Significant Carotid Research Articles

Association between anatomical distribution of symptomatic peripheral artery disease and cerebrovascular disease.

Peripheral arterial disease is frequently associated with significant atherosclerosis of other vascular beds. The aim of the present study was to investigate a possible association between peripheral arterial disease segment-specific disease burden and cerebrovascular disease. Two-hundred and twenty-six patients with clinically symptomatic peripheral arterial disease from the prospective PureASO registry were followed up after revascularization. The breadth of peripheral arterial disease was quantified at the time patients entered the study. The segment-specific peripheral arterial disease burden was correlated to cerebrovascular disease and imaging findings during a five-year follow-up. At five years, cerebrovascular disease-free survival after lower limb revascularization was 31%. Patients with peripheral arterial disease involving the crural arteries had significantly more ischemic degenerative changes at brain imaging (p = 0.031), whereas patients with aorto-iliac and femoropopliteal segment peripheral arterial disease had more significant (>50% uni- or bilaterally) internal carotid artery stenosis compared to patients with crural peripheral arterial disease (p = 0.006). According to Cox regression analyses, crural arteries burden was associated with a significantly increased risk of mortality (adjusted HR 2.07, CI 95% 1.12-3.28, p = 0.021) and cerebrovascular events (adjusted HR 1.97, CI 95% 1.19-3.26, p = 0.008). Present results suggest that atherosclerosis burden at different lower limb artery segments is associated with defined cerebrovascular disease. This further suggests that risk factors and pathophysiological mechanisms are congruent across particular vascular beds.

Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting: The Campania Salute Network.

Hypertensive urgencies (HypUrg) are defined as severe elevation in blood pressure (BP) without acute target organ damage. In the office setting, treated asymptomatic patients, with severe BP elevation meeting criteria for urgency are often seen. We evaluate incident Cardiovascular (CV) events (n = 311) during follow-up (FU) in patients with HypUrg at first outpatient visit. HypUrg was defined by systolic BP ≥180 mm Hg and/or diastolic BP ≥110 mm Hg. Patients were >18 years old, with available ultrasound data, without prevalent CV disease, and no more than stage III Chronic Kidney Disease. BP control was defined as the average BP during FU <140/90 mm Hg. Four hundred and sixty-nine of 6,929 patients presented with HypUrg at first visit. Patients with HypUrg were more likely to be women, obese and diabetic and with higher prevalence of left ventricle (LV) hypertrophy and carotid plaque (all P < 0.05). During FU patients with HypUrg had 5-fold higher risk of uncontrolled BP (95% confidence interval (CI) 4.1-6.8, P < 0.0001). In Cox regression presenting with HypUrg was not associated with increased CV risk after adjusting for significant covariates, including age, sex, BP control, LV hypertrophy, and carotid plaque (hazard ratio (HR) 1.42, 95% CI (0.96-2.11), P = 0.08). Patients with HypUrg have worst CV risk profile, reduced probability of BP control during FU and greater prevalence of target organ damage, but the excess CV event risk appears to be mediated through BP control, non-BP cardio-vascular disease risk factors, and demographic attributes. NCT02211365.

Carotid plaque score, independent risk factor for cardiovascular events and mortality after acute coronary syndrome

The carotid plaque score (CPS) is the sum of max endoluminals eaves of all atherosclerostic plaques of Common carotids carotid, bifurcations and Internal Carotides. It reflects the atherosclerotic load of the carotid arteries. As intima media thickness, it is strongly related to mortality risk in hypertensive patient and the increase of stroke risk. It is also an independant predictor of coronary heart disease and has a strong link with the SYNTAX score. By a prospective study, recruiting consecutive three hundred thirty-six inpatient coronary care unit for acute coronary syndrome, the aim is to evaluate the impact of a high CPS on mortality and cardiovascular events at 6 and 12 months of follow-up. Among patients (Men = 69.0%; mean age = 63.3y), The carotid bulb is the most frequent location of atherosclerotic plaques: 207 patients (61.3%). In our study population, 20.8% have cerebrovascular disease and 16.1% peripheral artery disease (defined by Anckle brachial index < 0.9). One hundred and seven patients (31.8%) have an atherosclerotic bulb plaque of more than 3 mm. A CPS greater than 7 mm is objectified in 91 patients (27.1%) and a significant carotid stenosis is seen in 57 patients (16.7%). A High CPS is significantly related with the presence of multitroncular coronary disease. CPS greater than 12 mm appears as an independent and powerful predictor of mortality and cardiovascular events in medium term in patients with acute coronary syndrome. The hazard ratio of High CPS (CPS > 12 mm) for cardiovascular events at 6 and 12 months of hospitalization are respectively 3,5 (95% CI:1.75–7.13) and 3.4 (95% CI:1.78–6.5). The hazard ratio of High CPS (CPS > 12 mm) for cardiovascular mortality at 6 and 12 months of hospitalization are 4.23 (95% CI:1.42–12.66) and 5.77 (95% CI:2.30–14.47) respectively.

