Extracranial Carotid Artery Research Articles

Transcarotid Stenting of Extracranial Carotid Artery Aneurysm With Covered Stents and Flow Reversal

Transcarotid Stenting of Extracranial Carotid Artery Aneurysm With Covered Stents and Flow Reversal

Duplex Ultrasound and Cross-sectional Imaging in Carotid Artery Occlusion Diagnosis

Investigations into imaging modalities in the diagnosis of extracranial carotid artery occlusion (CAO) have raised questions about the intermodality comparability of duplex ultrasound (DUS) and cross-sectional imaging. This study examines the relationship between DUS and cross-sectional imaging diagnoses of extracranial CAO. This single-institution retrospective analysis studied patients with CAO diagnosed by DUS imaging from 2010 to 2021. Patients were identified in our office-based accredited vascular laboratory database. Imaging and clinical data were obtained via our institutional electronic medical records. Our 140-patient cohort is characterized in Table I. A total of 95 patients (67.9%) had DUS follow-up (mean: 42.7 ± 31.3 months). Seventy-five patients (53.6%) had cross-sectional imaging of the carotids after CAO diagnosis; 18 (24%) underwent magnetic resonance angiography and 57 (76%) underwent computed tomography. Indications for cross-sectional imaging included follow-up of DUS findings of carotid stenosis/occlusion (44%), stroke/transient ischemic attack (16%), other symptoms (12%), preoperative evaluation (2.7%), unrelated pathology follow-up (9.3%), and outside institution imaging with unavailable indications (16%). When comparing patients with cross-sectional imaging and those without, there were no differences with regard to symptoms at diagnosis, prior neck interventions, or hypertension. There was a significant difference between cross-sectionally imaged and nonimaged patients in antihypertensive medications (72% vs 53.8%, P = .04). Despite initial DUS diagnoses of carotid occlusion, 10 patients (13.3%) ultimately had cross-sectional imaging indicating nonoccluded carotids. Six of these 10 patients had stenoses of approximately 99%, one patient had 70% to 99%, one had 50% to 69%, and one had less than 50% on cross-sectional imaging. A total of 7 patients had discordant cross-sectional imaging within 1 month of DUS CAO diagnosis. The imaging comparison is displayed in Table II. When using cross-sectional imaging as confirmatory imaging, DUS imaging has a negative predictive value of 86.6% for the diagnosis of CAO within our cohort. In our experience, duplex diagnosis of CAO is associated with a greater than 10% discordance when compared with cross-sectional imaging. These patients may benefit from closer surveillance as well as confirmatory CT or magnetic resonance angiography. Digital subtraction angiography may be helpful in elucidating contributing factors to these imaging discrepancies.Table IPatient characteristics (N = 140)DemographicsValue, n (%)Mean age at diagnosis, years69.7 (47.8-91.2)Female44 (31.4)Comorbidities Active smoking21 (15.0) Prior smoking61 (43.6) Hypertension101 (72.3) Hyperlipidemia90 (63.6) Diabetes mellitus38 (27.1) Coronary artery disease8 (5.7) Chronic kidney disease43 (30.7) Cognitive decline5 (3.6)Medications at diagnosis Antihypertensive88 (63.4) Aspirin85 (60.7) Statin94 (67.1) P2Y12 inhibitor33 (23.6) Anticoagulation16 (11.4) Open table in a new tab Table IIComparison of cross-sectional imaging to initial ultrasoundOccluded on duplexTotalPatent on cross-sectional imaging10 (false negatives)10Occluded on cross-sectional imaging65 (true negatives)65Total75 Open table in a new tab

Hyperacute stenting and angioplasty for acute extracranial non-tandem internal carotid artery strokes within the first 48 h: A 20-year experience and a systematic review and meta-analysis.

