagnostics13040644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
The intima-media thickness (IMT) and its irregularities or ulcerations in the common carotid artery (CCA) are useful tools as sentinel biomarkers for the integrity of the cardiovascular system. Total homocysteine and lipoprotein levels are the most commonly used elements in cardiovascular risk stratification. Duplex ultrasound (DUS), associated with serum biomarkers, can be used simply to assess the degree of atherosclerotic disease and cardiovascular risk. This study highlights the role of different kinds of biomarkers, showing their usefulness and potentiality in multi-district atherosclerotic patients, especially for early diagnosis and therapy effectiveness monitoring. A retrospective analysis performed from September 2021 to August 2022, of patients with carotid artery disease, was performed. A total of 341 patients with a mean age of 53.8 years were included in the study. The outcomes showed an increased risk of stroke in patients with significative carotid artery disease, nonresponsive to therapy, monitored through a series of serum biomarkers (homocysteine, C-reactive protein, and oxidized LDL). In this reported experience, the systematic use of DUS in association with the multiple biomarkers approach was effective for the early identification of patients at higher risk of disease progression or inefficient therapy.
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3
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Saba L, Loewe C, Weikert T, Williams MC, Galea N, Budde RPJ, Vliegenthart R, Velthuis BK, Francone M, Bremerich J, Natale L, Nikolaou K, Dacher JN, Peebles C, Caobelli F, Redheuil A, Dewey M, Kreitner KF, Salgado R. State-of-the-art CT and MR imaging and assessment of atherosclerotic carotid artery disease: standardization of scanning protocols and measurements-a consensus document by the European Society of Cardiovascular Radiology (ESCR). Eur Radiol 2023; 33:1063-1087. [PMID: 36194267 PMCID: PMC9889495 DOI: 10.1007/s00330-022-09024-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 06/26/2022] [Accepted: 06/30/2022] [Indexed: 02/04/2023]
Abstract
The European Society of Cardiovascular Radiology (ESCR) is the European specialist society of cardiac and vascular imaging. This society's highest priority is the continuous improvement, development, and standardization of education, training, and best medical practice, based on experience and evidence. The present intra-society consensus is based on the existing scientific evidence and on the individual experience of the members of the ESCR writing group on carotid diseases, the members of the ESCR guidelines committee, and the members of the executive committee of the ESCR. The recommendations published herein reflect the evidence-based society opinion of ESCR. We have produced a twin-papers consensus, indicated through the documents as respectively "Part I" and "Part II." The first document (Part I) begins with a discussion of features, role, indications, and evidence for CT and MR imaging-based diagnosis of carotid artery disease for risk stratification and prediction of stroke (Section I). It then provides an extensive overview and insight into imaging-derived biomarkers and their potential use in risk stratification (Section II). Finally, detailed recommendations about optimized imaging technique and imaging strategies are summarized (Section III). The second part of this consensus paper (Part II) is focused on structured reporting of carotid imaging studies with CT/MR. KEY POINTS: • CT and MR imaging-based evaluation of carotid artery disease provides essential information for risk stratification and prediction of stroke. • Imaging-derived biomarkers and their potential use in risk stratification are evolving; their correct interpretation and use in clinical practice must be well-understood. • A correct imaging strategy and scan protocol will produce the best possible results for disease evaluation.
