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Carotid artery disease: plaque features and vulnerability
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Atherosclerosis is an important cause of stroke. Ultrasound offers the convenience of real-time and detailed assessment of carotid plaque features as well as arterial wall thickening and composition. Evaluation of these features is important for determining patients’ risk of suffering vascular events and also contributes to selecting the best treatment strategy.

Methods: Using ultrasound data analysis we have determined plaque features in the bifurcation and internal carotid artery (ICA), including: surface plaque irregularities, calcification, echogenicity (grey scale median-GSM) and other textural plaque features (Juxtaluminal black area, entropy, coarseness). In addition, intima media thickens (IMT) and its grey scale median (IM-GSM) was measured in common carotid artery (CCA). Using Cone Beam CT (CBCT) we have quantified calcification volume of the carotid plaques extracted after carotid endarterectomy procedure. For the meta-analysis we have used comprehensive meta-analysis software version 3. Study I: We have included 39 patients and we compared carotid plaque features of the contralateral arteries with those located ipsilateral to symptomatic side and arteries of asymptomatic patients.

Study II: The accuracy of US to detect atherosclerosis calcification was assessed against CBCT in 88 patients. Study III: Based on the previous vascular events in coronary, carotid and lower extremity arterial system, 87 patients were divided into three groups: asymptomatic, symptoms in one vascular system and symptoms in more that one vascular system. IMT, IM-GSM and plaque features were compared between groups.

Study IV: We have meta-analyzed ten cohort prospective studies evaluating carotid plaque echogenicity for cerebrovascular symptoms prediction. Results: Study I. Plaques of the contralateral to symptomatic arteries had similar features to those in symptomatic and more vulnerable than asymptomatic arteries.

Study II. Carotid ultrasound was accurate in detecting calcification volumes of ≥8mm3 with very high sensitivity but it was less accurate in detecting lower calcification volumes (<8mm3). Carotid calcification was not different between symptomatic and asymptomatic patients. Study III. Echogenicity of the intima-media complex (IM-GSM), but not its thickness (IMT), was significantly decreased with increasing number of arterial systems affected by atherosclerosis. IM-GSM was lower in patients with prior myocardial infarction and stroke.

Study IV. Carotid plaque echogenicity evaluated by US could predict future cerebrovascular events in patients with asymptomatic, relative risk RR 2.72 (95% CI, 1.86 to 3.96), and recurrent symptoms in symptomatic patients, RR 2.97 (95% CI, 1.85-4.78). Conclusion: Plaques located in the contralateral to symptomatic arteries have similar features as

symptomatic side and more vulnerable than asymptomatic arteries. Carotid ultrasound could accurately detect larger but not smaller carotid plaque calcification volumes (<8 mm3). Low IM- GSM could identify patients with multi-system atherosclerosis disease, suggesting a better marker for determining systemic atherosclerosis disease burden compared to conventional IMT. Finally, carotid plaque echogenicity predicts future cerebrovascular events in patients with symptomatic and asymptomatic carotid stenosis. 

Place, publisher, year, edition, pages
Umeå: Umeå University , 2015. , 86 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1760
Keyword [en]
Carotid atherosclerosis, ultrasound, plaque features, echogenicity, calcification, surface plaque irregularities, subclinical atherosclerosis, cerebrovascular symptoms
National Category
Cardiac and Cardiovascular Systems
Research subject
Cardiology; Medicine, cardiovascular disease
Identifiers
URN: urn:nbn:se:umu:diva-111048ISBN: 978-91-7601-364-9 (print)OAI: oai:DiVA.org:umu-111048DiVA: diva2:866385
Public defence
2015-11-26, hörsal D, Unod T9., Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2015-11-05 Created: 2015-11-02 Last updated: 2015-11-06Bibliographically approved
List of papers
1. Vulnerable plaques in the contralateral carotid arteries in symptomatic patients: a detailed ultrasound analysis
Open this publication in new window or tab >>Vulnerable plaques in the contralateral carotid arteries in symptomatic patients: a detailed ultrasound analysis
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2014 (English)In: Atherosclerosis, ISSN 0021-9150, E-ISSN 1879-1484, Vol. 235, no 2, 526-531 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND AND AIM: Carotid plaques may represent a generalized atherosclerotic syndrome or a localized disease. The aim of this study was to assess the morphological and textural features of carotid plaques located contralateral to the symptomatic side and compare them with the symptomatic side and with plaques from asymptomatic patients. METHODS: We studied 66 arteries in 39 patients (mean age 70 ± 7 year, 33% females). Arterial plaques were classified as either symptomatic (n = 30), contralateral to symptomatic (n = 25) or asymptomatic (n = 11). We compared several plaque features between these groups including the mean values of the grey scale median (GSM), entropy, juxtaluminal black area (JBA) without visible echogenic cap, GSM of the JBA and surface irregularity. RESULTS: The plaques contralateral to symptomatic arteries had similar morphological and textural features to those in the symptomatic arteries. In contrast, they had more vulnerable morphological and textural features than those in asymptomatic arteries: less smooth plaques (12% vs. 55%) and instead more often mildly irregular (60% vs 36%) or markedly irregular (28% vs. 9%; p = 0.03), lower GSM (26.2 ± 8 vs. 49.4 ± 14, p < 0.001) and lower GSM of the JBA (5.0 ± 3.6 vs. 11.4 ± 2.1, p = 0.008). The frequency of entropy and plaque calcification was similar in all groups. CONCLUSION: Symptomatic patients with carotid artery disease seem to have similar morphological and textural features of vulnerability in the symptomatic and the contralateral carotid arteries, which are profound compared with asymptomatic carotid arteries. These findings support the concept of generalized carotid atherosclerotic pathology rather than incidental unilateral disease, and also emphasize a need for aggressive measures for plaque stabilization, particularly in symptomatic patients.

