Left Carotid Research Articles

Arterial inflammation induced by immune checkpoint inhibitors assessed on 18F-FDG PET-CT scans in stage III/IV melanoma patients

Abstract Background In recent years, immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment, as they lead to a substantial improvement in the prognosis of cancer patients. In high-grade melanoma patients, ICIs have doubled the three-year survival rate. However, ICIs may not only increase the immune response to tumor cells, but also to non-tumor cells, potentially inducing pro-atherogenic effects that can result in increased vascular inflammation and subsequent cardiovascular events. Purpose The objective of this study is to assess differences in vascular inflammation in the large arteries, as detected by 18F-FDG PET-CT scans, between stage III/IV melanoma patients receiving ICI therapy compared to stage III/IV melanoma patients not treated with ICIs. Methods The study population consisted of a cohort stage III/IV melanoma patients who underwent PET-CT scans at baseline, defined as < 1 year after diagnosis of stage III/IV melanoma and at T1 and T2, 6 months and 18 months after the baseline scan respectively. Patients with a history of cardiovascular events, treated with statins or corticosteroids (prednisolone > 10 mg per day) were excluded. Vascular inflammation was evaluated in the following eight arterial segments: the left and right carotid artery, ascending aorta, aortic arch, thoracic descending aorta, abdominal aorta and the left and right iliac artery. For each segment, the maximum standardized uptake value (SUV) for 18F-FDG uptake was derived and target-to-background ratio (TBR) was calculated from the ratio of the maximum SUV of the segment and the mean SUV of the superior and inferior vena cava. Vascular inflammation was defined as the total TBR per patient, calculated by sum of the TBR values of the eight arterial segments. The study endpoint was the difference in the increase in total TBR between patients treated with ICIs (exposure group) and patients without ICI treatment (control group). Results A total of 70 stage III/IV melanoma patients of whom 46 received ICIs and 24 did not receive ICI therapy were analyzed in this study. The median age at diagnosis was 61 years [IQR: 49-69] and 37 patients (52.9%) were female. The exposure group had a median ICI treatment of 9 [6-13] cycles. The results showed a significant difference in the TBR between the baseline PET-CT scan and T1 between the two groups. The control group showed a decrease in TBR by -0.33 [95% CI: -0.66 – 0.01], whereas the exposure group showed an increase in TBR by 0.17 [-0.14 – 0.49] (p = 0.045). No differences in TBR were found between T1 and T2. Conclusion The present study demonstrated that in stage III/IV melanoma patients treated with ICIs, there was a significant increase in vascular inflammation assessed by PET-CT in the large arteries during the first six months after treatment initiation, as compared to a control group without ICI treatment.∆TBR on PET-CT between baseline and T1∆TBR on PET-CT between T1 and T2

Association of unilateral low ankle-brachial index and bilateral low ankle-brachial index with incident cardiovascular disease and mortality: The Northern Shanghai Study

Abstract Background and Aims Ankle-brachial index (ABI) has been used as a marker for atherosclerosis and a risk factor of cardiovascular disease (CVD). Nevertheless, it is not yet clear whether there is a difference in cardiovascular risk between patients with one leg low ABI (<0.9) (unilateral low ABI) and those with both legs low ABI (bilateral low ABI). Therefore, we investigated the association of target organ damage (TOD) and incident of major cardiovascular events (MACE) in participants with unilateral low ABI and bilateral low ABI. Methods We enrolled 3168 participants (mean age 71.3 years, 1361 men) from North Shanghai Study. The participants were divided into 3 groups according to both legs ABI (bilateral low ABI, unilateral low ABI and bilateral normal ABI). TOD, including left ventricular hypertrophy, arterial stiffness, carotid plaque, and renal damage, were measured using standard methods at baseline. MACE was a composite outcome that consisted of nonfatal myocardial infarction, nonfatal stroke and CVD death. Results Compared with bilateral normal ABI, bilateral low ABI had higher risk of all TOD, but unilateral low ABI only had higher risk of carotid plaque and renal damage after adjustment covariates. During a median follow-up of 5.4 years, 199 MACE and 192 all-cause mortality occurred. The multivariable-adjusted risk for MACE in individuals with bilateral low ABI (hazard ratio (HR): 1.86; 95% confidence interval (CI), 1.20-2.88) and individuals with unilateral low ABI (HR: 1.58; 95% CI, 1.04-2.41) were higher than individuals with bilateral normal ABI (referent group). Compared with bilateral normal ABI, both unilateral low ABI (hazard ratio: 1.70; 95% CI, 1.13-2.57) and bilateral low ABI (HR: 2.10; 95% CI, 1.39-3.18) had higher risk of all-cause mortality after adjustment covariates. Conclusion Both unilateral low ABI and bilateral low ABI are associated with increased CVD risk, but bilateral low ABI with a trend towards increasing CVD risk. More attention should be paid to whether a patient has a unilateral or bilateral low ABI for a more accurate CVD risk assessment.Kaplan-Meier curve for ABI categoriesOR for ABI categories for TOD

Abstract 13378: Identifiable Differences in Comorbidities and Surgical History Among Asian, Native Hawaiian, and Pacific Islander Stroke Patients With Carotid Artery Disease

