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Tătaru DA, Olinic M, Homorodean C, Ober MC, Spînu M, Lazăr FL, Onea L, Olinic DM. Correlation between Ultrasound Peak Systolic Velocity and Angiography for Grading Internal Carotid Artery Stenosis. J Clin Med 2024; 13:517. [PMID: 38256651 PMCID: PMC10816984 DOI: 10.3390/jcm13020517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
(1) Background: The success of carotid revascularization depends on the accurate grading of carotid stenoses. Therefore, it is important for every vascular center to establish its protocols for the same. In this study, we aimed to determine the peak systolic velocity (PSV) thresholds that can predict moderate and severe internal carotid artery (ICA) stenoses. (2) Methods: To achieve this, we enrolled patients who underwent both duplex ultrasound (DUS) and invasive carotid artery digital subtraction angiography (DSA). The degree of ICA stenosis was assessed using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) protocols. The PSV thresholds were determined using receiver operating characteristic (ROC) curves. (3) Results: Our study included 47 stenoses, and we found that the PSV cut-off for predicting ≥70% NASCET ICA stenoses was 200 cm/s (sensitivity 90.32%, specificity 93.75%). However, PSV did not correlate significantly with ≥50% NASCET ICA stenoses. On the other hand, the optimal PSV threshold for predicting ≥80% ECST ICA stenoses was 180 cm/s (sensitivity 100%, specificity 81.82%). (4) Conclusions: Based on our findings, we concluded that PSV is a good and simple marker for the identification of severe stenoses. We found that PSV values correlate significantly with severe NASCET and ECST stenoses, with 200 cm/s and 180 cm/s PSV thresholds. However, PSV was not reliable with moderate NASCET stenoses. In such cases, complementary imaging should be used.
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Affiliation(s)
- Dan-Alexandru Tătaru
- Medical Clinic No. 1, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400006 Cluj-Napoca, Romania; (D.-A.T.); (C.H.); (M.S.); (F.-L.L.); (L.O.); (D.-M.O.)
- Interventional Cardiology Department, Cluj County Emergency Hospital, 400006 Cluj-Napoca, Romania;
| | - Maria Olinic
- Medical Clinic No. 1, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400006 Cluj-Napoca, Romania; (D.-A.T.); (C.H.); (M.S.); (F.-L.L.); (L.O.); (D.-M.O.)
- Interventional Cardiology Department, Cluj County Emergency Hospital, 400006 Cluj-Napoca, Romania;
| | - Călin Homorodean
- Medical Clinic No. 1, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400006 Cluj-Napoca, Romania; (D.-A.T.); (C.H.); (M.S.); (F.-L.L.); (L.O.); (D.-M.O.)
- Interventional Cardiology Department, Cluj County Emergency Hospital, 400006 Cluj-Napoca, Romania;
| | - Mihai-Claudiu Ober
- Interventional Cardiology Department, Cluj County Emergency Hospital, 400006 Cluj-Napoca, Romania;
| | - Mihail Spînu
- Medical Clinic No. 1, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400006 Cluj-Napoca, Romania; (D.-A.T.); (C.H.); (M.S.); (F.-L.L.); (L.O.); (D.-M.O.)
- Interventional Cardiology Department, Cluj County Emergency Hospital, 400006 Cluj-Napoca, Romania;
| | - Florin-Leontin Lazăr
- Medical Clinic No. 1, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400006 Cluj-Napoca, Romania; (D.-A.T.); (C.H.); (M.S.); (F.-L.L.); (L.O.); (D.-M.O.)
| | - Laurențiu Onea
- Medical Clinic No. 1, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400006 Cluj-Napoca, Romania; (D.-A.T.); (C.H.); (M.S.); (F.-L.L.); (L.O.); (D.-M.O.)
| | - Dan-Mircea Olinic
- Medical Clinic No. 1, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400006 Cluj-Napoca, Romania; (D.-A.T.); (C.H.); (M.S.); (F.-L.L.); (L.O.); (D.-M.O.)
- Interventional Cardiology Department, Cluj County Emergency Hospital, 400006 Cluj-Napoca, Romania;
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Baumgartner R, Berg M, Matic L, Polyzos KP, Forteza MJ, Hjorth SA, Schwartz TW, Paulsson-Berne G, Hansson GK, Hedin U, Ketelhuth DFJ. Evidence that a deviation in the kynurenine pathway aggravates atherosclerotic disease in humans. J Intern Med 2021; 289:53-68. [PMID: 32794238 DOI: 10.1111/joim.13142] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/24/2020] [Accepted: 06/04/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The metabolism of tryptophan (Trp) along the kynurenine pathway has been shown to carry strong immunoregulatory properties. Several experimental studies indicate that this pathway is a major regulator of vascular inflammation and influences atherogenesis. Knowledge of the role of this pathway in human atherosclerosis remains incomplete. OBJECTIVES In this study, we performed a multiplatform analysis of tissue samples, in vitro and in vivo functional assays to elucidate the potential role of the kynurenine pathway in human atherosclerosis. METHODS AND RESULTS Comparison of transcriptomic data from carotid plaques and control arteries revealed an upregulation of enzymes within the quinolinic branch of the kynurenine pathway in the disease state, whilst the branch leading to the formation of kynurenic acid (KynA) was downregulated. Further analyses indicated that local inflammatory responses are closely tied to the deviation of the kynurenine pathway in the vascular wall. Analysis of cerebrovascular symptomatic and asymptomatic carotid stenosis data showed that the downregulation of KynA branch enzymes and reduced KynA production were associated with an increased probability of patients to undergo surgery due to an unstable disease. In vitro, we showed that KynA-mediated signalling through aryl hydrocarbon receptor (AhR) is a major regulator of human macrophage activation. Using a mouse model of peritoneal inflammation, we showed that KynA inhibits leukocyte recruitment. CONCLUSIONS We have found that a deviation in the kynurenine pathway is associated with an increased probability of developing symptomatic unstable atherosclerotic disease. Our study suggests that KynA-mediated signalling through AhR is an important mechanism involved in the regulation of vascular inflammation.
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Affiliation(s)
- R Baumgartner
- From the, Cardiovascular Medicine Unit, Center for Molecular Medicine, Department of Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - M Berg
- From the, Cardiovascular Medicine Unit, Center for Molecular Medicine, Department of Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - L Matic
- Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institute, Stockholm, Sweden.,Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - K P Polyzos
- From the, Cardiovascular Medicine Unit, Center for Molecular Medicine, Department of Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - M J Forteza
- From the, Cardiovascular Medicine Unit, Center for Molecular Medicine, Department of Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - S A Hjorth
- Section for Metabolic Receptology, Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark.,Laboratory for Molecular Pharmacology, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - T W Schwartz
- Section for Metabolic Receptology, Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark.,Laboratory for Molecular Pharmacology, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - G Paulsson-Berne
- From the, Cardiovascular Medicine Unit, Center for Molecular Medicine, Department of Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - G K Hansson
- From the, Cardiovascular Medicine Unit, Center for Molecular Medicine, Department of Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - U Hedin
- Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institute, Stockholm, Sweden.,Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - D F J Ketelhuth
- From the, Cardiovascular Medicine Unit, Center for Molecular Medicine, Department of Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.,Department of Cardiovascular and Renal Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
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3
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Song JW, Pavlou A, Burke MP, Shou H, Atsina KB, Xiao J, Loevner LA, Mankoff D, Fan Z, Kasner SE. Imaging endpoints of intracranial atherosclerosis using vessel wall MR imaging: a systematic review. Neuroradiology 2020; 63:847-856. [PMID: 33029735 DOI: 10.1007/s00234-020-02575-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 09/29/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The vessel wall MR imaging (VWI) literature was systematically reviewed to assess the criteria and measurement methods of VWI-related imaging endpoints for symptomatic intracranial plaque in patients with ischemic events. METHODS PubMed, Scopus, Web of Science, EMBASE, and Cochrane databases were searched up to October 2019. Two independent reviewers extracted data from 47 studies. A modified Guideline for Reporting Reliability and Agreement Studies was used to assess completeness of reporting. RESULTS The specific VWI-pulse sequence used to identify plaque was reported in 51% of studies. A VWI-based criterion to define plaque was reported in 38% of studies. A definition for culprit plaque was reported in 40% of studies. Frequently scored qualitative imaging endpoints were plaque quadrant (21%) and enhancement (21%). Frequently measured quantitative imaging endpoints were stenosis (19%), lumen area (15%), and remodeling index (14%). Reproducibility for all endpoints ranged from good to excellent (range: ICCT1 hyperintensity = 0.451 to ICCstenosis = 0.983). However, rater specialty and years of experience varied among studies. CONCLUSIONS Investigators are using different criteria to identify and measure VWI-imaging endpoints for culprit intracranial plaque. Early awareness of these differences to address methods of acquisition and measurement will help focus research resources and efforts in technique optimization and measurement reproducibility. Consensual definitions to detect plaque will be important to develop automatic lesion detection tools particularly in the era of radiomics.
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Affiliation(s)
- Jae W Song
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
| | - Athanasios Pavlou
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Morgan P Burke
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Haochang Shou
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Kofi-Buaku Atsina
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Jiayu Xiao
- Department of Biomedical Sciences, Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Laurie A Loevner
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - David Mankoff
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Zhaoyang Fan
- Department of Biomedical Sciences, Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Scott E Kasner
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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4
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Furmanik M, Chatrou M, van Gorp R, Akbulut A, Willems B, Schmidt H, van Eys G, Bochaton-Piallat ML, Proudfoot D, Biessen E, Hedin U, Perisic L, Mees B, Shanahan C, Reutelingsperger C, Schurgers L. Reactive Oxygen-Forming Nox5 Links Vascular Smooth Muscle Cell Phenotypic Switching and Extracellular Vesicle-Mediated Vascular Calcification. Circ Res 2020; 127:911-927. [PMID: 32564697 DOI: 10.1161/circresaha.119.316159] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
RATIONALE Vascular calcification, the formation of calcium phosphate crystals in the vessel wall, is mediated by vascular smooth muscle cells (VSMCs). However, the underlying molecular mechanisms remain elusive, precluding mechanism-based therapies. OBJECTIVE Phenotypic switching denotes a loss of contractile proteins and an increase in migration and proliferation, whereby VSMCs are termed synthetic. We examined how VSMC phenotypic switching influences vascular calcification and the possible role of the uniquely calcium-dependent reactive oxygen species (ROS)-forming Nox5 (NADPH oxidase 5). METHODS AND RESULTS In vitro cultures of synthetic VSMCs showed decreased expression of contractile markers CNN-1 (calponin 1), α-SMA (α-smooth muscle actin), and SM22-α (smooth muscle protein 22α) and an increase in synthetic marker S100A4 (S100 calcium binding protein A4) compared with contractile VSMCs. This was associated with increased calcification of synthetic cells in response to high extracellular Ca2+. Phenotypic switching was accompanied by increased levels of ROS and Ca2+-dependent Nox5 in synthetic VSMCs. Nox5 itself regulated VSMC phenotype as siRNA knockdown of Nox5 increased contractile marker expression and decreased calcification, while overexpression of Nox5 decreased contractile marker expression. ROS production in synthetic VSMCs was cytosolic Ca2+-dependent, in line with it being mediated by Nox5. Treatment of VSMCs with Ca2+ loaded extracellular vesicles (EVs) lead to an increase in cytosolic Ca2+. Inhibiting EV endocytosis with dynasore blocked the increase in cytosolic Ca2+ and VSMC calcification. Increased ROS production resulted in increased EV release and decreased phagocytosis by VSMCs. CONCLUSIONS We show here that contractile VSMCs are resistant to calcification and identify Nox5 as a key regulator of VSMC phenotypic switching. Additionally, we describe a new mechanism of Ca2+ uptake via EVs and show that Ca2+ induces ROS production in VSMCs via Nox5. ROS production is required for release of EVs, which promote calcification. Identifying molecular pathways that control Nox5 and VSMC-derived EVs provides potential targets to modulate vascular remodeling and calcification in the context of mineral imbalance. Graphic Abstract: A graphic abstract is available for this article.
