Usefulness of Contrast-Enhanced Ultrasound for Detection of Carotid Plaque Ulceration in Patients With Symptomatic Carotid Atherosclerosis

Kate, Gerrit L. ten; Dijk, Anouk C. van; Oord, Stijn C.H. van den; Hussain, Burhan; Verhagen, Hence J.M.; Sijbrands, Eric J.G.; Steen, Antonius F.W. van der; Lugt, Aad van der; Schinkel, Arend F. L.

doi:10.1016/j.amjcard.2013.03.028

Cited by 75 publications

(65 citation statements)

References 18 publications

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“…Compared with B-mode and color-Doppler ultrasonography, CEUS has higher interobserver agreement, sensitivity, specificity, and accuracy in identifying plaque ulceration. 109 A summary of plaque characteristics on ultrasonography evaluation is provided in Table 1.…”

Section: Ceusmentioning

confidence: 99%

Contemporary carotid imaging: from degree of stenosis to plaque vulnerability

Brinjikji¹,

Huston²,

Rabinstein

et al. 2016

JNS

278

172

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abbreviatioNs AHA = American Heart Association; CAS = carotid artery stenting; CEA = carotid endarterectomy; CEUS = contrast-enhanced ultrasonography; CTA = CT angiography; DCE = dynamic contrast-enhanced; DSCT = dual-source CT; FDG = fluorodeoxyglucose; FSE = fast spin echo; Gd = gadolinium; HU = Hounsfield units; IPH = intraplaque hemorrhage; LRNC = lipid-rich necrotic core; MDCT = multidetector-row CT; MDCTA = MDCT angiography; MES = microembolic signal; MMP-9 = matrix metalloproteinase-9; MRA = MR angiography; PDW = proton density-weighted; SUV = standardized uptake value; SUVmax = maximal SUV; TBR = target-to-background ratio; TCD = transcranial Doppler ultrasonography; TIA = transient ischemic attack; TOF = time of flight; USPIO = ultrasmall superparamagnetic iron oxide. Carotid artery stenosis is a well-established risk factor of ischemic stroke, contributing to up to 10%-20% of strokes or transient ischemic attacks. Many clinical trials over the last 20 years have used measurements of carotid artery stenosis as a means to risk stratify patients. However, with improvements in vascular imaging techniques such as CT angiography and MR angiography, ultrasonography, and PET/CT, it is now possible to risk stratify patients, not just on the degree of carotid artery stenosis but also on how vulnerable the plaque is to rupture, resulting in ischemic stroke. These imaging techniques are ushering in an emerging paradigm shift that allows for risk stratifications based on the presence of imaging features such as intraplaque hemorrhage (IPH), plaque ulceration, plaque neovascularity, fibrous cap thickness, and presence of a lipid-rich necrotic core (LRNC). It is important for the neurosurgeon to be aware of these new imaging techniques that allow for improved patient risk stratification and outcomes. For example, a patient with a low-grade stenosis but an ulcerated plaque may benefit more from a revascularization procedure than a patient with a stable 70% asymptomatic stenosis with a thick fibrous cap. This review summarizes the current state-of-the-art advances in carotid plaque imaging. Currently, MRI is the gold standard in carotid plaque imaging, with its high resolution and high sensitivity for identifying IPH, ulceration, LRNC, and inflammation. However, MRI is limited due to time constraints. CT also allows for high-resolution imaging and can accurately detect ulceration and calcification, but cannot reliably differentiate LRNC from IPH. PET/CT is an effective technique to identify active inflammation within the plaque, but it does not allow for assessment of anatomy, ulceration, IPH, or LRNC. Ultrasonography, with the aid of contrast enhancement, is a cost-effective technique to assess plaque morphology and characteristics, but it is limited in sensitivity and specificity for detecting LRNC, plaque hemorrhage, and ulceration compared with MRI. Also summarized is how these advanced imaging techniques are being used in clinical practice to risk stratify patients with low- and high-grade carotid artery stenosis....

