Carotid Duplex Ultrasonography Research Articles

Abstract TP224: A Deep Learning Based-Algorithm to Automatically Measure Carotid Stenosis Using Cine-Images of Carotid Duplex Ultrasonography

Background and Objective: The present study was performed to develop an automated algorithm to measure the carotid stenosis by considering both deep learning and mathematical model using carotid duplex ultrasonography (CDU) images. Methods: We first obtained cine images of CDU from right and left carotid arteries of 18 ischemic stroke patients by continuous moving from supraclavicular to submandibular area. Then, we collected raw axial-CDU images from the cine-CDU images, and then, labelled segmentation of the stenosis caused by atherosclerotic plaque from the vessel wall in the individual axial image by two experts. To develop segmentation algorithm from the axial-CDU images, we first applied a deep learning algorithm to segment vessel lumen from vessel wall. Next, a mathematical algorithm using Gaussian mixture was used to segment atherosclerotic stenosis from the vessel lumen. Dice coefficient was obtained to evaluate whether the segmentation algorithms could accurately segment lumen of carotid artery and predict the stenosis severity measured by the experts using python packages including TensorFlow and scikit-learn on a workstation (Intel i9-7900X CPU, Nvidia Titan Xp GPU and 128G 2400GHz memory). Results: We finally collected total 13,586 raw axial-CDU images from the cine-CDU images of the 18 patients. After application of two steps of segmentation algorithms to the axial-CDU images, accuracy of the algorithm to segment lumen from the carotid vessel wall was mean 0.92 (±standard deviation 0.46) of dice coefficient. And, accuracy to estimate the stenotic area was mean 0.201 (±standard deviation 0.137) of dice coefficient. Conclusions: We proposed an algorithm to automatically quantify the carotid stenosis using two steps of approach. First, a deep learning based-algorithm to segment lumen of carotid artery; second, a mathematical model based-algorithm using Gaussian mixture to segment carotid stenosis from the lumen. Even though we need more studies to increase the accuracy to predict the stenosis, the present prediction algorithms provide a possible tool to automatically measure the severity and regional characteristics of carotid stenosis using cine-CDU images.

Abstract WP181: Preprocedual Carotid Plaque Characterization by Duplex Ultrasonography as a Predictor of in-Stent Intimal Restenosis 6 months After Carotid Stenting

Background and Purpose: In-stent intimal restenosis (ISR) caused by neo-intimal hyperplasia generally occurs <24 months after carotid stenting (CAS). Although the real clinical impact of ISR are still unclear, several studies suggested the development of ISR significantly correlated with ipsilateral stroke and death. Also differences in the rate of ISR between open-cell and closed-cell stents have yet to be well evaluated. We aimed to investigate predictors of ISR 6 months after CAS. Methods: We examined 133 patients (mean age of 72.1±8.4 years old) received CAS in a single hospital during 2014 and 2018. Preoperative carotid plaque evaluation was performed by carotid angiography, duplex carotid ultrasonography (CUS), and black-blood carotid artery MRI (BB-MRI). Mean stenosis rate (NASCET) was 71.0±12.3% (44%-100%). Follow-up carotid angiography was performed six months after CAS in all patients according to a predefined protocol. ISR was defined as in-stent intimal hyperplasia more than 50% stenosis based on the NASCET method. Selection of stent type was at the discretion of the treating physician. Predictors of ISR were determined by multivariate logistic regression analysis. Results: Follow-up angiography demonstrated ISR in 33 patients (24.8%). In 44 patients, more than 2 stents were deployed. Univariate analyses demonstrated hypoechoic plaque, 1 mobile plaque with jerry fish sign, complete occlusive or pseudo occlusive lesion, closed-cell stent are significantly associated with ISR (>50%), however no association was observed in traditional risk factors, MRI plaque characterization, and implantation of multiple stents. Multivariate analysis demonstrated low echoic plaque in preoperative CUS (OR4.67; 95%CI, 1.85-11.78) and closed-cell stent (OR 0.378; 95%CI, 0.15-0.97) as significant predictors of ISR. Conclusions: Preprocedual plaque characterization by CUS but not MRI appeared to be useful to predict ISR 6 months after CAS even after adjustment of stent type.

