Associations between Cerebral Embolism and Carotid Intraplaque Hemorrhage during Protected Carotid Artery Stenting

Chung, Gyung Ho; Jeong, Jae Yeong; Kwak, Hyo Sung; Hwang, Seung Bae

doi:10.3174/ajnr.a4576

Cited by 24 publications

(23 citation statements)

References 21 publications

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“…To the best of our knowledge, disruption of carotid plaques triggers the formation of thromboembolus and subsequent ischemic stroke. In addition, some previous studies documented that no association can be found between the presence of IPH and ischemic stroke [23]. Our findings suggest that quantification of the size of IPH is warranted in patients with carotid plaques in stratification of stroke risk beyond the mere presence of IPH.…”

Section: Discussionmentioning

confidence: 55%

“…Third, carotid vessel wall imaging of our study was performed with 2D multicontrast CMR imaging protocol with limited longitudinal coverage which may not capture the atherosclerotic plaque in more proximal or distal segments of extracranial carotid arteries. Wang et al [27] proposed a simultaneous noncontrast angiography and intraplaque hemorrhage sequence with large longitudinal coverage [23] which could be used to evaluate carotid IPH in future studies.…”

Section: Discussionmentioning

confidence: 99%

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Size of carotid artery intraplaque hemorrhage and acute ischemic stroke: a cardiovascular magnetic resonance Chinese atherosclerosis risk evaluation study

Liu

Wang

Zhang

et al. 2019

Journal of Cardiovascular Magnetic Resonance

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Background To determine the usefulness of the size of carotid artery intraplaque hemorrhage (IPH) in discriminating the risk of acute ischemic stroke using cardiovascular magnetic resonance (CMR) vessel wall imaging. Methods Symptomatic patients with carotid atherosclerotic plaque who participated in a cross-sectional, multicenter study of CARE-II (NCT02017756) were included. All patients underwent carotid and brain CMR imaging. Carotid plaque burden and the size of plaque compositions including calcification, lipid-rich necrotic core (LRNC), and IPH were measured. Presence of acute cerebral infarct (ACI) in ipsilateral hemisphere of carotid plaque was determined. The relationship between carotid plaque features and presence of ipsilateral ACI was then analyzed. Results Of 687 recruited patients (62.7 ± 10.1 years; 69.4% males) with carotid plaque, 28.5% had ACI in ipsilateral hemispheres. Logistic regression revealed that carotid plaque burden was significantly associated with the presence of ACI before and after adjusted for clinical confounding factors. The volume of LRNC, %LRNC volume, volume of IPH, and %IPH volume were significantly associated with ACI before (volume of LRNC: OR = 1.297, p = 0.005; %LRNC volume: OR = 1.119, p = 0.018; volume of IPH: OR = 2.514, p = 0.003; %IPH volume: OR = 2.202, p = 0.003) and after (volume of LRNC: OR = 1.312, p = 0.006; %LRNC volume: OR = 1.90, p = 0.034; volume of IPH: OR = 2.907, p = 0.007; % IPH volume: OR = 2.374, p = 0.004) adjusted for clinical confounding factors. The association between volume of IPH and ACI remained statistically significant after further adjusted for plaque volume (OR = 2.813, p = 0.016) or both plaque volume and volume of LRNC (OR = 4.044, p = 0.024). Conclusions In symptomatic patients with carotid atherosclerotic plaques, the size of IPH is independently associated with ipsilateral ACI, suggesting the size of IPH might be a useful indicator for the risk of ACI. Trial registration Clinical Trial Registration-URL: http://www.clinicaltrials.gov . Unique Identifier: NCT02017756.

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Section: Discussionmentioning

confidence: 55%

Section: Discussionmentioning

confidence: 99%

Size of carotid artery intraplaque hemorrhage and acute ischemic stroke: a cardiovascular magnetic resonance Chinese atherosclerosis risk evaluation study

Liu

Wang

Zhang

et al. 2019

Journal of Cardiovascular Magnetic Resonance

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“… 3 – 5) Recent quantitative color-coded T1-weighted MR plaque imaging for preoperative plaque diagnosis can accurately distinguish lipid core and intraplaque hemorrhages (IPHs) 5) ; however, high-resolution MRI is not always an option for patients before revascularization. 6) An additional imaging modality that can accurately identify the lipid components of carotid plaque at high risk for embolic complications during CAS would be therefore required.…”

Section: Introductionmentioning

confidence: 99%

Lipid Core Plaque Distribution Using Near-infrared Spectroscopy Is Consistent with Pathological Evaluation in Carotid Artery Plaques

Kotsugi

Nakagawa

Hatakeyama

et al. 2020

Neurol. Med. Chir.(Tokyo)

