Significant Carotid Research Articles

Cost-effectiveness of novel imaging tests to select patients for carotid endarterectomy

ObjectiveWe estimated the cost-effectiveness of novel imaging tests to select patients for carotid endarterectomy (CEA) in patients with significant carotid stenosis using a computer model and explored the minimum prognostic performance that a new confirmatory test must have in order to be cost-effective versus the guideline-based strategy. MethodsThe guidelines recommend initial duplex ultrasonography (DUS) followed by a confirmatory test if DUS shows 30–69% stenosis; a positive CT-angiography (CTA) is an indication for CEA. In an alternative strategy, we replaced CTA with CE-DUS, and in another strategy we replaced it by a hypothetical imaging test and estimated the minimum prognostic performance that the test must have in order to be cost-effective versus the guideline-based strategy. We assessed the potential cost-effectiveness in four age- and sex-specific subpopulations. ResultsFor 60-year-old men, a perfect confirmatory test (100% sensitivity and specificity) improves health (0.066 quality-adjusted life years) and reduces costs (€110/$146) versus the guideline-based strategy. Potential health gain is smaller for 80-year-old men, while no health gain is expected for women. Assuming 100% sensitivity, a test must have a specificity of at least 66% for 60-year-old men and 87% for 80-year-old men to be cost-effective. Similarly, assuming 100% specificity, a test must have a sensitivity of at least 58% for 60-year-old men and 66% for 80-year-old men. ConclusionsInformation from new imaging technologies may improve stroke risk prediction and thereby improve decisions about which patients should undergo CEA. However, their cost-effectiveness strongly depends on the current test strategy and choice of patient subpopulation.

Progression of brain white matter hyperintensities in asymptomatic patients with carotid atherosclerotic plaques and no indication for revascularization

Background and aimsBrain white matter hyperintensities (WMHs) have been associated with an increased risk of ischemic stroke and considered as markers of brain ischemia. Progression of WMHs in asymptomatic patients with non-hemodynamically significant carotid plaque could represent a putative marker of plaque vulnerability. We prospectively evaluate progression and determinants of WMHs in this population. MethodsThis prospective study included 51 asymptomatic patients with carotid stenosis <70% that underwent brain magnetic resonance imaging scans at baseline and after a median follow up of 595 days (interquartile range 553–641 days). Patients (mean age of 69 years and 45% females) underwent baseline carotid computed tomography angiography, contrast-enhanced ultrasound for carotid plaque characterization and analysis of subsets of circulating lymphocytes and monocytes by flow cytometry. ResultsSeventeen subjects (33.3%) had carotid stenoses of 50–70% (Doppler flow velocity) while the rest had stenoses of <50%. In 25 (49.0%) patients, new WMHs, with 5 new lesions on average and a median volume of 134 mm3, were detected at follow-up. None of the plaque characteristics or of the circulating cellular biomarkers investigated were associated with the global and ipsilateral occurrence of new WMHs whereas, at multivariate analysis, female sex, hypercholesterolemia, and lower glomerular filtration rate (GFR) emerged as independent variables associated with new WMHs. ConclusionsHalf of the patients with carotid plaques of intermediate severity had evidence of WMH progression at follow up. Female gender and systemic factors such as hypercholesterolemia, and lower GFR, but not plaque characteristics or circulating cellular biomarkers, are associated with WMH progression.

Evolution of surgical treatment of carotid artery stenosis: a single center observational study

