Extracranial Carotid Artery Research Articles

Acute periapical dental abscesses and increased risk for extracranial carotid artery aneurysms

Aim: To assess the prevalence of acute periapical abscesses (PAs) in patients with a history of extracranial carotid artery aneurysms (ECAA). Materials and methods: History of acute PAs and ECAA diagnosis was retrieved by searching the appropriate query in the database. All cases were diagnosed for acute PAs by calibrated dentists for patients admitted to urgent care. The odds ratio (OR) for the prevalence of acute PAs and its association with history of ECAA were then calculated. Results: The prevalence of acute PAs in patients with a history ECAA was significantly higher as compared to the general hospital patient population (p < 0.0001). The OR was 5.5. Females were more affected than males by 1.7 folds (p < 0.001). Whites were more affected than African Americans by 1.6 folds (p < 0.00001). Conclusions: The high prevalence of acute PAs in patients with a history of ECAA may suggest an association between these two conditions warranting a thorough medical examination.

ROLE OF NON-CONTRAST MAGNETIC RESONANCE ANGIOGRAPHY IN THE DIAGNOSIS OF THE ATHEROSCLEROTIC LESIONS OF THE EXTRACRANIAL CAROTID ARTERIES

Formation of atherosclerotic plaque in the carotid arteries is the leading factor of hemodynamic disturbance in the cere-bral arteries. Visualization and characteristic of these plaques are most important factors from the viewpoint of preven-tive treatment- surgical or conservative. The goal of this study was to assess sensitivity and specificity of non-contrast MRA in evaluation and characteristics of atherosclerotic plaques in the extracranial carotid arteries. Our data was ob-tained from 130 patients: 38 were female (29.2%) and 92-male (70.8%). The middle age is 54.8 years (range 17-78 years). Patients were subjected to 3 diagnosis procedures, namely 85 patients were investigated by Doppler USG & 45 patients by MRA method. All patients underwent selective cerebral arterial angiography by DSA as a gold standard method. From 130 patients 27 patients had no atherosclerotic disease; 57 had bilateral atherosclerotic changes; 46 pa-tients had monolateral carotid atherosclerotic process. From 260 investigated carotid arteries 51 arteries were detected with complete occlusion (22 right and 21 left occlusion), in 4 patients (8 carotid arteries) bilateral occlusion was seen. 54 carotid arteries had severe degree of stenosis. From this stenosis 27 arteries were more than 90%.32 carotid arteries had moderate degree of stenosis. In 23 carotid arteries mild degree was seen, but in a 100 carotid arteries had complete pa-tency. We concluded that complex noninvasive methods- colored Doppler USG and non-contrast MRA distinguished good accuracy (90%) and may be used as an alternative to DSA.

Aneurysm of Extracranial Internal Carotid Artery: A Case Report

Aneurysms of the extracranial internal artery (ICA) are rare and accountable for about 1% of all cerebral anerysms , it's an uncommon patology, reported in literature as individual case or small series. Aneurysm of extracranial carotid artery etiology is diverse and ranges from athrosclerosis, infection, fibromuscolar dysplasia, connettive tissue desease to traumatic or spontaneous dissection, patch pseudoaneurysm from prior repair. Rupture and thrombo-embolism are two major risk of aneurysm of ICA, wich may lead to acute ischaemic attacks and strokes.

Association of Carotid Artery Intima Media Thickness With Ischemic Stroke Patients

Background: Atherosclerotic risk factors frequently lead to ischemic stroke. The thickness of the carotid intima-media thickness (CIMT) is a significant indicator for early atherosclerosis alterations. The aim of the study is to evaluate the association between ischemic stroke patients and CIMT. Methods: A total of 50 patients were recruited in this cross-sectional descriptive study which was carried out in the Department of Neurology, BSMMU, from January 2015 to June 2016. All patients of ischemic stroke were confirmed by history, examination and CT scan of head/MRI of brain. Carotid ultrasound scan was done to detect intima-media thickness (IMT) of both sided carotid bifurcation, common carotid and internal carotid artery and performed by a single sonographer at the Department of Neurology, BSMMU. Results: This population has a total of 27 male and 23 female with mean age 60.7± 13.6 years. Maximum patients (72%) were found to be above 50 year of age. After risk factor stratification among the study population, HTN, dyslipidemia was the most followed by positive family history, smoker, DM, IHD. Among study population 45 cases were anterior circulation stroke and only 5 cases were posterior circulation stroke. Maximum mean IMT=1.2± 0.3, minimum mean IMT=1.0±0.10 mm and least IMT was 0.7mm. (Normal CIMT value is < 0.8mm). The mean IMT was higher at symptomatic side in comparison to the asymptomatic side. Higher IMT was found mostly at the carotid bifurcation and higher IMT at one site was significantly correlated with other sites (r= +0.435, p=0.002), there was also correlation between IMT and risk factor (r=+0.265, p=0.063). Increased IMT was more marked in patients with risk factors in comparison to without risk factor, like smoker & nonsmoker but not statistically significant (ORR=2.00, 95% CI 0.636- 6.286, p=0.233). Conclusion: The present Study found that extra-cranial carotid artery intima media thickness (IMT) was higher than normal level in ischemic stroke patients. Higher CIMT was found at symptomatic side in comparison to the asymptomatic side. Bangladesh J Medicine 2022; 33: 24-30