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Affiliation(s)
- Malgorzata Furmanik
- From the Biochemistry (M.F., M.C., R.v.G., A.A., B.W., G.v.E., C.R., L.S.) and Pathology (E.B.), Cardiovascular Research Institute Maastricht, Pharmacology and Personalised Medicine, Faculty of Health, Medicine and Life Sciences (H.S.), Maastricht University, The Netherlands; Pathology and Immunology, Faculty of Medicine, University of Geneva, Switzerland (M.-L.B.-P.); Signalling Programme, Babraham Institute, Cambridge, United Kingdom (D.P.); Molecular Medicine and Surgery, Vascular Surgery Division, Karolinska Institute, Stockholm, Sweden (U.H., L.P.M.); Vascular Surgery, Maastricht University Medical Centre, The Netherlands (B.M.); and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (C.S.)
| | - Martijn Chatrou
- From the Biochemistry (M.F., M.C., R.v.G., A.A., B.W., G.v.E., C.R., L.S.) and Pathology (E.B.), Cardiovascular Research Institute Maastricht, Pharmacology and Personalised Medicine, Faculty of Health, Medicine and Life Sciences (H.S.), Maastricht University, The Netherlands; Pathology and Immunology, Faculty of Medicine, University of Geneva, Switzerland (M.-L.B.-P.); Signalling Programme, Babraham Institute, Cambridge, United Kingdom (D.P.); Molecular Medicine and Surgery, Vascular Surgery Division, Karolinska Institute, Stockholm, Sweden (U.H., L.P.M.); Vascular Surgery, Maastricht University Medical Centre, The Netherlands (B.M.); and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (C.S.)
| | - Rick van Gorp
- From the Biochemistry (M.F., M.C., R.v.G., A.A., B.W., G.v.E., C.R., L.S.) and Pathology (E.B.), Cardiovascular Research Institute Maastricht, Pharmacology and Personalised Medicine, Faculty of Health, Medicine and Life Sciences (H.S.), Maastricht University, The Netherlands; Pathology and Immunology, Faculty of Medicine, University of Geneva, Switzerland (M.-L.B.-P.); Signalling Programme, Babraham Institute, Cambridge, United Kingdom (D.P.); Molecular Medicine and Surgery, Vascular Surgery Division, Karolinska Institute, Stockholm, Sweden (U.H., L.P.M.); Vascular Surgery, Maastricht University Medical Centre, The Netherlands (B.M.); and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (C.S.)
| | - Asim Akbulut
- From the Biochemistry (M.F., M.C., R.v.G., A.A., B.W., G.v.E., C.R., L.S.) and Pathology (E.B.), Cardiovascular Research Institute Maastricht, Pharmacology and Personalised Medicine, Faculty of Health, Medicine and Life Sciences (H.S.), Maastricht University, The Netherlands; Pathology and Immunology, Faculty of Medicine, University of Geneva, Switzerland (M.-L.B.-P.); Signalling Programme, Babraham Institute, Cambridge, United Kingdom (D.P.); Molecular Medicine and Surgery, Vascular Surgery Division, Karolinska Institute, Stockholm, Sweden (U.H., L.P.M.); Vascular Surgery, Maastricht University Medical Centre, The Netherlands (B.M.); and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (C.S.)
| | - Brecht Willems
- From the Biochemistry (M.F., M.C., R.v.G., A.A., B.W., G.v.E., C.R., L.S.) and Pathology (E.B.), Cardiovascular Research Institute Maastricht, Pharmacology and Personalised Medicine, Faculty of Health, Medicine and Life Sciences (H.S.), Maastricht University, The Netherlands; Pathology and Immunology, Faculty of Medicine, University of Geneva, Switzerland (M.-L.B.-P.); Signalling Programme, Babraham Institute, Cambridge, United Kingdom (D.P.); Molecular Medicine and Surgery, Vascular Surgery Division, Karolinska Institute, Stockholm, Sweden (U.H., L.P.M.); Vascular Surgery, Maastricht University Medical Centre, The Netherlands (B.M.); and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (C.S.)
| | - Harald Schmidt
- From the Biochemistry (M.F., M.C., R.v.G., A.A., B.W., G.v.E., C.R., L.S.) and Pathology (E.B.), Cardiovascular Research Institute Maastricht, Pharmacology and Personalised Medicine, Faculty of Health, Medicine and Life Sciences (H.S.), Maastricht University, The Netherlands; Pathology and Immunology, Faculty of Medicine, University of Geneva, Switzerland (M.-L.B.-P.); Signalling Programme, Babraham Institute, Cambridge, United Kingdom (D.P.); Molecular Medicine and Surgery, Vascular Surgery Division, Karolinska Institute, Stockholm, Sweden (U.H., L.P.M.); Vascular Surgery, Maastricht University Medical Centre, The Netherlands (B.M.); and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (C.S.)
| | - Guillaume van Eys
- From the Biochemistry (M.F., M.C., R.v.G., A.A., B.W., G.v.E., C.R., L.S.) and Pathology (E.B.), Cardiovascular Research Institute Maastricht, Pharmacology and Personalised Medicine, Faculty of Health, Medicine and Life Sciences (H.S.), Maastricht University, The Netherlands; Pathology and Immunology, Faculty of Medicine, University of Geneva, Switzerland (M.-L.B.-P.); Signalling Programme, Babraham Institute, Cambridge, United Kingdom (D.P.); Molecular Medicine and Surgery, Vascular Surgery Division, Karolinska Institute, Stockholm, Sweden (U.H., L.P.M.); Vascular Surgery, Maastricht University Medical Centre, The Netherlands (B.M.); and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (C.S.)
| | - Marie-Luce Bochaton-Piallat
- From the Biochemistry (M.F., M.C., R.v.G., A.A., B.W., G.v.E., C.R., L.S.) and Pathology (E.B.), Cardiovascular Research Institute Maastricht, Pharmacology and Personalised Medicine, Faculty of Health, Medicine and Life Sciences (H.S.), Maastricht University, The Netherlands; Pathology and Immunology, Faculty of Medicine, University of Geneva, Switzerland (M.-L.B.-P.); Signalling Programme, Babraham Institute, Cambridge, United Kingdom (D.P.); Molecular Medicine and Surgery, Vascular Surgery Division, Karolinska Institute, Stockholm, Sweden (U.H., L.P.M.); Vascular Surgery, Maastricht University Medical Centre, The Netherlands (B.M.); and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (C.S.)
| | - Diane Proudfoot
- From the Biochemistry (M.F., M.C., R.v.G., A.A., B.W., G.v.E., C.R., L.S.) and Pathology (E.B.), Cardiovascular Research Institute Maastricht, Pharmacology and Personalised Medicine, Faculty of Health, Medicine and Life Sciences (H.S.), Maastricht University, The Netherlands; Pathology and Immunology, Faculty of Medicine, University of Geneva, Switzerland (M.-L.B.-P.); Signalling Programme, Babraham Institute, Cambridge, United Kingdom (D.P.); Molecular Medicine and Surgery, Vascular Surgery Division, Karolinska Institute, Stockholm, Sweden (U.H., L.P.M.); Vascular Surgery, Maastricht University Medical Centre, The Netherlands (B.M.); and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (C.S.)
| | - Erik Biessen
- From the Biochemistry (M.F., M.C., R.v.G., A.A., B.W., G.v.E., C.R., L.S.) and Pathology (E.B.), Cardiovascular Research Institute Maastricht, Pharmacology and Personalised Medicine, Faculty of Health, Medicine and Life Sciences (H.S.), Maastricht University, The Netherlands; Pathology and Immunology, Faculty of Medicine, University of Geneva, Switzerland (M.-L.B.-P.); Signalling Programme, Babraham Institute, Cambridge, United Kingdom (D.P.); Molecular Medicine and Surgery, Vascular Surgery Division, Karolinska Institute, Stockholm, Sweden (U.H., L.P.M.); Vascular Surgery, Maastricht University Medical Centre, The Netherlands (B.M.); and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (C.S.)
| | - Ulf Hedin
- From the Biochemistry (M.F., M.C., R.v.G., A.A., B.W., G.v.E., C.R., L.S.) and Pathology (E.B.), Cardiovascular Research Institute Maastricht, Pharmacology and Personalised Medicine, Faculty of Health, Medicine and Life Sciences (H.S.), Maastricht University, The Netherlands; Pathology and Immunology, Faculty of Medicine, University of Geneva, Switzerland (M.-L.B.-P.); Signalling Programme, Babraham Institute, Cambridge, United Kingdom (D.P.); Molecular Medicine and Surgery, Vascular Surgery Division, Karolinska Institute, Stockholm, Sweden (U.H., L.P.M.); Vascular Surgery, Maastricht University Medical Centre, The Netherlands (B.M.); and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (C.S.)
| | - Ljubica Perisic
- From the Biochemistry (M.F., M.C., R.v.G., A.A., B.W., G.v.E., C.R., L.S.) and Pathology (E.B.), Cardiovascular Research Institute Maastricht, Pharmacology and Personalised Medicine, Faculty of Health, Medicine and Life Sciences (H.S.), Maastricht University, The Netherlands; Pathology and Immunology, Faculty of Medicine, University of Geneva, Switzerland (M.-L.B.-P.); Signalling Programme, Babraham Institute, Cambridge, United Kingdom (D.P.); Molecular Medicine and Surgery, Vascular Surgery Division, Karolinska Institute, Stockholm, Sweden (U.H., L.P.M.); Vascular Surgery, Maastricht University Medical Centre, The Netherlands (B.M.); and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (C.S.)
| | - Barend Mees
- From the Biochemistry (M.F., M.C., R.v.G., A.A., B.W., G.v.E., C.R., L.S.) and Pathology (E.B.), Cardiovascular Research Institute Maastricht, Pharmacology and Personalised Medicine, Faculty of Health, Medicine and Life Sciences (H.S.), Maastricht University, The Netherlands; Pathology and Immunology, Faculty of Medicine, University of Geneva, Switzerland (M.-L.B.-P.); Signalling Programme, Babraham Institute, Cambridge, United Kingdom (D.P.); Molecular Medicine and Surgery, Vascular Surgery Division, Karolinska Institute, Stockholm, Sweden (U.H., L.P.M.); Vascular Surgery, Maastricht University Medical Centre, The Netherlands (B.M.); and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (C.S.)
| | - Catherine Shanahan
- From the Biochemistry (M.F., M.C., R.v.G., A.A., B.W., G.v.E., C.R., L.S.) and Pathology (E.B.), Cardiovascular Research Institute Maastricht, Pharmacology and Personalised Medicine, Faculty of Health, Medicine and Life Sciences (H.S.), Maastricht University, The Netherlands; Pathology and Immunology, Faculty of Medicine, University of Geneva, Switzerland (M.-L.B.-P.); Signalling Programme, Babraham Institute, Cambridge, United Kingdom (D.P.); Molecular Medicine and Surgery, Vascular Surgery Division, Karolinska Institute, Stockholm, Sweden (U.H., L.P.M.); Vascular Surgery, Maastricht University Medical Centre, The Netherlands (B.M.); and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (C.S.)
| | - Chris Reutelingsperger
- From the Biochemistry (M.F., M.C., R.v.G., A.A., B.W., G.v.E., C.R., L.S.) and Pathology (E.B.), Cardiovascular Research Institute Maastricht, Pharmacology and Personalised Medicine, Faculty of Health, Medicine and Life Sciences (H.S.), Maastricht University, The Netherlands; Pathology and Immunology, Faculty of Medicine, University of Geneva, Switzerland (M.-L.B.-P.); Signalling Programme, Babraham Institute, Cambridge, United Kingdom (D.P.); Molecular Medicine and Surgery, Vascular Surgery Division, Karolinska Institute, Stockholm, Sweden (U.H., L.P.M.); Vascular Surgery, Maastricht University Medical Centre, The Netherlands (B.M.); and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (C.S.)
| | - Leon Schurgers
- From the Biochemistry (M.F., M.C., R.v.G., A.A., B.W., G.v.E., C.R., L.S.) and Pathology (E.B.), Cardiovascular Research Institute Maastricht, Pharmacology and Personalised Medicine, Faculty of Health, Medicine and Life Sciences (H.S.), Maastricht University, The Netherlands; Pathology and Immunology, Faculty of Medicine, University of Geneva, Switzerland (M.-L.B.-P.); Signalling Programme, Babraham Institute, Cambridge, United Kingdom (D.P.); Molecular Medicine and Surgery, Vascular Surgery Division, Karolinska Institute, Stockholm, Sweden (U.H., L.P.M.); Vascular Surgery, Maastricht University Medical Centre, The Netherlands (B.M.); and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (C.S.)