Background: In 2009 and 2011 respectively ESVS and AHA/ASA guidelines recommended to operate patients with a symptomatic carotid artery stenosis within 14 days. This study aimed primarily to determine if an academic hospital has implemented these international guidelines about indication and timing of surgical treatment of carotid stenosis. Second, the influence of referral from another hospital on time from symptoms to surgery and the influence of time between neurological event and surgery on 30-day complication rate was studied. Third, the number of asymptomatic carotid artery lesions treated surgically was also evaluated in both periods.Methods: Retrospective study to compare patients with significant atherosclerotic carotid stenosis who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) in 2005–2006 versus patients treated in 2014–2016. Demographic data, treatment characteristics, interval between symptom and surgery and 30-day outcomes were collected.Results: In 2005–2006 38.1% (59/155) of the patients were treated for symptomatic carotid artery stenosis, in 2014–2016 this increased to 66.5% (121/182) (p < .001, 95% CI: 0.179–0.383). Median time from neurological symptom to surgery in symptomatic patients decreased from 30 to 13 d (p <.001, 95% CI: 1.476–2.763). Early surgery did not increase the 30-day postoperative complications (p = .19, 95% CI: 0.987–1.003). Referral from another hospital almost doubled the time interval between symptoms and surgery in 2014–2016 (p <.001, 95% CI: 1.386–2.827).Conclusions: Since the publication of the international guidelines, patients with symptomatic carotid artery stenosis were preferably surgically treated within 2 weeks at an academic institution. The number of treated asymptomatic carotid stenoses was drastically reduced.

Dexmedetomidine improves cognition after carotid endarterectomy by inhibiting cerebral inflammation and enhancing brain-derived neurotrophic factor expression.

ObjectivesCarotid endarterectomy (CEA) is efficient in preventing stroke for patients with significant carotid stenosis, but results in mild cognitive dysfunction. Dexmedetomidine is neuroprotective in stroke models. We hypothesized that dexmedetomidine may improve cognition after CEA.MethodsForty-nine patients scheduled for elective CEA were randomly assigned to intravenous dexmedetomidine treatment group (n = 25) and control group C (normal saline, n = 24). Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MOCA), as well as lactate, TNF-α, IL-6, and BDNF levels in blood, were assessed before, during, and after surgery.ResultsMMSE and MOCA scores showed subtle decline in both groups at 24 hours postoperatively; this decline remained at 48 hours postoperatively in group C. Both scores were higher in group D than in group C at 48 and 72 hours postoperatively. TNF-α and IL-6 were lower from 5 minutes post-clamping through 24 hours postoperatively in group D; lactate was lower at 5 minutes post-clamping in group D. BDNF was higher from 5 minutes post-clamping through 1 hour postoperatively in both groups, and remained high in group D at 24 hours postoperatively.ConclusionsDexmedetomidine improved recovery of cognition after CEA, potentially due to reduced inflammation and enhanced BDNF expression.

Contemporary prevalence of carotid stenosis in patients presenting with ischaemic stroke.

Carotid stenosis is a common cause of ischaemic stroke and transient ischaemic attack (TIA). Despite rising recognition and centralization of stroke services there has been a decline in interventions for carotid stenosis in recent years. The aim of this study was to determine the current prevalence and management of carotid stenosis in the UK. This was a 1-year prospective observational study of consecutive patients presenting with ischaemic stroke, TIA or ischaemic retinal artery occlusion to a central London hyperacute stroke unit. Patients with significant carotid stenosis, defined as atherosclerotic narrowing of 50 per cent or greater, underwent multidisciplinary team (MDT) discussion to determine the cause of stroke/TIA and classify carotid stenosis as symptomatic or incidental. In total, 2707 patients were seen; half had an ischaemic event and the majority had carotid imaging (1252 of 1444). Carotid stenosis of at least 50 per cent was seen in 238 (prevalence 19·0 (95 per cent c.i. 16·6 to 21·4) per cent). Patients with significant carotid stenosis were more likely to have hypertension, hypercholesterolaemia, diabetes and ischaemic heart disease. Carotid stenosis was deemed symptomatic in 99 patients (7·9 (6·3 to 9·5) per cent); of these, 17 had carotid occlusion, 17 were unfit for surgery and 58 patients were referred for carotid intervention. Among 139 patients with asymptomatic stenosis, 75 had carotid stenosis ipsilateral to the stroke but, after MDT discussion, the cause was deemed to be atrial fibrillation (32), small-vessel disease (15), another determined cause (5), or not determined owing to atypical imaging or clinical presentation. Carotid stenosis is common, affecting one in five patients presenting with stroke or TIA. Careful MDT discussion may avoid unnecessary intervention and should be the standard of care.