Management of extracranial carotid artery stenosis during endovascular treatment for acute ischaemic stroke: results from the MR CLEAN Registry

BackgroundThe optimal management of ipsilateral extracranial internal carotid artery (ICA) stenosis during endovascular treatment (EVT) is unclear. We compared the outcomes of two different strategies: EVT with vs without carotid...

Extracranial Carotid Artery Aneurysms: 20-Year Experience of Surgical Management

Extracranial carotid artery aneurysm (ECAA) is a rare vascularpathology with reported incidence of 0.2-5.0% of all carotid artery surgical interventions. Most of ECAAs remain clinically asymptomatic, however, they can manifest in neurological symptoms as transient ischemic attack or stroke. The presence of a pulsating formation, swallowing disorders, signs of compression of cranial nerves may beindicative of the aneurysm growth, which is associated with higher risk of thromboembolic complications and less oftenwith rupture. Surgical treatment is a method of choice in symptomatic patients or in cases of the aneurysm growth and includes resection with arterial reconstruction, ligation of the artery or endovascular intervention.
 The aim. To improve the results of surgical treatment of ECAAs.
 Materials and methods. The results of clinical examination, laboratory, instrumental, intraoperative observations were analyzed in 39 patients (35 [89.7%] men and 4 [10.3%] women) with 44 ECAAs, who were admitted to the Vascular Surgery Department of Lviv Regional Clinical Hospital for the period from 2003 to 2022. To conϐirm the diagnosis of ECAA, preoperative instrumental examination included duplex ultrasonography and multispiral computed tomography angiography.
 Results. Etiological causes of ECAAs included: atherosclerosis (79.5%),ϐibromuscular dysplasia (7.7%), trauma (5.1%), previous operations in the neck region (5.1%) and infection (2.6%). The justiϐication of the choice of surgical tactics depended on the localization of aneurysm, concomitant carotid occlusive disease or pathological deviation of carotid arteries. Early results of surgical treatment were evaluated up to 30 days of the postoperative period. The postoperative complications included: transient ischemic attack in 1 (2.6%), ischemic stroke in 2 (5.1%), cranial nerve damages in 4 (10.3%), thrombosis of arterial reconstruction in 2 (5.1%), hematoma of postoperative wound in 4 (10.3%), infection of postoperative wound in 1 (2.6%) cases. Postoperative mortality was 2.6%.
 Conclusion. ECAA is a rare clinical disease that requires an active surgical approach to reduce the risk of ischemic stroke. Reconstructive surgery of ECAAs is a highly effective method of treatment that allows to achieve satisfactory results and prevent the development of severe complications.

Automated measurement of carotid angle with use of CT images

Carotid stenosis is an important etiological factor in the forming of ischemic stroke. The weight of stroke which is formed as a result of extracranial internal carotid artery stenosis or occlusion differs according to the location, size of interaction, collateral supply, and the mechanisms those cause interact. Therefore, it is important to measure the narrowness of the carotid with the calculation of the bifurcation angle. In this study, CT cross-sectional image sequences are used. The images are unsupervised classified, and the carotid veins are identified with the boundaries and centers of the clusters. Then, the angles are calculated with three center points of the veins from successive images. The center point of the calculation is from the vein which has the maximum area difference between one of the successive images. The results are evaluated using 5 samples with visual interpretation regarding the position and the correctness of the three successive images which have maximum area jump.