Acute strokes involving complete, isolated occlusion of the extracranial cervical internal carotid artery (EC-ICA) with no intracranial clot burden account for a minority of stroke cases that are managed variably. Here we present our two-decade experience and a systematic review of endovascular management of acute isolated EC-ICA strokes in the hyperacute phase (<48 h) and attempt to evaluate clinical effectiveness and safety. Our prospectively maintained database was retrospectively searched for patients who presented between January 1, 2003 and December 31, 2022 with acute cervical ICA stroke confirmed on angiography. Only patients who had an isolated 100% occlusion of the cervical ICA segment and attempted acute stenting with/without angioplasty within the first 48 h of time since last known well were included. Demographics, procedural details, and outcomes were recorded. For the systematic review, a search of PubMed and Embase databases was conducted. Forty-six patients with acute, isolated EC-ICA occlusive stroke were included. Median presenting National Institutes of Health Stroke Scale (NIHSS) score was 8 (interquartile range 3-10) with a perfusion deficit in 78.3% of the 40 cases assessed with computed tomography perfusion imaging. Median time from symptom onset to intra-arterial puncture was 14.4 h. Immediate recanalization was achieved in 82.6% cases. Two cases (4.3%) of symptomatic intracranial hemorrhage (sICH) occurred postprocedure. Outcome measures were stable or improved discharge NIHSS score in 86.9% of cases, functional independence at 90 days (modified Rankin scale score ≤2) in 78.3%, and mortality in 6.5%. The systematic review included 167 patients from four articles. The estimated rate of immediate recanalization was 92.7% (95% confidence interval (CI), 88.77-96.77%), favorable outcome was 62.01% (95% CI, 55.04-69.87%), and sICH was 6.2% (95% CI, 3.41-11.32%). Stenting and angioplasty for acute cervical ICA occlusive strokes during the hyperacute phase can be performed successfully with favorable clinical outcomes and an acceptable recanalization rate.

Association Between Spotty Calcification in Nonstenosing Extracranial Carotid Artery Plaque and Ipsilateral Ischemic Stroke.

Background Small spotty calcifications in the coronary arteries are associated with an increased risk of myocardial infarction. We examined the association between spotty calcifications near the carotid bifurcations and ipsilateral ischemic stroke in patients with <50% luminal stenosis of the extracranial carotid arteries. Methods and Results We used data from the CAESAR (Cornell Acute Stroke Academic Registry), a prospective registry of all patients with acute ischemic stroke admitted to our institution. We included patients who met criteria for cryptogenic stroke and underwent computed tomography angiography and brain magnetic resonance imaging. Patients with extracranial carotid artery stenosis ≥50% and patients with posterior or bilateral anterior circulation infarcts were excluded. We examined the carotid bifurcations for spotty calcifications, defined as ≥1 contiguous regions of luminal calcification ≤3 mm along the long axis of the vessel. We also measured low-density plaque and maximum plaque thickness. The eligible cohort consisted of 117 patients with a mean age of 66.7±1.65 years with a median National Institute of Health Stroke Scale stroke at the time of arrival of 6 (range, 3-13). The number of spotty calcifications present within a low-density plaque was significantly associated with ipsilateral infarction (0.3±0.8 versus 0.1±0.4, P=0.02). Maximum plaque thickness was also significantly associated with ipsilateral infarction (1.4 mm ±1.5 versus 1.0 mm ±1.1, P=0.004). Conclusions Spotty calcifications associated with low-density plaque and maximum plaque thickness were associated with ipsilateral ischemic stroke in patients with nonstenotic carotid atherosclerosis, suggesting a role as imaging markers of high-risk plaque.

Diagnostic potential of routine brain MRI and high-resolution, multi-contrast vessel wall imaging in the detection of internal carotid artery dissection.

Cervical artery dissection (CAD) is one of the major causes of stroke and most commonly occurs at the site of the extracranial internal carotid artery (ICA). This study aimed to assess the value of routine brain MRI, clinical information, and high-resolution, multi-contrast vessel wall MR imaging (hrVWI) for the timely detection of ICA dissection. A total of 105 patients with CAD and 105 without CAD were recruited for this study. The lesion type in the patients was determined based on images from different modalities, including brain MRI, magnetic resonance angiography (MRA), computed tomography angiography (CTA), digital subtraction angiography (DSA), ultrasonography, and hrVWI and clinical information. Each lesion was reviewed to determine the type following a stepwise procedure by referring to (1) brain MRI only; (2) brain MRI and clinical information; (3) hrVWI only; and (4) hrVWI, CTA, DSA, and clinical information. Typical clinical presentations of patients with potential CAD include headache, neck pain, and/or Horner's syndrome. Representative imaging signs in the brain MRI included a crescentic or circular iso- or hyperintensity around the lumen, a curvilinear and isointense line crossing the lumen, or aneurysmal vessel dilation. Based on brain MRI alone, 54.3% (57/105) of the patients with CAD were correctly classified, and the accuracy increased to 73.3% (77/105) when clinical information was combined (P < 0.001) with high specificity and low sensitivity. Further analysis showed that hrVWI had the superior capability in detecting CAD, with a sensitivity and a specificity of 95.1% and 97.0%, respectively. The combination of brain MRI and clinical information could be used for the diagnosis of CAD; however, hrVWI should be sought for uncertain cases.

