Vulnerable carotid arterial plaque causing repeated ischemic stroke can be detected with B-mode ultrasonography as a mobile component: Jellyfish sign

Abstract

Mobile plaque is associated with increased risk of ischemic stroke, but definitions have remained unclear. We have previously reported that carotid ultrasonography can detect the mobile component of the carotid plaque surface, which rises and falls in a manner inconsistent with arterial pulsatile wall motion (Jellyfish sign). However, clinical and pathological features of Jellyfish sign remain unclear. The subjects comprised of 165 patients with carotid plaque and degree of area stenosis ≥50% on ultrasonography. Using magnetic resonance imaging, we quantified intraplaque hemorrhage (IPH) and defined ischemic stroke in each patient. Fifteen surgical specimens were obtained by carotid endarterectomy, and pathological features (area of fibrous cap and intraplaque atheromatous lesion) were compared with ultrasonographic plaque surface movement rate. Carotid plaques with IPH were seen in 78 cases, with Jellyfish sign in 31 cases. Jellyfish sign was not detected in patients without IPH. In these 15 patients, the fibrous cap covered the atheromatous lesion, and cap thickness correlated negatively with Jellyfish-positive plaque surface movement rate. Kaplan-Meier and Cox multiple regression analysis demonstrated that the most important predictor of ischemic stroke during follow-up is Jellyfish sign, not IPH. Stroke events in patients with Jellyfish sign repeated within a short interval after diagnosis. Jellyfish sign on ultrasonography is a sign of high-risk plaque vulnerability, suggesting rupture of the fibrous cap associated with the release of thrombogenic factors into the arterial lumen, and resulting in repeated ischemic stroke during a short interval after diagnosis.

Ultrasound Characteristics of Symptomatic Carotid Plaques: A Systematic Review and Meta-Analysis

“…In a study of 45 patients, Meairs et al [39] demonstrated that symptomatic plaques also had more motion than asymptomatic plaques and postulated that increased plaque motion can lead to 'fatigue' of the plaque surface resulting in plaque rupture. These findings support the theory that the shearing effect of intraplaque motion can disrupt the plaque microvasculature and result in IPH [38,40] .…”

“…Intraplaque motion, defined as any motion within the plaque itself or on the plaque surface, was strongly correlated with symptomatic status in our study [37,38] . Iannuzzi et al [37] defined intraplaque motion as any change in the longitudinal axis of the carotid plaque during the cardiac cycle.…”

“…Such plaque movement was thought to be related to symptomatic status due to a shearing effect at the base of the plaque leading to the rupture of the vasa vasorum causing IPH and plaque instability. Kume et al [38] looked at surface plaque mobility and found a strong correlation between plaque mobility and symptomatic status. All patients with evidence of plaque mobility on ultrasound who underwent MRI were found to have IPH.…”

Comparison of Carotid Atherosclerotic Plaque Characteristics by High-Resolution Black-Blood MR Imaging between Patients with First-Time and Recurrent Acute Ischemic Stroke

“…This finding is in accordance with those of a number of previous studies that have demonstrated that carotid IPH [37][38][39] and fibrous cap rupture 40 are correlated with recurrent cerebrovascular events. Accordingly, early identification of high-risk plaque features may be necessary for prevention of secondary ischemic stroke.…”

Low Stroke Rate of Carotid Stenosis Under the Guideline-Oriented Medical Treatment Compared With Surgical Treatment

“…Magnetic resonance imaging, 38,39) ultrasound, [40][41][42][43][44][45][46][47][48][49] transcranial Doppler, 13,49,50) and computed tomography of the head 51) have revealed findings suggestive of unstable plaque. A number of imaging parameters may be predictive of increased risk of stroke, but none of these factors have been independently validated.…”