Movable Thrombi Diagnosed Using Ultrasonography in Non-Significant Carotid Stenosis

Stenosis of an artery of more than 50% is usually regarded as significant stenosis, which may cause ischemic stroke. However, the nature of plaque may be important, even though the stenosis does not reach a significant degree. A 75-year old man with right arm weakness showed multiple scattered small infarct lesions at the left middle cerebral artery territory with mild stenosis of the left carotid artery. No embolic source was detected from cardiac assessments. Carotid duplex sonography showed a mobile plaque at the carotid artery, which was not detected by conventional angiography. Our case report suggests that direct vessel wall imaging can be useful in patients who have ischemic stroke with an embolic pattern without significant arterial stenosis. Key words: Carotid artery ulcerating plaque; Ultrasonography, Doppler, Duplex; Carotid artery thromboses

THE EFFECT OF PATIENT-SPECIFIC NON-NEWTONIAN BLOOD VISCOSITY ON ARTERIAL HEMODYNAMICS PREDICTIONS

Blood flow simulations can identify arterial regions that are vulnerable to atherosclerotic or thrombotic evolution. To accurately define vulnerable arterial regions, hemodynamic parameters such as arterial geometry, blood flow velocity and blood viscosity (BV) must be measured individually. However, previous numerical studies have largely employed either a single representative value or simply used a nonspecific curve of non-Newtonian characteristics of BV. This study aimed to evaluate whether various BV models could produce similar arterial wall shear stress (WSS) results. We performed a blood flow simulation in carotid arteries obtained from time-of-flight magnetic resonance (TOF MR) angiography using the hemodynamic characteristics of subjects via carotid duplex ultrasonography. The BV models were categorized into the following five types: patient-specific non-Newtonian BV (model 1), representative non-Newtonian BV based on the Carreau model (BV model 2), Newtonian BV measured at a specific shear rate of 300[Formula: see text][Formula: see text] (BV model 3), Newtonian BV obtained from a hematocrit-based equation (BV model 4) and a representative Newtonian BV of 4[Formula: see text]cP (BV model 5). In total, 20 carotid arteries from 20 healthy volunteers (mean age [Formula: see text] SD of [Formula: see text] years; 50% women) were examined. Compared with the mean values of carotid WSS in BV model 1 as the reference model, the other four models showed significant differences in both genders for all carotid segments. To obtain reliable physiological WSS results, patient-specific non-Newtonian BV should be carefully employed.

Extracranial internal carotid artery occlusion-a prospective study

Backround Symptomatic and asymptomatic occlusions of the extracranial internal carotid artery (EICA) is linked with high risk of stroke event. Objective This study aimed to compare symptomatic and asymptomatic occlusion of EICA by carotid duplex ultrasonography (CDU) and determine the risk factors of atherosclerotic plaques and identify the clinical features. Methods This was a hospital based prospective study, conducted at the Third General Central Hospital , between 2015- 2017. Totally, 492 ischemic stroke and complained before symptoms of transient ischemic attack patients aged below and above 50 years of both sexes were included in the CDU study from which 56 cases were determined total EICA occlusions. RESULTS: Of these 56 (11.38%) patients with complete occlusion of EICA, men were predominant (81.6%) with mean age of 58.0±14.8 years and sex ratio 2.5:1. Symptomatic EICA was detected in 49 (87.5%) cases with mean age of 57.5±17.6 while asymptomatic EICA was determined in 7 cases (12.5%) with mean age of 48.3±15.3 years. The most frequent identified risk factors were hypertension (87.5%), smoking (63.6%) and coronary artery disease (69.2%)(p

Hemodynamic hemichorea associated with severe stenosis of internal carotid artery

Hemichorea refers to forcible, flowing, involuntary arrhythmic movements on one side of the body. Impaired cerebral perfusion due to internal carotid artery (ICA) stenosis would be a rare cause of hemichorea. We report a patient with hemichorea which was associated with severe stenosis of contralateral ICA. A 61 year old man with multiple myeloma admitted to hematologic department because of febrile sense. At admission, he reported involuntary movement of right hemibody which begun one day ago. Moreover, he had experienced several times of recurrent right side transient motor weakness within last month. As the presence of neck bruit in the left carotid bifurcation, brain MRI with angiography was performed. The MR angiography showed severe stenosis of left proximal ICA. Carotid duplex sonography showed 93% stenosis of left proximal ICA with elevated velocity (782 cm/sec). We prescribed massive hydration with administration of aspirin 300mg and clopidogrel 300mg. Hemichorea was subsided with the treatment. With the finding of decreased vasomotor reactivity in TCD breath holding test, we planned revascularization of the severe carotid stenosis. Carotid artery stenting was successful for the symptomatic carotid stenosis and there was no recurrent hemichorea. Hemichorea is an unusual presentation of extracranial ICA stenosis. In our patient, massive hydration and administration of antiplatelet agent resolved hemichorea, implicating cerebral hypoperfuison was the cause of the hemichorea.