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5
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Matic LP, Jesus Iglesias M, Vesterlund M, Lengquist M, Hong MG, Saieed S, Sanchez-Rivera L, Berg M, Razuvaev A, Kronqvist M, Lund K, Caidahl K, Gillgren P, Pontén F, Uhlén M, Schwenk JM, Hansson GK, Paulsson-Berne G, Fagman E, Roy J, Hultgren R, Bergström G, Lehtiö J, Odeberg J, Hedin U. Novel Multiomics Profiling of Human Carotid Atherosclerotic Plaques and Plasma Reveals Biliverdin Reductase B as a Marker of Intraplaque Hemorrhage. JACC Basic Transl Sci 2018; 3:464-480. [PMID: 30175270 PMCID: PMC6115646 DOI: 10.1016/j.jacbts.2018.04.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 04/09/2018] [Accepted: 04/10/2018] [Indexed: 12/31/2022]
Abstract
Clinical tools to identify individuals with unstable atherosclerotic lesions are required to improve prevention of myocardial infarction and ischemic stroke. Here, a systems-based analysis of atherosclerotic plaques and plasma from patients undergoing carotid endarterectomy for stroke prevention was used to identify molecular signatures with a causal relationship to disease. Local plasma collected in the lesion proximity following clamping prior to arteriotomy was profiled together with matched peripheral plasma. This translational workflow identified biliverdin reductase B as a novel marker of intraplaque hemorrhage and unstable carotid atherosclerosis, which should be investigated as a potential predictive biomarker for cardiovascular events in larger cohorts.
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Key Words
- BLVR, biliverdin reductase
- BiKE, Biobank of Karolinska Endarterectomies
- CAC, coronary artery calcium
- CEA, carotid endarterectomy
- HMOX, heme oxygenase
- Hb, hemoglobin
- Hp, haptoglobin
- IPH, intraplaque hemorrhage
- LC-MS/MS, liquid chromatography mass spectrometry/mass spectrometry
- TMT, tandem mass tags
- atherosclerosis
- biomarkers
- intraplaque hemorrhage
- mRNA, messenger ribonucleic acid
- omics analyses
- translational studies
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Affiliation(s)
- Ljubica Perisic Matic
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Maria Jesus Iglesias
- Science for Life Laboratory, Department of Proteomics, School of Biotechnology, Royal Institute of Technology, Stockholm, Sweden
| | - Mattias Vesterlund
- Department of Oncology-Pathology, Cancer Proteomics, Science for Life Laboratory, Karolinska Institute, Stockholm, Sweden
| | - Mariette Lengquist
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Mun-Gwan Hong
- Science for Life Laboratory, Department of Proteomics, School of Biotechnology, Royal Institute of Technology, Stockholm, Sweden
| | - Shanga Saieed
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Laura Sanchez-Rivera
- Science for Life Laboratory, Department of Proteomics, School of Biotechnology, Royal Institute of Technology, Stockholm, Sweden
| | - Martin Berg
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Anton Razuvaev
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Malin Kronqvist
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Kent Lund
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Kenneth Caidahl
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Peter Gillgren
- Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden.,Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Fredrik Pontén
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Mathias Uhlén
- Science for Life Laboratory, Department of Proteomics, School of Biotechnology, Royal Institute of Technology, Stockholm, Sweden
| | - Jochen M Schwenk
- Science for Life Laboratory, Department of Proteomics, School of Biotechnology, Royal Institute of Technology, Stockholm, Sweden
| | - Göran K Hansson
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | | | - Erika Fagman
- Department of Radiology, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Göran Bergström
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Janne Lehtiö
- Department of Oncology-Pathology, Cancer Proteomics, Science for Life Laboratory, Karolinska Institute, Stockholm, Sweden
| | - Jacob Odeberg
- Science for Life Laboratory, Department of Proteomics, School of Biotechnology, Royal Institute of Technology, Stockholm, Sweden.,Department of Medicine, Karolinska Institute, Stockholm, Sweden.,Coagulation Unit, Centre for Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Ulf Hedin
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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6
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Mahdessian H, Perisic Matic L, Lengquist M, Gertow K, Sennblad B, Baldassarre D, Veglia F, Humphries SE, Rauramaa R, de Faire U, Smit AJ, Giral P, Kurl S, Mannarino E, Tremoli E, Hamsten A, Eriksson P, Hedin U, Mälarstig A. Integrative studies implicate matrix metalloproteinase-12 as a culprit gene for large-artery atherosclerotic stroke. J Intern Med 2017; 282:429-444. [PMID: 28734077 DOI: 10.1111/joim.12655] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Ischaemic stroke and coronary heart disease are important contributors to the global disease burden and share atherosclerosis as the main underlying cause. Recent evidence from a genome-wide association study (GWAS) suggested that single nucleotide polymorphisms (SNP) near the MMP12 gene at chromosome 11q22.3 were associated with large-vessel ischaemic stroke. Here, we evaluated and extended these results by examining the relationship between MMP12 and atherosclerosis in clinical and experimental studies. METHODS AND RESULTS Plasma concentrations of MMP12 were measured at baseline in 3394 subjects with high-risk for cardiovascular disease (CVD) using the Olink ProSeek CVD I array. The plasma MMP12 concentration showed association with incident cardiovascular and cerebrovascular events (130 and 67 events, respectively, over 36 months) and carotid intima-media thickness progression (P = 3.6 × 10-5 ). A GWAS of plasma MMP12 concentrations revealed that SNPs rs499459, rs613084 and rs1892971 at chr11q22.3 were independently associated with plasma MMP12 (P < 5 × 10-8 ). The lead SNPs showed associations with mRNA levels of MMP12 and adjacent MMPs in atherosclerotic plaques. MMP12 transcriptomic and proteomic levels were strongly significantly increased in carotid plaques compared with control arterial tissue and in plaques from symptomatic versus asymptomatic patients. By combining immunohistochemistry and proximity ligation assay, we demonstrated that MMP12 localizes to CD68 + macrophages and interacts with elastin in plaques. MMP12 silencing in human THP-1-derived macrophages resulted in reduced macrophage migration. CONCLUSIONS Our study supports the notion that MMP12 is implicated in large-artery atherosclerotic stroke, functionally by enhancing elastin degradation and macrophage invasion in plaques.
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Affiliation(s)
- H Mahdessian
- Cardiovascular Medicine, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - L Perisic Matic
- Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - M Lengquist
- Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - K Gertow
- Cardiovascular Medicine, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - B Sennblad
- Cardiovascular Medicine, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - D Baldassarre
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano & Centro Cardiologico Monzino I.R.C.C.S., Milan, Italy
| | - F Veglia
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - S E Humphries
- Department of Medicine, British Heart Foundation Laboratories, University College of London, London, UK
| | - R Rauramaa
- Foundation for Research in Health Exercise and Nutrition, Kuopio Research Institute of Exercise Medicine, Kuopio, Finland
| | - U de Faire
- Division of Cardiovascular Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Solna, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - A J Smit
- Department of Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - P Giral
- Assistance Publique-Hopitaux de Paris, Paris, France.,Service Endocrinologie-Metabolisme, Unités de Prévention Cardiovasculaire, Groupe Hôpitalier Pitie-Salpetriere, Paris, France
| | - S Kurl
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - E Mannarino
- Internal Medicine, Angiology and Arteriosclerosis Diseases, Department of Clinical and Experimental Medicine, University of Perugia, Perugia, Italy
| | - E Tremoli
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano & Centro Cardiologico Monzino I.R.C.C.S., Milan, Italy.,Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - A Hamsten
- Cardiovascular Medicine, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - P Eriksson
- Cardiovascular Medicine, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - U Hedin
- Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - A Mälarstig
- Cardiovascular Medicine, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Pfizer Worldwide Research and Development, Stockholm, Sweden
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7
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Perisic L, Aldi S, Sun Y, Folkersen L, Razuvaev A, Roy J, Lengquist M, Åkesson S, Wheelock CE, Maegdefessel L, Gabrielsen A, Odeberg J, Hansson GK, Paulsson-Berne G, Hedin U. Gene expression signatures, pathways and networks in carotid atherosclerosis. J Intern Med 2016; 279:293-308. [PMID: 26620734 DOI: 10.1111/joim.12448] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Embolism from unstable atheromas in the carotid bifurcation is a major cause of stroke. Here, we analysed gene expression in endarterectomies from patients with symptomatic (S) and asymptomatic (AS) carotid stenosis to identify pathways linked to plaque instability. METHODS Microarrays were prepared from plaques (n = 127) and peripheral blood samples (n = 96) of S and AS patients. Gene set enrichment, pathway mapping and network analyses of differentially expressed genes were performed. RESULTS These studies revealed upregulation of haemoglobin metabolism (P = 2.20E-05) and bone resorption (P = 9.63E-04) in S patients. Analysis of subgroups of patients indicated enrichment of calcification and osteoblast differentiation in S patients on statins, as well as inflammation and apoptosis in plaques removed >1 month compared to <2 weeks after symptom. By prediction profiling, a panel of 30 genes, mostly transcription factors, discriminated between plaques from S versus AS patients with 78% accuracy. By meta-analysis, common gene networks associated with atherosclerosis mapped to hypoxia, chemokines, calcification, actin cytoskeleton and extracellular matrix. A set of dysregulated genes (LMOD1, SYNPO2, PLIN2 and PPBP) previously not described in atherosclerosis were identified from microarrays and validated by quantitative PCR and immunohistochemistry. CONCLUSIONS Our findings confirmed a central role for inflammation and proteases in plaque instability, and highlighted haemoglobin metabolism and bone resorption as important pathways. Subgroup analysis suggested prolonged inflammation following the symptoms of plaque instability and calcification as a possible stabilizing mechanism by statins. In addition, transcriptional regulation may play an important role in the determination of plaque phenotype. The results from this study will serve as a basis for further exploration of molecular signatures in carotid atherosclerosis.