The Natural History of Carotid Artery Occlusions Diagnosed on Duplex Ultrasound

There is a paucity of literature on the natural history of extracranial carotid artery occlusion (CAO). This study reviews the natural history of this patient cohort. This single-institution retrospective analysis studied patients with CAO diagnosed by duplex ultrasound between 2010 and 2021. Patients were identified by searching our office-based IAC accredited vascular laboratory database. Imaging and clinical data were obtained via our institutional Electronic Medical Record. Outcomes of interest included ipsilateral stroke, attributable neurologic symptoms, and ipsilateral intervention after diagnosis. The full duplex database consisted of 5523 patients who underwent carotid artery duplex exam during the study period. The CAO cohort consisted of 139 patients; incidence of CAO was 2.5%. Mean age at diagnosis was 69.7 years; 31.4% were female. Hypertension (72.7%), hyperlipidemia (64.7%), and prior smoking (43.9%) were the most common comorbid conditions. Of the CAO cohort, 61.3% (n=85) of patients were asymptomatic at diagnosis; 38.8% (n=54) were diagnosed after a stroke or transient ischemic attack (TIA) occurring within six months prior to diagnosis, with 21.6% occurring ipsilateral to the CAO and 10.1% occurring contralateral to the CAO. 7.2% (n=10) had unclear symptoms or laterality at presentation. Of the CAO cohort, ninety-five patients (68.3%) had duplex imaging follow-up (mean 42.7±31.3 months). Of those with follow up studies, seven patients (5.0%) developed subsequent stroke ipsilateral to the CAO with mean occurrence 27.8 ±39.0 months post-diagnosis. In addition, five patients (3.6%) developed other related symptoms, including global hypoperfusion, (2.4%) and TIA (1.2%). Of those 95 patients with follow up duplex ultrasound imaging, six (4.3%) underwent eventual ipsilateral intervention, including CEA (n=4), TF-CAS (n=1), and carotid bypass (n=1), with mean occurrence 17.7±23.7 months post-diagnosis. The aggregate rate of ipsilateral CVA, attributable neurologic symptoms, or ipsilateral intervention was 11.5%. Of 95 patients with follow up duplex ultrasound imaging, 5 underwent subsequent duplex studies demonstrating ipsilateral patency, resulting in a 5.3% discrepancy rate between sequential duplex studies. All 6 patients undergoing intervention received periprocedural cross-sectional imaging (MRA or CTA). In 5 of these 6 patients, cross-sectional demonstrated severe stenosis rather than CAO, disputing prior duplex ultrasound findings. In this large, institutional cohort of patients with a CAO diagnosis on duplex ultrasound, a clinically meaningful subset of patients experienced CVA, related symptoms, or intervention. We also found a notable rate of temporal duplex discrepancies among patients with CAO diagnoses, and discrepancies between CAO diagnosis per duplex ultrasound and findings on cross-sectional imaging for those patients who underwent intervention. These results suggest that use of a single duplex ultrasound as a sole diagnostic tool in CAO may not be sufficient, and that physicians should consider close duplex ultrasound surveillance of these patients, potentially in conjunction with additional confirmatory imaging modalities. Further investigation into optimal workup and surveillance protocols for CAO is needed.

888 THE USE OF QFR FOR THE FUNCTIONAL ASSESSMENT OF EXTRACRANIAL INTERNAL CAROTID ARTERY STENOSIS

Abstract Background In asymptomatic patients with haemodynamically significant internal carotid artery stenosis, if endarterectomy cannot be considered, a selective invasive angiography is indicated before deciding for percutaneous revascularization. Sometimes, the angiographic assessment of the stenosis might be discordant with the non-invasive assessment, usually performed with Doppler. Therefore, the use of an angiography-based method that allows a functional assessment of the stenosis could be useful to help the diagnostic-therapeutic process. The aim of this study was to evaluate the diagnostic accuracy of Quantitative Flow Ratio (QFR) in the assessment of extracranial internal carotid artery stenosis. Materials and methods This registry prospectively enrolled asymptomatic patients with an indication to perform a selective angiography of the supra-aortic trunks. The systolic peak velocity obtained by colour Doppler ultrasound was used to determine the hemodynamic significance of the carotid stenosis (PSV> 120 cm / sec), whereas it was defined angiographically significant a stenosis with a %DS > 60%, according to NASCET criteria (%DSNASCET). After three-dimensional reconstruction of the angiographic data, QFR, Area Stenosis (AS%) and the minimum luminal area (MLA, mm2) were obtained. Results 30 consecutive patients were enrolled, and 60 carotid arteries analysed, 8 of which were excluded because of previous percutaneous (n = 3) or surgical (n = 5) revascularization. On linear regression analysis, an inverse linear correlation was observed between QFR and PSV values ​​(r2 = 0.71, p <0.001) and% DSNASCET (r2 = 0.79, p <0.001) (Figure 1). Similarly, the MLA values ​​showed a significant correlation with both PSV and% DSNASCET (respectively, r2 = 0.67 and r2 = 0.75, p <0.001), as well as AS values, which also showed a significant correlation with both PSV and% DSNASCET (respectively, r2 = 0.68 and r2 = 0.88, p <0.001). The QFR and the% DSNASCET showed a comparable and high diagnostic accuracy (AUC = 0.99, p <0.001) using PSV as a reference, with a cut-off value of 0.95 for the QFR (Figure 2). However, considering the% DSNASCET cut-off values, the QFR showed higher diagnostic accuracy, sensitivity and negative predictive value as compared with % DSNASCET. Conclusions This study showed the feasibility of QFR for the assessment of extracranial internal carotid artery stenosis. It was effective indeed for predicting the functional significance of the stenosis considering the Doppler as standard of reference. However, whether revascularization of the carotid stenosis should be guided by QFR rather than the angiography alone has still to be evaluated.