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Affiliation(s)
- Luca Saba
- Department of Radiology, University of Cagliari, Cagliari, Italy
| | - Christian Loewe
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Thomas Weikert
- Department of Radiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB, UK
- Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh, UK
| | - Nicola Galea
- Policlinico Umberto I, Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Ricardo P J Budde
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Rozemarijn Vliegenthart
- Department of Radiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, Utrecht University Medical Center, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marco Francone
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072, Milan, Italy
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Jens Bremerich
- Department of Radiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luigi Natale
- Department of Radiological Sciences - Institute of Radiology, Catholic University of Rome, "A. Gemelli" University Hospital, Rome, Italy
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University of Tuebingen, Tübingen, Germany
| | - Jean-Nicolas Dacher
- Department of Radiology, Normandie University, UNIROUEN, INSERM U1096 - Rouen University Hospital, F 76000, Rouen, France
| | - Charles Peebles
- Department of Cardiothoracic Radiology, University Hospital Southampton, Southampton, UK
| | - Federico Caobelli
- University Clinic of Nuclear Medicine Inselspital Bern, University of Bern, Bern, Switzerland
| | - Alban Redheuil
- Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
- Department of Cardiovascular and Thoracic, Imaging and Interventional Radiology, Institute of Cardiology, APHP, Pitié-Salpêtrière University Hospital, Paris, France
- Laboratoire d'Imagerie Biomédicale, Sorbonne Universités, UPMC Univ Paris 06, INSERM 1146, CNRS 7371, Paris, France
| | - Marc Dewey
- Department of Radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Karl-Friedrich Kreitner
- Department of Diagnostic and Interventional Radiology, University Medical Center, Mainz; Langenbeckstraße 1, 55131, Mainz, Germany
| | - Rodrigo Salgado
- Department of Radiology, Antwerp University Hospital & Antwerp University, Holy Heart Lier, Belgium.
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Han N, Ma Y, Li Y, Zheng Y, Wu C, Gan T, Li M, Ma L, Zhang J. Imaging and Hemodynamic Characteristics of Vulnerable Carotid Plaques and Artificial Intelligence Applications in Plaque Classification and Segmentation. Brain Sci 2023; 13:brainsci13010143. [PMID: 36672124 PMCID: PMC9856903 DOI: 10.3390/brainsci13010143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/24/2022] [Accepted: 01/10/2023] [Indexed: 01/18/2023] Open
Abstract
Stroke is a massive public health problem. The rupture of vulnerable carotid atherosclerotic plaques is the most common cause of acute ischemic stroke (AIS) across the world. Currently, vessel wall high-resolution magnetic resonance imaging (VW-HRMRI) is the most appropriate and cost-effective imaging technique to characterize carotid plaque vulnerability and plays an important role in promoting early diagnosis and guiding aggressive clinical therapy to reduce the risk of plaque rupture and AIS. In recent years, great progress has been made in imaging research on vulnerable carotid plaques. This review summarizes developments in the imaging and hemodynamic characteristics of vulnerable carotid plaques on the basis of VW-HRMRI and four-dimensional (4D) flow MRI, and it discusses the relationship between these characteristics and ischemic stroke. In addition, the applications of artificial intelligence in plaque classification and segmentation are reviewed.
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Affiliation(s)
- Na Han
- Department of Magnetic Resonance, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Province Clinical Research Center for Functional and Molecular Imaging, Lanzhou 730030, China
- Second Clinical School, Lanzhou University, Lanzhou 730030, China
| | - Yurong Ma
- Department of Magnetic Resonance, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Province Clinical Research Center for Functional and Molecular Imaging, Lanzhou 730030, China
| | - Yan Li
- School of Mathematics and Statistics, Lanzhou University, Lanzhou 730030, China
| | - Yu Zheng
- Department of Magnetic Resonance, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Province Clinical Research Center for Functional and Molecular Imaging, Lanzhou 730030, China
- Second Clinical School, Lanzhou University, Lanzhou 730030, China
| | - Chuang Wu
- Department of Magnetic Resonance, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Province Clinical Research Center for Functional and Molecular Imaging, Lanzhou 730030, China
| | - Tiejun Gan
- Department of Magnetic Resonance, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Province Clinical Research Center for Functional and Molecular Imaging, Lanzhou 730030, China
| | - Min Li