Changes in Carotid Duplex Ultrasound Velocities After Aortic Valve Replacement for Severe Aortic Stenosis.

The peak systolic velocity (PSV) and end-diastolic velocity (EDV) obtained by carotid duplex ultrasound (CDU) imaging of the internal carotid arteries (ICAs) are parameters used to determine the severity of ICA stenosis. Severe aortic stenosis (AS) results in a parvus-et-tardus pattern on spectral Doppler waveforms; however, the impact of severe AS on CDU velocities is unclear. The purpose of this study was to assess the impact of severe AS on CDU velocities by evaluating changes in CDU velocities before and after aortic valve replacement (AVR) METHODS: A single-center retrospective review of patients with severe AS who underwent surgical AVR and who had preoperative and postoperative CDU examinations performed within 12 months of each other was conducted. Patients with any carotid intervention between the preoperative and postoperative CDU were excluded. We identified 92 patients who satisfied all inclusion criteria. The mean age was 72.2 years; 71.7% were men; the mean preoperative aortic valve area ± SD was 0.8 ± 0.2 cm2 ; and the mean time from preoperative to postoperative AVR CDU was 182.3 ± 98.4 days. The peak aortic valve gradient decreased from 62.5 to 22.0 mm Hg after AVR (P < .001); however, there were no significant changes in the PSV or EDV in either the right or left ICA. Although severe AS may cause characteristic changes in the spectral Doppler waveform on CDU imaging, there is no significant effect on the ICA PSV or EDV. Adjustments in velocity criteria to determine the degree of carotid artery stenosis in patients with substantial AS may not be necessary.

EARLY NEUROLOGICAL DETERIORATION IN ACUTE ISCHEMIC STROKE: POTENTIAL PREDICTORS, CAUSES AND RELATION TO INFARCT GROWTH

Background: Worsening of acute stroke early in its course (within 48–72 h of its onset) is a common occurrence and haspotentially serious short term and long term consequences. The incidence of early neurological deterioration (END) amonghospitalized patients varies widely in different studies between 13% and 38%. Aim of the Work: To define incidence and timing of END in relation to acute ischemic stroke (AIS) onset. To identify possible causes and predictors associated with END. To assess the relation between END and the patient functional level at three months post stroke. Patients and Methods: Three hundred patients were recruited into this hospital prospective comparative study. Clinical history,laboratory indices, structural brain imaging, Magnetic Resonance Angiography (MRA) and Carotid Duplex ultrasonography were done. Patients were examined on NIHSS and Glasgow Coma Scale (GCS) in day 1, 2, 3 and patients with END did a follow up (MRI diffusion film or CT brain) at day4 or 5 and all patients were followed up by Modified Rankin scale (MRs) at three-month post stroke. Results: Of the Three hundred patients included in the study, the incidence of END was 16.7%. The median NIHSS on admission was 9.25. END was associated with long duration of DM (P 0.012), IHD (p 0.015), AF (p 0.048), severe stroke (p 0.0044), low blood pressure on admission (p 0.0079), high uric acid (p 0.033) and MCA occlusion(p 0.0007). END was associated with significant increase in MRS at 3 month (p<0.0001) and mortality rate (44% vs 4.4). Patients with END are more prone for aspiration pneumonia (p 0.0001) and hemorrhagic transformation. Conclusion: Early neurological deterioration is a frequent complication after acute stroke, with a poor short-term prognosis. This study provides that hyperglycemia, hyperuricemia and cardiac disease (IHD and AF) may increase the risk of END.

RS04. Ultrasound Surveillance Following Carotid Endarterectomy: Prudent or Pointless?