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Affiliation(s)
- L Perisic
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - S Aldi
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Y Sun
- Translational Science Center, Personalized Healthcare and Biomarkers, R&D, Astra Zeneca, Stockholm, Sweden
| | - L Folkersen
- Department of Molecular Genetics, Novo Nordisk, Copenhagen, Denmark.,Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - A Razuvaev
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - J Roy
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - M Lengquist
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - S Åkesson
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - C E Wheelock
- Division of Physiological Chemistry 2, Department of Medical Biochemistry and Biophysics, Karolinska Institute, Stockholm, Sweden
| | - L Maegdefessel
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - A Gabrielsen
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - J Odeberg
- Department of Medicine, Karolinska Institute, Stockholm, Sweden.,Science for Life Laboratory, Department of Proteomics, School of Biotechnology, Royal Institute of Technology, Stockholm, Sweden
| | - G K Hansson
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | | | - U Hedin
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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8
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Do RK, Katz SS, Gollub MJ, Li J, LaFemina J, Zabor EC, Moskowitz CS, Klimstra DS, Allen PJ. Interobserver agreement for detection of malignant features of intraductal papillary mucinous neoplasms of the pancreas on MDCT. AJR Am J Roentgenol 2014; 203:973-9. [PMID: 25341134 DOI: 10.2214/AJR.13.11490] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The purpose of this retrospective study was to measure interobserver agreement in the assessment of malignant imaging features of intraductal papillary mucinous neoplasms (IPMNs) on MDCT. MATERIALS AND METHODS Pancreatic protocol CT studies were reviewed for 84 patients with resected IPMNs. Maximal diameter of the dominant cyst, presence of a mural nodule, presence of a solid component, and diameters of the main pancreatic duct (MPD) and common bile duct (CBD) were measured by four radiologists independently. In each patient, the IPMN was classified into one of three types: main duct, branch duct, or mixed IPMN. Interobserver agreement of lesion features was examined using the intraclass correlation coefficient (ICC) for continuous features and Fleiss kappa for categorical features. RESULTS The final dataset included 55 branch duct IPMNs, nine main duct IPMNs, and 20 mixed IPMNs. Moderate agreement (ĸ = 0.458; 95% CI, 0.345-0.564) was observed in assigning branch duct, main duct, or mixed IPMN subtypes. Measurement agreement was substantial to excellent for dominant cyst (ICC = 0.852; 95% CI, 0.777-0.907), MPD (0.753, 0.655-0.837), and CBD (0.608, 0.463-0.724) but only fair to moderate for the detection of the presence of mural nodule (ĸ = 0.284, 0.125-0.432) or solid component (ĸ = 0.405, 0211-0.577). CONCLUSION Substantial to excellent interobserver agreement in the measurement of cyst diameter, MPD, and CBD support their use for characterizing malignant features of IPMN on MDCT. However, the subjective interpretation of the presence of solid components and mural nodules by individual radiologists was more variable.
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9
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Abstract
Background:Since the validation of carotid endarterectomy (CEA) as an effective means of stroke prevention, there has been renewed interest in its best indications and methods, as well as in how it compares to carotid angioplasty and stenting (CAS). This review examines these topics, as well as the investigation of carotid stenosis and the role of auditing and reporting CEAresults.Investigation:Brain imaging with CTor MRI should be obtained in patients considered for CEA, in order to document infarction and rule out mass lesions. Carotid investigation begins with ultrasound and, if results agree with subsequent, good-quality MRAor CTangiography, treatment can be planned and catheter angiography avoided. An equally acceptable approach is to proceed directly from ultrasound to catheter angiography, which is still the gold-standard in carotid artery assessment.Indications:Appropriate patients for CEA are those symptomatic with transient ischemic attacks or nondisabling stroke due to 70-99% carotid stenosis; the maximum allowable stroke and death rate being 6%. Uncertain candidates for CEA are those with 50 - 69% symptomatic stenosis, and those with asymptomatic stenosis ≥ 60% but, if selected carefully on the basis of additional risk factors (related to both the carotid plaque and certain patient characteristics), some will benefit from surgery. Asymptomatic patients will only benefit if surgery can be provided with exceptionally low major complication rates (3% or less). Inappropriate patients are those with less than 50% symptomatic or 60% asymptomatic stenosis, and those with unstable medical or neurological conditions.Techniques:Carotid endarterectomy can be performed with either regional or general anaesthesia and, for the latter, there are a number of monitoring techniques available to assess cerebral perfusion during carotid cross-clamping. While monitoring cannot be considered mandatory and no single monitoring technique has emerged as being clearly superior, EEG is most commonly used. “Eversion” endarterectomy is a variation in surgical technique, and there is some evidence that more widely practiced patch closure may reduce the acute risk of operative stroke and the longer-term risk of recurrent stenosis.Carotid angioplasty and stenting:Experience with this endovascular and less invasive procedure grows, and its technology continues to evolve. Some experienced therapists have reported excellent results in case series and a number of randomized trials are now underway comparing CAS to CEA. However, at this time it is premature to incorporate CAS into routine practice replacing CEA.Auditing:It has been shown that auditing of CEA indications and results with regular feed-back to the operating surgeons can significantly improve the performance of this operation. Carotid endarterectomy auditing is recommended on both local and regional levels.
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Affiliation(s)
- J Max Findlay
- Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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10
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Abstract
We have reliable data on the degree of stenosis above which endarterectomy for symptomatic carotid stenosis is beneficial, but benefit is also influenced by other factors, particularly age, sex, the timing of surgery, plaque surface morphology and the nature of the presenting symptomatic event(s). This review will consider the selection of patients for carotid surgery based on the factors that influence the likely risk of stroke on medical treatment. In order to take into account all of the relevant factors, a risk prediction model is considered.
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Affiliation(s)
- Peter M Rothwell
- Stroke Prevention Research Unit, University of Oxford, Radcliffe Infirmary, Oxford, UK.
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11
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Abstract
BACKGROUND Uncertainty exists over whether listening for carotid bruits as part of the clinical examination is informative in terms of predicting the presence or severity of carotid stenosis. AIM We sought to undertake a comprehensive meta-analysis and meta-regression of all studies to date that have assessed the relationship between a carotid bruit and severity of degree of stenosis. METHODS Electronic databases were used to identify all published studies in humans evaluating the association between bruit and stenosis published until and including October 2011. Pooled sensitivity, specificity and diagnostic odds ratio (DOR) were calculated for each stenosis group. Summary receiver operating characteristic (SROC) curve analysis was performed in studies assessing clinically relevant (i.e. >70%) stenosis. Meta-regression was performed in all studies, using random effects. RESULTS We identified 26 studies evaluating the association between carotid bruit and stenosis, in 15 117 arteries. For clinically relevant stenosis (i.e. >70%), we found pooled sensitivity 0.53 [95% confidence interval (CI): 0.5-0.55], specificity 0.83 (95% CI: 0.82-0.84) and DOR 4.32 (95% CI: 2.78-6.66). SROC curve analysis gave an area under the curve of 0.73. Meta-regression analysis showed a (non-significant) (P = 0.067) inverse relationship between carotid bruit and stenosis. CONCLUSION The carotid bruit is of moderate value for detecting clinically relevant carotid stenosis. It gives high specificity but low sensitivity. The likelihood of a carotid bruit does not increase at increasing degrees of stenosis.
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Affiliation(s)
- P McColgan
- Imperial College Cerebrovascular Research Unit (ICCRU), Imperial College & Hammersmith Hospitals, Fulham Palace Rd, London W6 8RF, UK
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12
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Vicenzini E, Giannoni MF, Ricciardi MC, Toscano M, Sirimarco G, Di Piero V, Lenzi GL. Noninvasive imaging of carotid arteries in stroke: emerging value of real-time high-resolution sonography in carotid occlusion due to cardiac embolism. J Ultrasound Med 2010; 29:1635-1641. [PMID: 20966475 DOI: 10.7863/jum.2010.29.11.1635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVE Comprehension of the pathophysiologic characteristics of atherosclerosis has focused its attention on the study of dynamic and metabolic processes involving the vessel wall as possible causes of stroke. When compared with conventional radiologic techniques, sonography has the main advantage of being a real-time imaging modality. We report 2 acute stroke cases in which carotid sonography showed some dynamic features that could not be identified with computed tomography (CT) and magnetic resonance angiography (MRA). METHODS Carotid sonography with high-resolution probes (9-14 MHz) was compared with CT and MRA findings showing carotid axis occlusion in 2 patients with acute stroke. RESULTS In case 1, the internal carotid artery occlusion observed on CT and MRA was interpreted as a dissection on a clinical basis, but sonography showed a mobile embolus originating from the heart in the internal carotid artery. In case 2, the occlusion of the whole carotid axis observed on CT and MRA was instead related to a heart-originating embolus floating in the common carotid artery. CONCLUSIONS The evaluation of dynamic aspects of atherosclerosis is fundamental to understanding the pathophysiologic characteristics of stroke. Sonography is fundamental in carotid artery imaging for its possibility of showing dynamic processes that could be misdiagnosed with "static" imaging. The correct identification of the pathophysiologic characteristics of stroke in these cases could have led to different diagnostic and therapeutic algorithms.
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Affiliation(s)
- Edoardo Vicenzini
- Department of Neurological Sciences, University of Rome La Sapienza, Viale dell'Università 30, Rome, Italy.
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14
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Waaijer A, Weber M, van Leeuwen MS, Kardux J, Veldhuis WB, Lo R, Beek FJ, Prokop M. Grading of carotid artery stenosis with multidetector-row CT angiography: visual estimation or caliper measurements? Eur Radiol 2009; 19:2809-18. [PMID: 19618190 DOI: 10.1007/s00330-009-1508-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Revised: 05/27/2009] [Accepted: 06/04/2009] [Indexed: 11/30/2022]
Abstract
To assess the optimal method for grading carotid artery stenosis with computed tomographic angiography (CTA), we compared visual estimation to caliper measurements, and determined inter-observer variability and agreement relative to digital subtraction angiography (DSA). We included 46 patients with symptomatic carotid stenosis for whom CTA and DSA of 55 carotids was available. Stenosis quantification by CTA using visual estimation (CTAVE) (method 1) was compared with caliper measurements using subjectively optimized wide window settings (method 2) or predefined contrast-dependent narrow window settings (method 3). Measurements were independently performed by two radiologists and two residents. To determine accuracy and inter-observer variability, we calculated linear weighted kappa, performed a Bland-Altman analysis and calculated mean difference (bias) and standard deviation of differences (SDD). For inter-observer variability, kappa analysis was “very good” (0.85) for expert observers using CTAVE compared with “good” (0.61) for experts using DSA. Compared with DSA, method 1 led to overestimation (bias 5.8–8.0%, SDD 10.6–14.4), method 3 led to underestimation (bias −6.3 to −3.0%, SDD 13.0–18.1). Measurement variability between DSA and visual estimation on CTA (SDD 11.5) is close to the inter-observer variability of repeated measurements on DSA that we found in this study (SDD 11.6). For CTA of carotids, stenosis grading based on visual estimation provides better agreement to grading by DSA compared with stenosis grading based on caliper measurements.
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15
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16
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Chappell FM, Wardlaw JM, Young GR, Gillard JH, Roditi GH, Yip B, Pell JP, Rothwell PM, Brown MM, Gough MJ, Randall MS. Carotid artery stenosis: accuracy of noninvasive tests--individual patient data meta-analysis. Radiology 2009; 251:493-502. [PMID: 19276319 DOI: 10.1148/radiol.2512080284] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE To find clinically relevant estimates of the accuracy of noninvasive imaging-Doppler ultrasonography (US), computed tomographic (CT) angiography, magnetic resonance (MR) angiography, and contrast material-enhanced MR angiography-in diagnosing both severe and moderate symptomatic carotid artery stenosis; to ascertain the effect of prespecified clinical factors and clinical setting on diagnostic accuracy; and to estimate the probability of agreement between two noninvasive tests. MATERIALS AND METHODS Original principal investigators obtained ethics approval for each data set. All data were anonymized. Individual patient data sets (IPDs) for noninvasive imaging tests were used to determine sensitivity, specificity, and agreement between the tests for symptomatic carotid artery stenosis; to compare ipsilateral with contralateral arteries; to compare IPDs with literature estimates; to compare routine audit and research data; and to determine the effect of age and sex on sensitivity and specificity. RESULTS Contrast-enhanced MR angiography was the most accurate (sensitivity, 0.85 [30 of 35]; 95% confidence interval [CI]: 0.69, 0.93; and specificity, 0.85 [67 of 78]; 95% CI: 0.76, 0.92) for 70%-99% symptomatic stenosis. Sensitivity for a 50%-69% stenosis was poor, although data were limited. Sensitivity and specificity were generally lower in the ipsilateral than in the contralateral artery. IPD estimates were lower than literature values. Results of comparison of research with audit-derived data were inconclusive. Neither age nor sex affected accuracy. Agreement was better between two Doppler US tests and between two contrast-enhanced MR angiographic tests than it was between Doppler US and contrast-enhanced MR angiography, except for a 70%-99% symptomatic stenosis. CONCLUSION Primary studies should distinguish ipsilateral from contralateral arteries and carefully describe the patients' characteristics and study environment. The literature overestimates noninvasive imaging accuracy. More data are needed to inform physicians in routine clinical practice.