Carotid endarterectomy with primary closure versus patch angioplasty in patients with symptomatic and significant stenosis: protocol for a systematic review with meta-analyses and trial sequential analysis of randomised clinical trials

IntroductionUse of patch angioplasty in carotid endarterectomy (CEA) is suggested to reduce the risk of restenosis and recurrent ipsilateral stroke. The objective is to conduct a systematic review with meta-analysis...

Is Duplex carotid artery screening prior to CABG justified?

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

Comparison of outcomes after carotid endarterectomy between type 2 diabetic and non-diabetic patients with significant carotid stenosis

BackgroundWe aimed to compare early and late outcomes after carotid endarterectomy (CEA) between Korean type 2 diabetic and non-diabetic patients and to investigate the impact of diabetes on the overall incidence of cardiovascular events after CEA.MethodsWe retrospectively analyzed 675 CEAs, which were performed on 613 patients with significant carotid stenosis between January 2007 and December 2014. The CEAs were divided into a type 2 diabetes mellitus (DM) group (n = 265, 39.3%) and a non-DM group (n = 410, 60.7%). The study outcomes included the incidence of major adverse events (MAEs), defined as fatal or nonfatal stroke or myocardial infarction or all-cause mortality, during the perioperative period and within 4 years after CEA.ResultsPatients in the DM and non-DM groups did not differ significantly in the incidence of MAEs or any of the individual MAE manifestations during the perioperative period. However, within 4 years after CEA, the difference in the MAE incidence was significantly greater in the DM group (P = 0.040). Analysis of the individual MAE manifestations indicated a significantly higher risk of stroke in the DM group (P = 0.006). Multivariate analysis indicated that diabetes was not associated with MAEs or individual MAE manifestations during the perioperative period, whereas within 4 years after CEA, diabetes was an independent risk factor for MAEs overall (hazard ratio [HR], 1.62; 95% confidence interval [CI] 1.06–2.48; P = 0.026) and stroke (HR, 2.55; 95% CI 1.20–5.41; P = 0.015) in particular.ConclusionsDiabetic patients were not at greater risk of perioperative MAEs after CEA; however, the risk of late MAE occurrence was significantly greater in these patients. Within 4 years after CEA, DM was an independent risk factor for the occurrence of MAEs overall and stroke in particular.

A STRATEGY FOR THE TREATMENT OF PATIENTSWITH CORONARY ARTERY DISEASE AND THE PRESENCE OF SIGNIFICANT CAROTID ARTERY STENOSIS: ANALYSIS OF THE "STAGED" AND "CONCOMITANT" APPROACHES

Today, there is no unequivocal overview of how to treat patients undergoing myocardial revascularization and have associated significant carotid artery stenosis. In this group of patients, there are several ways to treat, and our study analyzed patients who were exposed to a Staged and Concomitant approach. During 2016 in three cardiac surgery centers of Serbia, the perioperative results of the patients subjected to a Staged and Concomitant approach were analyzed. Group 1 including patients with cardiac revascularization and endarterectomy was made at least 30 days earlier, and group 2 consisted of patients who underwent endarterectomy with cardiac revascularization simultaneously. In both groups, CVI appearance was observed 7 days after the revascularization of the heart. We followed the risk factors for the occurrence of CVI. The conducted study included a total of 49 patients, divided into two groups. In 28 patients (group 1) Eversion Carotid endarterectomy was performed 30 days to 26 months prior to coronary revascularization. The average age of patients was 64 and 65 years, with the prevalence of male sex (86%: 14%). The only parameters that showed a significant difference between the groups were left main syndrome and unstable angina pectoris, both in Group 2. In the ensuing period, in both groups, there were no postoperative major neurological events (CVI). In one patient, clinical signs of neurological deficits occurred in the form of weakness of one side of the body, but CVI was not proven by CTom and MRA. It can be concluded that the Staged and Concomitant approaches are safe and effective.