- Department of Magnetic Resonance, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Province Clinical Research Center for Functional and Molecular Imaging, Lanzhou 730030, China
| | - Laiyang Ma
- Department of Magnetic Resonance, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Province Clinical Research Center for Functional and Molecular Imaging, Lanzhou 730030, China
- Second Clinical School, Lanzhou University, Lanzhou 730030, China
| | - Jing Zhang
- Department of Magnetic Resonance, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Province Clinical Research Center for Functional and Molecular Imaging, Lanzhou 730030, China
- Correspondence: ; Tel.: +86-139-1999-2479
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5
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Safety of Carotid Artery Stenting in Elderly Patients by Treatment Selection Based on Plaque Characteristics. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03585-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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6
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Identification Markers of Carotid Vulnerable Plaques: An Update. Biomolecules 2022; 12:biom12091192. [PMID: 36139031 PMCID: PMC9496377 DOI: 10.3390/biom12091192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 12/02/2022] Open
Abstract
Vulnerable plaques have been a hot topic in the field of stroke and carotid atherosclerosis. Currently, risk stratification and intervention of carotid plaques are guided by the degree of luminal stenosis. Recently, it has been recognized that the vulnerability of plaques may contribute to the risk of stroke. Some classical interventions, such as carotid endarterectomy, significantly reduce the risk of stroke in symptomatic patients with severe carotid stenosis, while for asymptomatic patients, clinically silent plaques with rupture tendency may expose them to the risk of cerebrovascular events. Early identification of vulnerable plaques contributes to lowering the risk of cerebrovascular events. Previously, the identification of vulnerable plaques was commonly based on imaging technologies at the macroscopic level. Recently, some microscopic molecules pertaining to vulnerable plaques have emerged, and could be potential biomarkers or therapeutic targets. This review aimed to update the previous summarization of vulnerable plaques and identify vulnerable plaques at the microscopic and macroscopic levels.
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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: 9] [Impact Index Per Article: 4.5] [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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Carballo-Perich L, Puigoriol-Illamola D, Bashir S, Terceño M, Silva Y, Gubern-Mérida C, Serena J. Clinical Parameters and Epigenetic Biomarkers of Plaque Vulnerability in Patients with Carotid Stenosis. Int J Mol Sci 2022; 23:5149. [PMID: 35563540 PMCID: PMC9101730 DOI: 10.3390/ijms23095149] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 12/24/2022] Open
Abstract
Atheromatous disease is the first cause of death and dependency in developed countries and carotid artery atherosclerosis is one of the main causes of severe ischaemic strokes. Current management strategies are mainly based on the degree of stenosis and patient selection has limited accuracy. This information could be complemented by the identification of biomarkers of plaque vulnerability, which would permit patients at greater and lesser risk of stroke to be distinguished, thus enabling a better selection of patients for surgical or intensive medical treatment. Although several circulating protein-based biomarkers with significance for both the diagnosis of carotid artery disease and its prognosis have been identified, at present, none have been clinically implemented. This review focuses especially on the most relevant clinical parameters to take into account in routine clinical practice and summarises the most up-to-date data on epigenetic biomarkers of carotid atherosclerosis and plaque vulnerability.
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Affiliation(s)
- Laia Carballo-Perich
- Cerebrovascular Pathology Research Group, Girona Biomedical Research Institute (IDIBGI), RICORS-ICTUS, Parc Hospitalari Martí I Julià, Edifici M2, 17190 Salt, Spain; (L.C.-P.); (D.P.-I.)
| | - Dolors Puigoriol-Illamola
- Cerebrovascular Pathology Research Group, Girona Biomedical Research Institute (IDIBGI), RICORS-ICTUS, Parc Hospitalari Martí I Julià, Edifici M2, 17190 Salt, Spain; (L.C.-P.); (D.P.-I.)
| | - Saima Bashir
- Cerebrovascular Pathology Research Group, Stroke Unit, Department of Neurology, Girona Biomedical Research Institute (IDIBGI), Dr. Josep Trueta University Hospital, RICORS-ICTUS, Av. França s/n (7a Planta), 17007 Girona, Spain; (S.B.); (M.T.); (J.S.)
| | - Mikel Terceño
- Cerebrovascular Pathology Research Group, Stroke Unit, Department of Neurology, Girona Biomedical Research Institute (IDIBGI), Dr. Josep Trueta University Hospital, RICORS-ICTUS, Av. França s/n (7a Planta), 17007 Girona, Spain; (S.B.); (M.T.); (J.S.)