Introduction: A detailed characterization of comorbidity prevalence among carotid artery disease patients has not been thoroughly explored in Asian, as well as Native Hawaiian and Pacific Islander (NHPI) populations. Research Question: This study investigated the types of comorbidities and surgical procedures associated with carotid artery disease in Asian and NHPI populations. Methods: This retrospective study utilized data from a stroke treatment center in Hawaii between the years 2020-21. Patients were identified with ICD-10 codes for stroke and only those ≥18 years old with either a completed carotid artery Doppler ultrasound or carotid angiography were included in the study. Collected data included demographics, location of stroke, degree and location of carotid stenosis, comorbidities, and previous surgical history. Wilcoxon rank sum test and Fisher's exact test were used as appropriate. Results: Overall, 117 patients were included with 74 of identifiable race (45% NHPI, 32% Asian, and 23% White). The average age at the time of stroke was 69 years and 40.0% (47/117) of patients were female. Amongst all races, there were no differences in the greatest degree of carotid stenosis (p=.15) or location of stenosis along the right carotid artery (p=.16), but there was a difference in the location of left carotid stenosis (p=.04). Endocrine conditions were the only comorbidity identified at significantly different rates between all racial groups (p=.02). Prior cardiac (p=.03), otolaryngological (0=.007), and orthopedic (p=.01) procedures differed significantly by race among the cohort. The majority of these differences were present when comparing NHPI or Asian patients against White patients, with no significant differences found between Asian and NHPI patients. Conclusions: Asian and NHPI stroke patients were found to have significantly different rates of left carotid stenosis, endocrine conditions, and prior cardiac, otolaryngological, or orthopedic surgeries when compared to White patients. Due to these race-specific differences in patient demographics and history, the implementation and investigation of carotid artery disease risk assessments should be pursued to best improve stroke outcomes among all patients.

Non-arteritic anterior ischemic optic neuropathy associated with ipsilateral hypoplastic internal carotid artery.

Vascular insufficiency of the optic nerve head is the cause of non-arteritic ischemic optic neuropathy (NAION). Carotid artery abnormalities are now considered as a predisposing factor for developing NAION. In this report, we present a case of NAION associated with ipsilateral internal carotid artery hypoplasia. A 69-year-old female was referred for evaluating the cause of vision loss in her left eye. The patient was diagnosed with left NAION, however, the magnetic resonance imaging (MRI) showed a considerably smaller left internal carotid artery (ICA) than the right side. The magnetic resonance angiography (MRA) confirmed the disparity as well as perfusion abnormalities of intracranial carotid arteries. The diagnosis of left ICA hypoplasia was made and verified by depicting a left side small carotid canal on the computed tomography (CT) scan. This report suggests that ICA hypoplasia could be associated with NAION.

Abstract 126: Bilateral Limb Shaking TIA secondary to Severe Bilateral Carotid Stenosis

Introduction A case describing bilateral limb shaking episodes in a patient with severe bilateral carotid disease ‐ a rare manifestation of limb‐shaking TIA. Methods '‐ Results CASE A 71‐year‐old male patient with a past medical history significant for type 2 diabetes mellitus and bilateral carpal tunnel syndrome is being followed for symptomatic management of known axonal sensorimotor diabetic polyneuropathy in the neuromuscular clinic. He reported on one of his follow‐up visits that he had been experiencing an eight‐month history of presyncopal to syncopal events occurring solely in the standing position, not followed by postictal state but amnesia to the syncope itself, and resulting in falls with mild injuries. He was experiencing new‐onset dry eyes and mouth but denied anhidrosis or early satiety, and cardiac event monitoring during one of these events was unremarkable for rhythmic causes. Examination was unchanged from previously and was significant for findings consistent with length‐dependent sensory loss with hyporeflexia/areflexia. The constellation of symptoms was suggestive of autonomic dysfunction, and while this may be seen with diabetic polyneuropathy, workup for alternative autonomic neuropathies (including SSA/SSB antibodies, paraneoplastic antibody panel, serum protein electrophoresis with immunofixation, serum free light chains, transthyretin amyloid) was obtained with plan for follow‐up. A few months later, he presented to the ED with intermittent upper extremity shaking (more pronounced on the right than on the left) preceding the syncopal events, which only occurred in the standing position or during physical activity and resolved with rest. There were no (transient) focal neurological deficits, including monocular vision loss or hemispheric syndrome. CTA of the head/neck was obtained and was notable for severe to critical stenoses of the bilateral internal carotid arteries (see figure 1). Duplex US revealed 80‐99% stenosis of both right and left proximal internal carotid arteries. The constellation of findings was most suggestive of bilateral limb‐shaking TIA secondary to bilateral carotid stenosis. He was started on secondary stroke prevention and referred to vascular surgery for evaluation of revascularization. The patient underwent left carotid endarterectomy briefly afterward and experienced resolution of the events – he later also underwent carotid endarterectomy of the right side and remains asymptomatic. DISCUSSION: Limb‐shaking TIA is a well‐described yet underrecognized manifestation of severe carotid disease reported by C.M. Fisher in 1962. The “limb shaking” episodes are typically unilateral, affecting the arm or leg, and are often mistaken for seizures [1]. Pathogenesis involves hemodynamic impairment related to extracranial/intracranial carotid stenosis or occlusion resulting in stereotypical recurrent contralateral limb shaking episodes precipitated by physical activity [2], [3]. The constellation of “limb shaking” spells precipitated upon standing or physical activity with resolution after activity cessation should raise suspicion for limb‐shaking TIA and warrant vascular imaging. Treatment includes medical secondary stroke prevention and revascularization procedures [4], which can alleviate or even resolve the transient symptoms [2]. Conclusion Limb‐shaking TIA is an important yet underrecognized manifestation of relative cerebral hypoperfusion related to severe cerebrovascular disease. This case describes bilateral limb shaking episodes in a patient with severe bilateral carotid disease ‐ a rare manifestation of limb‐shaking TIA.