Preclinical atherosclerotic burden in carotid and lower extremity arteries in adults with congenital heart disease.

Background: Over 90% of patients with congenital heart defects now reach adulthood, due to significant medical advances in recent decades. With advancing age, the risk of acquired cardiovascular diseases increases in addition to the already existing risk due to the congenital defect. The aim of this study was to evaluate the prevalence of atherosclerotic lesions in carotid and lower extremity arteries in adults with congenital heart disease (ACHD). Patients and methods: A total number of 108 ACHD patients (40.6±15.0 years, 50.0% male) and 22 healthy controls (39.3±16.6 years, 40.9% male) were included in this prospective study and underwent a comprehensive angiological examination that included vascular strain analysis on the common carotid artery. Results were stratified by the underlying ACHD lesion groups: shunt lesions (n=26), left-sided obstructive lesions (n=29), right-sided lesions (n=26) and complex lesions (n=27). Results: Colour-coded duplex sonography revealed atherosclerotic lesions in lower extremity arteries in 19 ACHD patients (17.6%). This prevalence did not significantly differ from the one assessed in controls (13.6%, p=0.77). All cases were asymptomatic and therefore classified as Fontaine stage I. 20.4% of ACHD patients presented atherosclerotic lesions in extracranial carotid arteries; amongst controls, the corresponding proportion was 18.4% (p=1.00). No significant differences were observed in atherosclerotic burden in extracranial carotid and lower limb arteries across the four ACHD patient groups (p=0.67 and p=0.89, respectively). Vascular strain analysis revealed no differences between patients and controls. Though circumferential strain varied over ACHD groups (p<0.05), comparison of strain measurements across all specific underlying defect subgroups revealed no significant difference for any of the studied strain parameters. Conclusions: ACHD patients present an atherosclerotic burden in extracranial carotid and lower limb arteries and a vascular stiffness that is comparable to healthy controls.

Systemic arterial calcium burden in patients with chronic limb-threatening ischemia

Introduction5-year mortality of chronic limb-threatening ischemia (CLTI) is 50–60% and coronary artery disease (CAD) is the main cause of death of CLTI patients, followed by stroke. The aim of this study is to quantify and qualify the calcium load in different arterial territories in patients with CLTI. MethodsProspectively, 60 patients with CLTI were included and received a full-body CT scan. 6 patients were excluded. Different arterial territories (the peripheral lower extremity arteries, coronary arteries, extracranial and intracranial carotid arteries, thoracic and abdominal aorta) were analyzed. Analysis and interrelations of both quantitative and semi-quantitative CT measurements was performed. ResultsMean age was 72 years (range 47–95; SD 11.4). Almost all CLTI patients had calcified arterial beds (femoropopliteal 100%, crural 98.1%, coronary 100%, carotid bifurcation 96.2%, internal carotid artery 98.1%, thoracic aorta 96.2%, abdominal aorta 92.3%). Nearly all arterial territories had severe calcifications. 57% had a very high coronary Agatston score (>1000), and 35% extremely high (>2000). Calcifications in the lower extremity were significantly correlated to CAC score, carotid artery bifurcation calcification score, and to a lesser extent correlated to annular calcifications in the aorta. Very high and extremely high total CAC scores were strongly correlated with severe lower extremity arterial calcifications and severe carotid and intracranial internal carotid artery, thoracic and abdominal aorta calcifications in patients with CLTI patients. ConclusionsIn CLTI patients nearly all arterial territories are severely calcified, suggesting that systemic calcification plays an important role in the poor outcome of this disease.