| | - Yolanda Silva
- Cerebrovascular Pathology Research Group, Stroke Unit, Department of Neurology, Girona Biomedical Research Institute (IDIBGI), Dr. Josep Trueta University Hospital, RICORS-ICTUS, Av. França s/n (7a Planta), 17007 Girona, Spain; (S.B.); (M.T.); (J.S.)
| | - Carme Gubern-Mérida
- Cerebrovascular Pathology Research Group, Girona Biomedical Research Institute (IDIBGI), RICORS-ICTUS, Parc Hospitalari Martí I Julià, Edifici M2, 17190 Salt, Spain; (L.C.-P.); (D.P.-I.)
| | - Joaquín Serena
- Cerebrovascular Pathology Research Group, Stroke Unit, Department of Neurology, Girona Biomedical Research Institute (IDIBGI), Dr. Josep Trueta University Hospital, RICORS-ICTUS, Av. França s/n (7a Planta), 17007 Girona, Spain; (S.B.); (M.T.); (J.S.)
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Xin R, Yang D, Xu H, Han H, Li J, Miao Y, Du Z, Ding Q, Deng S, Ning Z, Shen R, Li R, Li C, Yuan C, Zhao X. Comparing Symptomatic and Asymptomatic Carotid Artery Atherosclerosis in Patients With Bilateral Carotid Vulnerable Plaques Using Magnetic Resonance Imaging. Angiology 2021; 73:104-111. [PMID: 34018407 DOI: 10.1177/00033197211012531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We compared plaque characteristics between symptomatic and asymptomatic sides in patients with bilateral carotid vulnerable plaques using magnetic resonance imaging (MRI). Participants (n = 67; mean age: 65.8 ± 7.7 years, 61 males) with bilateral carotid vulnerable plaques were included. Vulnerable plaques were characterized by intraplaque hemorrhage (IPH), large lipid-rich necrotic core (LRNC), or fibrous cap rupture (FCR) on MRI. Symptomatic vulnerable plaques showed greater plaque burden, LRNC volume (median: 221.4 vs 134.8 mm3, P = .003), IPH volume (median: 32.2 vs 22.5 mm3, P = .030), maximum percentage (Max%) LRNC (median: 51.3% vs 41.8%, P = .002), Max%IPH (median: 13.4% vs 9.5%, P = .022), cumulative slices of LRNC (median: 10 vs 8, P = .005), and more juxtaluminal IPH and/or thrombus (29.9% vs 6.0%, P = .001) and FCR (37.3% vs 16.4%, P = .007) than asymptomatic ones. After adjusting for plaque burden, differences in juxtaluminal IPH and/or thrombus (odds ratio [OR]: 5.49, 95% CI: 1.61-18.75, P = .007) and FCR (OR: 2.90, 95% CI: 1.16-7.24, P = .022) between bilateral sides remained statistically significant. For patients with bilateral carotid vulnerable plaques, symptomatic plaques had greater burden, more juxtaluminal IPH and/or thrombus, and FCR compared with asymptomatic ones. The differences in juxtaluminal IPH and/or thrombus and FCR between bilateral sides were independent of plaque burden.