Early Outcomes in the ROADSTER 2 Clinical Trial of Transcarotid Artery Revascularization in Patients with Significant Carotid Artery Disease

Introduction: Transcarotid artery revascularization (TCAR) involves carotid artery stenting with cerebral protection via reversal of carotid arterial flow. The aim of the present study was to evaluate the real world safety and efficacy of TCAR using the ENROUTE Transcarotid Neuroprotection System (NPS) Methods: The ROADSTER 2 trial is a prospective, open label, single arm, multicenter post-approval registry for patients undergoing TCAR. Patients considered at high risk for complications from carotid endarterectomy (CEA) with symptomatic stenosis ≥50% or asymptomatic stenosis ≥80% were included. The primary endpoint was procedural success, which encompassed technical success plus the absence of stroke, myocardial infarction, or death within the 30 day postoperative period. Secondary endpoints were acute device success (delivery of device, establishment of flow reversal, and retrieval), technical success (acute device success plus introduction of interventional tools), stroke, death, and the composite of stroke, death, or myocardial infarction (S/D/MI). Results: This study enrolled 623 patients who underwent TCAR at 41 sites with 599 having completed 30 day follow up. The cohort included 67.0% (417/623) male patients, 42% over the age of 75, and 26.8% (167/623) with symptoms. Overall, 425 (68.2%) patients had anatomic-related high risk factors, 352 (56.5%) had physiologic high risk factors, and 154 (24.7%) had both. The majority (81.2%) of operators in this study were new to TCAR and did not participate in the ROADSTER 1 trial. The early postoperative outcomes included five patients (0.8%) suffering a stroke, one patient (0.2%) dying from a ruptured AAA two weeks post-procedure, and six (1.0%) having an MI. The composite stroke/death/MI rate was 1.9%. Acute device success and technical success occurred in 99.7% of cases. Conclusion: Transcarotid artery revascularization results in excellent early outcomes with a combined stroke/death rate of 1.0%. These results were achieved despite the majority of operators were new to this technology. Longer follow up data is needed to confirm these early outcomes. Disclosure: Stents and neuroprotection devices were provided by SILKROAD within the trial.

Molecular imaging of carotid artery atherosclerosis with PET: a systematic review.

To conduct a systematic review of articles on PET imaging of carotid atherosclerosis with emphasis on clinical usefulness and comparison with other imaging modalities. Research articles reporting carotid artery PET imaging with different radiotracers until 30 November 2018 were systematically searched for in Medline/PubMed, Scopus, Embase, Google Scholar, and Cochrane Library. Duplicates were removed, and editorials, case studies, and investigations on feasibility or reproducibility of PET imaging and of patients with end-stage diseases or immunosuppressive medications were omitted. After quality assessment of included articles using Joanna Briggs Institute checklists, all eligible articles were reviewed. Of 1718 primary hits, 53 studies comprising 4472 patients, aged 47-91years (78.8% males), were included and grouped under the following headlines: diagnostic performance, risk factors, laboratory findings, imaging modalities, and treatment. 18F-fluorodeoxyglucose (FDG) (49/53) and 18F-sodium fluoride (NaF) (5/53) were the most utilized tracers to visualize carotid wall inflammation and microcalcification, respectively. Higher carotid FDG uptake was demonstrated in patients with than without symptomatic carotid atherosclerosis. Normal carotid arteries presented with the lowest FDG uptake. In symptomatic atherosclerosis, carotid arteries ipsilateral to a cerebrovascular event had higher FDG uptake than the contralateral carotid artery. FDG uptake was significantly associated with age, male gender, and body mass index in healthy individuals, and in addition with arterial hypertension, hypercholesterolemia, and diabetes mellitus in patients. Histological assessment indicated a strong correlation between microcalcification and NaF uptake in symptomatic patients. Histological evidence of calcification correlated inversely with FDG uptake, which was associated with increased macrophage and CD68 count, both accounting for increased local inflammatory response. FDG-PET visualizes the inflammatory part of carotid atherosclerosis enabling risk stratification to a certain degree, whereas NaF-PET seems to indicate long-term consequences of ongoing inflammation by demonstrating microcalcification allowing discrimination of atherosclerotic from normal arteries and suggesting clinically significant carotid atherosclerosis.