Abstract 252: The outcomes and complications in patients undergoing subclavian‐carotid artery bypass surgery: A case series

Introduction Endovascular intervention has become the mainstay of treatment for acute ischemic stroke. However, in certain cases, open surgery is the only option to achieve revascularization. This study presented two patients with symptomatic common carotid artery occlusion (CCAO) who subsequently underwent subclavian‐carotid artery bypass surgery using the polytetrafluorethylene graft. The complications of the procedure and patient’s outcomes were discussed. Methods We identified two patients who were admitted to our medical center between January 2022 to December 2022 for subclavian‐carotid artery bypass procedure. Clinical data were reviewed retrospectively. Results Case 1. A 69‐year‐old woman with a history of lung cancer, hypertension, chronic tobacco use, atherosclerosis, and known calcified plaque at the left carotid bifurcation on dual antiplatelet therapy presented with acute onset of expressive aphasia and right hemiparesis due to acute left CCAO. Endovascular procedure was deferred due to difficult arterial access. An endarterectomy of CCA, eversion endarterectomy of external carotid artery, and subclavian‐carotid artery bypass surgery were performed. She developed neck hematoma post‐operatively, requiring evacuation. She was discharged to acute rehabilitation facility and eventually home. Six months after surgery, she still had severe expressive aphasia and spasticity of the right arm and leg (Figure A‐C). Case 2. A 79‐year‐old man with a strong family history of arterial dissection, hypertension, coronary artery disease, and obesity experienced intense chest pain and left hemiparesis secondary to Type A aortic dissection with extension from the innominate artery to the right carotid bifurcation. Endovascular intervention was deferred given the angulation of aortic arch after surgical repair. Decision was made to perform subclavian‐carotid artery bypass surgery. Post‐operatively, he had evacuation of neck hematoma. He also had tracheostomy and gastrostomy tube placement prior to discharge to skilled nursing facility. At 6‐month follow up, he could ambulate with a walker and oral diet was resumed (Figure D‐F). Conclusion CCAO is a rare condition, and there is no prospective randomized trial that compares various treatment strategies for symptomatic CCAO. Consistent with the findings of our study, bypass surgeries have been shown as an effective treatment to prevent further ischemic infarct in patients with symptomatic CCAO. Both patients in our study survived at 6‐month follow up with no recurrence of stroke. Additionally, no other surgical complications were noted except for neck hematoma. Bypass surgery was performed as a salvage procedure for both patients after they suffered from stroke. Early identification of CCAO and collaboration between vascular surgeon and endovascular interventionist would maximize the benefit of this life‐saving procedure to the appropriate candidates.

Abstract 054: Transradial Thrombectomy Using "Sheathless PV" Guide Catheter in Armenia: Three‐Year Institutional Experience in 103 Cases

Introduction Transradial access (TRA) in neuroendovascular procedures has gained popularity in recent years (1). It offers numerous advantages and stimulated development of long flexible large lumen guiding catheters as well as adoption of existing cost‐efficient alternatives used in cardiac and peripheral interventions (2,3). We report our three‐year experience using the Sheathless PV guide catheter (Asahi Intecc, Japan) in a consecutive series of acute stroke patients undergoing endovascular thrombectomy (ET) at a Comprehensive Stroke Center in Yerevan, Armenia. The interest in its use specifically for TRA stemmed from competitive price (∼ $100 per catheter vs ), hydrophilic coating of the outer shaft, as well as lack of femoral closure devices in the country. Methods We retrospectively identified all consecutive acute stroke patients who had undergone ET via TRA from a prospectively maintained institutional stroke database between June 2020 and June 2023. Data were collected on determinants of decision to proceed with TRA‐first approach, baseline patient imaging and clinical characteristics, location of the occlusion, puncture‐to‐reperfusion time (PT‐RT), conversion to transfemoral access (TFA), periprocedural complications, and procedural/clinical outcomes. Results were compared to patients who underwent TFA‐first ET over the same time period. The Mann‐Whitney U‐test was used to analyze the continuous variables and chi‐square test was used for categorical variables. Standardized TRA technique involved exchanging the puncture needle to a short 6Fr introducer first, then over a J‐wire, to a 90cm (0.090" ID/0.110" OD) Sheathless PV guide catheter over a dilator. The dilator was then removed, and a long JR4 diagnostic catheter was used to select cervical vessels over a 0.035 wire and advance the guide over in a triaxial fashion. Results A total of 538 patients underwent ET during the analyzed 3‐year period, of which access was either not recorded, or was other than TRA/TFA in 23 patients (excluded from analysis). Of the remaining 515 patients, 103 had TRA‐first (all using Sheathless PV guide catheter) and 412 had TFA‐first (various guide catheters). The decision to proceed with TRA was at the discretion of the operator and was influenced by presence of bovine arch on CTA (for left anterior occlusions), favorable angle between the right subclavian and the right common carotid arteries (for right anterior occlusions), dominant right vertebral artery or favorable angle of V1 origin (for posterior circulation occlusions). Of 103 TRA cases, 71 (68.9%) were in the right carotid circulation, 18 (17.5%) ‐ in the left carotid circulation, and 14 (13.6%) in posterior circulation. TRA‐>TFA conversion occurred in 5 patients (4.8%), TFA‐>TRA ‐ in 1 patient (0.24%) all of which were due to prohibitive anatomy, rather than guide catheter limitations. There were no significant differences in baseline patient characteristics between the TRA and TFA groups. Angiographic outcomes (TICI 2B or greater) were similar for TRA vs TFA (96.1% vs 93.9%, p=0.39), as were good clinical outcome (discharge mRS 0‐2) rates (58% vs 55.4%, p=0.63). There was a trend towards shorter PT‐RT with TRA (29.5 min vs 38.3 min) although it did not reach statistical significance (p=0.11). No access‐related complications were noted with TRA. Conclusion Transradial thrombectomy using Sheathless PV Guide catheter is safe, effective, and offers substantial cost‐savings and shorter procedural times with low rate of access conversions, similar to other reported TRA thrombectomy series. Randomized trials are needed to validate its rates of technical success and complications against other frequently‐used TRA guide catheters.