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Affiliation(s)
- Francesca M Chappell
- Division of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Crewe Rd, Edinburgh EH42XU, Scotland.
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17
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Runck F, Steiner RP, Bautz WA, Lell MM. MR imaging: influence of imaging technique and postprocessing on measurement of internal carotid artery stenosis. AJNR Am J Neuroradiol 2008; 29:1736-42. [PMID: 18635618 DOI: 10.3174/ajnr.a1179] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE MR angiography (MRA) is increasingly used as an alternative to digital subtraction angiography (DSA) to evaluate internal carotid artery (ICA) stenosis. Because MRA is not standardized in data acquisition and postprocessing, we sought to evaluate the effects of different acquisition techniques (time-of-flight MRA [TOF-MRA]) and contrast-enhanced MRA [CE-MRA]) and postprocessing methods (maximum intensity projection [MIP], multiplanar reformation [MPR], and volume-rendering on stenosis grading. MATERIALS AND METHODS Fifty patients (33 men, 17 women) with symptomatic ICA stenosis were examined at 1.5T. Two imaging techniques and 3 postprocessing methods resulted in 6 image datasets per patient. Two readers independently evaluated ICA stenosis according to the North American Symptomatic Carotid Endarterectomy Trial criteria. Interobserver variability was calculated with the Pearson correlation coefficient and simultaneous confidence intervals (CI). The relationship of the values of ICA stenosis between the techniques was assessed by means of simultaneous 95% Tukey CI. RESULTS Interobserver agreement was high. Higher concordance was found for postprocessing techniques with TOF- than with CE-MRA; the mean difference between TOF-MPR and TOF-MIP was 0.4% (95% CI, -2.9%-3.8%). Stenosis values for CE-MPR differed significantly from those of CE volume-rendering (7.2%; 95% CI, 3.9%-10.6%). CONCLUSION Stenosis grading was found to be independent of the postprocessing technique except for comparison of CE-MPR with CE volume-rendering, with the volume-rendering technique resulting in higher stenosis values. MPR seems to be best-suited for measurement of ICA stenosis. Parameter setting is critical with volume-rendering, in which stenosis values were consistently higher compared with the other methods.
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Affiliation(s)
- F Runck
- Department of Radiology and Neuroradiology, Klinikum Augsburg, Augsburg, Germany.
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18
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Rothwell PM. Carotid endarterectomy, stenting, and other prophylactic interventions. Handb Clin Neurol 2009; 94:1295-325. [PMID: 18793902 DOI: 10.1016/S0072-9752(08)94065-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register]
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19
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Soiza RL, Sharma V, Ferguson K, Shenkin SD, Seymour DG, Maclullich AMJ. Neuroimaging studies of delirium: a systematic review. J Psychosom Res 2008; 65:239-48. [PMID: 18707946 DOI: 10.1016/j.jpsychores.2008.05.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Revised: 05/03/2008] [Accepted: 05/15/2008] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Neuroimaging offers clear potential in developing a better understanding of the pathophysiology of delirium. We performed a systematic review of structural and functional neuroimaging findings in delirium. The aims were to categorize and summarize the existing literature, and to determine whether this literature provides conclusive information on structural or functional brain predictors, correlates, or consequences of delirium. METHODS Studies were identified by comprehensive textword and MeSH-based electronic searches of MEDLINE, EMBASE, and Evidence-Based Medicine reviews, combining multiple terms for neuroimaging, brain structure, and delirium. RESULTS Twelve studies met the inclusion criteria. There were a total of 194 patients with delirium and 570 controls. Patient age, population, comorbidities, and identified precipitating factors were heterogeneous. Of the 10 structural studies, 3 studies used computed tomography (CT), 3 studies used magnetic resonance imaging (MRI), and 4 studies used a mixture of CT and MRI. One functional study used xenon CT, and the other used single photon emission computed tomography. There was a wide range of measurement techniques and timing of scans. Some studies found associations between delirium and cortical atrophy, and between ventricular enlargement and white matter lesion burden, but many studies did not control for potential confounders. Only two small studies of cerebral blood flow were identified, with both suggesting that there may be reduced regional cerebral blood flow, but the data were limited and somewhat inconsistent. CONCLUSIONS The small sample sizes and other limitations of the studies identified in this review preclude drawing any clear conclusions regarding neuroimaging findings in delirium, but these studies suggest multiple avenues for future research.
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Affiliation(s)
- Roy L Soiza
- Department of Medicine and Therapeutics, University of Aberdeen, Aberdeen, Scotland, UK.
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Abstract
Carotid imaging is key to effective secondary stroke prevention. It is commonly performed, but is a rather specialist procedure requiring regular practice to maintain acceptable accuracy. Previously the domain of the neuroradiologist, noninvasive carotid imaging is now widely practiced in general departments where specialist knowledge of anatomy and intracranial disorders may be less available. Noninvasive imaging is largely replacing intraarterial angiography in the assessment of carotid stenosis in most centres because the accuracy is perceived to be sufficient. However, effective stroke prevention needs to be delivered rapidly, guided by imaging tests that are used with an understanding of their limitations and accuracy. This review will discuss currently available imaging methods, their advantages and disadvantages, difficulties in determining their accuracy, current estimates of accuracy and gaps in knowledge. Introduction: Stroke is common, has a poor outcome, and treatment must be delivered quickly. Many pharmacological acute stroke treatments have failed, reinforcing the need for effective prevention. There has been extensive testing of many pharmacological secondary prevention treatments and most of the ‘positive’ stroke trials have been in secondary prevention of ischaemic stroke. The surgical procedures for stroke prevention, carotid endarterectomy and angioplasty, have also been subjected to far closer scrutiny in large randomised-controlled trials than almost any other surgical or interventional radiological procedures. However, it is unfortunate that much of the focus of secondary stroke prevention has been on drug mechanisms, or surgery vs. endovascular methods, rather than on how to identify accurately and quickly the right patients for each intervention. Thus, until fairly recently ( 1 , 2 ), the need for very rapid initiation of medical and surgical interventions in patients whose carotid stenosis has been accurately diagnosed by imaging ( 3 ), and the service modifications required to deliver this ( 4 ), have largely been overlooked.
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Khan S, Cloud GC, Kerry S, Markus HS. Imaging of vertebral artery stenosis: a systematic review. J Neurol Neurosurg Psychiatry 2007; 78:1218-25. [PMID: 17287234 PMCID: PMC2117584 DOI: 10.1136/jnnp.2006.111716] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Revised: 01/11/2007] [Accepted: 01/14/2007] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE Posterior circulation stroke accounts for 20% of ischaemic strokes. Recent data suggest that the early stroke recurrence risk is high and comparable with carotid artery disease. Vertebral artery stenosis accounts for approximately 20% of posterior circulation stroke, and with endovascular treatment available accurate diagnostic imaging is important. We performed a systematic literature review to validate the accuracy of the non-invasive imaging techniques Duplex ultrasound (DUS), magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) in detecting severe vertebral artery stenosis, with intra-arterial angiography (IAA) as the reference standard. METHODS We identified studies that used non-invasive imaging and IAA as the reference standard to determine vertebral artery stenosis and provided adequate data to calculate sensitivity and specificity. We analysed the quality of these studies, looked for evidence of heterogeneity and performed subgroup analysis for different degrees of stenosis. RESULTS 11 studies categorised stenosis into 50-99%. The sensitivity of CTA (single study) and pooled sensitivities of contrast enhanced MRA (CE-MRA) and colour duplex were 100% (95% CI 15.8 to 100), 93.9% (79.8 to 99.3) and 70.2% (54.2 to 83.3), respectively. The specificities for CTA, CE-MRA and colour duplex were 95.2% (83.8 to 99.4), 94.8% (91.1 to 97.3) and 97.7% (95.2 to 99.1). However, specificities for CE-MRA and colour duplex demonstrated significant heterogeneity (p = 0.003 and p = 0.002, respectively). CONCLUSIONS CE-MRA and possibly CTA may be more sensitive in diagnosing vertebral artery stenosis than DUS. However, data are limited and further high quality studies comparing DUS, MRA and CTA with IAA are required.
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Affiliation(s)
- S Khan
- St George's University of London, Cranmer Terrace, London SW17 0RE, UK
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22
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Bucek RA, Puchner S, Haumer M, Reiter M, Minar E, Lammer J. CTA Quantification of Internal Carotid Artery Stenosis: Application of Luminal Area vs. Luminal Diameter Measurements and Assessment of Inter-observer Variability. J Neuroimaging 2007; 17:219-26. [PMID: 17608907 DOI: 10.1111/j.1552-6569.2007.00124.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND PURPOSE In contrast to digital subtraction angiography (DSAdia), computed tomography angiography (CTA) provides exact delineation of the perfused lumen in the axial plane, thus allowing luminal (CTAdia) as well as cross-sectional area (CTAarea) internal carotid artery stenosis (ICAS) assessment. The purposes of the present study were to correlate CTAdia and CTAarea with DSAdia and to assess the inter-observer variabilities of both CTA techniques. METHODS In a retrospective analysis, CTA images were reviewed by two observers and ICAS was assessed according to North American Symptomatic Carotid Endarterectomy Trial applying CTAdia and CTAarea. DSAdia was assessed by a third observer. RESULTS Based on 54 consecutive patients (40 males [74.1%] and 14 females [25.9%]; median age 73.3 years), ICAS percentages of CTAdia and CTAarea revealed significant correlations with DSAdia (r= 0.79-0.87, all P<.001) with median differences in the range of +8% to -6%. Inter-observer agreement was moderate for CTAdia (kappa= 0.60) and excellent for CTAarea (kappa= 0.86). Sensitivity of CTAarea for the detection of ICAS >70% was 100% for both observers, corresponding results for CTAdia were 97.1% and 71.4%, respectively, using DSAdia as the gold standard. CONCLUSION CTAarea assessment of ICAS correlates well with the results of DSAdia and provides an excellent sensitivity for the detection of ICAS >70% with superior inter-observer agreement compared to CTAdia.
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Affiliation(s)
- Robert A Bucek
- Department of Angiography and Interventional Radiology, Vienna Medical University, Vienna, Austria.
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Puchner S, Haumer M, Rand T, Reiter M, Minar E, Lammer J, Bucek RA. CTA in the detection and quantification of vertebral artery pathologies: a correlation with color Doppler sonography. Neuroradiology 2007; 49:645-50. [PMID: 17453179 DOI: 10.1007/s00234-007-0234-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2006] [Accepted: 03/21/2007] [Indexed: 10/23/2022]
Abstract
INTRODUCTION We evaluated the feasibility of multidetector CT angiography (MDCTA) in the examination of vertebral artery (VA) pathologies and correlated the results with those of color Doppler sonography (CDS). METHODS In this retrospective cohort analysis, we identified 65 patients with suspected cerebrovascular disease, who underwent MDCTA and CDS of the supraaortic vessels within a maximum period of 1 month. We evaluated the feasibility and image quality of MDCTA in this indication, compared the value of reformatted images and axial source images in the grading of stenoses and correlated these results with those of CDS. RESULTS The image quality of the MDCTA examination was classified as good in 64 patients (98.5%) and as moderate in 1 patient (1.5%). Axial source images and reformatted images agreed perfectly in terms of stenosis detection and grading as well as the detection of hypoplastic VAs (kappa = 1). The correlation between MDCTA and CDS was moderate (kappa = 0.56) in terms of stenosis detection and quantification and poor (kappa = 0.35) in terms of detection of hypoplasia of the VA. CONCLUSION MDCTA is a feasible method for the evaluation of VA pathologies providing a good image quality. Image reformatting does not add any diagnostic value to the interpretation of axial source images. The correlation between MDCTA and CDS is only moderate, reflecting the clinically important limitations of CDS in this indication.