English

To determine the frequency, risk factors, and outcomes of significant carotid artery disease (CAD) in patients with ischemic stroke. The frequency of significant CAD in patients admitted to the Stroke Unit between January 2014 and December 2015 was determined from radiological data. Outcomes were determined clinically and radiologically. Among 435 patients, 273 were men (62.8%), with a mean age of 57.4+/-12.2 years. Significant CAD was found in 48 vessels in 40 (9.2%) patients, of which 30 patients were symptomatic. Nine of these patients were treated with carotid artery stenting, one underwent carotid endarterectomy, and 3 underwent an urgent thrombectomy, without stenting. Seventeen symptomatic patients were not treated for the following reasons: patient/family refusal (n=2), contraindications (n=5), and complete occlusion (n=10). One (7.7%) of the 13 treated patients had an ipsilateral stroke on follow up, one (7.7%) had contralateral transient ischemic attack (TIA), 9 (69.2%) had no recurrence, and no clinical data were available for 2 patients. Among the 17 untreated patients, one (5.9%) had an ipsilateral stroke, 7 (41.2%) had no recurrence, and 9 (52.9%) were lost to follow up. Significant carotid artery disease is uncommon in our cohort found in less than 10% of patients. Vascular risk factors are more or less similar between patients with or without CAD except obesity which appears to have inverse relation with CAD. A small number of patients received carotid intervention with no recurrence of stroke at limited follow up.

Association of Significant Coronary Arterial Disease, Coronary Calcification and Carotid Intima Media Thickness with Glycosylated Hemoglobin Levels in Patients without History of Diabetes Mellitus Sent for Coronary CT Angiography

Background: Diabetes mellitus (DM) is a risk factor for the development of the coronary heart disease (CHD), and individuals with DM have more extensive atherosclerosis, more cardiac events, and higher prevalence of silent ischemia as compared with individuals without DM. Objective: The aim of the study is to assess the association of significant coronary arterial disease, coronary calcification and carotid intima media thickness with glycosylated hemoglobin levels in patients without history of diabetes mellitus sent for coronary CT angiography. Patients and methods: This prospective study included 39 patients who underwent 320 Multi-slice CT coronary angiography (Aquilion ONE 320 MSCT) at (Nasr-City Police Hospital) through the period from May 2017 to April 2018. They divided into 3 equal groups according to HbA1c (G1, non-diabetic, G2, pre-diabetic and G3 diabetic). The study was approved by Ain Shams University academic and ethical committee and an informed written consent was obtained from all patients. Results: At level of multi-slice CT coronary, CCS was significantly higher in Group C than in Group A and B. But no significant difference could be picked in subgroup analysis between Group A and Group B. There were no significant differences among groups as regarding significant coronary artery stenosis. But there was a trend towards significance in Group C; however, it failed to reach significance mostly because of the small sample size. At level of carotid Doppler US, there were significant differences between groups as regarding bilateral CIMT. But this significance was mainly between Group C and the other groups in subgroup analysis. As regarding correlation, age and HbAlc had a positive strong correlation with CCS, LT CIMT, and RT CIMT. Conclusion: HbAlc positively correlates with coronary and carotid atherosclerosis and patients with mild elevation of HbAlc has significantly more CIMT than individuals with normal HbAlc.