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Affiliation(s)
- Ruijing Xin
- Department of Radiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, China
| | - Dandan Yang
- Center for Brain Disorders Research, Capital Medical University and Beijing Institute of Brain Disorders, Beijing, China
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, 118223Tsinghua University School of Medicine, Beijing, China
| | - Huimin Xu
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Hualu Han
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, 118223Tsinghua University School of Medicine, Beijing, China
| | - Jin Li
- Department of Radiology, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
| | - Yingyu Miao
- Department of Radiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, China
| | - Ziwei Du
- Department of Radiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, China
| | - Qian Ding
- Department of Radiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, China
| | - Shasha Deng
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zihan Ning
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, 118223Tsinghua University School of Medicine, Beijing, China
| | - Rui Shen
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, 118223Tsinghua University School of Medicine, Beijing, China
| | - Rui Li
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, 118223Tsinghua University School of Medicine, Beijing, China
| | - Cheng Li
- Department of Radiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, China
| | - Chun Yuan
- Department of Radiology, 7284University of Washington, Seattle, USA
| | - Xihai Zhao
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, 118223Tsinghua University School of Medicine, Beijing, China
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Ultrasound-based internal carotid artery plaque characterization using deep learning paradigm on a supercomputer: a cardiovascular disease/stroke risk assessment system. Int J Cardiovasc Imaging 2021; 37:1511-1528. [DOI: 10.1007/s10554-020-02124-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 11/28/2020] [Indexed: 12/17/2022]
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11
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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: 0.8] [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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Vessel Wall–Imaging Biomarkers of Carotid Plaque Vulnerability in Stroke Prevention Trials. JACC Cardiovasc Imaging 2020; 13:2445-2456. [DOI: 10.1016/j.jcmg.2020.07.046] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/27/2020] [Accepted: 07/31/2020] [Indexed: 02/06/2023]
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Mura M, Della Schiava N, Long A, Chirico EN, Pialoux V, Millon A. Carotid intraplaque haemorrhage: pathogenesis, histological classification, imaging methods and clinical value. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1273. [PMID: 33178805 PMCID: PMC7607119 DOI: 10.21037/atm-20-1974] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Vulnerable carotid atherosclerotic plaques are characterised by several risk factors, such as inflammation, neovascularization and intraplaque haemorrhage (IPH). Vulnerable plaques can lead to ischemic events such as stroke. Many studies reported a relationship between IPH, plaque rupture, and ischemic stroke. Histology is the gold standard to evaluate IPH, but it required carotid endarterectomy (CEA) surgery to collect the tissue sample. In this context, several imaging methods can be used as a non-invasive way to evaluate plaque vulnerability and detect IPH. Most imaging studies showed that IPH is associated with plaque vulnerability and stroke, with magnetic resonance imaging (MRI) being the most sensitive and specific to detect IPH as a predictor of ischemic events. These conclusions are however still debated because of the limited number of patients included in these studies; further studies are required to better assess risks associated with different IPH stages. Moreover, IPH is implicated in plaque vulnerability with other risk factors which need to be considered to predict ischemic risk. In addition, MRI sequences standardization is required to compare results from different studies and agree on biomarkers that need to be considered to predict plaque rupture. In these circumstances, IPH detection by MRI could be an efficient clinical method to predict stroke. The goal of this review article is to first describe the pathophysiological process responsible for IPH, its histological detection in carotid plaques and its correlation with plaque rupture. The second part will discuss the benefits and limitations of imaging the carotid plaque, and finally the clinical interest of imaging IPH to predict plaque rupture, focusing on MRI-IPH.