The effect of combining coronary bypass with carotid endarterectomy in patients with unrevascularized severe coronary disease

ObjectiveManagement of significant carotid stenosis in those with symptomatic coronary disease remains controversial. Staged and combined carotid endarterectomy (CEA) with coronary artery bypass grafting has been described. Yet, an understanding of the additive risks of these approaches is poor. This study sought to assess outcomes in patients with clinically relevant coronary disease undergoing either isolated CEA (ICEA) or combined CEA and coronary artery bypass (concurrent coronary artery bypass [CCAB]). MethodsAll CEAs in the Vascular Quality Initiative from 2003 to 2017 were reviewed. CCABs were identified, as were ICEAs in patients with unrevascularized stable angina, unstable angina, or myocardial infarction (MI) within 6 months of operation. CCABs were compared with ICEAs as well as with a risk-matched cohort of ICEAs. Primary outcomes included perioperative stroke, all-cause death, MI, and these as composite (SDM). Univariate analysis and logistic regression were performed. ResultsThere were 4042 patients identified, including 2582 ICEA patients (64%) and 1460 CCAB patients (36%); 61% were male, 91% were white, and 39% had symptomatic carotid disease. Overall stroke was 3.5%, death 1.8%, and SDM 6.0%. ICEA had higher rates of postoperative MI (1.9% vs 0.9%; P = .01) but lower rates of stroke (2.8% vs 4.7%; P = .002), death (1.0% vs 3.0%; P < .001), and SDM (5.1% vs 7.5%; P = .002). After regression, predictors of SDM were congestive heart failure (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.3-2.4; P < .001), urgent operation (OR, 1.6; 95% CI, 1.2-2.2; P = .001), and CCAB (OR, 1.3; 95% CI, 1.01-1.7; P = .04). After propensity matching, ICEA continued to have higher rates of perioperative MI (2.6% vs 1.0%; P = .01) and lower rates of death (1.0% vs 3.0%; P = .001). However, there were no longer differences in stroke (3.2% vs 4.6%; P = .10) or SDM (6.3% vs 7.8%; P = .18). Within the matched cohort, predictors of SDM included chronic obstructive pulmonary disease (OR, 1.6; 95% CI, 1.1-2.2; P = .01), congestive heart failure (OR, 1.7; 95% CI, 1.1-2.5; P = .01), and symptomatic carotid disease (OR, 1.5; 95% CI, 1.03-2.1; P = .03). CCAB was not significant (OR, 1.3; 95% CI, 0.9-1.8; P = .18). ConclusionsIn patients with unrevascularized, clinically relevant coronary disease, CCAB reduces operative MI but increases risk of stroke and death. After risk adjustment, MI remains higher in ICEA, but differences in 30-day stroke and SDM between ICEA and CCAB are no longer appreciated. These data suggest that CEA risk undertaken in patients with unrevascularized coronary disease is not inconsequential, and outcomes are similar to those of CCAB.

The role of SYNTAX score in decision-making for preoperative carotid artery screening in patients undergoing coronary artery bypass surgery.

The coexistence ofcoronary artery disease (CAD) in patients undergoing coronary artery bypass surgery (CABG) is a risk factor for stroke and death. The aim of this study is to evaluate the potential of the SYNTAX score (SXscore) for predicting carotid stenosis in patients undergoing CABG. We retrospectively reviewed 291 patients (225 males, mean age 60.5 ± 8.5 years) who underwent CABG in a single center in 2014 and were screened for carotid artery preoperatively. The total SXscore was obtained by scoring every luminal narrowing greater than 50% in coronary vessels larger than 1.5 mm using the SXscore algorithm. Correlations between the severity of carotid stenosis and SXscore were analyzed. As the degree of carotidartery stenosis increases (≤%50; ≥%50 vs ≥%70), the mean SXscore (19.06 ± 7.72, P > 0,05; 28.40 ± 6.89, P < 0,01; 31.02 ± 7.04, P < 0.01, respectively) were found to increase. Receiver operating characteristic analysis revealed a cut-off point of 27 or more in SXscore according to the presence of carotid stenosis greater than or equal to %70. The risk of existence of significant carotid stenosis was 58-fold greater in cases with SXscore greater than or equal to 27. In cases with SXscore greater than or equal to 27, the risk of existence of significant carotid stenosis was 58-fold greater with a confidence interval of 95%. Moreover, the presence of left main CAD was associated with the severity of carotid stenosis (<50% carotid stenosis, P > 0.05; ≥%50, P = 0.001; and ≥70, P = 0.001). This study suggests that the presence of left main coronary artery disease or SXscore greater than or equal to 27 should require preoperative carotid screening in patients undergoing CABG, regardless of the presence of risk factors.