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Carotid artery stenting (CAS) is performed as a treatment for carotid artery stenosis. However, lipid-rich plaques cause embolic complications and sequelae. Near-infrared spectroscopy (NIRS) can identify lipid components by applying a near-infrared absorption pattern, and the distribution of lipid components can be evaluated as the maximum lipid core burden index (maxLCBI). Intravascular ultrasound (IVUS) equipped with NIRS has been clinically applied recently, and its diagnostic usefulness and validation have been reported for coronary arteries; however, its consistency with actual pathological diagnosis in carotid artery lesions has not been validated. In this study, we investigated the consistency between the maxLCBI values and histopathological diagnoses. Patients with cervical carotid artery stenosis who underwent carotid endarterectomy (CEA) were examined in this prospective study. Pathological diagnosis was determined after NIRS evaluation, which was performed on the extracted plaques ex vivo . The histological slices of decalcified and paraffin-embedded sections were stained by hematoxylin–eosin (HE) and Elastica van Gieson (EVG), and for low-density lipoprotein (LDL), C-reactive protein (CRP), CD68, and glycophorin A. The correlation between maxLCBI values and histological findings. Seventy lesions assessed by NIRS were pathologically analyzed. There was a positive linear correlation between maxLCBI values and pathological findings as determined by HE (angle), HE (area%), EVG, CRP, and CD68 staining (respectively, r = 0.624, p <0.001; r = 0.578, p <0.001; r = 0.534, p <0.001; r = 0.723, p <0.001; r = 0.653, p <0.001). In conclusion, the maxLCBI values assessed by NIRS showed a significant positive linear correlation with pathological evaluations in carotid lesions. The maxLCBI values in carotid arteries are consistent with pathological evaluations.

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“…In a previous study from our group (20), we reported that IPH is not a significant risk factor for cerebral embolism during CAS in patients with severe carotid artery stenosis. However, to the best of our knowledge, the relationship between unstable plaque on carotid HR-MRI and the safety of CAS have not been previously reported.…”

Section: Introductionmentioning

confidence: 99%

“…Recently, a group studied the relationship between the presence of unstable plaque such as IPH on carotid HR-MRI and the development of ischemic stroke in previously asymptomatic and symptomatic patients (18)(19)(20)(21). In particular, IPH is associated with plaque progression and consequently induces luminal narrowing (22,23).…”

Section: Introductionmentioning

confidence: 99%

The Safety of Protected Carotid Artery Stenting in Patients with Unstable Plaque on Carotid High-Resolution MR Imaging

Jeong

Kwak

Hwang

et al. 2018

J Korean Soc Radiol

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Purpose:The aim of this study was to determine the safety of the carotid artery stenting (CAS) procedure, using an embolic protection device which is based on the presence of unstable plaques on carotid MR imaging in patients who presented with severe carotid artery stenosis. Materials and Methods: This prospective study assessed 102 consecutive patients who had been noted with severe carotid stenosis. These patients underwent a preprocedural carotid MR imaging, and a periprocedural diffusion-weighted imaging (DWI) after the CAS. The unstable plaque on the carotid MR imaging was defined as characterized as intraplaque hemorrhage (IPH), thin/ruptured fibrous caps, or ulcers. We analyzed the incidence of the noted periprocedural ipsilateral ischemic events on the DWI, and noted the primary outcomes within 30 days of the CAS. Results: In the study, it is noted that 50 patients (49.0%) had IPH, 84 patients (82.4%) had thin/ruptured fibrous caps, and 43 patients (42.2%) had ulcers as seen on the carotid plaque MR imaging. The IPH was more common in the symptomatic group than in the asymptomatic group (58.7% vs. 41.1%, p = 0.12). Overall, the DWI was positive after CAS in 25.5% of cases. Additionally, the combined rate of 30-day stroke, myocardial infarction, or death was recorded at 3.9%. The new periprocedural ischemic lesions on the DWI were characteristically more frequently observed in the symptomatic group (17/46, 37.0%) than in the asymptomatic group (9/56, 16.1%) (p = 0.03). There was no significant difference in the primary outcome of the CAS, based on the type of unstable plaque of IPH, thin/ruptured fibrous caps, or ulcers. Conclusion:The protected CAS appears to be safe, regardless of the noted unstable plaque findings as seen on the carotid MR imaging. In this case, because of the higher risk of periprocedural ipsilateral ischemic events, it is therefore recommended that the symptomatic patients should receive more careful treatment during the CAS placement going forward. Korea. Tel. 82-63-250-2582 Fax. 82-63-272-0481 E-mail: kwak8140@jbnu.ac.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Index terms

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Associations between Cerebral Embolism and Carotid Intraplaque Hemorrhage during Protected Carotid Artery Stenting

Cited by 24 publications

References 21 publications

Size of carotid artery intraplaque hemorrhage and acute ischemic stroke: a cardiovascular magnetic resonance Chinese atherosclerosis risk evaluation study

Size of carotid artery intraplaque hemorrhage and acute ischemic stroke: a cardiovascular magnetic resonance Chinese atherosclerosis risk evaluation study

Lipid Core Plaque Distribution Using Near-infrared Spectroscopy Is Consistent with Pathological Evaluation in Carotid Artery Plaques

The Safety of Protected Carotid Artery Stenting in Patients with Unstable Plaque on Carotid High-Resolution MR Imaging

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