Lipoprotein(a) is associated with a larger systemic burden of arterial calcification.

Lipoprotein(a) [Lp(a)] is a genetically determined risk factor for cardiovascular disease. However, population-based evidence on the link between Lp(a) and subclinical arteriosclerosis is lacking. We assessed associations of Lp(a) concentrations with arteriosclerosis in multiple arteries. From the population-based Rotterdam study, 2354 participants (mean age: 69.5 years, 52.3% women) underwent non-contrast computed tomography to assess arterial calcification as a hallmark of arteriosclerosis. We quantified the volume of coronary artery calcification (CAC), aortic arch calcification (AAC), extracranial (ECAC), and intracranial carotid artery calcification (ICAC). All participants underwent blood sampling, from which plasma Lp(a) concentrations were derived. The association of plasma Lp(a) levels was assessed with calcification volumes and with severe calcification (upper quartile of calcification volume) using sex-stratified multivariable linear and logistic regression models. Higher Lp(a) levels were associated with larger ln-transformed volumes of CAC [fully adjusted beta 95% confidence interval (CI) per 1 standard deviation (SD) in women: 0.09, 95% CI 0.04-0.14, men: 0.09, 95% CI 0.03-0.14], AAC (women: 0.06, 95% CI 0.01-0.11, men: 0.09, 95% CI 0.03-0.14), ECAC (women: 0.07, 95% CI 0.02-0.13, men: 0.08, 95% CI 0.03-0.14), and ICAC (women: 0.09, 95% CI 0.03-0.14, men: 0.05, 95% CI -0.02 to 0.11]. In the highest Lp(a) percentile, severe ICAC was most prevalent in women [fully adjusted odds ratio (OR) 2.41, 95% CI 1.25-4.63] and severe AAC in men (fully adjusted OR 3.29, 95% CI 1.67-6.49). Higher Lp(a) was consistently associated with a larger calcification burden in all major arteries. The findings of this study indicate that Lp(a) is a systemic risk factor for arteriosclerosis and thus potentially an effective target for treatment. Lp(a)-reducing therapies may reduce the burden from arteriosclerotic events throughout the arterial system. In 2354 participants from the Rotterdam study, we assessed the link between Lp(a) concentrations and arterial calcifications, as proxy for arteriosclerosis, in major arteries. We found that higher Lp(a) levels were consistently associated with larger volumes of calcification in the coronary arteries, aortic arch, extracranial carotid arteries, and intracranial carotid arteries. The findings of our study indicate that Lp(a) is a systemic risk factor for arteriosclerosis, suggesting that the systemic burden of arteriosclerosis throughout the arterial system could be reduced by targeting Lp(a).

To Determine Frequency of Carotid Stenosis in Patients with Recurrent Stroke

Objective: To determine frequency of carotid stenosis in patients with recurrent ischemic stroke by Doppler ultrasound Study design: Cross sectional study Place and Duration: This study is performed at Divisional Headquarter Teaching Hospital, Mirpur AJK from January 2021 to January 2022 Methodology: This study is conducted in sample size of 99 patients, with history of minor stroke or TIA within three month. Now presented with recurrent ischemic stroke .All patients with recurrent ischemic stroke advised carotid Doppler of extracranial carotid arteries. Carotid artery intima media thickness, thrombus, atheromatous plaques and percentage of carotid stenosis and peak systolic flow velocity of affected artery were also determined on Doppler Ultrasound. In addition, association between carotid stenosis and its risk factors such as Age,gender, Hypertension, diabetes ,smoking and dyslipidemia is also determined. Results: We found that 59% of study population with recurrent ischemic stroke have carotid stenosis and percentage of carotid stenosis is variable among study population. Out of 99 patients with recurrent stroke 52% population are Hypertensive, 46% have diabetic, and 58% are smoker and 51% have Dyslipidemia. Conclusion: We concluded that carotid artery stenosis is a risk factor for Recurrent ischemic stroke. It predisposes patients to further attacks of stroke in future .So Doppler Ultrasound must be advised to every patient with history of minor stroke/TIA. So that early intervention should be offered to patients to reduce risk of recurrent ischemic stroke . Keyword: Carotid stenosis, carotid Doppler or Duplex scan ,Stroke /TIA