Association of Significant Coronary Arterial Disease, Coronary Calcification and Carotid Intima Media Thickness with Glycosylated Hemoglobin Levels in Patients without History of Diabetes Mellitus Sent for Coronary CT Angiography

Background: Diabetes mellitus (DM) is a risk factor for the development of the coronary heart disease (CHD), and individuals with DM have more extensive atherosclerosis, more cardiac events, and higher prevalence of silent ischemia as compared with individuals without DM. Objective: The aim of the study is to assess the association of significant coronary arterial disease, coronary calcification and carotid intima media thickness with glycosylated hemoglobin levels in patients without history of diabetes mellitus sent for coronary CT angiography. Patients and methods: This prospective study included 39 patients who underwent 320 Multi-slice CT coronary angiography (Aquilion ONE 320 MSCT) at (Nasr-City Police Hospital) through the period from May 2017 to April 2018. They divided into 3 equal groups according to HbA1c (G1, non-diabetic, G2, pre-diabetic and G3 diabetic). The study was approved by Ain Shams University academic and ethical committee and an informed written consent was obtained from all patients. Results: At level of multi-slice CT coronary, CCS was significantly higher in Group C than in Group A and B. But no significant difference could be picked in subgroup analysis between Group A and Group B. There were no significant differences among groups as regarding significant coronary artery stenosis. But there was a trend towards significance in Group C; however, it failed to reach significance mostly because of the small sample size. At level of carotid Doppler US, there were significant differences between groups as regarding bilateral CIMT. But this significance was mainly between Group C and the other groups in subgroup analysis. As regarding correlation, age and HbAlc had a positive strong correlation with CCS, LT CIMT, and RT CIMT. Conclusion: HbAlc positively correlates with coronary and carotid atherosclerosis and patients with mild elevation of HbAlc has significantly more CIMT than individuals with normal HbAlc.

P3706Atrial fibrillation with CHA2DS2-VASC =0. Really no need for anticoagulation?

Abstract Background Based on the ESC guidelines on Atrial Fibrillation, oral anticoagulation is recommended in male patients with CHA2DS2-VASC score ≥1, in females if CHA2DS2-VASC is ≥2. In our research, we evaluated if there are patients at risk of significant thromboembolic events among those whose CHA2DS2-VASC score is apparently = 0, that could benefit of anticoagulant therapy. Methods Over the last 12 years, 20,154 outpatients were evaluated in our clinics. We found the presence of non valvular atrial fibrillation in 3.043 (15.1%) patients. In 176 (5.7%) of them the CHA2DS2-VASC was = 0. None of them, as suggested in the guidelines, received oral anticoagulants or antiplatelet drugs. In these patients, we evaluated the presence of other two important cardiovascular risk factors, not included in CHA2DS2-VASC score: cigarette smoking and hypercholesterolemia. Results Smoking patients were 70, of whom heavy smokers (≥20 cigarettes/day) were 32. Patients with LDL cholesterol&gt;115 mg/dl were 55. During one year follow-up, 3 of 176 patients (1.7%) with CHA2DS2-VASC score = 0 had a stroke. These patients were all heavy smokers and one of them also had high LDL values; they didn't show significant carotid stenosis or carotid dissection. None of the patients was found to have thrombophilic disorders. Transthoracic echocardiogram was performed, resulting negative for patent foramen ovale, ventricular dysfunction, or masses. All patients underwent 24 hours blood pressure monitoring, and it was found that all of them had masked hypertension; lower extremity arterial evaluation revealed mild, asymptomatic peripheral arterial disease, with ABI &lt;0.9. No events occurred in patients with elevated LDL, not heavy smokers. The risk of stroke in the population of heavy smokers, even if CHA2DS2-VASC score was apparently = 0, was 9.3%, with a clear indication for anticoagulation. Conclusions In heavy smokers patients with atrial fibrillation, CHA2DS2-VASC score could apparently be =0, when they are only clinically evaluated. In fact, these patients often have asymptomatic peripheral arterial disease of the lower limbs and masked hypertension. Our research highlights how in some subgroups of patients there could be some “hidden” risk factors, that we should keep in mind and closely search for when evaluating the risk of cardioembolic stroke, that remains high.

Frequency, risk factors, and outcomes in patients with significant carotid artery disease admitted to King Abdulaziz Medical City, Riyadh with Ischemic Stroke