Abstract 213: Successful Mechanical Thrombectomy in Acute Stroke With Pre‐interventional Thrombolysis‐Induced Intracerebral Hemorrhage: Case Report

Introduction Intravenous thrombolytics (IVT) and mechanical thrombectomy (MT) have become the standards of care for treating patients with large vessel occlusion (LVO) acute ischemic strokes (AIS) [1‐4}. Intracerebral hemorrhage (ICH) is a main complication of IVT, with prevalence reported around 3.2% in a large multicentered meta‐analysis [2,6]. However, limited data remains about the safety and efficacy for patients to undergo MT with IVT associated pre‐interventional ICH as no randomized control trials or standard of care guidelines are available [2,4,5,7]. Methods NA Results 56‐yo male with history of alcohol abuse presented via EMS as a stroke alert with acute onset right hemiplegia, global aphasia, right facial droop, and leftward gaze preference two hours prior to arrival. RACE 10+ with NIHSS 24. No known history antiplatelet or anticoagulation use. Computerized Tomography (CT) Brain scan showed left middle cerebral artery (MCA) hyperdense sign with left insular cortical ribboning. CT angiography (CTA) showed near occlusive stenosis of the left carotid bulb with an acute thrombus within Supraclinoid Internal Carotid Artery (ICA) extending into the Left MCA and origin of Left Anterior Cerebral Artery (ACA). Patient was emergently administered IV‐tissue Plasminogen Activator (IV‐tPA) and taken for endovascular thrombectomy. During initial angiogram, after crossing the stenotic cervical bulb, the left Supraclinoid ICA and MCA occlusions were visualized. There was longitudinal partially occlusive thrombus extending from the M1 into the M2 divisions. No opacification of the inferior M2 branch was visualized, with perfusion deficit over the temporal, parietal and frontal regions. Additionally, extravasation of contrast was seen within the left basal ganglia region, concerning for hemorrhagic transformation from IV‐tPA. Reversal of IV‐tPA was initiated, and patient was given cryoprecipitate, platelets, and tranexamic acid. Decision to undergo MT was made secondary to severity of debilitating neurologic symptoms, age, and large perfusion deficit observed. He underwent single pass complete recanalization, TICI 2C using Stent retriever and aspiration. Left ICA stenting was not completed secondary to hemorrhagic transformation. Repeat CT Brain confirmed moderate left frontal lobe hemorrhage with vasogenic edema and 3mm left‐to‐right midline shift. No neurosurgical intervention required. Magnetic resonance imaging (MRI) Brain showed left cerebral hematoma with mass effect, acute infarct within left caudate nucleus, and minimal posterior cortical restricted diffusion without hemorrhagic conversion. Patient was monitored for 1 week with serial brain imaging. Patient was discharged on Aspirin 81 mg daily to inpatient rehabilitation with NIHSS 21, mRS 4 (0 prestroke). Today, in rehab he ambulates with walker with moderate expressive aphasia and right upper extremity weakness. Plan to follow‐up 2‐month post‐hospitalization for left ICA stenting. Conclusion While pre‐interventional IVT‐associated ICH in AIS with LVO are rare, few cases have been shown to have positive neurological outcomes [2,5,7]. We demonstrate a unique case of early identification of reperfusion hemorrhage on fluoroscopy with prompt reversal initiated. The decision to continue with MT based on downstream occlusion of basal ganglia hemorrhage not at further risk of expansion from reperfusion. The patient did well on follow‐up imaging despite the hemorrhage. Further randomized control clinical trials are required to establish best care guidelines, safety, and efficacy.