Comparison between intracranial collaterals and cerebral hemodynamics in patients with extracranial carotid stenosis versus combined extra- and intracranial stenosis using transcranial duplex

BackgroundIn acute ischemic stroke, collateral circulation plays an important role in maintaining blood flow to the tissue that is at risk of progressing into ischemia, and in increasing the successful recanalization rate without hemorrhagic transformation.ObjectivesTo compare between collaterals in patients with extracranial carotid stenosis alone and in patients having both extracranial and intracranial carotid stenosis and therefore the difference in prognosis between them.Materials and methodsA total of 30 patients of acute ischemic stroke were enrolled. The extracranial part of the carotid artery was assessed with color-coded duplex. Transcranial color-coded duplex was done to assess cerebral hemodynamics and collaterals to differentiate between extracranial significant carotid stenosis alone versus combined extra- and intracranial significant carotid stenosis.ResultsOut of 15 patients with significant extracranial stenosis, 3 of them obtained reversed flow in the ophthalmic artery and 3 patients of them showed change of flow in the anterior cerebral artery(ACA), whereas the other 15 patients of combined stenosis did not show any reversed blood flow in the same arteries which considered nonsignificant. The residual deficit of patients with extracranial stenosis alone was better when compared to that of the other group.ConclusionOur study concluded that transcranial duplex provides useful information about cerebral reserve and status of collaterals which show nonsignificant difference between two studied groups regarding intracranial collaterals. Furthermore, patients with combined extra- and intracranial stenosis were found to have more deficit and worse prognosis than patients with internal carotid stenosis only.

A High Prevalence of Intracranial Stenosis in Patients with Coronary Artery Disease and the Diagnostic Value of Transcranial Duplex Sonography

Background: According to the data from the population-based Rotterdam study, intracranial carotid artery calcification detected by computed tomography is very common and contributed to 75% of all strokes. The aim of the present study was to estimate the prevalence of intracranial stenosis (IS) using noninvasive transcranial color-coded duplex sonography (TCCS) in neurologically asymptomatic patients with coronary artery disease (CAD). Methods: Three hundred and eighty-nine patients with angiographically-confirmed, severe CAD were included prospectively. All of them were examined using extracranial and TCCS. Results: Out of 389 patients (age 66.7 ± 9.2, 39-88), 237 (61%) were diagnosed with 3 vessels disease and 152 patients (39%) with left stem disease with/without 3 vessels damage. Transcranial sonography revealed at least 1 IS in 63.6% of echo positive patients (220/346). IS was found in 127 (61.4%) patients with 3 vessels disease, 20 patients (58.8%) with isolated left stem disease, and 73 patients (69.5%) with 3 vessels and left stem disease (P = .305). In the case of significant (≥50%) extracranial internal carotid artery stenosis, intracranial stenosis were detected in 84.8% (50 of 59), in the case of mild (<50%) stenosis, in 59.2% (170 of 287), P < .001. Conclusions: It was found that two thirds of patients with advanced CAD have a silent IS. TCCS is a reliable method for the evaluation of intracranial atherosclerosis in such patients in order to gain useful information about cerebrovascular disease as a risk factor for stroke.

Syntax Score I and II for Predicting Carotid Artery Stenosis in Patients with Multivessel Coronary Artery Disease: A Propensity Score Matching Analysis.