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Affiliation(s)
- Mathilde Mura
- Univ Lyon, University Claude Bernard Lyon 1, Interuniversity Laboratory of Human Movement Biology EA7424, Lyon, France
| | - Nellie Della Schiava
- Department of Vascular and Endovascular Surgery, Groupement Hospitalier Est, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France.,Institut National des Sciences Appliquées Lyon, Laboratoire de Génie Electrique et Ferroélectricité EA 682, Villeurbanne, France
| | - Anne Long
- Univ Lyon, University Claude Bernard Lyon 1, Interuniversity Laboratory of Human Movement Biology EA7424, Lyon, France.,Departement of Internal Medicine and Vascular Medicine, Groupement Hospitalier Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Erica N Chirico
- Department of Biomedical Sciences, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Vincent Pialoux
- Univ Lyon, University Claude Bernard Lyon 1, Interuniversity Laboratory of Human Movement Biology EA7424, Lyon, France.,Institut Universitaire de France, Paris, France
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Groupement Hospitalier Est, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France.,Univ Lyon, University Claude Bernard Lyon 1, CarMeN Laboratory, INSERM U1060, Bron, France
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14
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Mota RI, Morgan SE, Bahnson EM. Diabetic vasculopathy: macro and microvascular injury. CURRENT PATHOBIOLOGY REPORTS 2020; 8:1-14. [PMID: 32655983 PMCID: PMC7351096 DOI: 10.1007/s40139-020-00205-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Diabetes is a common and prevalent medical condition as it affects many lives around the globe. Specifically, type-2 Diabetes (T2D) is characterized by chronic systemic inflammation alongside hyperglycemia and insulin resistance in the body, which can result in atherosclerotic legion formation in the arteries and thus progression of related conditions called diabetic vasculopathies. T2D patients are especially at risk for vascular injury; adjunct in many of these patients heir cholesterol and triglyceride levels reach dangerously high levels and accumulate in the lumen of their vascular system. RECENT FINDINGS Microvascular and macrovascular vasculopathies as complications of diabetes can accentuate the onset of organ illnesses, thus it is imperative that research efforts help identify more effective methods for prevention and diagnosis of early vascular injuries. Current research into vasculopathy identification/treatment will aid in the amelioration of diabetes-related symptoms and thus reduce the large number of deaths that this disease accounts annually. SUMMARY This review aims to showcase the evolution and effects of diabetic vasculopathy from development to clinical disease as macrovascular and microvascular complications with a concerted reference to sex-specific disease progression as well.
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Affiliation(s)
- Roberto I. Mota
- Department of Surgery, Division of Vascular Surgery; University of North Carolina at Chapel Hill, NC 27599
- Center for Nanotechnology in Drug Delivery; University of North Carolina at Chapel Hill, NC 27599
- McAllister Heart Institute, University of North Carolina at Chapel Hill, NC 27599
| | - Samuel E. Morgan
- Department of Surgery, Division of Vascular Surgery; University of North Carolina at Chapel Hill, NC 27599
- Center for Nanotechnology in Drug Delivery; University of North Carolina at Chapel Hill, NC 27599
| | - Edward M. Bahnson
- Department of Surgery, Division of Vascular Surgery; University of North Carolina at Chapel Hill, NC 27599
- Center for Nanotechnology in Drug Delivery; University of North Carolina at Chapel Hill, NC 27599
- McAllister Heart Institute, University of North Carolina at Chapel Hill, NC 27599
- Department of Cell Biology and Physiology. University of North Carolina at Chapel Hill, NC 27599
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15
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Seyedsaadat SM, Rizvi A, Alzuabi M, Dugani SB, Murad MH, Huston J, Saba L, Brinjikji W. Correlation of MRI-detected vulnerable carotid plaques with clinical presentation: a systematic review and meta-analysis. J Neurosurg Sci 2019; 64:263-271. [PMID: 31738030 DOI: 10.23736/s0390-5616.19.04820-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION To determine the association between magnetic resonance imaging (MRI)-detected vulnerable Carotid Plaques and clinical presentation related to ipsilateral carotid artery territory. EVIDENCE ACQUISITION We searched three databases including Ovid MEDLINE, Ovid EMBASE, and Scopus from 2000 to 2018 for studies that evaluated vulnerable carotid plaques by MRI defined as intraplaque hemorrhage (IPH), lipid-rich necrotic core (LRNC), or thinning/rupture of the fibrous cap (TRFC). Data on study characteristics, clinical presentation, and MRI findings were extracted. Publication bias, methodologic quality, and study heterogeneity were assessed. Random-effects meta-analysis model was used to estimate incidence rate ratio (IRR) and 95% confidence intervals (CI) of MRI-detected vulnerable carotid plaque between symptomatic and asymptomatic arteries. EVIDENCE SYNTHESIS Of 2855 studies, 33 studies containing 6210 participants with 8401 assessed arteries were included. Overall, the risk of bias was moderate in 13, and low in 20 studies. The prevalence of MRI-positive IPH, TRFC, and LRNC were higher in symptomatic groups compared with the asymptomatic groups. In 11 studies that compared vulnerable carotid plaques between symptomatic and asymptomatic groups, symptomatic presentation was correlated with increased risk of IPH (IRR=1.57; 95% CI: 1.24-1.99), TRFC (IRR=2.26; 95% CI: 1.83 to 3.76), and LRNC (IRR=1.95; 95% CI: 1.28 to 2.97), respectively. CONCLUSIONS The presence of MRI-positive vulnerable carotid plaques including IPH, LRNC, and TRFC is positively associated with symptomatic clinical presentation. Therefore, carotid plaque MRI might be a useful risk stratification tool in determining the risk of ischemic stroke.