Objectives:To determine the frequency, risk factors, and outcomes of significant carotid artery disease (CAD) in patients with ischemic stroke.Methods:The frequency of significant CAD in patients admitted to the Stroke Unit between January 2014 and December 2015 was determined from radiological data. Outcomes were determined clinically and radiologically.Results:Among 435 patients, 273 were men (62.8%), with a mean age of 57.4±12.2 years. Significant CAD was found in 48 vessels in 40 (9.2%) patients, of which 30 patients were symptomatic. Nine of these patients were treated with carotid artery stenting, one underwent carotid endarterectomy, and 3 underwent an urgent thrombectomy, without stenting. Seventeen symptomatic patients were not treated for the following reasons: patient/family refusal (n=2), contraindications (n=5), and complete occlusion (n=10). One (7.7%) of the 13 treated patients had an ipsilateral stroke on follow up, one (7.7%) had contralateral transient ischemic attack (TIA), 9 (69.2%) had no recurrence, and no clinical data were available for 2 patients. Among the 17 untreated patients, one (5.9%) had an ipsilateral stroke, 7 (41.2%) had no recurrence, and 9 (52.9%) were lost to follow up.Conclusion:Significant carotid artery disease is uncommon in our cohort found in less than 10% of patients. Vascular risk factors are more or less similar between patients with or without CAD except obesity which appears to have inverse relation with CAD. A small number of patients received carotid intervention with no recurrence of stroke at limited follow up.

3041Wall shear stress measurement by ultrafast vector flow imaging for atherosclerotic carotid stenosis

Abstract Background Carotid plaque vulnerability assessment is an important factor in guiding the decision to treat significant carotid stenosis. Ultrafast Ultrasound Imaging (UF) offers the possibility of evaluating local flow velocities over an entire 2D image, allowing access to velocity measurements in contact with the arterial wall and to measure the wall shear stress (WSS). Purpose To evaluate the feasibility of WSS measurement in a prospective series of patients with carotid stenosis. Methods A 7.5 MHz linear probe of an Aixplorer scanner was used. UF acquisitions had 3 tilted plane waves transmits (−10; 0; 10°) and an effective frame rate of 5000Hz. We evaluated the flow velocity in 5 areas of the carotid wall: common carotid artery (1), plaque ascent (2), plaque peak (3), plaque descent (4), internal carotid artery (5) (Figure). WSS was computed with the vector field speed using the following formula, WSS=μ·δn·v with v the blood velocity, n the normal vector to the vessel wall and μ, the blood viscosity, calculated from the hematocrit value for each patient. WSS measurement method was first validated using a laminar flow phantom and known viscosity. And then, 33 patients were then prospectively evaluated, with a median carotid stenosis degree of 80% [75–85]. Results Significant correlation was found between in vitro measurement and the theoretical WSS values (R2=0.95; p&lt;0.001).In patients,the maximum WSS value over the cardiac cycle follows the shape of the plaque with an increase during the ascend, reaching its maximum value of 3.57 Pa [2.47–4.45] at the peak of the plaque, and a fall after passing the peak (0.99 Pa [0.8–1.32]) lower than the WSS values in the non-stenotic areas (1.55 Pa [1.13–1.90] for the common carotid artery) (Table). Table 1 Wall's area Wall shear stress (Pa) Min Max Delta 1. Common carotid artery 0.14 [0.05–0.27] 1.55 [1.13–1.90] 0.73 [0.55–0.96] 2. Plaque's ascent 0.39 [0.24–0.59] 2.63 [1.89–3.28] 1.20 [0.89–1.79] 3. Plaque's peak 0.60 [0.32–0.89] 3.57 [2.47–4.45] 1.78 [1.44–2.46] 4. Plaque's descent 0.16 [0.13–0.22] 0.99 [0.80–1.32] 0.52 [0.34–0.73] 5. Internal carotid artery 0.17 [0.13–0.35] 1.37 [1.04–1.75] 0.72 [0.50–0.87] Results are median [25th–75th percentile]. Figure 1 Conclusion UF provide reliable WSS values. High WSS was present at the peak of the plaque, whereas lowest WSS values were found at the post-stenotic zone. WSS evaluation may help to better characterize the carotid plaque vulnerability.

Subclinical Peripheral Arterial Disease in Patients with Acute Ischemic Stroke: A Study with Ultrasonography