Concurrence of multiple aneurysms, extreme coiling of the extracranial internal carotid artery and ipsilateral persistent primitive hypoglossal artery: A case report and literature review.

The primitive hypoglossal artery (PHA) is an anastomotic vessel of the carotid-basilar artery system that is prevalent only transiently during the embryonic period. Persistent primitive hypoglossal artery (PPHA) is a rare vessel variation in which PHA exists persistently in adulthood and occurs in approximately 0.02-0.1% of the population. Tortuosity of the extracranial internal carotid artery (ICA) is relatively common, impacting 10-43% of the population, and is caused by either congenital or acquired factors. It is still unknown whether PPHA and tortuosity of extracranial ICA are associated. Here, we present a case report of the concurrence of three types of pathologies of the carotid artery: extreme coiling of the extracranial internal carotid artery, multiple aneurysms and persistent primitive hypoglossal artery. A 66-year-old woman suffered intermittent headaches, dizziness and numbness of the right eyelid for 5 years. Magnetic resonance angiography performed in a local hospital reported an aneurysm of the posterior communicating artery segment of the left ICA and a left PPHA. Digital subtraction angiography conducted after admission showed a PPHA originating from the left cervical ICA and an extremely coiling segment of the ICA distal to the beginning of PPHA. Except for the aneurysm of the posterior communicating artery segment of the left ICA, multiple aneurysms were found at the coiling segment of the ICA. To the best of our knowledge, this is the first report of PPHA accompanied by an adjacent, extremely coiling ICA. There are no reports of similar tortuous ICAs to this extent or at this position. Including aneurysms, three types of pathologies suggest their congenital origin, and a review of the literature infers the probable association of these lesions.

The joint association of arteriosclerosis and plasma amyloid with cognitive function: the population‐based Rotterdam Study

AbstractBackgroundAlzheimer's disease and vascular brain injury are the most common causes of dementia, and are present jointly in 40% of individuals at time of death. Yet, the interaction between Alzheimer's and vascular pathology on cognition is largely undetermined. We studied the interaction between arteriosclerosis and plasma biomarkers of Alzheimer's disease on cognition in a general population without dementia.MethodOn stored plasma samples, obtained between 2002‐2005, we measured plasma levels of amyloid‐β40 and amyloid‐β42 by Simoa assay in 2252 participants of the population‐based Rotterdam Study (mean age: 68.9 years, 52% women). Arteriosclerosis was assessed using arterial calcification volumes that were quantified (semi‐)automatically on unenhanced computed tomography (CT). We captured the systemic burden of calcification, using a principal component analysis of calcification volumes in 4 different arterial vessel beds (intracranial and extracranial carotid arteries, coronary arteries and aortic arch). Cognitive assessment included the verbal fluency test, the letter‐digit substitution task, a 15‐word learning test, the Stroop test, and Purdue pegboard task. Global cognition (g‐factor) was calculated using a principal component analysis of these tests. We then determined the interaction between plasma amyloid‐β and calcification on cognitive performance, using multivariable linear regression models.ResultPlasma levels of amyloid‐β and systemic arteriosclerosis were both associated with poorer cognitive performance. After mutual adjustment in multivariable models only calcification remained significantly associated (beta [95%CI] for g‐factor per 1‐SD increase in amyloid‐β40: ‐0.02 [‐0.07; 0.03]; amyloid‐β42: 0.03 [‐0.01; 0.08]; and calcification burden: ‐0.06 [‐0.09; ‐0.04]). The association between amyloid‐β and cognition was stronger in individuals with higher burden of calcification (Figure 1), particularly for amyloid‐β40 (interaction amyloid‐β40×calcification: p = 0.04; amyloid‐β42×calcification: p = 0.001). Results were broadly similar across cognitive tests. The observed interaction between amyloid‐β40 and calcification volume was most profound for calcification burden in the intracranial carotid artery and aortic arch.ConclusionArteriosclerosis and amyloid‐β display synergistic effects on cognition in the general population. This interaction was more profound for amyloid‐β40 than for amyloid‐β42, suggesting our observations may relate particularly to amyloid angiopathy.