To assess the usefulness of routine duplex ultrasound (DUS) surveillance following carotid endarterectomy (CEA) with respect to rates, outcomes, and management of carotid restenosis, and to outline the natural history of carotids after CEA. This is a cohort study of patients who underwent CEA at The Ottawa Hospital (TOH) from 2003 to 2018. DUS was completed at TOH's accredited Vascular Diagnostic Center as per protocol (currently performed at 3 and 12 months postoperatively and yearly thereafter). Follow-up DUS and clinical data were obtained from Vascubase and electronic medical records (vOacis). Primary outcomes included time to more than 80% restenosis, post-CEA stroke rate, and number of surgical reinterventions. Statistical analyses involved survival analysis, χ2 and Fisher's exact tests, and a cost-effectiveness analysis. There were 1190 CEAs performed in 1129 patients over the study period. The majority were for symptomatic (78.0%) carotids ranging from 70% to 99% stenosis (93.3%). 769 surgeries (729 patients) had DUS surveillance data available for a mean of 3.52 years. DUS detected more than 80% ipsilateral restenosis in 31 patients (4.03%; Fig 1). There were 34 total postoperative strokes. Twenty-five (73.5%) occurred within 30 days of surgery—before the initial surveillance DUS—and 16 of those occurred within the first 24 hours. No stroke beyond 30 days was attributed to ipsilateral carotid restenosis (Fig 2). As per the TOH post-CEA protocol, the estimated cost of DUS surveillance in this cohort was $359,925.20 total, or $11,610.49 per restenosis. DUS surveillance did not lead to a single ipsilateral redo surgery during this period. Severe carotid restenosis after CEA is rare and not associated with worse outcomes. Despite historical recommendation, TOH's management of severe restenosis has been conservative based on its benign natural history. Routine post-CEA DUS surveillance is costly and unlikely to improve outcomes or affect management, even if more than 80% ipsilateral restenosis is detected. Further research should determine the usefulness of routine contralateral carotid DUS surveillance in this population, who may be at greater risk for severe contralateral carotid disease.Fig 2Stroke etiology for strokes detected beyond 30 days from carotid endarterectomy (CEA). Strokes were attributed to contralateral carotid stenosis/occlusion (n = 5), hypoperfusion (n = 3), and basilar artery occlusion (n = 1). Not a single stroke beyond 30 days was attributed to ipsilateral carotid restenosis. ICA, Internal carotid artery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Is Duplex carotid artery screening prior to CABG justified?

Objectives:To evaluate the use of duplex carotid artery screening in patients undergoing coronary artery bypass graft (CABG).Methods:This descriptive, observational study was conducted in Radiology Department at King Fahad Military Medical Complex, Dhahran, Kingdomof Saudi Arabia from April 2015-2018. All Saudi patients (n=178) who underwent duplex carotid sonography prior to CABG were retrospectively reviewed for essential morphologic and hemodynamic information to estimate severity of extra-cranial internal carotid artery (ICA) stenosis. Patients with combined CABG and cardiac surgery, and those with limited carotid studies were excluded. Advancing age (65 years or above), gender, smoking, obesity, diabetes (DM), hypertension (HTN), dyslipidemia, coronary vessel disease, cardiac disease and previous stroke were recorded. Post-coronary artery bypass graft neurologic event (namely, transient ischemic attack [TIA] or stroke) was recorded. Chi-square test was used to determine association of stenosis degree with post-CABG neurologic event.Results:One hundred twenty eight patients (72%) were having ICA disease, while significant carotid artery stenosis (>70%) was seen in 11 patients (6.2%). Post-coronary artery bypass graft neurologic event was seen in 4.5% of patients. Advancing age, significant ICA stenosis and multi-vessel coronary disease were seen associated with a post-CABG event.Conclusion:Significant ICA stenosis on duplex screening in elderly patients with multi-vessel coronary artery disease or certain risk factors may predict post-CABG stroke.

Peak Systolic Velocity for Calcified Plaques Fails to Estimate Carotid Stenosis Degree