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Affiliation(s)
- Stefan Puchner
- Department of Cardiovascular and Interventional Radiology, Medical University Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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Abstract
PURPOSE To evaluate the feasibility and accuracy of automated analysis software for use with multidetector computed tomographic angiography (CTA) in the exact grading of internal carotid artery stenosis. METHODS A retrospective pilot trial was performed using CTA datasets from 87 stenotic carotid arteries in 46 consecutive patients (34 men; median age 73.5 years) with known cerebrovascular disease. Internal carotid artery (ICA) stenosis was graded according to NASCET criteria by 2 experienced vascular radiologists in consensus using axial source images as well as curved planar reformations and digital subtraction angiography (DSA). These results were then compared to those obtained from the automated CTA analysis software and the results of manually adapted automated CTA analysis. RESULTS Measurements from automated CTA analysis as well as manually adapted automated CTA analysis correlated significantly to those of axial/reformatted CTA and DSA (r=0.53 and r=0.82, r=0.58 and 0.70, respectively, all p<0.05). Compared to axial/reformatted CTA measurements, automated CTA analysis had a median difference of -16%, while manually adapted automated CTA had a difference of -10%. Corresponding differences in a comparison with DSA were +4% and -2%, respectively. Circumferential calcification or kinking of the ICA origin did not significantly interfere with these differences (all p>0.05). Sensitivities for the detection of ICA stenosis >70% by manually adapted automated CTA analysis and automated measurement were 44.2% and 34.9%, respectively, versus axial/reformatted CTA. Compared with DSA as the gold standard, the sensitivities were 54.2% and 62.5%, respectively. Specificities for both methods and gold standards all exceeded 90%. CONCLUSION Commercially available automated CTA analysis is a feasible tool, but sensitivities are still not sufficient for clinical application.
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Affiliation(s)
- Robert A Bucek
- Department of Angiography and Interventional Radiology, Medical University Vienna, Austria.
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Abstract
PURPOSE To compare the measurements of internal carotid artery (ICA) stenosis obtained from multidetector computed tomographic angiography (CTA) and digital subtraction angiography (DSA) based on the NASCET and ECST grading methods. METHODS In a retrospective cohort analysis from data at a tertiary care university clinic, the CTA and DSA images from 69 consecutive patients (52 men; mean age 70.3+/-8.0 years, range 51-85) who underwent both imaging studies within a maximum period of 28 days were interpreted by 2 radiologists blinded to the results of the other modality. The exact degree of ICA stenosis was calculated for both modalities according to NASCET and ECST guidelines. RESULTS The agreement between both stenosis grading methods was comparable for CTA (R2=0.87) and DSA (R2=0.84); mean differences in stenoses grades between ECST and NASCET were 13.9% (CTA) and 12.9% (DSA, p>0.05). Corresponding results for the intermodality correlation were almost equal for NASCET (R2=0.59) and ECST (R2=0.55), with mean differences of 13.4% and 13.5%, respectively (p>0.05). Sensitivity and specificity of CTA for detecting occlusions was 100% for both modalities and grading systems. For detecting stenoses >70%, the sensitivity and specificity were 90.9% and 54.9%, respectively, for NASCET and 94.7% and 46.3%, respectively, for ECST. For stenoses >50%, the values were 95.8% and 59.6%, respectively, for NASCET and 96.4% and 42.5%, respectively, for ECST. CONCLUSION The introduction of multidetector CTA cannot overcome the confusion in the exact grading of ICA stenosis because the application of both tested modalities as well as both grading methods results in clinically important differences.
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Affiliation(s)
- Robert A Bucek
- Department of Angiography and Interventional Radiology, Medical University, Vienna, Austria.
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Barth A, Arnold M, Mattle HP, Schroth G, Remonda L. Contrast-Enhanced 3-D MRA in Decision Making for Carotid Endarterectomy: A 6-Year Experience. Cerebrovasc Dis 2006; 21:393-400. [PMID: 16534196 DOI: 10.1159/000091964] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2005] [Accepted: 11/07/2005] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Systematic need for angiography in diagnosis of carotid artery stenosis and indication of surgical therapy is still debated. Noninvasive imaging techniques such as MR angiography (MRA) or CT angiography (CTA) offer an alternative to digital subtraction angiography (DSA) and are increasingly used in clinical practice. In this study, we present the radiological characteristics and clinical results of a series of patients operated on the basis of combined ultrasonography (US)/MRA. METHODS This observational study included all the patients consecutively operated for a carotid stenosis in our Department from October 1998 to December 2004. The applied MRA protocol had previously been established in a large correlation study with DSA. DSA was used only in case of discordance between US and MRA. The preoperative radiological information furnished by MRA was compared with intraoperative findings. The outcome of the operation was assessed according to ECST criteria. RESULTS Among 327 patients, preoperative MRA was performed in 278 (85%), DSA in 44 (13.5%) and CT angiography in 5 (1.5%). Most of DSA studies were performed as emergency for preparation of endovascular therapy or for reasons other than carotid stenosis. Eleven additional DSA (3.3%) complemented US/MRA, mostly because diverging diagnosis of subocclusion of ICA. No direct morbidity or intraoperative difficulty was related to preoperative MRA. Combined mortality/major morbidity rate was 0.9% (3 patients) and minor morbidity rate 5.5% (18 patients). CONCLUSIONS This observational study describes a well-established practice of carotid surgery and supports the exclusive use of non invasive diagnostic imaging for indicating and deciding the operation.
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Affiliation(s)
- Alain Barth
- Department of Neurosurgery, University Hospital of Bern, Bern, Switzerland.
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Wardlaw JM, Chappell FM, Best JJK, Wartolowska K, Berry E. Non-invasive imaging compared with intra-arterial angiography in the diagnosis of symptomatic carotid stenosis: a meta-analysis. Lancet 2006; 367:1503-12. [PMID: 16679163 DOI: 10.1016/s0140-6736(06)68650-9] [Citation(s) in RCA: 186] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Accurate carotid imaging is important for effective secondary stroke prevention. Non-invasive imaging, now widely available, is replacing intra-arterial angiography for carotid stenosis, but the accuracy remains uncertain despite an extensive literature. We systematically reviewed the accuracy of non-invasive imaging compared with intra-arterial angiography for diagnosing carotid stenosis in patients with carotid territory ischaemic symptoms. METHODS We searched for articles published between 1980 and April 2004; included studies comparing non-invasive imaging with intra-arterial angiography that met Standards for Reporting of Diagnostic Accuracy (STARD) criteria; extracted data to calculate sensitivity and specificity of non-invasive imaging, to test for heterogeneity and to perform sensitivity analyses; and categorised percent stenosis by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method. RESULTS In 41 included studies (2541 patients, 4876 arteries), contrast-enhanced MR angiography was more sensitive (0.94, 95% CI 0.88-0.97) and specific (0.93, 95% CI 0.89-0.96) for 70-99% stenosis than Doppler ultrasound, MR angiography, and CT angiography (sensitivities 0.89, 0.88, 0.76; specificities 0.84, 0.84, 0.94, respectively). Data for 50-69% stenoses and combinations of non-invasive tests were sparse and unreliable. There was heterogeneity between studies and evidence of publication bias. INTERPRETATION Non-invasive tests, used cautiously, could replace intra-arterial carotid angiography for 70-99% stenosis. However, more data are required to determine their accuracy, especially at 50-69% stenoses where the balance of risk and benefit for carotid endarterectomy is particularly narrow, and to explore and overcome heterogeneity. Methodology for evaluating imaging tests should be improved; blinded, prospective studies in clinically relevant patients are essential basic characteristics.
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Affiliation(s)
- J M Wardlaw
- Division of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Edinburgh, EH4 2XU, UK.
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Bucek RA, Puchner S, Haumer M, Rand T, Sabeti S, Minar E, Lammer J. Grading of Internal Carotid Artery Stenosis:Comparative Analysis of Different Flow Velocity Criteria and Multidetector Computed Tomographic Angiography. J Endovasc Ther 2006; 13:182-9. [PMID: 16643072 DOI: 10.1583/05-1768r.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To evaluate multidetector computed tomographic angiography (CTA) versus published color Doppler sonography (CDS) velocity criteria in the grading of internal carotid artery (ICA) stenosis. METHODS Sixty-eight consecutive patients (50 men; mean age 70.2 +/- 8.1 years, range 51- 85) with known ICA stenosis and complete CTA and CDS data for 127 carotid arteries were enrolled in this retrospective analysis. The degree of stenosis was determined using CDS velocities according to 5 published sets of criteria, as well as the criteria used at the authors' institution. These outcomes were then correlated using kappa-statistics with the results of multidetector CTA according to NASCET. RESULTS The best overall agreement was achieved applying the criteria sets of Hwang (kappa = 0.70) and AbuRahma (kappa = 0.68). All 5 occlusions were correctly identified with both modalities. CTA detected 73 ICA stenoses > 70%; the best correlation was with the application of Hwang criteria, which correctly identified 69 (94.5%) > 70% stenoses. In order of increasing tendency to underscore the grade of stenosis, the corresponding results for the other criteria sets were 62 (84.9%) for Mittl, 59 (80.8%) for AbuRahma, 55 (75.3%) each for Nicolaides and Filis, and 50 (68.5%) for Nederkoorn. CTA detected 85 stenoses >50%; the sensitivity of all applied CDS criteria sets exceeded 90%. CONCLUSION Grading of ICA stenosis > 70% with CDS and CTA results in clinically relevant discrepancies, with higher grades of stenoses assessed by CTA. The choice of CDS grading criteria is of significant clinical importance, especially in the identification of high-grade ICA stenosis.
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Affiliation(s)
- Robert A Bucek
- Department of Angiography and Interventional Radiology, Medical University Vienna, Austria.
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U-King-Im JM, Hollingworth W, Trivedi RA, Cross JJ, Higgins NJ, Graves MJ, Gutnikov S, Kirkpatrick PJ, Warburton EA, Antoun NM, Rothwell PM, Gillard JH. Cost-effectiveness of diagnostic strategies prior to carotid endarterectomy. Ann Neurol 2005; 58:506-15. [PMID: 16178014 DOI: 10.1002/ana.20591] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The main objective of this study was to assess the long-term cost-effectiveness of five alternative diagnostic strategies for identification of severe carotid stenosis in recently symptomatic patients. A decision-analytical model with Markov transition states was constructed. Data sources included a prospective study involving 167 patients who had screening Doppler ultrasound (DUS), confirmatory contrast-enhanced magnetic resonance angiography (CEMRA) and confirmatory digital subtraction angiography (DSA), individual patient data from the European Carotid Surgery Trial and other published clinical and cost data. A "selective" strategy, whereby all patients receive DUS and CEMRA (only proceeding to DSA if the CEMRA is positive and the DUS is negative), was most cost-effective. This was both the cheapest imaging and treatment strategy (35,205 dollars per patient) and yielded 6.1590 quality-adjusted life years (QALYs), higher than three alternative imaging strategies. Probabilistic sensitivity analysis demonstrated that there was less than a 10% probability that imaging with either DUS or DSA alone are cost-effective at the conventional 50,000 dollars/QALY threshold. In conclusion, DSA is not cost-effective in the routine diagnostic workup of most patients. DUS, with additional imaging in the form of CEMRA, is recommended, with a strategy of "CEMRA and selective DUS review" being shown to be the optimal imaging strategy.