Carotid Intima-Media Thickness and Its Correlation With Echocardiographic Left Ventricular Function and Geometry in Hypertensive Individuals: A Cross-Sectional Study.

Background It is important to consider left ventricular hypertrophy (LVH) and carotid intima-media thickness (CIMT) in assessing hypertensive patients' global cardiovascular risk profile, as LVH and arterial wall changes occur concurrently. This study aimed to assess the relationship between CIMT and left ventricular geometry and function in hypertensive patients. Methodology This cross-sectional study included 200 hypertensive individuals and sought to correlate their CIMT with left ventricular geometry and function in Lagos University Teaching Hospital. Hypertension was defined as blood pressure ≥140/90 mmHg or on treatment for hypertension presenting at the outpatient clinics. Patients who satisfied the inclusion criteria were recruited. Abnormal CIMT was defined as >0.9 mm. Patients' demographic data were obtained in addition to general characteristics, physical examination, transthoracic echocardiography, and CIMT. The statistical relationship between CIMT and left ventricular geometry and function was obtained and analyzed. Results Normal geometry and LVH were observed in 50.5% and 15.5%, respectively. Left ventricular geometry was associated with abnormal CIMT (χ2 = 31.688, p < 0.001). Furthermore, the mean left ventricular mass index was statistically different between abnormal and normal CIMT (97.84 ± 30.5 vs. 80.75 ± 15.6; p < 0.001). Regardingleft ventricular function, there was no significant difference in E-point septal separation, left ventricular fractional shortening, and left ventricular ejection fraction in abnormal versus normal CIMT groups. However, there was a significant association of CIMT with grades of diastolic dysfunction (χ2 = 7.069, p = 0.029). Additionally, individual parameters of diastolic dysfunction such as left atrial volume index and septal mitral were significantly different (p < 0.001). Conclusions There was an association between age, left ventricular geometry, diastolic function, and CIMT in hypertensive individuals. Therefore, it is beneficial to evaluate CIMT and for these patients to receive more targeted blood pressure control which may reduce the risk of cardiovascular diseases.

Factors Affecting Carotid Artery Stenosis in the Elderly Living at High Altitudes.

Factors affecting carotid artery stenosis have been generally investigated. However, considering the protective effect of altitude, studies on elderly individuals at high altitudes are few. Our aim is to investigate the systematic adaptive changes caused by high-altitude exposure through the causes of carotid artery stenosis. Carotid Doppler ultrasound was performed on 250 patients over the age of 50 years. The patients' age, gender, height, weight, smoking history, place of residence, and presence of comorbidities were questioned. Those with diabetes, hypertension, hyperlipidemia, and coronary disease were excluded from the study. Those who did not reside at high altitudes were excluded from the study. One hundred and thirty-five patients were included in the study. Carotid artery Doppler findings and biochemical parameters were recorded. Factors affecting stenosis in the carotid arteries were compared. In our study, the factors affecting carotid stenosis were determined to be age, gender, presence of plaque, plaque type, and mean carotid intima-media thickness (CIMT). The mean CIMT of the patients was calculated as 0.71±0.14 mm. The mean CIMT measurement level was significantly higher in patients with plaque in the carotid artery (p<0.05). According to receiver operating characteristic curves, CIMT values higher than 0.72 mm increase plaque and stenosis formation in the common carotid artery (CCA) and internal carotid artery (ICA) in elderly people living at high altitudes (p<0.05, area under the curve [AUC]: 0.71-0.83). The most important factors affecting carotid stenosis in individuals living at high altitudes are age, gender, CIMT, plaque, and plaque type. When soft plaques were detected, the risk of stenosis was found to be higher than in calcific plaques. Additionally, the number of factors affecting stenosis was greater on the left (ICA). This suggests that the left carotid system is more vulnerable. It can be said that in elderly individuals living at high altitudes, a CIMT higher than 0.72 mm is a cutoff value in the presence of plaque and stenosis in the carotid arteries.

Sonographic evaluation of common carotid artery intima-media thickness in adults with coexisting type two (2) diabetes and hypertension: A case-controlled study

Diabetes mellitus (DM) and hypertension (HTN) are the two leading risk factors for atherosclerosis. Carotid intima-media thickness (CIMT) is considered a reliable surrogate measure for detecting subclinical atherosclerosis including its progression and regression. The study aim at evaluating the intima-media thickness of the common carotid artery in adults with coexisting diabetes mellitus and hypertension (DM+HTN) and compare with healthy controls.. A prospective case control study involving 115 adult subjects with coexisting DM+HTN and 144 healthy adult controls was carried out. Common carotid intima-media thickness (CCIMT) was measured at point approximately 1 cm distal to the right and left carotid bulb using the 7-12 MHz, multi-frequency linear array transducer of high resolution, touch Venue 50 ultrasound machine equipped with electronic callipers. The overall mean CCIMT was 1.13±0.40 mm and 0.82±0.23 mm for subjects with coexisting DM and HTN; and healthy controls, respectively. There was a statistically significant difference in CIMT of subjects with DM+HTN compared to healthy controls (p=0.000 each for both males and females, respectively). There were positive correlations between CCIMT and age in subjects with DM+HTN (r=0.260 and r=0.424 for males and females respectively); with healthy controls (r=0.619 and 0.626 for males and females, respectively). There was a statistically significant difference in CCIMT between subjects with DM+HTN and healthy controls. This implies that the increase in CCIMT is associated with both DM and HTN. In addition, age has a significant positive relationship with CCIMT in both subjects with DM+HTN and healthy controls.