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Section: Ceusmentioning

confidence: 99%

Contemporary carotid imaging: from degree of stenosis to plaque vulnerability

Brinjikji¹,

Huston²,

Rabinstein

et al. 2016

JNS

278

172

View full text Add to dashboard Cite

show abstract

“…However, a simplified criteria adopted by Muraki et al who simply considered plaque ulceration as a clearly depicted concavity with a less intense border echo at its base resulted in significant improvement in the diagnostic accuracy of plaque ulceration compared to the use of conventional criteria (72). Both CEUS and 3D ultrasound have been suggested to reliably characterize the surface morphology of atherosclerotic carotid plaques and is superior to 2D in detecting ulcers in the plaques (73,74).…”

Section: Plaque Ulcerationmentioning

confidence: 99%

“…Compared with MRI and CT, ultrasound is inferior to detect ulceration (76,77) but is relatively sensitive for detecting LRNC and IPH which appear as plaque echolucency (78). With the aid of contrast imaging, the sensitivity and specificity of ultrasound for detecting ulceration and neovascularization can be increased (68,74). Therefore carotid ultrasound may be used for risk assessment for ischemic stroke beyond measurement of luminal stenosis.…”

Section: From Degree Of Stenosis To Plaque Vulnerabilitymentioning

confidence: 99%

Current status of carotid ultrasound in atherosclerosis

Ho¹

2016

Quant. Imaging Med. Surg.

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“…Computed tomographic angiography of the carotid artery was used as the reference technique. With respect to sensitivity and diagnostic accuracy, CEUS was found to be clearly superior to color Doppler ultrasound [20]. …”

Section: Carotid Plaque Imaging With Ceusmentioning

confidence: 99%

Molecular Imaging of Carotid Plaque Vulnerability

2014

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Background: Carotid endarterectomy (CEA) has been shown to be beneficial in patients with high-grade symptomatic carotid artery stenosis. Patients with high-grade asymptomatic stenosis may only exceptionally benefit from CEA during periods of increased plaque vulnerability. Imaging modalities to characterize unstable, vulnerable plaques are strongly needed for better risk stratification in these patients. Summary: Contrast-enhanced ultrasound (CEUS) is a novel and noninvasive technique capable to identify several surrogate markers of vulnerable carotid plaques. The use of specific ultrasound microbubbles allows a reliable detection of microulcerations due to an optimized visualization of the plaque-lumen border. As microbubbles are strictly intravascular tracers, the detection of individual microbubbles within the plaque corresponds to intraplaque neovessels. The accuracy of CEUS in the visualization of newly formed microvessels has been confirmed in histological studies on carotid endarterectomy specimens. Together with the formation of adventitial vasa vasorum, intraplaque neovascularization is a strong predictor for symptomatic disease. The phenomenon of late phase contrast enhancement is based on the adherence of microbubble-containing monocytes on inflamed endothelium. Recent studies suggest that late phase contrast enhancement may reflect endothelial inflammation or activation within carotid plaques. The development of conjugated microbubbles that bind to specific ligands such as thrombotic material or neovessels has led to the term ‘molecular imaging'. CEUS with microbubbles targeted to P-selectin and VCAM-1, key molecules in leukocyte trafficking, was used to detect an inflammatory plaque phenotype, whereas microbubbles coupled to the VEGF-receptor may allow for a detection of neovascularization. Even though imaging with targeted microbubbles is yet in an experimental stage, this technique can visualize active plaque reorganization with increased vulnerability leading to generation of arterio-arterial embolism. Key Messages: The use of contrast-enhanced ultrasound can be recommended to assess atherosclerotic carotid lesions at risk for rupture. Prospective clinical studies are needed to validate the use of CEUS in patients with high risks of recurrent large artery strokes. In particular, this applies to the detection of intraplaque neovascularization, a well-established marker in preclinical and observational studies, while the clinical significance of late phase contrast enhancement still needs to be determined.

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Usefulness of Contrast-Enhanced Ultrasound for Detection of Carotid Plaque Ulceration in Patients With Symptomatic Carotid Atherosclerosis

Cited by 75 publications

References 18 publications

Contemporary carotid imaging: from degree of stenosis to plaque vulnerability

Contemporary carotid imaging: from degree of stenosis to plaque vulnerability

Current status of carotid ultrasound in atherosclerosis

Molecular Imaging of Carotid Plaque Vulnerability

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