Role of CT Angiography in Detection of Extracranial Carotid and Vertebral Artery Disease in Patients With Acutely Ruptured Intracranial Aneurysms

Introduction: Computed tomography (CT) and CT angiography are standard imaging modalities for suspected acute intracerebral hemorrhage due to ruptured intracranial aneurysms. In this clinical setting, several protocols of computed tomography and CT angiography may be implemented. The standard CT angiography protocol is limited to intracranial vessels. The extended protocol may also include carotid and vertebral arteries and the aortic arch.Objective: To define the CT angiography role in detection of extracranial carotid and vertebral artery disease and clinical significance of this method for patients with suspected acute intracerebral hemorrhages due to ruptured intracranial aneurysms.Materials and methods: The study included 275 neurosurgical patients with acute nontraumatic intracranial hemorrhages due to ruptured intracranial aneurysms who were treated in Scientific Research Institute – Ochapovsky Regional Clinical Hospital No. 1 (Krasnodar, Russian Federation) from September 2017 to August 2020. Computed tomography and CT angiography were performed in all patients. The scanned area included both intracranial and extracranial arteries (an arch-to-vertex angiogram) to detect extracranial carotid and vertebral artery diseases such as stenoses, occlusions, tortuosity, and hypoplasia.Results: Atherosclerosis of internal carotid and vertebral arteries was diagnosed in 95 patients (34.5% of the total number of patients included in the study). In 13 (4.7%) patients these stenoses were hemodynamically significant. We identified a high frequency of tortuous carotid and vertebral arteries (122 cases, 44.3%) and vertebral artery hypoplasia (59 cases, 21.5%). The carotid and vertebral artery stenoses and congenital anomalies of vertebral arteries (however, not of carotid arteries) were associated with a higher incidence of unfavorable outcomes after endovascular treatment of intracranial aneurysms.Conclusions: The optimal CT angiography protocol for acute nontraumatic intracranial hemorrhage should focus on the arteries of the head and neck (up to the aortic arch). This protocol shows higher detection rate of concomitant anomalies of carotid and vertebral arteries. These findings are important for planning and successful performance of endovascular treatment for intracranial aneurysms.

Functional and Safety Outcomes of Carotid Artery Stenting and Mechanical Thrombectomy for Large Vessel Occlusion Ischemic Stroke With Tandem Lesions

Approximately 10% to 20% of large vessel occlusion (LVO) strokes involve tandem lesions (TLs), defined as concomitant intracranial LVO and stenosis or occlusion of the cervical internal carotid artery. Mechanical thrombectomy (MT) may benefit patients with TLs; however, optimal management and procedural strategy of the cervical lesion remain unclear. To evaluate the association of carotid artery stenting (CAS) vs no stenting and medical management with functional and safety outcomes among patients with TL-LVOs. This cross-sectional study included consecutive patients with acute anterior circulation TLs admitted across 17 stroke centers in the US and Spain between January 1, 2015, and December 31, 2020. Data analysis was performed from August 2021 to February 2022. Inclusion criteria were age of 18 years or older, endovascular therapy for intracranial occlusion, and presence of extracranial internal carotid artery stenosis (>50%) demonstrated on pre-MT computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography. Patients with TLs were divided into CAS vs nonstenting groups. Primary clinical and safety outcomes were 90-day functional independence measured by a modified Rankin Scale (mRS) score of 0 to 2 and symptomatic intracranial hemorrhage (sICH), respectively. Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), discharge mRS score, ordinal mRS score, and mortality at 90 days. Of 685 patients, 623 (mean [SD] age, 67 [12.2] years; 406 [65.2%] male) were included in the analysis, of whom 363 (58.4%) were in the CAS group and 260 (41.6%) were in the nonstenting group. The CAS group had a lower proportion of patients with atrial fibrillation (38 [10.6%] vs 49 [19.2%], P = .002), a higher proportion of preprocedural degree of cervical stenosis on digital subtraction angiography (90%-99%: 107 [32.2%] vs 42 [20.5%], P < .001) and atherosclerotic disease (296 [82.0%] vs 194 [74.6%], P = .003), a lower median (IQR) National Institutes of Health Stroke Scale score (15 [10-19] vs 17 [13-21], P < .001), and similar rates of intravenous thrombolysis and stroke time metrics when compared with the nonstenting group. After adjustment for confounders, the odds of favorable functional outcome (adjusted odds ratio [aOR], 1.67; 95% CI, 1.20-2.40; P = .007), favorable shift in mRS scores (aOR, 1.46; 95% CI, 1.02-2.10; P = .04), and successful reperfusion (aOR, 1.70; 95% CI, 1.02-3.60; P = .002) were significantly higher for the CAS group compared with the nonstenting group. Both groups had similar odds of sICH (aOR, 0.90; 95% CI, 0.46-2.40; P = .87) and 90-day mortality (aOR, 0.78; 95% CI, 0.50-1.20; P = .27). No heterogeneity was noted for 90-day functional outcome and sICH in prespecified subgroups. In this multicenter, international cross-sectional study, CAS of the cervical lesion during MT was associated with improvement in functional outcomes and reperfusion rates without an increased risk of sICH and mortality in patients with TLs.