SAT487 A Case of Mistaken Identity: A Rare Presentation of Ectopic Thyroid Tissue

Abstract Disclosure: N. Doshi: None. R. Azimzade: None. A. Rajpal: None. Background: Ectopic thyroid tissue (ETT) lateral to the midline is very rare, and its presence at the carotid bifurcation is exceedingly unique. Paraganglioma is the most common primary tumor at the carotid bifurcation, often called a carotid body tumor. We hereby present a case of lateral ETT with radiological features similar to paraganglioma. Case Description: A 72-year-old female with history of GERD was referred to us for evaluation of a well-circumscribed, slightly tender left neck mass. She has had the mass for approximately 15 years with previous evaluation with ultrasound in Yemen, where she was told to undergo surgery to remove it. She did not pursue surgery at that time. She moved to the U.S. one year ago and was re-evaluated for the neck mass. On examination, a firm mass was noted on the left side of the neck, followed by an ultrasound which demonstrated a 4.5 cm mass at the left carotid bifurcation and an enlarged right thyroid lobe of the same echogenicity with no tissue in the left thyroid bed. She had no clinical symptoms suggesting of hypo or hyperthyroidism. Laboratory examination showed suppressed TSH with elevated T3 suggesting thyrotoxicosis. CT neck was obtained for further characterization of the left neck mass which showed a hyper-enhancing, lobular soft tissue mass at the carotid bifurcation extending from the mandible to the level of the thyroid isthmus, concerning for carotid body paraganglioma or schwannoma. An I-123 scan demonstrated 24% (increased) uptake in the right thyroid lobe and minimal uptake in the carotid bifurcation tissue. The patient is currently being treated medically for thyrotoxicosis. Based on its ultrasonographic appearance, mild uptake on the I-123 scan, and no clinical suggestion of paraganglioma, the left neck mass is presumed to be ETT and no surgical intervention is being pursued. It is possible that the right lobe is thyrotoxic, suppressing iodine uptake in the ectopic tissue. Conclusion: This case demonstrates a unique presentation of ETT in the left carotid bifurcation with a thyrotoxic right lobe. It is difficult to distinguish the precise composition of neck masses at the carotid bifurcation, which has important implications for management. Often, an official diagnosis of thyroid tissue is made with histopathology only after the mass is surgically excised. Most ETT is benign in nature, and many times it is the only thyroid tissue available, thus surgery is not indicated. It is especially difficult to distinguish between ETT and paraganglioma on imaging itself. Somatostatin receptor scintigraphy, Ga-68/PET scanning, or iodine uptake scan can be useful to distinguish ETT from paraganglioma. Despite its rarity, lateral ETT must be included in the differential diagnosis of carotid body paraganglioma. Presentation Date: Saturday, June 17, 2023

Cervical schwannoma: diagnosis and treatment

Schwannomas are benign, encapsulated, slow-growing, tumours deriving from the peri neural cells located in the nerve sheath. They can arise from any cranial, peripheral or autonomic nerves, and show a predilection for the head and neck region. They may produce secondary symptoms like nasal obstruction, dysphagia, and hoarseness of voice depending upon the location of the tumour. Preoperative diagnosis is difficult, relying on clinical suspicion, and confirmed by surgical pathology. Preoperative imaging or fine needle aspiration cytology may help to reveal diagnosis. The definitive diagnosis is made by histopathological examinations. A 28 years old female patient presented to the OPD with painless swelling on the left lateral side of the neck since 1 year. The swelling was mobile, non-tender, non-pulsatile firm in consistency measuring 4×3 cm with no bruit. MRI neck with contrast was done which revealed a moderately enhancing lesion of size 7×4×3 cm in the left carotid sheath. The tumour was approached by an anterior approach along the medial border of the sternocleidomastoid. Platysma and fascia were dissected followed by carotid sheath to reach the tumour. As the mass was seen arising from a branch of the ansa cervicalis, it had to be sacrificed.

Myeloid-derived growth factor suppresses VSMC dedifferentiation and attenuates postinjury neointimal formation in rats by activating S1PR2 and its downstream signaling.