Large Carotid Aneurysm: An Illustrative Case of Open Surgical Repair

Abstract Background Extracranial carotid artery aneurysms are rare and are often localized at the level of the carotid bulb or in the distal internal carotid artery. Generally asymptomatic until an embolic event or a local compression reveals their presence, the rupture is rare. Case Report We presented a case of a 68-year-old female referred to our hospital for a pulsatile mass on the right side of her neck with no other symptoms. The patient had a history of hypertension that was medically controlled. The duplex ultrasound confirmed the presence of a large internal carotid aneurysm. Angiotomography shows a large 5 cm diameter type 1 aneurysm of the right internal carotid artery and a type 1 2.7 cm diameter of the left carotid artery. Open surgery with aneurysmal resection and direct end-to-end anastomosis was performed with an uneventful course. Conclusion This is an illustrative case of managing large carotid aneurysms by open surgery.

Multi-institutional patterns of clopidogrel response among patients undergoing transcarotid artery revascularization.

Current guidelines recommend dual antiplatelet therapy (DAPT) in patients undergoing carotid artery stenting. The most common DAPT regimen is aspirin and clopidogrel, a P2Y12 receptor antagonist; however, the prevalence of clopidogrel resistance (CR) in patients undergoing percutaneous coronary interventions may exceed 60%. Few studies have investigated the prevalence and impact of CR in patients undergoing extracranial carotid artery stenting, particularly transcarotid artery revascularization (TCAR). Consecutive high-risk patients ≥ 18years who underwent TCAR for high grade (≥70%) and/or symptomatic (≥50%) carotid stenosis with preoperative P2Y12 testing between August 2019 and December 2021 were identified across five institutions. Preoperative platelet reactivity was measured with the VerifyNow P2Y12 Reaction Unit (PRU) Test (Instrumentation Laboratory, Bedford, MA), with CR defined as PRU ≥ 194 and hyper-response as PRU <70. Patients without preoperative P2Y12 testing within 30days prior to TCAR or those on a non-clopidogrel P2Y12 inhibitor preoperatively were excluded. The primary outcome of interest was prevalence of CR. Secondary outcomes of interest included the incidence of ischemic and hemorrhagic complications. Of 92 patients identified, the majority were male (59%) and Caucasian (75%) with a mean age of 75years (±8, range 56-92). Preoperatively, 93% of patients were on aspirin, 100% on clopidogrel, and 13% on therapeutic anticoagulation. At presentation, 36% were symptomatic. The mean preoperative P2Y12 was 156 PRU (±76, range 6-349). In total, 30 (33%) patients met criteria for CR (mean PRU 240 ± 37; range 197-349), and 15 (16%) met criteria for hyper-responder (mean PRU 38 ± 20; range 6-68). There was no significant difference by clopidogrel response phenotype in terms of sex (p = 0.246), race (p = 0.384), or symptomatic presentation (p = 0.956). Postoperatively, the cumulative incidence of stroke and MI was 2.1%, with no statistically significant difference in the incidence of in-hospital stroke (PRU 238, p = 0.489) or MI (PRU 168, p = 1) between clopidogrel phenotypes. Three (3.3%) patients, one CR (PRU 240) and two responders (PRU 119 and PRU 189), experienced postoperative access site hematomas that required no subsequent intervention. No other index hospitalization hemorrhagic complications occurred. Using preoperative P2Y12 testing with a threshold PRU ≥ 194 to define CR, we identified a high prevalence of CR in patients undergoing TCAR similar to that in the pre-existing coronary literature. We found no significant differences in postoperative ischemic or hemorrhagic complications by clopidogrel response phenotype, although complication rates in the overall study cohort were low. CR may be a spectrum from responder to partial responder to complete non-responder, and this may account for the differences in our CR cohort compared to the ROADSTER 2 protocol deviation cohort. Further investigation is warranted to determine if a quantitative assessment of CR is sufficient to identify patients at risk of developing secondary cerebrovascular ischemic events in this patient population.