ObjectiveTo evaluate the predictive accuracy of SYNTAX score (SS) I and II for detecting significant carotid artery stenosis (CAS) in patients with multivessel coronary artery disease undergoing coronary artery bypass grafting (CABG) surgery.MethodsThe study population consisted of 416 patients. Clinical, demographic, and radiological records were retrospectively reviewed. Characteristics of patients with CAS (n=66) and patients without CAS (n=350) were compared before and after propensity score matching analysis.ResultsPatients with significant CAS were older compared to those without significant CAS [(60 (53-65) vs. 63 (59-67); P=0.01]. However, atherosclerotic risk factors and SS I were similar between groups. SS II CABG and percutaneous coronary intervention (PCI) were significantly higher in patients with CAS [37.4 (30.9-43.5) vs. 33.8 (29.9-38.9); P=0.02]. After propensity score matching analysis (66 vs. 66), age, SS II PCI and CABG were significantly higher in patients with CAS than those without CAS [37.4 (30.9-43.5) vs. 33 (29.3-36.9); P=0.03]. Age, SS II PCI and CABG were associated with CAS in logistic regression analysis [OR=1.086, 95% CI (1.032-1.143), P<0.001; OR=1.054, 95% CI (1.010-1.101), P=0.02; OR=1.078, 95% CI (1.029-1.129), P<0.01].In ROC curve analysis, SS II PCI >33.1 had 68.2% sensitivity and 54.6% specificity [AUC=0.624, P=0.01, 95% CI (0.536-0.707)] whereas SS II CABG >26.1 had 81.8% sensitivity and 54.6% specificity [AUC=0.670, P<0.01, 95% CI (0.583-0.749)] to predict CAS. Pairwise comparison of ROC curves revealed similar statistical accuracy for prediction of CAS (z statistic: 0.683, P=0.49)ConclusionSS II is useful to predict asymptomatic CAS in patients with multivessel coronary artery disease.

Outcome of 472 Chronic Myeloid Leukemia Patients Treated with Frontline Nilotinib: A Gimema CML WP Analysis

BACKGROUND: In chronic phase (CP) chronic myeloid leukemia (CML) nilotinib showed better efficacy compared to imatinib. The higher rates of deep molecular response with nilotinib may translate in more patients (pts) eligible for treatment discontinuation. On the other hand, cardiovascular toxicity may limit nilotinib use in selected groups of pts (e.g. elderly pts).AIM: To investigate the efficacy and safety, overall and according to age, of first-line treatment with nilotinib in CML pts.METHODS: We analyzed response rates, events and outcome of 472 pts ≥ 18 y of age with CP CML, enrolled in clinical trials of the GIMEMA CML WP with nilotinib frontline. Pts were treated with: nilotinib 300 mg BID (n=276); nilotinib 400 mg BID (n=73); rotation of nilotinib 400 mg BID / imatinib 400 mg OD (3-month periods for each drug)(n=123). The median follow-up was 36 (3-82) months. Pts were further analyzed considering 3 age groups: 18-39 y (98 pts); 40-59 y (217 pts); and ≥ 60 y (157 pts). Definitions: Major molecular response (MR3): BCR-ABL≤0.1% (IS), with > 10.000 ABL copies; MR4: BCR-ABL≤0.01% (IS), with > 10.000 ABL copies. Events: permanent discontinuation of nilotinib for any reason, including adverse events, progression to accelerated/blast phase (AP/BP), or deaths. Arterial thrombotic events (ATEs): peripheral arterial obstructive disease, acute coronary syndrome, chronic ischemic heart disease, significant carotid stenosis and ischemic stroke, or other significant ischemic events.RESULTS: Overall, the cumulative incidences of MR3 by 12, 24, and 36 months were 75, 88, and 93%, respectively. The cumulative incidences of MR4 by 12, 24, and 36 months were 38, 63, and 76%, respectively. Events leading to permanent nilotinib discontinuation occurred in 132 (27.9%) pts. ATEs occurred in 33 (7% of pts) ATEs, corresponding to 19.7 ATEs/1000 pt-y. Fifteen (3.1%) pts progressed to AP/BP. Overall, 23 (4.9%) pts died, 11 of them after progression to AP/BP. The estimated 5-year OS was 93%.The sub-analysis according to age showed that: MR3 and MR4 rates were similar across the 3 age groups (cumulative incidences of MR4 by 24 months were 55, 62, and 70% in pts 18-39 y, 40-59 y, and ≥ 60 y, respectively; p=0.25). Progressions to AP/BP were: 6.1% in pts 18-39 y, 2.8% in pts 40-59 y, and 1.9% in pts ≥ 60 y. ATEs were: 0 in pts 18-39y, 4.1% (11.7/1000 pt-years) in pts 40-59 y, and 15.3% (41.3/1000 pt-years) in pts ≥ 60 y (no difference in ATEs was found between pts 60-69 y and those ≥ 70 y). The 5-y OS was 91, 97, and 89% in pts 18-39 y, 40-59 y, and ≥ 60 y, respectively (p=0.065). Death was always leukemia-related in pts 18-39 y (100%), while it was mainly leukemia-unrelated (75%) in pts ≥ 60 y.SUMMARY/CONCLUSION: Nilotinib as first-line treatment of newly diagnosed CP CML pts showed high rates of deep molecular responses, few progressions to AP/BP, and a high OS. Deep molecular response were similar in all age groups; as expected, ATEs were more frequent in pts > 60 y. These data suggest that: in pts > 60 y, the high efficacy of nilotinib should be weighed against its potential toxicity; in pts < 60 years, nilotinib may be a very good choice, with high efficacy and low toxicity. DisclosuresGugliotta:Novartis: Honoraria; Pfizer: Honoraria; Incyte: Honoraria; Bristol-Myers Squibb: Honoraria. Castagnetti:Bristol Myers Squibb: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Incyte: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria. Breccia:Novartis: Honoraria; Pfizer: Honoraria; BMS: Honoraria; Incyte: Honoraria. Levato:Novartis: Other: Advisory board. Abruzzese:Pfizer: Consultancy; Ariad: Consultancy; Novartis: Research Funding; BMS: Consultancy. Soverini:Bristol Myers Squibb: Consultancy; Incyte Biosciences: Consultancy; Novartis: Consultancy. Foà:NOVARTIS: Speakers Bureau; JANSSEN: Other: ADVISORY BOARD, Speakers Bureau; CELTRION: Other: ADVISORY BOARD; INCYTE: Other: ADVISORY BOARD; CELGENE: Other: ADVISORY BOARD, Speakers Bureau; ABBVIE: Other: ADVISORY BOARD, Speakers Bureau; ROCHE: Other: ADVISORY BOARD, Speakers Bureau; GILEAD: Speakers Bureau; AMGEN: Other: ADVISORY BOARD. Cavo:AbbVie: Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Adaptive Biotechnologies: Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees; GlaxoSmithKline: Honoraria, Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees. Pane:Novartis: Research Funding, Speakers Bureau; BMS: Speakers Bureau; AMGEN: Speakers Bureau.