IS SCREENING FOR EXTRACRANIAL CAROTID STENOSIS EFFECTIVE IN PREVENTING ISCHEMIC STROKE? LITERATURE REVIEW

This literature review shows the essence of the problem of extracranial carotid artery stenosis, since this disease is a treatable cause of ischemic stroke and can be reliably detected and assessed by using vascular ultrasound. In Kazakhstan, due to acute disorders of cerebral circulation, 11.1 thousand patients die every year. The reliability of the information in the article was obtained by using the literature data of the last 10 years. The reflection of the criteria for diagnosing stenosis of the extracranial carotid artery, the use of which, in conjunction with standard tests and other sensitive methods, makes it possible to determine the lesion of the extracranial carotid artery at an early stage, as well as a detailed description of diagnostic methods of this complication and evaluation of their effectiveness. Screening for carotid stenosis is important, and whether routine carotid ultrasound is recommended in general population for the prevention of ischemic stroke remains controversial. Screening for carotid stenosis by ultrasound is crucial not only for the daily clinical setting, but also for the management of patients with acute ischemic stroke.

Abstract Number ‐ 216: Limb‐Shaking Transient Ischemic Attack in the Setting of Moyamoya Disease

Introduction Moyamoya disease (MMD) is a cerebrovascular disorder characterized by progressive narrowing of the large intracranial arteries, primarily the internal carotid artery (ICA) and its branches, with secondary development of prominent small‐vessel collaterals. Limb shaking is a rare manifestation of transient ischemic attack (TIA) that is characterized by brief, irregular, involuntary jerking of the arms or legs and momentary disorientation without complete loss of consciousness. It is mainly associated with high grade carotid stenosis. In rare cases, limb‐shaking TIA can occur in the setting of MMD. Methods The patient was identified in routine clinical practice. Results A woman in her 50s presented with a six‐year history of progressive weakness below the neck when standing and initiating movement. These episodes were followed by violent shaking of her arms and legs that lasted several seconds to minutes. She reported transient confusion after the events, but no seizure activity was seen on multiple EEGs, and anti‐epileptic drugs (AEDs) failed to alleviate her symptoms. Further neurological workup included a MR angiogram of the brain that was suggestive of MMD. Catheter angiography confirmed bilateral occlusion of the M1 segments of the middle cerebral arteries (MCAs) and the A1 segment of the left anterior cerebral artery (ACA). There was neovascularization in the same territories with significant collateral flow from the posterior circulation. She was diagnosed with bilateral limb‐shaking TIA in the setting of MMD. She recently underwent two revascularization procedures, a left superficial temporal artery (STA) to middle cerebral artery (MCA) bypass and a right sided encephaloduroarteriosynangiosis (EDAS). Conclusions Limb‐shaking TIA is predominantly associated with severe atherosclerotic extracranial carotid artery stenosis. In rare cases, the limb‐shaking episodes are caused by cerebral hypoperfusion secondary to severe stenosis of the ICAs, and their branches, in the setting of moyamoya disease. Treatment of limb‐shaking TIA to prevent further brain ischemia includes adjustment of fluid intake, careful blood pressure management to avoid episodes of relative brain hypoperfusion, and revascularization procedures. Revascularization is also the most effective method of treating MMD and patients will often experience improvement of their symptoms within one year. Early recognition of limb‐shaking TIA in MMD is critical to avoid unnecessary and potentially harmful treatments (e.g. AEDs), provide patients with accurate explanations of their symptoms, and ensure timely administration of the appropriate treatments.