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Affiliation(s)
| | - Asim Rizvi
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.,University of Texas Medical Branch, Galveston, TX, USA
| | - Muayad Alzuabi
- Evidence-based Practice Center, Mayo Clinic, Rochester, MN, USA
| | - Sagar B Dugani
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - M Hassan Murad
- Evidence-based Practice Center, Mayo Clinic, Rochester, MN, USA
| | - John Huston
- Department of Radiology, 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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Porcu M, Anzidei M, Suri JS, A Wasserman B, Anzalone N, Lucatelli P, Loi F, Montisci R, Sanfilippo R, Rafailidis V, Saba L. Carotid artery imaging: The study of intra-plaque vascularization and hemorrhage in the era of the "vulnerable" plaque. J Neuroradiol 2019; 47:464-472. [PMID: 30954549 DOI: 10.1016/j.neurad.2019.03.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 02/04/2019] [Accepted: 03/04/2019] [Indexed: 01/01/2023]
Abstract
Intraplaque hemorrhage (IPH) is one of the main factors involved in atherosclerotic plaque (AP) instability. Its recognition is crucial for the correct staging and management of patients with carotid artery plaques to limit ischemic stroke. Imaging plays a crucial role in identifying IPH, even if the great variability of intraplaque vascularization and the limitations of our current imaging technologies make it difficult. The intent of this review is to give a general overview of the main features of intraplaque vascularization and IPH on Ultrasound (US), Computed Tomography (CT), Magnetic Resonance (MR) and Nuclear Medicine, and a brief description on the future prospectives.
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Affiliation(s)
- Michele Porcu
- Department of Medical Imaging, AOU of Cagliari, University of Cagliari, Cagliari, Italy.
| | - Michele Anzidei
- Department of Radiological, Oncological and Anatomo-pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Jasjit S Suri
- Monitoring and Diagnostic Division, AtheroPoint, Roseville, CA, USA
| | - Bruce A Wasserman
- The Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nicoletta Anzalone
- Neuroradiology Unit and CERMAC, San Raffaele Scientific Institute and Vita-Salute San Raffaele University, via Olgettina 60, 20132, Milan, Italy
| | - Pierleone Lucatelli
- Department of Radiological, Oncological and Anatomo-pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Federico Loi
- Department of Biomedial Sciences, Unit of Oncology and Molecular Pathology, University of Cagliari, Cagliari, Italy
| | - Roberto Montisci
- Department of Vascular Surgery, AOU of Cagliari, University of Cagliari, Cagliari, Italy
| | - Roberto Sanfilippo
- Department of Vascular Surgery, AOU of Cagliari, University of Cagliari, Cagliari, Italy
| | - Vasileios Rafailidis
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloníki, Greece
| | - Luca Saba
- Department of Medical Imaging, AOU of Cagliari, University of Cagliari, Cagliari, Italy
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Saba L, Saam T, Jäger HR, Yuan C, Hatsukami TS, Saloner D, Wasserman BA, Bonati LH, Wintermark M. Imaging biomarkers of vulnerable carotid plaques for stroke risk prediction and their potential clinical implications. Lancet Neurol 2019; 18:559-572. [PMID: 30954372 DOI: 10.1016/s1474-4422(19)30035-3] [Citation(s) in RCA: 270] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 01/15/2023]
Abstract
Stroke represents a massive public health problem. Carotid atherosclerosis plays a fundamental part in the occurence of ischaemic stroke. European and US guidelines for prevention of stroke in patients with carotid plaques are based on quantification of the percentage reduction in luminal diameter due to the atherosclerotic process to select the best therapeutic approach. However, better strategies for prevention of stroke are needed because some subtypes of carotid plaques (eg, vulnerable plaques) can predict the occurrence of stroke independent of the degree of stenosis. Advances in imaging techniques have enabled routine characterisation and detection of the features of carotid plaque vulnerability. Intraplaque haemorrhage is accepted by neurologists and radiologists as one of the features of vulnerable plaques, but other characteristics-eg, plaque volume, neovascularisation, and inflammation-are promising as biomarkers of carotid plaque vulnerability. These biomarkers could change current management strategies based merely on the degree of stenosis.