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Affiliation(s)
- Jean Marie U-King-Im
- Department of Radiology, Addenbrooke's Hospital and the University of Cambridge, Cambridge, United Kingdom
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Sprouse LR, Meier GH, Parent FN, Demasi RJ, Lesar CJ, Nelms C, Carter K, Marcinczyk MJ, Gayle RG, Mendoza B. Are we undertreating carotid stenoses diagnosed by ultrasound alone? Vasc Endovascular Surg 2005; 39:143-51. [PMID: 15806275 DOI: 10.1177/153857440503900203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Clinical management of carotid disease is primarily based on results of national trials (ACAS and NASCET) that used the distal internal carotid artery diameter as a reference. However, commonly accepted ultrasound (US) criteria for carotid stenosis were derived from the correlation of velocity measurements with angiographic bulb diameter reductions (BDR). This study was undertaken to compare the degree of carotid stenosis determined by conventional velocity criteria to the degree of stenosis measured by B-mode (gray scale) diameter at both the carotid bulb and at the distal internal carotid artery, and, second, to evaluate US imaging to derive distal diameter reductions (DDR) noninvasively. During a 3-month period patients referred for carotid US were prospectively analyzed for standard velocity criteria and plaque morphology. Minimum carotid diameter was measured by longitudinal and transverse B-mode measurements and compared to carotid bulb diameter and internal carotid diameter distal to all disease. B-mode diameter reductions were compared to the degree of stenosis determined by velocity criteria and to patient symptoms and the decision for carotid endarterectomy. In total, 131 carotid arteries in 74 patients were evaluated. Based on the University of Washington velocity criteria, lesions were classified as grade I (n = 61, 46%), IIA (n = 58, 44%), IIB (n = 7, 5%), or III (n = 5, 4%). BDR measured by B-mode predicted the grade of disease based on velocity criteria (p < 0.001) with an overall accuracy of 95%. With use of the B-mode for DDR (NASCET style), 18 patients exceeded the 60% threshold for surgical intervention. Of these, only 3 patients were symptomatic and were operated on. An additional 3 operated-on patients had an asymptomatic grade III stenosis, our usual threshold for intervention. Twelve additional patients were appropriate for surgical intervention by B-mode but were not treated based on conventional velocity criteria alone. Bulb diameter reduction by B-mode imaging correlates strongly with diameter reduction determined by velocity criteria, and independently predicts the grade of carotid disease. With this in mind, the accuracy of B-mode imaging may be extended to the measurement of carotid stenosis based on DDR. By B-mode criteria, many patients appropriate for intervention were not offered treatment based on conventional velocity criteria. Modern B-mode imaging provides a noninvasive method to obtain 'arteriographic equivalent'' measurements and should be added as a routine to carotid ultrasound interrogation.
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Affiliation(s)
- L Richard Sprouse
- Eastern Virginia Medical School, Vascular and Transplant Specialists, Norfolk, VA, USA.
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Jahromi AS, Cinà CS, Liu Y, Clase CM. Sensitivity and specificity of color duplex ultrasound measurement in the estimation of internal carotid artery stenosis: A systematic review and meta-analysis. J Vasc Surg 2005; 41:962-72. [PMID: 15944595 DOI: 10.1016/j.jvs.2005.02.044] [Citation(s) in RCA: 146] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Duplex ultrasound is widely used for the diagnosis of internal carotid artery stenosis. Standard duplex ultrasound criteria for the grading of internal carotid artery stenosis do not exist; thus, we conducted a systematic review and meta-analysis of the relation between the degree of internal carotid artery stenosis by duplex ultrasound criteria and degree of stenosis by angiography. METHODS Data were gathered from Medline from January 1966 to January 2003, the Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, ACP Journal Club, UpToDate, reference lists, and authors' files. Inclusion criteria were the comparison of color duplex ultrasound results with angiography by the North American Symptomatic Carotid Endarterectomy Trial method; peer-reviewed publications, and >/=10 adults. RESULTS Variables extracted included internal carotid artery peak systolic velocity, internal carotid artery end diastolic velocity, internal carotid artery/common carotid artery peak systolic velocity ratio, sensitivity and specificity of duplex ultrasound scanning for internal carotid artery stenosis by angiography. The Standards for Reporting of Diagnostic Accuracy (STARD) criteria were used to assess study quality. Sensitivity and specificity for duplex ultrasound criteria were combined as weighted means by using a random effects model. The threshold of peak systolic velocity >/=130 cm/s is associated with sensitivity of 98% (95% confidence intervals [CI], 97% to 100%) and specificity of 88% (95% CI, 76% to 100%) in the identification of angiographic stenosis of >/=50%. For the diagnosis of angiographic stenosis of >/=70%, a peak systolic velocity >/=200 cm/s has a sensitivity of 90% (95% CI, 84% to 94%) and a specificity of 94% (95% CI, 88% to 97%). For each duplex ultrasound threshold, measurement properties vary widely between laboratories, and the magnitude of the variation is clinically important. The heterogeneity observed in the measurement properties of duplex ultrasound may be caused by differences in patients, study design, equipment, techniques or training. CONCLUSIONS Clinicians need to be aware of the limitations of duplex ultrasound scanning when making management decisions.
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Affiliation(s)
- Afshin S Jahromi
- Division of Vascular Surgery, McMaster University, Toronto, Ontario, Canada
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Abstract
Carotid artery occlusive disease is an important stroke risk factor and accounts for a significant proportion of stroke morbidity and mortality. In this article we survey the major clinical trials related to stroke risk in symptomatic and asymptomatic patients who have internal carotid artery (ICA) stenosis; techniques for noninvasive screening of ICA stenosis including ultrasound, MR angiography, and CT angiography; and evolving algorithms for ICA evaluation. We comment on current interest in plaque morphology as a risk factor for stroke.
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Affiliation(s)
- Javier M Romero
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Whiting P, Rutjes AWS, Dinnes J, Reitsma JB, Bossuyt PMM, Kleijnen J. A systematic review finds that diagnostic reviews fail to incorporate quality despite available tools. J Clin Epidemiol 2005; 58:1-12. [PMID: 15649665 DOI: 10.1016/j.jclinepi.2004.04.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVE To review existing quality assessment tools for diagnostic accuracy studies and to examine to what extent quality was assessed and incorporated in diagnostic systematic reviews. METHODS Electronic databases were searched for tools to assess the quality of studies of diagnostic accuracy or guides for conducting, reporting or interpreting such studies. The Database of Abstracts of Reviews of Effects (DARE; 1995-2001) was used to identify systematic reviews of diagnostic studies to examine the practice of quality assessment of primary studies. RESULTS Ninety-one quality assessment tools were identified. Only two provided details of tool development, and only a small proportion provided any indication of the aspects of quality they aimed to assess. None of the tools had been systematically evaluated. We identified 114 systematic reviews, of which 58 (51%) had performed an explicit quality assessment and were further examined. The majority of reviews used more than one method of incorporating quality. CONCLUSION Most tools to assess the quality of diagnostic accuracy studies do not start from a well-defined definition of quality. None has been systematically evaluated. The majority of existing systematic reviews fail to take differences in quality into account. Reviewers should consider quality as a possible source of heterogeneity.
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Affiliation(s)
- Penny Whiting
- Centre for Reviews and Dissemination, University of York, United Kingdom.
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Abstract
Internal carotid artery stenosis (ICAS) is responsible for approximately 30% of ischemic strokes. Internal carotid artery stenosis of greater than 50% is present in about 4% to 8% of the population aged 50 to 79 years. Natural history studies and clinical trials have shown a small increase in stroke risk in patients with increasing degrees of ICAS, especially in those with greater than 80% reduction in carotid artery diameter. Randomized, prospective multicenter trials have revealed the superiority of carotid endarterectomy (CEA) over medical therapy in recently symptomatic patients with severe ICAS. However, the evidence from several randomized controlled trials of CEA in asymptomatic patients does not support the use of CEA in most of these patients; also, the role of noninvasive screening in this patient population remains uncertain and controversial. Furthermore, there is considerable uncertainty about whether the statistical benefit of avoiding a nondisabling stroke is worth the overall cost and risk of the procedure. Clinicians continue to struggle with treatment decisions for patients with asymptomatic ICAS. Carotid endarterectomy for asymptomatic ICAS should be considered only for medically stable patients with 80% or greater stenosis who are expected to live at least 5 years, and only in centers with surgeons who have a demonstrated low (<3%) perioperative complication rate. We outline the prevalence and natural history of ICAS, the evidence for CEA in patients with asymptomatic ICAS, the roles of screening and monitoring for ICAS, the methods of evaluating ICAS, and the implications for practicing clinicians.
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Affiliation(s)
- David W Dodick
- Department of Neurology, Mayo Clinic College of Medicine, Scottsdale, Ariz, USA
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U-King-Im JM, Trivedi RA, Graves MJ, Higgins NJ, Cross JJ, Tom BD, Hollingworth W, Eales H, Warburton EA, Kirkpatrick PJ, Antoun NM, Gillard JH. Contrast-enhanced MR angiography for carotid disease. Neurology 2004; 62:1282-90. [PMID: 15111663 DOI: 10.1212/01.wnl.0000123697.89371.8d] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To compare contrast-enhanced MR angiography (CEMRA) with intra-arterial digital subtraction angiography (DSA) for evaluating carotid stenosis.Methods: A total of 167 consecutive symptomatic patients, scheduled for DSA following screening duplex ultrasound (DUS), were prospectively recruited to have CEMRA. Three independent readers reported on each examination in a blinded and random manner. Agreement was assessed using the Bland-Altman method. Diagnostic and potential clinical impact of CEMRA was evaluated, singly and in combination with DUS.Results: CEMRA tended to overestimate stenosis by a mean bias ranging from 2.4 to 3.8%. A significant part of the disagreement between CEMRA and DSA was directly caused by interobserver variability. For detection of severe stenosis, CEMRA alone had a sensitivity of 93.0% and specificity of 80.6%, with a diagnostic misclassification rate of 15.0% (n = 30). More importantly, clinical decision-making would, however, have been potentially altered only in 6.0% of cases (n = 12). The combination of concordant DUS and CEMRA reduced diagnostic misclassification rate to 10.1% (n = 19) at the expense of 47 (24.9%) discordant cases needing to proceed to DSA. An intermediate approach of selective DUS review resulted in a marginally worse diagnostic misclassification rate of 11.6% (n = 22) but with only 6.8% of discordant cases (n = 13).Conclusions: DSA remains the gold standard for carotid imaging. The clinical misclassification rate with CEMRA, however, is acceptably low to support its safe use instead of DSA. The appropriateness of combination strategies depends on institutional choice and cost-effectiveness issues.
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Affiliation(s)
- J M U-King-Im
- University Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
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Sudlow C, Warlow CP. Long-Term Medical Management of Ischemic Stroke and Transient Ischemic Attack Due to Arterial Disease. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50066-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Findlay JM, Marchak BE. Carotid Endarterectomy. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50073-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Stroke is a major public-health burden worldwide. Prevention programmes are essential to reduce the incidence of stroke and to prevent the all but inevitable stroke epidemic, which will hit less developed countries particularly hard as their populations age and adopt lifestyles of the more developed countries. Efficient, effective, and rapid diagnosis of stroke and transient ischaemic attack is crucial. The diagnosis of the exact type and cause of stroke, which requires brain imaging as well as traditional clinical skills, is also important when it will influence management. The treatment of acute stroke, the prevention and management of the many complications of stroke, and the prevention of recurrent stroke and other serious vascular events are all improving rapidly. However, stroke management will only be most effective when delivered in the context of an organised, expert, educated, and enthusiastic stroke service that can react quickly to the needs of patients at all stages from onset to recovery.
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Affiliation(s)
- Charles Warlow
- Division of Clinical Neurosciences, Western General Hospital, EH4 2XU, Edinburgh, UK.