Outcomes of carotid stenting in patients with fibromuscular dysplasia

ObjectiveFibromuscular dysplasia (FMD) is a noninflammatory arterial disease that affects the extracranial carotid arteries in young patients. The ideal treatment of FMD has continued to be debated, and the role of carotid artery stenting (CAS) is controversial. The aim of the present study was to assess the feasibility and outcomes of CAS for patients with FMD. MethodsA retrospective analysis of patients who had undergone CAS was performed using the Vascular Quality Initiative database from December 2012 to May 2021. Patients who had undergone CAS for atherosclerosis and FMD were included and matched 1:1 by age, gender, and clinical presentation. The demographics, clinical parameters, and procedural data were analyzed. The end points included postoperative stroke and transient ischemic attack (TIA), and adverse events (perioperative and 1-year mortality, neurologic changes, access site complications, hematoma or bleeding, infection, congestive heart failure, arrhythmia, myocardial infarction, reperfusion symptoms), and hospital length of stay. ResultsAfter matching, 55 patients had undergone CAS for FMD (mean age, 58.7 ± 14 years; 62% women; 69% White; mean body mass index, 28 ± 6 kg/m2). Most of these procedures (69%) were elective. The FMD group had had a lower rate of hypertension (55% vs 82%; P = .002), smoking (35% vs 80%; P < .001), diabetes (13% vs 45%; P < .001), and coronary artery disease (9% vs 45%; P < .001) compared with the non-FMD group. In the FMD group, prior TIA and stroke was identified in 39 (71%) and 31 (57%) patients, respectively. The mean interval from a prior stroke or TIA to the index surgery was 160 days. Additionally, 23 patients (42%) had had anatomically high lesions above the level of the second cervical vertebra. In the FMD group, the transfemoral approach was used for 43 patients (78%), with distal embolic protection used for 40 patients (93%). Flow reversal was used for nine patients (23%). Most cases were performed with local anesthesia (58%). Three patients (6%) in the FMD group had had access site complications that were managed nonoperatively. No differences were found between the FMD and non-FMD groups in perioperative stroke, TIA, or 30-day mortality. The length of stay was similar between the two groups, and the 1-year survival was 100% for both groups. All the patients in the FMD group were discharged without neurologic complications, and 50 patients (91%) were receiving dual antiplatelet therapy. The median follow-up was 328 days (interquartile range, 1-732 days) with no mortality or reinterventions during follow-up. ConclusionsCAS for FMD is a feasible and safe procedure with favorable technical success, a low incidence of neurologic complications, and good clinical outcomes at 1 year of follow-up.

Impact on Silent Infarct Incidence of Early Screening of the Extracranial Portion of the Internal Carotid in a Longitudinal Cohort-Study of Children with Sickle Cell Anemia

Background Kaplan-Meier (KM) estimated cumulative incidence of silent cerebral infarcts (SCI) in a SCA-newborn cohort with sickle cell anemia (SCA) early screened by transcranial-color-Doppler-ultrasound (TCD-US) was shown to be high, despite initiation of chronic transfusion (CT), in children detected at risk by TCD, i.e., 28.2% by age 8, 37.4% by age 14, and an incidence of 3.4/100 patient-years (Bernaudin et al Blood 2011). We hypothesized that adding early extracranial Internal Carotid Artery (eICA) assessment would contribute to reducing SCI incidence. Patients and Methods TCD-US was systematically performed since May 1992 in our pediatric sickle cell anemia (SCA) cohort. Cerebral MRI/MRA was assessed every two years after age 5, or earlier in children on CT for abnormal time-averaged mean velocity (TAMV). eICA-color-Doppler-ultrasound and neck-MRA were added since June 2011. The highest TAMV in middle, anterior, posterior, basilar, intra and extracranial internal carotid cerebral arteries were recorded. Abnormal intracranial and eICA TAMV were defined as ≥ 200 cm/s and ≥ 160 cm/s, respectively. Stenosis was defined as a ≥ 25% decrease in the lumen of arteries. SCI was defined as an hyperintensity focus of at least 3 mm diameter, visible in two planes on FLAIR MRI. Genetic markers (alpha and beta genes, G6PD activity) and baseline biological parameters were recorded during the 2nd year of life before intensive therapy, and away from crisis and transfusion. Hospitalizations, annual check-up data, Doppler, MRI/MRA assessments and events (abnormal-TAMV, intra or extracranial stenosis and SCI) were prospectively recorded. CT was systematically applied in children with TAMV ≥ 200 cm/s for any artery and children with normalized TAMV and no stenosis were switched to hydroxyurea (HU) with CT overlap until reaching the maximal tolerated dose. For children with eICA TAMV 160-199 cm/s, neck-MRA was performed, and CT applied in those with eICA-stenosis while the others were given HU. Moreover, HU was initiated in children with frequent crises or baseline hemoglobin < 7g/dL. Stem cell transplantation was performed in children with cerebral vasculopathy and in those with frequent crises despite HU treatment. Cerebral arteriopathy was defined by history of abnormal intracranial or eICA TAMV or of intra or extracranial stenosis. Results We analyzed data updated in 7/2019 from stroke-free SCA children, born between 11/1992 and 8/2015, all assessed with cerebral MRI/MRA, including neck-MRA (n=338). Median (range) age at first and last cerebral MRI was 5.3 (1.8-16.6 yr) and 11.1 (2.8-19.9 yr), respectively, providing 3866 patient-years of MRI follow-up. SCI occurred in 65/388 SCA-children at median age of 6.4 (1.8-17.9 yr). Incidence of SCI was 65/3866 or 1.7/100 patient-years. The KM-estimated cumulative incidence of SCI was 15.1% (95%CI: 10.9-19.3%) by age 8 and 25.7% (95%CI: 19.7-31.7%) by age 14. Intracranial and isolated eICA-arteriopathies were present in 110/338 and 54/338 patients, respectively. SCI were significantly associated with the presence of intra or extracranial arteriopathy (Fisher test, p=0.013) as 41/65 children with SCI had intra or extracranial arteriopathy (20 isolated intra, 15 isolated extra and 6 intra and extracranial), while in the other 24 patients, 5 had history of conditional TAMV, 11 of acute anemia and 8 of recent acute chest syndrome. At first cerebral MRI, the multivariate Cox regression analysis retained as significant and independent predictive risk factors for SCI, baseline high reticulocyte count [HR=1.005 (95%CI: 1.002-1.008); p=0.004] and LDH [HR=1.001 (95%CI :1.001-1.002); p=0.001]. Discussion This long-term longitudinal study shows a reduction of the risk of SCI with time. The addition of eICA-assessment allowed the detection of isolated extracranial arteriopathy in 54 patients, with 15 who had SCI. The earlier HU initiation reducing the risk of ACS, acute anemia and hemolytic rate, along with detection of isolated eICA assessment and the use of transplantation in children with cerebral arteriopathy have most likely contributed to this overall improvement. Nevertheless, we suggest that initiating CT in patients with eICA-TAMV 160-199 cm/s, even in the absence of eICA stenosis, as done for intra- and extracranial-TAMV ≥ 200 cm/s, could further reduce SCI risk. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Prevalence of carotid artery stenosis with coronary artery disease in Japanese patients: A single-center study