Duplex ultrasonography (DUS), although consolidated as the primary tool for the estimation of carotid stenosis, may be impaired by calcified plaques that promote acoustic shadow (AcS). AcS seems to hamper the quantification of the main parameter used in the determination of percentage stenosis, that is, the maximal peak systolic velocity (PSV) at the lesion site. The aim of our study was to compare the degrees of carotid artery stenosis in DUS/PSV and computed tomography angiography (CTA) in the presence of AcS. During 36months, 1,178 carotid DUS tests were performed. A total of 164 carotids in 139 patients showed AcS resulting from calcified plaques. Carotids with AcS were referred for a second imaging examination; thus, 62 carotids were analyzed by both DUS/PSV and CTA. CTA measured the area reduction at the lesion site to calculate the percent stenosis. PSV was measured immediately after the end of the AcS. According to velocities-based DUS criteria, stenoses were classified as mild (PSV<125cm/s), moderate (125≤PSV≤230cm/s), and severe (PSV>230). CTA and DUS/PSV measurements were compared to determine the accuracy of PSV in characterizing the severity of carotid stenosis with AcS. Of the 62 lesions, PSV characterized 10 as severe, 21 as moderate, and 31 as mild. According to the CTA study, there were 36 severe, 8 moderate, and 18 mild lesions. PSV underestimated in 27.79% the incidence of cases of severe carotid artery stenosis detected by the CTA. In addition, PSV overestimated the incidence of the cases of moderate and mild stenosis in 61.91% and 37.78%, respectively. The agreement ratio between the imaging examinations used in this study was 50%. DUS/PSV discretely correlated with CTA (r=0.668, P<0.0001, 95% confidence interval=0.502-0.786). Using PSVs >125 and>230 as predictors of carotid lesions higher than 50% and 70%, respectively, the sensitivities were 63.3% and 27.8%, the specificities were 100%, the positive predictive values were 100%, and the negative predictive values were 71.9% and 50%. PSV alone is inadequate to quantify carotid stenosis in the presence of calcified plaques and AcS. Another image tool, such as CTA, could be recommendable for clinical decision-making.

Residential Exposure to PM2.5 and Ozone and Progression of Subclinical Atherosclerosis Among Women Transitioning Through Menopause: The Study of Women's Health Across the Nation.

Objective: This article aims to examine the association between long-term ambient air pollution and progression of subclinical atherosclerosis with 2-year follow-up among midlife women from the Study of Women's Health Across the Nation (SWAN). Materials and Methods: Carotid duplex ultrasonography was performed in participants from a SWAN ancillary study carried out at the Pittsburgh and Chicago sites. Mean and maximum carotid intima-media thickness (CIMT) and plaque burden were assessed throughout the common, bulb, and internal carotid artery. The yearly mean exposure to PM2.5 (particulate matter) and ozone was generated based on monitors within 20 km of the participants' home. The effect of air pollutants during follow-up on progression of CIMT was estimated using linear mixed-effects models, and the effect on progression of plaque presence and plaque index, a measure of extent of plaque, was evaluated using logistic regression. Results: This study included 417 (257 White and 160 Black) women with a mean age of 51 years at baseline. A 1 μg/m3 higher yearly mean exposure to PM2.5 during follow-up was associated with a 4.28 (95% confidence interval [CI]: 0.02-8.54) μm/year increase in maximum CIMT, after adjusting for socioeconomic and traditional cardiovascular disease (CVD) risk factors. Exposure to PM2.5 contributed to a 30% (95% CI: 3%-65%) higher odds of plaque index progression adjusting for socioeconomic factors only. Conclusions: PM2.5 independently contributed to progression of subclinical atherosclerosis, among women transitioning through menopause, a time of increasing CVD risk. Yet no significant associations between ozone and subclinical atherosclerosis were observed.

Association between non-high-density lipoprotein cholesterol levels and the prevalence of asymptomatic extracranial internal carotid artery stenosis in a Chinese community-based study.

Extracranial internal carotid artery thromboembolism is one major cause of ischaemic stroke and the predictive value of non-high-density lipoprotein cholesterol (non-HDLC) is superior to low-density lipoprotein cholesterol (LDLC). This study aimed to assess the association between non-HDLC levels and the prevalence of asymptomatic extracranial internal carotid artery stenosis (EICAS) as well as the predictive value of non-HDLC over LDLC on EICAS presence. The Asymptomatic Polyvascular Abnormalities Community study is a subset of the Kailuan study emphasizing asymptomatic polyvascular abnormalities in Chinese adults. A total of 5351 participants, aged ≥40, without history of cardiovascular disease were enrolled in this study. Carotid duplex ultrasonography was carried out for the detection of EICAS. Of the 5351 patients, 2.5% (131/5351) were diagnosed with EICAS (stenosis ≥50%). Univariate analysis showed that non-HDLC is an independent indicator for asymptomatic EICAS [odds ratio (OR) 1.49, 95% confidence interval (CI) 1.17-1.91]; the same result was reached in multivariate analysis after adjustment for confounding factors (OR 1.32, 95% CI 1.00-1.75), especially for people with hypertension (OR 1.52, 95% CI 1.11-2.08), whilst non-HDLC failed to show better predictive value of EICAS than LDLC (OR 1.45, 95% CI 1.02-2.05). Non-HDLC is an independent risk factor for EICAS prevalence, especially for hypertension patients. Although the predictive value of non-HDLC was no better than LDLC on EICAS presence, non-HDLC is still a powerful atherogenic factor and potential therapeutic target for EICAS.