Background: Peripheral arterial disease (PAD) is an advanced form of atherosclerosis defined by an abnormal ankle-brachial index (ABI). However, the ABI provides no information about the location of atherosclerosis. We investigated the clinical implication of PAD confirmed using lower-extremity ultrasonography (LEUS), with consideration of the atherosclerosis location. Methods: Patients with acute ischemic stroke who underwent LEUS were enrolled. Patients with PAD were further divided into those with PAD at the proximal (above-popliteal artery, PADP) and distal (below-tibialis artery, PADD) segments. The clinical outcome was compared between patients with and without PAD, and between PADP and PADD. The atherosclerosis location in the cerebral artery was also compared between groups. Results: Among 289 patients, PAD was observed in 108 (37.4%) patients (43 had PADP and 65 had PADD). Patients with PAD were slightly older (P < .001) and had more significant carotid artery stenosis (30.6% versus 12.7%, P < .001) than those without. Patients with PAD had poor 3-month functional outcome than those without (modified-Rankin Scale score: 3 [interquartile range, 1-4] versus 2 [1-3], respectively, P = .003). Diabetes, high-stroke severity, and the presence of PADP (odds ratio, 3.893; 95% confidence interval, 1.454-10.425; P = .007) were independently associated with poor functional outcome at 3 months. Patients with PADP showed higher prevalence of extracranial stenosis than those with PADD (41.9% versus 23.1%; P = .038). Conclusions: Our study suggests that subclinical PAD, especially PADP, is associated with poor functional outcome at 3 months after stroke onset. Interestingly, the location of cerebral atherosclerosis differed according to the location of PAD.

Helical Blood Flow in Hemodynamically Significant Carotid Stenosis.

To define helical blood flow (HBF) characteristics in hemodynamically significant atherosclerotic stenosis of the internal carotid artery (ICA) by means of duplex scanning. Twenty-five hemodynamically significant (65.0% [range, 63.0%-69.0%]) carotid stenoses were examined in 23 patients. The severity of the stenosis was calculated by the European Carotid Surgery Trial grading method by transverse section scanning in the B-mode. Rotational components were estimated in color flow mapping by transverse-section scanning of a vessel at the most narrowed site, as well as in the prestenotic and poststenotic segments. A quantitative evaluation of HBF was performed on the basis of pulsed wave Doppler imaging of longitudinal and transverse sections of the arterial lumen. Helical blood flow was most often (68%) registered in the poststenotic segment of the ICA as a single vortex (52%) or double vortices (16%). At the most narrowed site, HBF was registered in 48% of the cases (44% single vortex and 4% double vortices), whereas in the prestenotic segment of the blood vessel, it was registered in only 16% of the cases (8% single vortex and 8% double vortices). The time-averaged maximum blood flow velocities at the most narrowed site were 88.5 cm/s (25th-75th percentiles, 73.8-127.8 cm/s) for the axial component and 33.1 cm/s (22.7-40.9 cm/s) for the rotational component. The calculated summary velocity of motion of the blood particles in helical paths was 92.2 cm/s (75.7-144.2 cm/s). It has been shown that HBF can be registered by Doppler ultrasound in atherosclerotic stenosis, and its registration rate increases while passing through the narrowed segment of the ICA.

How Can We Treat Asymptomatic Carotid Disease in Patients with a Planned CABG?

Carotid artery intervention to the neurological asymptomatic patients is one of the most controversial issue of vascular surgery throughout the last decades. The decision about how to manage asymptomatic carotid disease in the setting of planned CABG becomes more complex due to surgical treatment of either pathology may be complicated by multiple factors. Current guidelines do not support routine screening for carotid artery stenosis before CABG because of given the low prevalence of stroke after CABG. Optimal surgical intervention and timing for patients having concomitant severe carotid and coronary artery stenosis remains uncertain. In this brief review, we analyze the incidence of significant carotid stenosis in patients undergoing CABG, association of untreated asymptomatic carotid stenosis on postoperative stroke, effects of carotid endarterectomy (CEA) on postoperative incidence of stroke, determination of surgical options and technical variations for CEA, scanning methods for identifying the vulnerable carotid plaque and revealing risk factors and predictors associated with stroke after CABG. Synchronous or staged CEA still remain valuable options in order to diminish postoperative risk of stroke for neurologically asymptomatic patients undergoing to CABG who have bilateral significant carotid artery stenosis or contralateral occlusion.

Identification of High Risk Carotid Artery Stenosis: A Multimodal Vascular and Perfusion Imaging Study.