There are a few reports of the prevalence of extracranial internal carotid artery stenosis (ICAS) in Asian patients with coronary artery disease (CAD). This was a prospective registry study of 157 consecutive Japanese patients undergoing coronary angiography that aimed to determine the prevalence of extracranial ICAS in recent Japanese patients. The associations between ICAS and the extent or the maximal stenosis of CAD were also investigated. The 131 eligible patients with suspected CAD were prospectively analyzed. Their mean age was 69.0 ± 8.2 years, and 75.6% were males. A total of 111 patients (84.7%) were angiographically diagnosed with CAD. ICAS (area stenosis ≥50% on ultrasonography) was present in 9 patients, and the prevalence in patients with CAD was 8.1%. All patients in the ICAS group had CAD, and this group was significantly more likely to have a history of stroke (p = 0.03). Although no significant relationships were found between the severity of ICAS and the maximal stenosis of CAD, the severity of ICAS increased gradually with the extent of CAD. The prevalence of ICAS in patients with CAD treated with current medical treatment was relatively low (8.1%) compared to previous reports, and the severity of ICAS was significantly associated with the extent of CAD.

Predicting early mortality following single-stage coronary artery or valve surgery and carotid endarterectomy.

Surgical management of coexisting cardiac disease and extra-cranial carotid artery disease is a controversial area of debate. Thus, in this challenging scenario, risk stratification may play a key role in surgical decision making. To report the results of single-stage coronary/valve surgery (CVS) and carotid endarterectomy (CEA), and to identify predictive factors associated with 30-day mortality. This was a multicenter, retrospective study of prospectively maintained data from three academic tertiary referral hospitals. For this study, only patients treated with single-stage CVS, meaning coronary artery bypass surgery or valve surgery, and CEA between March 1, 2000 and March 30,2020, were included. Primary outcome measure of interest was 30-day mortality. Secondary outcomes were neurologic events rate, and a composite endpoint of postoperative stroke/death rate. During the study period, there were 386 patients who underwent the following procedures: CEA with isolated coronary artery bypass graft in 243 (63%) cases, with isolated valve surgery in 40 (10.4%), and combination of coronary artery bypass grafting and valve surgery in 103 (26.7%). Postoperative neurologic event rate was 2.6% (n = 10) which includes 5 (1.3%) transient ischemic attacks and 5 (1.3%) strokes (major n = 3, minor n = 2). The 30-day mortality rate was 3.9% (n = 15). Predictors of 30-day mortality included preoperative left heart insufficiency (odds ratio [OR]: 5.44, 95% confidence interval [CI]: 1.63-18.17, p = .006), and postoperative stroke (OR: 197.11, 95%CI: 18.28-2124.93, p < .001). No predictor for postoperative stroke and for composite endpoint was identified. Considering that postoperative stroke rate and mortality was acceptably low, single-stage approach is an effective option in such selected high-risk patients.

Clinical Outcomes of Extracranial Carotid Artery-Related Stroke Eligible for Mechanical Reperfusion on Top of Per-Guidelines Thrombolytic Therapy: Analysis from a 6-Month Consecutive Patient Sample in 2 Centers.