Editors' note: Teaching NeuroImages: Multimodality imaging of carotid web

In “Teaching NeuroImages: Multimodality imaging of carotid web,” Renard et al. presented representative images of a carotid web identified in a 52-year-old woman presenting with an ipsilateral acute middle cerebral artery infarction on 3 modalities: Doppler ultrasound, CT, and magnetic resonance angiography. In response, Dr. Sharma discusses the relative strengths and limitations of different modalities in identifying carotid webs. Dr. Sharma notes that in an ongoing study of high-resolution MRI in patients with significant symptomatic carotid stenosis, carotid webs were identified in about 22% of cases, but that the role of such webs in cryptogenic stroke remains unknown. In “Teaching NeuroImages: Multimodality imaging of carotid web,” Renard et al. presented representative images of a carotid web identified in a 52-year-old woman presenting with an ipsilateral acute middle cerebral artery infarction on 3 modalities: Doppler ultrasound, CT, and magnetic resonance angiography.

Carotid Artery Calcification on Orthopantomograms (CACO Study) - is it indicative of carotid stenosis?

It is unclear whether incidental carotid artery calcification (CAC) on radiographs has a defined relationship to clinically significant carotid artery stenosis, and therefore risk of stroke. The primary objective of this study was to ascertain the relationship between dental radiograph detected carotid calcification and carotid artery stenoses ≥50% on carotid duplex ultrasound. We carried out an observational study of patients undergoing routine dental orthopantomogram (OPG) examinations. Consecutive patients with CAC on OPG were prospectively matched to those without CAC based on age and gender. Ultrasound of the carotid arteries was performed to determine the presence of stenosis (≥50%) in either vessel. Of 5780 consecutive OPG examinations with suitable images for analysis, CAC was detected in 10.8%. A total of 233 patients underwent carotid ultrasound (130 with and 103 without CAC on OPG). The prevalence of a clinically significant (≥50%) carotid stenosis on ultrasound was 15.4% (20/130) in those with CAC and 5.8% (6/103) for those without CAC on OPG. Incidental CAC detected on routine OPG requires both radiological reporting and clinical follow-up since 1 in 7 patients will have a clinically significant carotid artery stenosis as compared with 1 in 20 patients who do not have CAC. Trial Registration: Australian and New Zealand Clinical Trials Registry website (U1111-1148-1066). http://www.ANZCTR.org.au/ACTRN12613001038785.aspx.