Background: Risk stratification of asymptomatic carotid artery stenosis (ACAS) is still an issue for carotid revascularization. We sought to identify factors associated with symptomatic carotid artery stenosis (SCAS) using multimodal imaging techniques.Methods: We retrospectively collected data on patients who underwent carotid artery revascularization. Results from duplex sonography, computerized tomography angiography, brain magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), perfusion-weighted imaging, and demographic profiles were compared between ACAS and SCAS patients. Differences in baseline characteristics between the two groups were balanced by the propensity matching score method. Multivariable regression analysis was performed to identify factors associated with symptomaticity of carotid artery stenosis. We compared the strength of associations between significant imaging factors and symptomatic carotid stenosis using C statistics.Results: A total of 259 patients (asymptomatic 57.1%, symptomatic 42.9%) with carotid stenosis were included. After 1:1 propensity score matching, the multivariable regression analysis revealed that the absence of plaque calcification [Odds ratio 0.41, 95% confidence interval (CI) 0.182–0.870, p = 0.023], deep white matter hyperintensity (DWMH; Odds ratio 3.46, 95% CI 1.842–6.682, p < 0.001), susceptibility vessel sign seen on gradient-echo MRI (Odds ratio 2.35, 95% CI 1.113–5.107, p = 0.027), and increased cerebral blood volume (CBV) seen on perfusion-weighted MRI (CBV; Odds ratio 2.17, 95% CI 1.075–4.454, p = 0.032) were associated with SCAS. The combination of these variables had a fair accuracy to classify SCAS (Area under the curve 0.733, 95% CI 0.662–0.803).Conclusions: We identified several multimodal imaging markers independently associated with SCAS. These markers may provide information to identify ACAS patients with high risk of ischemic stroke. Future studies are needed to predict SCAS using our findings in other independent cohorts.

Clinical risk factors predictive of thrombotic stroke with large cerebral infarction.

Large cerebral infarctions have high morbidity and mortality. Patients with large cerebral infarctions may have recurrent ischemia as high as 8.1% within 7 days; highest among other types of strokes. Data regarding risk factors for large cerebral infarction in Asian populations are still scant. All adult (age ≥15 years old) patients with the diagnosis of thrombotic ischemic stroke who were treated at Srinagarind Hospital, Khon Kaen University, Thailand from January 2012 to December 2013 were studied. Large cerebral infarctions are defined by clinical criteria of having cerebral cortical impairment, brain stem or cerebellar dysfunction with infarction sizes of more than 1.5 cm. The association of various stroke risk factors and large infarction strokes were calculated using multiple logistic regression analysis. There were 276 thrombotic stroke patients who met the study criteria; classified as large cerebral infarctions in 59 patients (21.38%) and small cerebral infarctions in 217 patients (78.62%). Baseline characteristics and risk factors for stroke were comparable between both groups. The large cerebral infarction group had a significantly larger proportions of right internal carotid artery stenosis, plaques on the left side, left internal carotid artery stenosis, and internal carotid artery stenosis at any side than the small cerebral infarction group. Among various stroke risk factors, only internal carotid artery stenosis at any side was the only significant factor associated with large cerebral infarction with an adjusted odds ratio of 11.14 (95% CI: 3.46, 35.82). In conclusion, significant internal carotid artery stenosis is associated with large cerebral infarction.

Diagnostic criteria for the determination of clinically significant internal carotid artery stenosis using duplex ultrasound.

Carotid endarterectomy is beneficial in symptomatic patients with ≥70% stenosis at the bifurcation of the internal carotid artery. The fact that the duplex ultrasound is widely used, inexpensive and non-invasive for examination of the carotid arteries underlines the importance of high accuracy of this method for grading internal artery stenosis. Duplex scans and arteriograms of carotid arteries of 142 patients were reviewed. Peak and end-diastolic velocities of the common and internal carotid arteries were recorded, and the percent stenosis of the internal carotid artery was determined by arteriogram. Receiver-operator characteristic curves of sensitivity, specificity, positive and negative predictive values and accuracy were determined. The recommended criteria for the detection of ≥70% stenosis of the internal carotid artery were: peak systolic velocity in the internal carotid artery ≥215 cm/s, end-diastolic velocity in the internal carotid artery ≥65 cm/s, ratio of peak systolic velocities in the internal and common carotid arteries ≥2.7 and ratio of the end-diastolic velocities of the internal and common carotid arteries ≥3.7. These criteria allow for reliable determination of internal carotid artery stenosis ≥70% by duplex ultrasound.

Short-Term Double Layer Mesh Stent Patency for Emergent or Elective Carotid Artery Stenting.