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Abstract
Fibroadenoma (FA) is a common breast lesion occurring in 25% of asymptomatic women. Several studies considered FA as a risk factor for breast cancer, prompting a systematic review of the literature. We selected cohort and case-control studies. Seven studies satisfied the selection criteria. Dupont et al. (1994) and McDivitt et al. (1992) were considered to provide the strongest evidence, showing the relative risk for excised FA without hyperplasia in the range 1.48-1.7, with hyperplasia 3.47-3.7, and with hyperplasia and atypia 6.9-7.29, persisting for more than 20 years. Five studies by Levi et al. (1994), Ciatto et al. (1997), Moskowitz et al. (1980), Carter et al. (1988), and Levshin et al. (1998), were considered to provide weaker evidence, although they showed similar results. None of the results could be used to quantify the risks of excised, non-excised, and asymptomatic FA. More care should be taken in managing patients with complex FAs and FAs with hyperplasia with or without atypia. Core biopsy may be a better option in diagnosis of FAs. Regular screening may be advisable in patients with FAs and a family history of breast cancer in a first-degree relative. More rigorous research is needed in this area.
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Affiliation(s)
- H El-Wakeel
- Department of Surgery, The Breast Unit, The Royal United Hospital, Combe Park, Bath BA1 3NG, UK.
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Abstract
The risk of ischemic stroke increases proportionately to the severity of carotid stenosis, and carotid endarterectomy is a durable procedure that reduces this risk. Although a combination of noninvasive tests, such as ultrasound and magnetic resonance angiography (MRA), have low misclassification rates compared with invasive angiography, the need for invasive angiography may not yet be obviated. Ultrasound appears to be a cost-effective screening strategy for a significant carotid stenosis that warrants angiographic confirmation and possible intervention. A combination of ultrasound and MRA appears to be the most common clinical pathway that can be accurate and cost-effective, if rigorous local validation of diagnostic criteria is performed. Ultrasound further supplements angiography by providing information about plaque morphology and physiologic measurements of collateralization of flow and vasomotor reactivity when additional tests, such as transcranial Doppler, are performed. Ultrasound and various angiographic imaging modalities have complementary value in patient selection for carotid endarterectomy. Currently, more invasive angiograms are being performed, due to a variety of new experimental interventions such as angioplasty and stenting, a subject of current clinical trials.
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Affiliation(s)
- Andrei V Alexandrov
- The University of Texas-Houston Medical School, MSB 7.044, 6431 Fannin Street, Houston, TX 77030, USA.
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Rothwell PM, Eliasziw M, Gutnikov SA, Fox AJ, Taylor DW, Mayberg MR, Warlow CP, Barnett HJM. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 2003; 361:107-16. [PMID: 12531577 DOI: 10.1016/s0140-6736(03)12228-3] [Citation(s) in RCA: 985] [Impact Index Per Article: 46.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Endarterectomy reduces risk of stroke in certain patients with recently symptomatic internal carotid stenosis. However, investigators have made different recommendations about the degree of stenosis above which surgery is effective, partly because of differences between trials in the methods of measurement of stenosis. To accurately assess the overall effect of surgery, and to increase power for secondary analyses, we pooled trial data and reassessed carotid angiograms. METHODS We pooled data from the European Carotid Surgery Trial (ECST), North American Symptomatic Carotid Endarterectomy Trial, and Veterans Affairs trial 309 from the original electronic data files. Outcome events were re-defined, if necessary, to achieve comparability. Pre-randomisation carotid angiograms from ECST were re-measured by the method used in the other two trials. RESULTS Risks of main outcomes in both treatment groups and effects of surgery did not differ between trials. Data for 6092 patients, with 35000 patient-years of follow-up, were therefore pooled. Surgery increased the 5-year risk of ipsilateral ischaemic stroke in patients with less than 30% stenosis (n=1746, absolute risk reduction -2.2%, p=0.05), had no effect in patients with 30-49% stenosis (1429, 3.2%, p=0.6), was of marginal benefit in those with 50-69% stenosis (1549, 4.6%, p=0.04), and was highly beneficial in those with 70% stenosis or greater without near-occlusion (1095, 16.0%, p<0.001). There was a trend towards benefit from surgery in patients with near-occlusion at 2 years' follow-up (262, 5.6%, p=0.19), but no benefit at 5 years (-1.7%, p=0.9). INTERPRETATION Re-analysis of the trials with the same measurements and definitions yielded highly consistent results. Surgery is of some benefit for patients with 50-69% symptomatic stenosis, and highly beneficial for those with 70% symptomatic stenosis or greater but without near-occlusion. Benefit in patients with carotid near-occlusion is marginal in the short-term and uncertain in the long-term.
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Affiliation(s)
- P M Rothwell
- Stroke Prevention Research Unit, University Department of Clinical Neurology, Radcliffe Infirmary, Oxford, UK.
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Patel SG, Collie DA, Wardlaw JM, Lewis SC, Wright AR, Gibson RJ, Sellar RJ. Outcome, observer reliability, and patient preferences if CTA, MRA, or Doppler ultrasound were used, individually or together, instead of digital subtraction angiography before carotid endarterectomy. J Neurol Neurosurg Psychiatry 2002; 73:21-8. [PMID: 12082040 PMCID: PMC1757321 DOI: 10.1136/jnnp.73.1.21] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To evaluate the accuracy of routinely available non-invasive tests (spiral computed tomographic angiography (CTA), time of flight magnetic resonance angiography (MRA), and colour Doppler ultrasound (DUS)), individually and together, compared with intra-arterial digital subtraction angiography (DSA) in patients with symptomatic tight carotid stenosis; and to assess the effect of substituting non-invasive tests for DSA on outcome, interobserver variability, and patient preference. METHODS Patients referred from a neurovascular clinic were subjected prospectively to DUS imaging. The operator was blind to symptoms. Patients with a tight carotid stenosis on the symptomatic side were admitted for DSA. CTA and MRA were performed during the admission. The CTA, MRA, and DSA films were each read independently by two of six experienced radiologists, blind to all other data. RESULTS 67 patients were included (34 had all four imaging procedures). DUS, CTA, and MRA all agreed with DSA in the diagnosis of operable v non-operable disease in about 80% of patients. CTA tended to underestimate (sensitivity 0.65, specificity 1.0), MRA to overestimate (sensitivity 1.0, specificity 0.57), and DUS to agree most closely with (sensitivity 0.85, specificity 0.71) the degree of stenosis as shown by DSA. When using any two of the three non-invasive tests in combination, adding the third if the first two disagreed would result in very few misdiagnoses (about 6%). MRA had similar interobserver variability to CTA (both worse than DSA). Patients preferred CTA over MRA and DSA. CONCLUSIONS DUS, CTA, and MRA all show similar accuracy in the diagnosis of symptomatic carotid stenosis. No technique on its own is accurate enough to replace DSA. Two non-invasive techniques in combination, and adding a third if the first two disagree, appears more accurate, but may still result in diagnostic errors.
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Affiliation(s)
- S G Patel
- Department of Neuroradiology, University of Edinburgh, Western General Hospital, Edinburgh, UK
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Abstract
Endarterectomy reduces the risk of stroke in selected patients with carotid artery stenosis, and the benefit is related to the degree of stenosis. Although the randomized trials demonstrating this benefit measured the degree of stenosis with conventional catheter angiography, many physicians are relying on noninvasive tests to select patients for surgery. Technologic advancement in this area is outpacing the availability of quality data supporting the clinical utility of the newer noninvasive tests.
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Affiliation(s)
- Dean C C Johnston
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, 1081 Burrard Street, Room 2369, Providence Wing, Vancouver, British Columbia V6Z 1Y6, Canada.
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Zachrisson H, Berthelsen B, Blomstrand C, Holm J, Volkmann R. Influence of poststenotic collateral pressure on blood flow velocities within high-grade carotid artery stenosis: differences between morphologic and functional measurements. J Vasc Surg 2001; 34:263-8. [PMID: 11496278 DOI: 10.1067/mva.2001.115803] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE The driving force for blood flow through a high-grade stenosis in the internal carotid artery can be expressed as the pressure gradient over the stenosis itself, which, however, might be reduced by the back pressure exerted by distal collateral vessels. Theoretically the maximum blood flow velocity as a measure of the functional grade of obstruction may therefore be lower than what is expected from morphologic gradations of the stenosis. This study was designed to test prospectively the influence of intracranial collateral vessels on blood flow velocities within high-grade internal carotid artery stenoses. PATIENTS AND METHODS Forty-five consecutive patients (age 66 +/- 11) with high-grade internal carotid artery stenoses were investigated before and during carotid endarterectomy. The preoperative investigations included duplex ultrasound scanning of the neck vessels, transcranial Doppler scanning for assessment of collateral flow to the middle cerebral artery and angiography. Carotid endarterectomy was performed with patients under deep general anesthesia without a shunt. Systolic and diastolic internal carotid artery blood pressures were measured before and during intraoperative cross-clamping (ie, stump pressure) of the carotid arteries. RESULTS Within high-grade internal carotid artery stenoses, maximum systolic and end-diastolic blood flow velocities showed a significant inverse correlation to the corresponding systolic and diastolic stump blood internal carotid artery blood pressures. All patients with spontaneous collateral flow to the ipsilateral anterior part of the circle of Willis were divided into a group with relatively high and another one with low end-diastolic blood flow velocities. The stump pressure was significantly lower in patients with high end-diastolic blood flow velocities in spite of the fact that the mean angiographic grade of stenosis did not differ significantly between the groups. CONCLUSIONS Flow velocities within a high-grade internal carotid artery stenosis are inversely dependent on the stump pressure, that is the poststenotic collateral perfusion pressure. This should be taken into consideration in case of discrepancies between angiography and ultrasound outcome.
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Affiliation(s)
- H Zachrisson
- Department of Clinical Physiology, Sahlgrenska University Hospital, Göteborg, Sweden.
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Abstract
Multiple clinical trials have demonstrated the efficacy of endarterectomy in selected groups of patients based primarily on percent diameter stenosis. Although measurement of stenosis in the clinical trials was established by conventional angiography, there is considerable interest in noninvasive alternatives. Magnetic resonance angiography, performed using time-of-flight methods or with contrast enhancement, is one of several alternatives for noninvasive carotid evaluation. Screening examinations are routinely performed for carotid stenosis. Preoperative evaluations based on one or a combination of noninvasive tests have been proposed, although these proposals are the subject of ongoing controversy. Evaluation of the vertebral arteries is more difficult and less well studied: however, the increasing availability of therapies for posterior circulation atherosclerotic narrowing is resulting in increased interest in this problem.
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Affiliation(s)
- J E Heiserman
- Department of Radiology, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA.
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Griffiths GD, Razzaq R, Farrell A, Ashleigh R, Charlesworth D. Variability in measurement of internal carotid artery stenosis by arch angiography and duplex ultrasonography--time for a reappraisal? Eur J Vasc Endovasc Surg 2001; 21:130-6. [PMID: 11237785 DOI: 10.1053/ejvs.2000.1286] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES to determine the inter- and intra-observer variability of ICA stenosis measurement using duplex, ECST and NASCET methods. DESIGN a retrospective review of arch angiograms and carotid duplex scans in 50 patients. MATERIALS AND METHODS carotid stenoses were calculated by three independent observers according to NASCET and ECST methods. Variation between observers for NASCET and ECST was determined. For each observer, the variation between NASCET and ECST was determined. The variation between duplex and both NASCET and ECST was determined. RESULTS inter-observer agreement on the degree of ICA stenosis was clinically and statistically good for NASCET but was poorer for ECST. For each observer, comparison between NASCET and ECST showed 95% limits of agreement of around 50 percentage points. Comparison of duplex with NASCET and ECST showed similar 95% limits of agreement. CONCLUSIONS arch angiography allows reproducible measurement of carotid stenosis by the NASCET method between different observers. For the ECST method, reproducibility is not so good. Variations in results between NASCET and ECST and between angiography and duplex are significant. In view of the similar results of the NASCET and ECST trials, this suggests that degree of stenosis may only be a surrogate marker for outcome following carotid endarterectomy.
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