BACKGROUND Systemic intravenous thrombolysis and mechanical thrombectomy (MT) are guideline-recommended reperfusion therapies in large-vessel-occlusion ischemic stroke. However, for acute ischemic stroke of extracranial carotid artery origin (AIS-CA) there have been no specific trials, resulting in a data gap. MATERIAL AND METHODS We evaluated referral/treatment pathways, serial imaging, and neurologic 90-day outcomes in consecutive patients, presenting in a real-life series in 2 stroke centers over a period of 6 months, with AIS-CA eligible for emergency mechanical reperfusion (EMR) on top of thrombolysis as per guideline criteria. RESULTS Of 30 EMR-eligible patients (33.3% in-window for thrombolysis and thrombolysed, 73.3% male, age 39-87 years, median Alberta Stroke Program Early Computed Tomography Score (ASPECTS) 10, pre-stroke mRS 0-1 in all, tandem lesions 26.7%), 20 (66.7%) were EMR-referred (60% - endovascular, 6.7% - surgery referrals). Only 40% received EMR, nearly exclusively in stroke centers with carotid artery stenting (CAS) expertise (100% eligible patient acceptance rate, 100% treatment delivery involving CAS±MT with culprit lesion sequestration using micronet-covered stents). The emergency surgery rate was 0%. Baseline clinical and imaging characteristics did not differ between EMR-treated and EMR-untreated patients. Ninety-day neurologic status was profoundly better in EMR-treated patients: mRS 0-2 (91.7% vs 0%; P<0.001); mRS 3-5 (8.3% vs 88.9%; P<0.001), mRS 6 (0% vs 11.1%; P<0.001). CONCLUSIONS In a real-life AIS-CA setting, the referral rate of EMR-eligible patients for EMR was low, and the treatment rate was even lower. AIS-CA revascularization was delivered predominantly in stroke thrombectomy-capable cardioangiology centers, resulting in overwhelmingly superior patient outcome. Large vessel occlusion stroke referral and management pathways should involve centers with proximal-protected CAS expertise. AIS-CA, irrespective of any thrombolysis administration, is a hyperacute cerebral emergency and EMR-eligible patients should be immediately referred for mechanical reperfusion.

Combined effects of hypertension, hyperlipidemia, and diabetes mellitus on the presence and severity of carotid atherosclerosis in community-dwelling elders: A community-based study.

Hypertension, hyperlipidemia, and diabetes mellitus (DM) are common cardiovascular disease (CVD) comorbidities and well-known major determinants of atherosclerosis. However, their combined effects and relative contributions have not been well explored. This study aimed to characterize the characteristics of carotid atherosclerosis and dissect the relative effects of these common CVD comorbidities on the presence and severity of carotid atherosclerosis in community-dwelling elderly individuals. We enrolled 817 elders from communities in northern Taiwan. We evaluated their cardiovascular risk profiles and scanned their extracranial carotid arteries using high-resolution ultrasonography systems. The prevalence rates for hypertension, hyperlipidemia, and DM were 45.4%, 37.1%, and 16.8%, respectively. Sixty-two (7.6%) and 188 (23.0%) elderly had all three and two of these common CVD comorbidities, respectively. The prevalent rates of carotid plaque and moderate-to-severe atherosclerosis were 62.9% and 35.5%, respectively. The percentages of one or more common CVD comorbidities in elders with carotid plaque and moderate-to-severe atherosclerosis were 78.2% and 83.1%, respectively. Multivariate analyses showed that the number of common CVD comorbidities was the most predictive determinant. Multivariable-adjusted odds ratios (ORs) per comorbidity for the presence of carotid plaque and advanced carotid atherosclerosis were 1.52 (95% CI, 1.28-1.81) and 1.57 (95% CI, 1.28-1.93), respectively. Models containing hypertension and DM were the second most predictive. Combinatory analyses showed distinct relationship patterns between carotid atherosclerosis and hypertension, hyperlipidemia, and DM. Hypertension was significantly correlated with higher ORs for the presence of carotid plaque and advanced carotid atherosclerosis but not for hyperlipidemia. Carotid plaques are highly prevalent in community-dwelling elders. The number of common CVD comorbidities was the most predictive determinant of carotid plaques and advanced carotid atherosclerosis. Our results indicate that to reduce the impact of atherosclerotic diseases, blood pressure controls precede the control of blood lipids and glucose in the community-dwelling elders.

Management of asymptomatic carotid artery stenosis in patients with coexistent unruptured intracranial aneurysms

Intracranial aneurysms are found incidentally in approximately 2% to 5% of patients undergoing cerebral imaging for extracranial carotid artery disease. These are generally located in the middle or anterior cerebral and communicating arteries. Most are asymptomatic, and when a patient presents with symptoms, it is most often with subarachnoid hemorrhage. Asymptomatic intracranial aneurysms have an overall 5-year risk of hemorrhage of 10% to 20%, which may result in major neurological morbidity and mortality.