Background and Purpose- Novel double layer micromesh stents have recently been introduced for treatment of patients with significant carotid stenosis. Strict evaluation of safety and patency of such novel devices is required both in elective and in emergency interventions. We report a single center experience with double layer mesh stents for carotid artery revascularization. Methods- Consecutive patients who underwent carotid artery stenting with a double layer mesh stent between June 2015 and September 2018 in our tertiary vascular referral center were included. Treatment indications were emergent carotid artery stenting for intracranial or extracranial carotid stenosis in patients undergoing intraarterial thrombectomy for acute ischemic stroke in the anterior circulation, or elective carotid artery stenting for significant symptomatic or asymptomatic stenosis. End points were postprocedural thrombotic stent occlusion and procedural stroke or death. Results- Fifty-four patients were included; 27 were treated for acute stroke with intracranial and extracranial (tandem) lesions and 27 for elective stenting. Follow-up imaging was available for 9/27 (33%) patients with acute stroke, and 19/27 (70%) electively treated patients. Five stent occlusions occurred, of which 2 were symptomatic with clinical deterioration within one day. Another patient deteriorated on postprocedural day one, but imaging of the carotids was not performed, and the stent turned out occluded on the 30-day duplex. All stent occlusions occurred in patients treated for acute stroke. Conclusions- This study suggests that occlusion of novel double layer mesh stents occurs in a considerable proportion of carotid artery stenting procedures performed in the emergency setting for acute stroke, with occlusion-related symptoms in half the cases. Future prospective studies should clarify the role of double layer mesh stents in this high-risk patient population.

Enfermedad carotídea aterosclerosa y enfermedad de sustancia blanca en sujetos sin historia de infarto cerebral o isquemia cerebral transitoria.

Atherosclerotic carotid artery disease (CAD) is a major risk factor for cerebrovascular disease. To analyze the association of major vascular risk factors with atherosclerotic CAD and white matter disease (WMD) in patients without a history of ischemic stroke. Risk factors were assessed with carotid examination using Doppler duplex ultrasound. Cases with a history cerebral infarction or transient ischemic attack were not included. Subjects had brain magnetic resonance imaging scans available and those with large-artery ischemic lesions were excluded. Multivariate models were constructed for the prediction of atherosclerotic CAD, significant carotid stenosis, atheroma burden and WMD. One-hundred and forty-five subjects were assessed (60.7% were females, mean age was 73 years). Atherosclerotic CAD was documented in 54.5%, carotid stenosis ≥ 50% in 9.0%, > 6 atheroma plaques in 7.6%, and periventricular or subcortical WMD in 28.3% (20.6% had atherosclerotic CAD and WMD concurrently). Risk factors independently associated with atherosclerotic CAD were age and hypertension; hypertension was associated with ≥ 50% carotid stenosis; age was associated with > 6 atheroma plaques; and age, diabetes and hypertension were associated with WMD. Obesity was not associated with any of the analyzed independent variables. In asymptomatic subjects without a history of ischemic stroke, age and hypertension were the most important risk factors for macrovascular disease. Diabetes mellitus was associated with microvascular disease. Obesity alone was not a major determinant of CAD or WMD.

Retinal vessel dynamic functionality in the eyes of asymptomatic patients with significant internal carotid artery stenosis.

The goal of this study was to assess the retinal microvascular function in asymptomatic patients with hemodynamically significant internal carotid artery stenosis (ICAS) and to assess the potential efficacy of carotid endarterectomy (CEA) for the improvement of vessel functionality. Retinal vessel caliber and reactions to flicker stimulation were assessed in both eyes of 65 asymptomatic patients with unilateral hemodynamically significant ICAS and 34 healthy subjects. Subsequently, the recruited ICAS patients were referred for standard unilateral CEA procedure. The full ophthalmologic examination of both eyes and vessel analysis were performed 1 day before and 3 months after CEA. The venous responses to flicker stimulation were significantly lower in the EIS (eyes ipsilateral to stenosis) and ECS (eyes contralateral to stenosis) compared with those in the controls (P<0.0001 and P<0.0001, respectively). No changes were identified in retinal vascular flicker responses after CEA in both groups of eyes compared with the baseline values. We observed a decrease in CRVE (central retinal venular equivalent) after the CEA both in eyes ipsilateral (P=0.01) and contralateral (P=0.04) to CEA. Likewise, a decrease in CRAE (central retinal arteriolar equivalent) was identified in the eyes ipsilateral to CEA (P<0.001). This outcome strongly indicates that microvascular dysfunction is long-lasting despite the recovery of the flow in the carotid artery.