Place, publisher, year, edition, pages
Elsevier, 2014
Keyword
carotid artery disease, plaque vulnerability, gray scale median, juxtaluminal black area
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-93540 (URN)10.1016/j.atherosclerosis.2014.05.934 (DOI)000342411000941 ()24953493 (PubMedID)
Available from: 2014-09-24 Created: 2014-09-24 Last updated: 2017-12-05Bibliographically approved
2. Atherosclerotic Calcification Detection: A Comparative Study of Carotid Ultrasound and Cone Beam CT
Open this publication in new window or tab >>Atherosclerotic Calcification Detection: A Comparative Study of Carotid Ultrasound and Cone Beam CT
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2015 (English)In: International Journal of Molecular Sciences, ISSN 1422-0067, E-ISSN 1422-0067, Vol. 16, no 8, 19978-19988 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND AND AIM: Arterial calcification is often detected on ultrasound examination but its diagnostic accuracy is not well validated. The aim of this study was to determine the accuracy of carotid ultrasound B mode findings in detecting atherosclerotic calcification quantified by cone beam computed tomography (CBCT).

METHODS: We analyzed 94 carotid arteries, from 88 patients (mean age 70 ± 7 years, 33% females), who underwent pre-endarterectomy ultrasound examination. Plaques with high echogenic nodules and posterior shadowing were considered calcified. After surgery, the excised plaques were examined using CBCT, from which the calcification volume (mm3) was calculated. In cases with multiple calcifications the largest calcification nodule volume was used to represent the plaque. Carotid artery calcification by the two imaging techniques was compared using conventional correlations.

RESULTS: Carotid ultrasound was highly accurate in detecting the presence of calcification; with a sensitivity of 88.2%. Based on the quartile ranges of calcification volumes measured by CBCT we have divided plaque calcification into four groups: <8; 8-35; 36-70 and >70 mm3. Calcification volumes ≥8 were accurately detectable by ultrasound with a sensitivity of 96%. Of the 21 plaques with <8 mm3 calcification volume; only 13 were detected by ultrasound; resulting in a sensitivity of 62%. There was no difference in the volume of calcification between symptomatic and asymptomatic patients.

CONCLUSION: Carotid ultrasound is highly accurate in detecting the presence of calcified atherosclerotic lesions of volume ≥8 mm3; but less accurate in detecting smaller volume calcified plaques. Further development of ultrasound techniques should allow better detection of early arterial calcification.

Place, publisher, year, edition, pages
MDPI, 2015
Keyword
carotid atherosclerosis, ultrasound, calcification
National Category
Cardiac and Cardiovascular Systems Dentistry Medical Biotechnology (with a focus on Cell Biology (including Stem Cell Biology), Molecular Biology, Microbiology, Biochemistry or Biopharmacy) Radiology, Nuclear Medicine and Medical Imaging
Research subject
Medicine, cardiovascular disease; Odontology; Radiology
Identifiers
urn:nbn:se:umu:diva-107990 (URN)10.3390/ijms160819978 (DOI)000366826100173 ()26307978 (PubMedID)
Available from: 2015-08-31 Created: 2015-08-31 Last updated: 2017-12-04Bibliographically approved
3. Carotid IM-GSM is more accurate than conventional IMT for monitoring systemic burden of atherosclerosis
Open this publication in new window or tab >>Carotid IM-GSM is more accurate than conventional IMT for monitoring systemic burden of atherosclerosis
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(English)Manuscript (preprint) (Other academic)
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-111073 (URN)
Available from: 2015-11-03 Created: 2015-11-03 Last updated: 2015-12-04
4. Carotid plaque echogenicity predicts cerebrovascular symptoms: A systematic review and metaanalysis
Open this publication in new window or tab >>Carotid plaque echogenicity predicts cerebrovascular symptoms: A systematic review and metaanalysis
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(English)Manuscript (preprint) (Other academic)
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-111121 (URN)
Available from: 2015-11-06 Created: 2015-11-06 Last updated: 2015-12-04

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