Routine assessment of carotid plaques on Doppler USG and associated presenting symptoms at a Tertiary Care Centre, Lahore

Objective: To determine the frequency of carotid plaques on Doppler USG and associated presenting symptoms at Tertiary Care Centre, Lahore. Methods: A cross-sectional study of 366 individuals was conducted from January 2020 to November 2020 at the Radiology Department of Shiekh Zayed Hospital, Lahore, Pakistan. A consultant radiologist scanned both sides of the extra-cranial carotid artery tree. The DUS of carotid arteries was done with a GE Voluson Expert 730 Doppler ultrasound machine, using a linear probe with a transducer frequency of 6-12.5MHz. Results: A total of 366 patients underwent bilateral carotid Doppler ultrasound examinations. Our findings showed carotid plaques in 156 (42.62%) patients; the majority were males 105(67.53). The mean age recorded was 61.17 ±9.54 years and the mean body mass index was 25.43±3.40 Kg/m2. The highest number of plaques were noted in the left carotid artery 64 (41.03%), the main location was the common carotid artery 88 (56.41%) and, the majority were homogenous plagues 88 (56.41%).The majority of patients presented with headaches 177 (48.36%). Associated comorbidities were diabetes mellitus, hypertension, and dyslipidemia. Conclusion: The accuracy of diagnosing Carotid artery plaques has greatly increased over time payable to radiological innovation.

Predictive Factors for Stroke and TIA Following Carotid Artery Stenting

Purpose: Carotid artery stenting (CAS) is an effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. The aim of the present study was to explore independent risk factors to predict cerebrovascular events following CAS to identify high-risk patients and improve the safety of CAS in this population. Materials and Methods: HISPANIAS is a national prospective multicenter study that included 14 hospitals that collected data from patients who underwent CAS. We analyzed morbidity and mortality within 30 days after CAS, looking for factors that might be associated with cerebrovascular events (stroke and transient ischemic attack [TIA]). Results: The HISPANIAS cohort included 757 patients: 80.32% were men, the mean age was 70.73 years, and 82.96% underwent symptomatic CAS. Cerebrovascular complications occurred in 42 patients (5.6%), including TIA in 24 patients (70.8% ipsilateral; mean 2.79 days after CAS) and stroke in 18 patients (72.2% ipsilateral; mean 6.72 days after CAS). The main independent clinical predictors of stroke/TIA identified by logistic regression were female sex (odds ratio [OR] 2.29, 95% CI 1.15–4.54) and diabetes (OR 3.29, 95% CI 1.71–6.40). Survival analysis showed that diabetic women, compared with the rest of the patients, had a higher number of events concentrated mainly in the first days after the intervention (p=0.003). Conclusion: Cerebrovascular ischemic complications after CAS continue to be a challenge for the management of these patients. Although there are other factors, female sex and the presence of diabetes are emerging as strong risk factors for the development of complications after symptomatic CAS. Clinical Impact Carotid artery stenting (CAS) is an effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. Although CAS has been regarded as a reliable and safety approach, some studies reported that CAS was associated with a higher risk of procedure-related stroke. Cerebrovascular complications after CAS continue to be a main problem and a challenge for the management of these patients. Therefore, it is essential to identify the factors involved in the development of these complications. Our study shows that the combination of female sex and diabetes is associated with a clearly worse outcome, with a greater number of events concentrated mainly in the first days. This is different from other studies that have explored each factor separately. It would be interesting to perform separate interventions for this group given the increased risk of complications.