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Affiliation(s)
- Luca Saba
- Department of Medical Sciences, University of Cagliari, Cagliari, Italy.
| | - Tobias Saam
- Department of Radiology, University Hospital Munich, Ludwig-Maximilians-University Munich, Munich, Germany; Radiologisches Zentrum Rosenheim, Rosenheim, Germany
| | - H Rolf Jäger
- Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, University College London Institute of Neurology, London, UK
| | - Chun Yuan
- Department of Radiology, University of Washington, Seattle, WA, USA
| | | | - David Saloner
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Bruce A Wasserman
- The Russell H Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Leo H Bonati
- Department of Neurology and Stroke Center, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Max Wintermark
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
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Sun B, Li X, Liu X, Ge X, Lu Q, Zhao X, Pu J, Xu J, Zhao H. Association between carotid plaque characteristics and acute cerebral infarction determined by MRI in patients with type 2 diabetes mellitus. Cardiovasc Diabetol 2017; 16:111. [PMID: 28893252 PMCID: PMC5594451 DOI: 10.1186/s12933-017-0592-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 08/28/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) might aggravate the carotid plaque vulnerability, and increase the risk for ischemic stroke. Few studies reported the acute stroke subtype with carotid plaque characteristics in T2DM patients. This study aimed to investigate the association between carotid plaque characteristics and acute cerebral infarct (ACI) lesion features determined by MRI in T2DM patients. METHODS Patients with acute cerebrovascular syndrome in internal carotid artery territory were recruited. All patients were stratified into T2DM and non-T2DM groups and underwent both carotid and brain MRI scans. Ipsilateral carotid plaque morphological and compositional characteristics, intracranial and extracranial carotid artery stenosis were also determined. Stroke subtype based on the Trial of ORG 10172 in Acute Stroke Treatment classification and ACI lesion patterns were evaluated. RESULTS Of the recruited 140 patients, 68 (48.6%) patients had T2DM (mean age 64.16 ± 11.38 years, 40 males). T2DM patients exhibited higher prevalence of carotid type IV-VI lesions, larger plaque burden as well as larger lipid-rich necrotic core (LRNC) compared with non-T2DM patients. Among the patients with carotid LRNC on symptomatic side, more concomitant large perforating artery infarct patterns and larger ACI size in the internal carotid artery territory were found in T2DM group than those in non-T2DM group. Carotid plaque with LRNC% > 22.0% was identified as an independent risk factor for the presence of ACI lesions confined to the carotid territory in T2DM patients, regardless of other risk factors. CONCLUSIONS This study shows that more concomitant large perforating artery infarct patterns and larger ACI size in the internal carotid artery territory were found in the T2DM patients with ipsilateral carotid LRNC plaque than those in non-T2DM patients. Quantification of the carotid plaque characteristics, particularly the LRNC% by MRI has the potential usefulness for stroke risk stratification.
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Affiliation(s)
- Beibei Sun
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, China
| | - Xiao Li
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, China
| | - Xiaosheng Liu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, China.
| | - Xiaoqian Ge
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, China
| | - Qing Lu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, China
| | - Xihai Zhao
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China
| | - Jun Pu
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, China.
| | - Jianrong Xu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, China
| | - Huilin Zhao
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, China.
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