Restenosis after angioplasty is caused usually by neointima formation characterized by aberrant vascular smooth muscle cell (VSMC) dedifferentiation. Myeloid-derived growth factor (MYDGF), secreted from bone marrow-derived monocytes and macrophages, has been found to have cardioprotective effects. In this study we investigated the effect of MYDGF to postinjury neointimal formation and the underlying mechanisms. Rat carotid arteries balloon-injured model was established. We found that plasma MYDGF content and the level of MYDGF in injured arteries were significantly decreased after balloon injury. Local application of exogenous MYDGF (50 μg/mL) around the injured vessel during balloon injury markedly ameliorated the development of neointimal formation evidenced by relieving the narrow endovascular diameter, improving hemodynamics, and reducing collagen deposition. In addition, local application of MYDGF inhibited VSMC dedifferentiation, which was proved by reversing the elevated levels of osteopontin (OPN) protein and decreased levels of α-smooth muscle actin (α-SMA) in the left carotid arteries. We showed that PDGF-BB (30 ng/mL) stimulated VSMC proliferation, migration and dedifferentiation in vitro; pretreatment with MYDGF (50-200 ng/mL) concentration-dependently eliminated PDGF-BB-induced cell proliferation, migration and dedifferentiation. Molecular docking revealed that MYDGF had the potential to bind with sphingosine-1-phosphate receptor 2 (S1PR2), which was confirmed by SPR assay and Co-IP analysis. Pretreatment with CCG-1423 (Rho signaling inhibitor), JTE-013 (S1PR2 antagonist) or Ripasudil (ROCK inhibitor) circumvented the inhibitory effects of MYDGF on VSMC phenotypic switching through inhibiting S1PR2 or its downstream RhoA-actin monomers (G-actin) /actin filaments (F-actin)-MRTF-A signaling. In summary, this study proves that MYDGF relieves neointimal formation of carotid arteries in response to balloon injury in rats, and suppresses VSMC dedifferentiation induced by PDGF-BB via S1PR2-RhoA-G/F-actin-MRTF-A signaling pathway. In addition, our results provide evidence for cross talk between bone marrow and vasculature.

Gender-based relationship between serum creatinine and carotid plaque stability: A cross-sectional study in China

ObjectiveCarotid plaque instability is a risk factor for ischemic stroke, and changes in serum creatinine are associated with carotid plaque. However, the relationship between serum creatinine and carotid plaque stability is not well explained. This study aimed to interpret this relationship for clinical treatment of carotid plaque. MethodsA total of 4363 subjects aged 29–86 from December 2013 to December 2018 were included in this study. The stability of carotid plaque was determined based on ultrasound echoes and divided into two groups: carotid plaque stable group and carotid plaque unstable group. The relationship between serum creatinine and carotid plaque stability was determined using curve fitting methods as well as logistic regression. ResultsAfter age stratification, there was an inverted U-shaped curve between the stability of right carotid plaque and serum creatinine in males, When serum creatinine levels were less than 84 μmol/L, the probability of carotid plaque instability gradually increased, and the carotid plaque became stable when creatinine levels were greater than 84 μmol/L. The relationship between left carotid female plaque stability and serum creatinine showed a U-shaped curve. When serum creatinine levels were less than 80 μmol/L, the carotid plaque stability stabilized, and the probability increased when creatitine levels were more than 80 μmol/L, as the carotid plaque instability rose. ConclusionThere was an inverted U-shaped relationship between the stability of carotid plaque in the right carotid artery and serum creatinine in males, and a U-shaped relationship between the stability of carotid plaque in the left carotid artery and serum creatinine in females.

Markers of terminally differentiated T-cells as predictors of vascular health in renal transplant recipients and healthy adults

Meta-analyses confirm a link between persistent human cytomegalovirus (HCMV) infections and cardiovascular disease, but the mechanisms are unclear. We assess whether proportions of T-cell populations are reliable predictors of subclinical atherosclerosis and/or reflect the burden of HCMV in healthy adults and renal transplant recipients (RTR). Samples were collected from healthy adults and RTR at baseline (T0) and after 32 (24–40) months (T1). Left carotid intima media thickness (cIMT) and proportions of T-cells expressing CD57, LIR-1 or the TEMRA phenotype increased in healthy adults and RTR. The T-cell populations correlated with levels of HCMV-reactive antibodies. Proportions of CD57+, LIR-1+ and TEMRA CD8+ T-cells correlated with left and right cIMT in healthy adults. Proportions of CD57+ and LIR-1+ CD8+ T-cells at T0 predicted left cIMT at T1 among healthy adults, but these associations disappeared after adjustment for covariates. We link LIR-1+ and CD57+CD8+ T-cells with the progression of cIMT in healthy adults.

Hypertension-mediated organ damage involving multiple sites is an independent risk factor for cardiovascular events.

Chronic pressure overload determines functional and structural alterations, leading to hypertension-mediated organ damage (HMOD), affecting multiple districts. We aim at evaluating the prognostic impact of the absence vs. presence of HMOD in one or more sites and of blood pressure (BP) and metabolic control in hypertensive patients. The study included 7237 hypertensive patients from the Campania Salute Network Registry, followed up for 5.3 ± 4.5 years. As HMOD, we analysed the presence of left ventricular hypertrophy, carotid plaques, and chronic kidney disease (CKD-EPI ≥3 stage) and evaluated the impact of zero vs. one vs. two vs. three sites of HMOD on the occurrence of major adverse cardiovascular events (MACEs). Blood pressure control and Metabolic Score for Insulin Resistance (METS-IR) were also considered. Optimal BP control was achieved in 57.3% patients. Major adverse cardiovascular events occurred in 351 (4.8%) patients. The MACE rate in patients without HMOD was 2.7%, whereas it was 4.7, 7.9, and 9.8% in patients with one, two, and three sites with HMOD, respectively. By using Cox multivariate models, adjusted for age, BP control, mean heart rate, mean METS-IR, number of HMOD sites, and drugs, MACE was found to be significantly associated with ageing, mean METS-IR, anti-platelet therapy, and multiple sites with HMOD, whereas a negative association was found with renin-angiotensin system inhibitor drugs. In hypertensive patients, the risk of MACE increases with the incremental number of districts involved by HMOD, independent of BP control and despite the significant impact of metabolic dysregulation. Hypertension-mediated organ damage involving multiple sites is the deleterious consequence of hypertension and dysmetabolism but, when established, it represents an independent cardiovascular risk factor for MACE occurrence.