Assessment of extracranial carotid artery disease using digital twins – A pilot study

To improve risk stratification in extracranial internal carotid artery disease (CAD), patients who would benefit maximally from revascularization must be identified. In cardiology, the fractional flow reserve (FFR) has become a reference standard for evaluating the functional severity of coronary artery stenosis, and noninvasive surrogates thereof relying on computational fluid dynamics (CFD) have been developed. Here, we present a CFD-based workflow using digital twins of patients’ carotid bifurcations derived from computed tomography angiography for the noninvasive functional assessment of CAD. We reconstructed patient-specific digital twins of 37 carotid bifurcations. We implemented a CFD model using common carotid artery peak systolic velocity (PSV) acquired with Doppler ultrasound (DUS) as inlet boundary condition and a two-element Windkessel model as oulet boundary condition. The agreement between CFD and DUS on the PSV in the internal carotid artery (ICA) was then compared. The relative error for the agreement between DUS and CFD was 9% ± 20% and the intraclass correlation coefficient was 0.88. Furthermore, hyperemic simulations in a physiological range were feasible and unmasked markedly different pressure drops along two ICA stenoses with similar degree of narrowing under comparable ICA blood flow. Hereby, we lay the foundation for prospective studies on noninvasive CFD-based derivation of metrics similar to the FFR for the assessment of CAD.

Posttraumatic pseudoaneurysm of the internal carotid artery extracranial segment due to chronic intimal transection - case report

Introduction. Carotid artery pseudoaneurysms can refer to pseudoaneurysms involving any segment of the carotid arteries. Post?traumatic internal carotid artery pseudoaneurysm dilatation due to intimal transection is extremely rare entity that requires detailed clinical examination and multiple diagnostic modalities to confirm the diagnosis. The aim of the study is to present rare entity of posttraumatic extracranial internal carotid artery pseudoaneurysm dilatation due to intimal transection, diagnostic algorithm and diagnostic findings. Case Report. The patient was a 30-year-old, previously healthy, female who came to see a cardiologist due to intermittent tachycardia, which first appeared a week before the examination. Duplex ultrasound was performed, and aneurysm of extracranial segment of internal carotid artery was found. The patient had severe neck trauma due to bicycle accident in childhood, which was treated at home, without medical examination. Further computed tomography angiography and magnetic resonance angiography were performed. All imaging findings were in favor of chronic arterial wall small pseudoaneurysmal dilatation, with intimal transection, without signs of acute trauma. Based on the above, a decision was made to continue conservative treatment in accordance with the recommendations of current guidelines. Periodic clinical diagnostic follow-up was performed. After the applied therapy, the complaints in terms of intermittent tachycardia disappeared completely. Conclusion. Formation of extracranial internal carotid artery pseudoaneurysm due to intimal transection is a rare entity, and requires multiple imaging findings in order to evaluate if the trauma is acute or chronic. In most cases, chronic pseudoaneurysm does not require surgical intervention. It requires conservative medical treatment and diagnostic follow-up.

Association between platelet lymphocyte ratio and neutrophil lymphocyte ratio and clinical outcomes following carotid endarterectomy.

Approximately 30% of stroke cases result from carotid disease. Although several risk factors for complications after carotid endarterectomy have been identified, the existence of a biomarker that can estimate postoperative risk in these patients has not yet been proven. This study aimed to investigate correlations between the platelet-lymphocyte ratio (PLR) and the neutrophil-lymphocyte ratio (NLR) and postoperative clinical outcomes in patients undergoing carotid endarterectomy. A retrospective study was conducted, including 374 patients who underwent carotid endarterectomy between 2002 and 2019 due to moderate to high extracranial internal carotid artery stenosis. Their platelet-lymphocyte ratio and neutrophil-lymphocyte ratios were obtained from the same blood samples. There was a statistically significant correlation between the PLR and the occurrence of restenosis (p < 0.01) and acute myocardial infarction (AMI) after endarterectomy (p = 0.03). Additionally, there was a statistically significant correlation between the PLR and the combined outcomes stroke and/or AMI and/or death (p = 0.03) and stroke and/or AMI and/or death and/or restenosis (p < 0.01). However, there were no significant correlations between NLR and these outcomes (p = 0.05, p = 0.16). The platelet-lymphocyte ratio proved to be a useful test for predicting occurrence of strokes, acute myocardial infarctions, and deaths during the postoperative period after carotid endarterectomy. It was also associated with the risk of postoperative restenosis.

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 &lt; 0.0001). The OR was 5.5. Females were more affected than males by 1.7 folds (p &lt; 0.001). Whites were more affected than African Americans by 1.6 folds (p &lt; 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 &amp; 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.