Prognosis of Acute Intracranial Atherosclerosis-Related Occlusion after Endovascular Treatment.

Background and PurposeLittle is known about prognosis after endovascular therapy (EVT) for acute large artery occlusion (LAO) caused by underlying intracranial atherosclerotic stenosis (ICAS). Therefore, we investigated the prognosis following EVT according to the underlying etiology of LAO. MethodsPatients from the Acute Stroke due to Intracranial Atherosclerotic occlusion and Neurointervention-Korean Retrospective (ASIAN KR) registry (n=720) were included if their occlusion was in the intracranial anterior circulation and their onset-to-puncture time was <24 hours. Occlusion was classified according to etiology as follows: no significant stenosis after recanalization (Embolic group), and fixed significant focal stenosis in the occlusion site with flow impairment or re-occlusion observed during EVT (ICAS group). Patients were excluded when significant extracranial carotid lesions existed, and when the intracranial occlusion was intractable to EVT so that the etiology was undetermined. The effect of angiographic etiologic classification on outcomes was evaluated using multivariable analysis that was adjusted for potential confounders. ResultsAmong eligible patients (n=520), 421 and 99 were classified in the Embolic and ICAS groups, respectively. Patients in the Embolic and ICAS groups had similar successful reperfusion rates with EVT (79.6% vs. 76.8%, P=0.537) and 3-month functional independence (54.5% vs. 45.5%, P=0.104). In multivariable analysis, ICAS-related occlusion (odds ratio, 0.495; 95% confidence interval, 0.269 to 0.913; P=0.024) showed poorer 3-month functional independence compared to embolic occlusion. ConclusionsAfter EVT, patients with acute ICAS-related occlusion have relatively poor functional outcomes compared to those with embolic occlusion. Novel strategies need to be developed to improve EVT outcomes for ICAS occlusion.

Comparison of Significant Carotid Stenosis for Nasopharyngeal Carcinoma between Intensity-Modulated Radiotherapy and Conventional Two-Dimensional Radiotherapy

Radiotherapy (RT) serves as the most efficient treatment for nasopharyngeal carcinoma (NPC) and can cause carotid stenosis. This work compared the incidence of significant carotid stenosis between intensity-modulated radiotherapy (IMRT) and two-dimensional conventional radiotherapy (2D-RT) for NPC and explored the risk factors. We retrospectively reviewed 233 cases with NPC who underwent carotid ultrasound post IMRT or 2D-RT from 2006 to 2015. The incidence of significant stenosis after RT was 19.3%. Significant stenosis was identified in 20 (14.6%) of 137 patients treated with IMRT and 25 (26.0%) of 96 patients with 2D-RT, respectively (p = 0.035). Multivariate logistic analysis indicated age (odds ratio = 1.054, 95% CI = 1.011–1.099, p = 0.014), radiation technique (IMRT) (odds ratio = 0.471, 95%CI = 0.241–0.919, p = 0.027) and time interval (odds ratio = 1.068, 95%CI = 1.033–1.105, p = 0.001) as independent predictors for significant carotid stenosis. Our study suggests that IMRT was associated with decreased incidence of significant carotid stenosis versus 2D-RT for NPC. Prevention and carotid ultrasound should be considered for older NPC survivors with longer interval from RT, especially those treated with 2D-RT.

CME Test for Prevalence of Hemodynamically Significant Internal Carotid Artery Disease Based on the Signs of the Zodiac

CME Test for Prevalence of Hemodynamically Significant Internal Carotid Artery Disease Based on the Signs of the Zodiac