Vascular, Cognitive, and Psychomental Survey on Elderly Recycling Volunteers in Northern Taiwan.

Background: Stroke and dementia represent frequent causes of psychophysical and socioeconomic burdens. We conducted a vascular, cognitive, and psychomental survey involving elderly volunteers at community-based recycling stations in Northern Taiwan.Methods: Recycling volunteers aged ≥60 years were surveyed. We recorded seven parameters, namely (1) body mass index (BMI), (2) fasting glucose, (3) fasting cholesterol, (4) ankle-brachial index (ABI), (5) carotid duplex sonography, (6) five-item Brief Symptom Rating Scale (BSRS-5) score, and (7) eight-item Interview to Differentiate Aging and Dementia (AD8). During the carotid duplex study, we measured the carotid intima-media thickness (CIMT) and the carotid total plaque score (CTPS) of the common and internal carotid arteries.Results: In total, 985 subjects (mean age: 70.8 years) participated in this study. Among these, 81% were women, and 52% were vegetarians. The average ABI, CIMT, and CTPS were higher in men, whereas women had higher cholesterol levels and BSRS-5 scores. Obesity, hypertension, hyperglycemia, and hyperlipidemia were present in 21, 38, 9, and 27% of all subjects, respectively. Carotid plaques with mild (CTPS 1–5), moderate (CTPS 5.1–10), and severe (CTPS > 10) atherosclerosis were detected in 45, 16, and 7% of the subjects, respectively. Mild cognitive impairment (AD8 > 2) was observed in 13% of the subjects, whereas moderate mood disorder (BSRS-5≧10) was observed in only 1% of subjects. Vegetarians had a lower BMI, systolic blood pressure (SBP), cholesterol, CIMT, and CTPS than did non-vegetarians. Substantial predictors of severe atherosclerosis were advanced age (>70 years), male sex, history of heart disease, hyperlipidemia, and currently elevated SBP and cholesterol levels. Predictors of mild cognitive impairment were illiteracy, history of hypertension, hyperlipidemia, and moderate mood disorder.Conclusions: Subclinical carotid atherosclerosis was common in elderly recycling volunteers, with 23% having moderate to severe stenosis. Vegetarians had a reduced risk of atherosclerosis. The low incidence of moderate mood disorder might indicate that recycling work enhances psychomental health. In addition, a healthier lifestyle, better mood condition, and vegetarian diet might contribute to lower incidence of mild cognitive impairment.

The correlation between the carotid artery plaque and the change of aldosterone level related indexes during captopril challenge test

To investigate the correlation between the carotid artery plaque and the change of plasma aldosterone level related indexes during captopril challenge test. The patients with hypertension were enrolled as research objects and the captopril challenge test were carried out when they were hospitalized to screen the cause of hypertension. There were intact carotid artery duplex ultrasonography diagnostic data in them (83 cases). They were divided into the plaque group(57 cases) with carotid artery plaque and no plaque group( 26 cases) without carotid artery plaque according to the carotid artery duplex ultrasonography diagnostic data. The correlation between the carotid artery plaque and the changes of aldosterone concentration, renin activity and aldosterone to renin activity ratio(ARR) in two groups were analyzed. The detection rate of carotid artery plaque was 68.67%. Compare with no plaque group, the patients in plaque group were elder and the level of apolipoprotein A1,(APOA1) was lower (all P＜0.05). The ARR difference value before and after captopril challenge test was lower ( P＜0.05).The aldosterone difference value and the renin activity difference value before and after captopril challenge test were higher in plaque group (all P＜0.05).The aldosterone difference value and the renin activity difference value were positive in plaque group and were negative in no plaque group. The difference value of the ARR was negative in plaque group and was positive in no plaque group. Logistic regression analysis showed that the age, the difference value of ARR and the aldosterone before and after captopril challenge test could be associated independently with carotid artery plaque occurrence after excluding gender difference and other factors. The detection rate of carotid artery plaque was high among hospitalized patients with hypertension, the difference value of ARR and the aldosterone before and after captopril challenge test could be associated independently with carotid artery plaque occurrence.