Reduced reward responsiveness in treatment resistant depression of middle-aged adults: Association with carotid artery stiffness and tetrahydrobiopterin.

Nearly one third of the population diagnosed with major depressive disorder (MDD) fail to respond to two or more antidepressant drugs of adequate dose and duration. This necessitates identification of confounding psychological and physiological factors that could contribute to treatment resistant depression (TRD). The present longitudinal study investigated the influence of behavioural inhibition system (BIS) and behavioural approach system (BAS) in treatment resistance. Further, the association of depression severity with physiological factors contributing to arterial stiffness was also investigated. Baseline data was acquired from 101 middle-aged (36-56 years) patients on immediate diagnosis with MDD using DSM-V criteria. Follow ups were conducted at 06 months and 12 months during treatment. Psychological assessment battery at baseline and follow ups comprised of Hamilton depression rating (HAM-D) for depression severity, WHODAS-2 and BIS-BAS score. Atherosclerosis and central arterial stiffness were measured by intima-media thickness of internal carotid artery and brachial-ankle pulse wave velocity. Physiological factors influencing central vascular function viz., body-mass index, estimated glomerular filtration rate, HbA1c, central systolic and diastolic blood pressure, heart rate and tetrahydrobiopterin were also investigated. Our results show lower reward responsiveness (BAS-RR) and higher BIS scores in TRD patients along with differentially higher intima-media thickness of left internal carotid artery. Higher depression severity at all stages of the study was correlated with lower tetrahydrobiopterin and BAS-RR scores. We, therefore, suggest that vascular depression resulting due to increased intima-media thickness of left carotid artery and lower tetrahydrobiopterin could be contributing factors for treatment resistance in middle-aged MDD patients.

Mild Hypoxia Postconditioning Induces Hypoxia-Inducible Factor 1 Alpha Expression and Improves the Neurobehavioral Abilities of Rats with Hypoxic-Ischemic Brain Damage

Background: While severe hypoxia is known to contribute to neurotoxicity and lead to abnormal behavior, mild hypoxia may have beneficial effects mediated through endogenous adaptive responses. Objectives: The present study aimed to investigate the effects of mild hypoxia postconditioning and long-term neurobehavioral ability rehabilitation after hypoxic-ischemic brain damage (HIBD). Methods: Seven-day-old rats underwent left carotid ligation followed by 2 hours of hypoxia stress. Rats received different protocols of mild hypoxia postconditioning for 5 days and underwent neurobehavioral testing during the last week of the study. Hypoxia-inducible factor 1 alpha (HIF-1a) expression was assessed, and neurobehavioral ability assays were performed. Results: Compared with the HIBD group, rats postconditioning with mild hypoxia showed increased HIF-1a expression, and their brain functions were better in neurobehavioral analyses. The rehabilitation of brain functions may be associated with high HIF-1a expression and better behavioral performance. Conclusions: Our findings indicate that mild hypoxia postconditioning improves neurobehavioral ability, and HIF-1a may be a potential mediator of the observed effects. Our findings suggest that there may be clinical implications for treating infants with HIBD.

Associations of blood pressure trajectories in early life with target organ damage in midlife : a 30-year cohort study.

Hypertension is a pivotal factor in cardiovascular risk. However, the association of longitudinal blood pressure (BP) trajectories in the early life and cardiovascular risk assessed by target organ damage (TOD) in adulthood is poorly reported. The objective of this study was to identify the association between systolic BP, diastolic BP, and mean atrial pressure (MAP) trajectories early in life with a single or multiple TOD in later life. We identified BP trajectories from 6 to 45 year-old using group-based trajectory models among 2430 individuals in the Hanzhong Adolescent Hypertension Study and examined the relationship between BP trajectories and cardiovascular risk in later life. Four discrete long-term systolic BP, diastolic BP, and MAP trajectories were identified, namely, low stable, moderate stable, high stable (low increasing), and moderate increasing groups, based on the BP levels at baseline and in the 30-year follow-up. The carotid intima-media thickness were higher in persistently high or increasing trajectories in comparison to the low stable group. Individuals with deteriorative trajectories during early life were at an increased risk of suffering from a single TOD, including left ventricular hypertrophy (LVH) and carotid atherosclerosis (CA) in middle age (36-49 years old). Moreover, higher BP trajectories were correlated with the presence of combined TODs load stage which were assessed by CA, LVH, arteriosclerosis and subclinical renal damage (SRD). Higher longitudinal BP trajectories early in life were associated with increased cardiovascular risk in midlife, and identifying BP trajectories in early life can help screen individuals with TOD later. LVH, left Ventricular Hypertrophy; CA, carotid atherosclerosis; SRD, subclinical renal damage; TOD, target organ damage.