Diagnosis of internal carotid artery stenosis in a patient referred to a physiotherapist for dizziness

ABSTRACT PURPOSEThe purpose of this report is to describe the diagnostic focus of the clinical decision-making process for a patient referred to a physiotherapist for treatment of persistent dizziness, who was subsequently diagnosed with severe stenosis of the internal carotid arteries. CASE DESCRIPTIONThe patient was a 79-year-old man who was referred to a physiotherapist by his primary care physician for the treatment of persistent intermittent dizziness. The patient’s dizziness began 6 months prior insidiously; it was worsening over time and now interfered with activities of daily living. The patient denied cervical pain or headaches, numbness or tingling in his extremities, difficulty maintaining balance with walking, unsteadiness, muscle weakness, dysphagia, drop attacks, diplopia or dysarthria. At the physiotherapist’s initial evaluation, cervical range of motion was moderately restricted in all motions and his dizziness was elicited with changes in head position. The patient’s neurological examination was unremarkable. Due to positional complaints of dizziness, a Dix–Hallpike test was used to screen for benign paroxysmal positional vertigo, which was positive for symptoms reproduction; however, no nystagmus was noted. The patient also became diaphoretic and exhibited significant discoloration of his face during the test. OUTCOMESDue to concern over vascular compromise, carotid duplex ultrasonography and magnetic resonance angiography were completed and revealed near complete occlusion of the left internal carotid artery at its origin. The patient subsequently underwent a left internal carotid endarterectomy with resolution of symptoms and a return to all activities of daily living. DISCUSSIONCarotid artery stenosis, although frequently asymptomatic until severe, may manifest as complaints of dizziness that mimic peripheral vestibular dysfunction. Appropriate and prudent screening and referral is necessary if clinical symptoms suggestive of vascular compromise are present.

Population-based stroke screening days in the 12th district of Budapest in 2011 and 2016 - What have and what have not changed?

Population-based screening is an option to identify persons at high risk for stroke. However it is associated with rather high expenses, necessitating the selection of effective methods that take local characteristics into account. The 12th district of Budapest has a long tradition of population-based screening for frequent and preventable diseases. The Szent János Hospital hosts an annual stroke screening day. In the present study, previously published data from the 2011 screening were compared with those obtained in 2016, looking for changes and tendencies throughout the examined period. The screening day was conducted in a generally similar way in 2011 and 2016. Similarly to the previous event, the program was organized on a Saturday, the call for the event was spread by the local newspaper. The crew composition was the same. As regards the components of the screening (currently including general history taking, risk status assessment, blood pressure measurement, BMI assessment, cholesterol and blood glucose tests, carotid duplex ultrasonography, and ophthalmological examination), the only difference was the absence of cardiologic examination (it was conducted on an independent day). The anonymous data sheet was the same. The number of participants in the 2016 event was 33, to provide more comfortable conditions. The female predominance was slightly less pronounced but was still present in 2016 (60.6% vs. 72.9%). The mean age became substantially higher (71.2 y vs. 62.9 y). The ratios of participants with higher level of education (97% vs. 94%) and those who are married were still remarkable. The most frequent risk factors were the same; however the ratio of participants with hypertension, 'other heart disease', and diabetes increased, whereas that of with hyperlipidemia and obesity decreased. The incidence of atrial fibrillation was unaltered. None of the participants in 2016 admitted smoking (previously this ratio was 20.8%) or drinking heavily. The findings of the carotid ultrasonography revealed a more favorable vascular status. Ophthalmological assessments (predominantly hypertensive alterations on fundoscopy) revealed that the pathological vs. physiological ratio switched to 1:2 from 2:1. The final evaluation of the screening program likewise demonstrated an improved overall state of health of the population. We observed a more favorable stroke risk status of the population in 2016. Whether it is indeed a tendency unknown at present. The role of the local media in calling for screening is still decisive, and the cohesive power of the family is important.

Duplex ultrasound for the diagnosis of symptomatic carotid stenosis: real value in clinical practice

Background: Atherosclerotic plaque leading to internal carotid stenosis greater than 50%, accounts for about 10 to 15% of all acute ischemic stroke (AIS) causes. Stenosis identification and severity is frequently estimated by Duplex ultrasound (DUS) assessment. Symptomatic carotid disease is defined as focal neurologic symptoms with sudden onset and related to the appropriate carotid artery cerebral distribution. It includes established acute ischemic stroke, one or more transient ischemic attacks characterized by focal neurologic dysfunction or transient monocular blindness, in the preceding 6 months of the carotid stenosis identification. Revascularization should be considered in symptomatic patients with a carotid artery stenosis of 50–69% and recommended in symptomatic patients with a stenosis of 70–99%. In our clinical practice it is seen frequently the indiscriminate use of DUS in the etiological study for AIS. Therefore, we consider the possibility of such an exam being excessively performed, since most patients may have no indication for DUS assessment. Objectives: (1) estimation of symptomatic carotid artery disease prevalence in hospitalized patients with the diagnosis of AIS and ≥ 50% carotid stenosis; (2) determination of carotid artery revascularization in this subgroup of patients; (3) evaluation of the centre clinical practice and to determine a real estimative of the therapeutic impact associated with DUS in patients with AIS. Methods: Retrospective observational cohort study of patients admitted with established AIS within the year of 2017 and followed for an additional 12 month period. Inclusion criteria: a definite diagnosis of AIS (based in symptoms within 24 hours’ period and/or image in CT scan suggestive of AIS), date of hospitalization within the mentioned timeframe and patients who underwent carotid DUS within the first 6 months after the event. No hemorrhagic stroke or transient ischemic attacks were considered in this study. Results: Of the 198 stroke patients, 144 (72%) underwent Doppler ultrasound. The average age was 78 years, 50% were male and 23.6% had previous stroke. From the total 144 included patients, only 18 (12.5%) had stenosis ≥50%, and 9 (6.25%) had ipsilateral lesions to the carotid stenosis. The remaining had lesions contralateral to the stenosis or lacunar strokes. Considering this, 6.25% of patients were assumed to have symptomatic carotid disease. None underwent surgical intervention for various reasons (e.g. high risk procedure, contraindications, high degree disability and/or multiple comorbidities). Conclusions: The present study reinforces the idea that etiological study of AIS is essential, and DUS appears as a first line exam. However, we emphasize that DUS should only be performed in patients with non-disabling AIS (mRS score 0–2) who are candidates for vascular intervention.

Extracranial Carotid Duplex Ultrasonography. Part II - Clinical Utility of Carotid Duplex Ultrasound

Carotid duplex ultrasonography (CDU) is noninvasive and easy to use for evaluation of various carotid artery diseases. Carotid atherosclerosis is a major indication for CDU. CDU can determine the degree of stenosis, plaque characteristics, and intima-media thickness for evaluation and estimation of carotid atherosclerosis, and can be used as a screening and follow-up tool after carotid revascularization. Here, we summarize the clinical indications and utility of CDU based on established evidence. The main topics include: 1) Evaluation and management of symptomatic and asymptomatic carotid atherosclerotic stenosis; 2) surveillance after carotid artery revascularization; 3) screening for cardiovascular risk; 4) perioperative evaluation; 5) evaluation of other diseases including cervical artery dissection, temporal arteritis, Takayasu’s disease, and subclavian artery steal syndrome; and 6) diagnosis of dizziness, vertigo, and syncope. This special review will discuss rational indications and utility of CDU, and will be of interest to clinicians who provide care for patients with various extracranial carotid/vertebral artery diseases. Key words: Carotid duplex ultrasonography; Clinical indication; Clinical utility

Extracranial Carotid Duplex Ultrasonography. Part I - Basic Principles and Standard Examination for Carotid and Vertebral Arteries, and Jugular Veins

Use of ultrasound is safe in humans, and has been widely used in medical applications. B-mode sonography produces cross-sectional images and Doppler sonography measures blood flow velocities. Carotid duplex ultrasonography (CDU) has been mainly utilized in cerebrovascular disease. Recently, its use has been expanded in Parkinson's disease and neuromuscular disease as well as pain management. Point-of-care ultrasound is used in emergency and intensive care settings, and has the advantage of short examination time, relatively low cost, and reproducibility. However, the results may vary depending on the examiner’s skill. Therefore, a standard protocol for examination is needed. This practice guideline discusses basic principles, artifacts, and standard techniques, and thus can improve understanding of CDU for neck vessels. Key words: Carotid duplex ultrasonography; Vertebral artery; Jugular vein; Basic principles of ultrasound; Guideline; Standard examination