CAROTID PLAQUES AND CEREBRAL EMBOLISM G.Marcucci Vascular and Endovascular Surgery Unit San Paolo Hospital Civitavecchia, Rome, Italy

Skip to main content Top Abstract Background Methods Results Discussion Conclusion Competing interests Authors' contributions References                                                                                            Log on / register BioMed Central home | Journals A-Z | Feedback | Support | My details   Abstract Background Carotid plaque severity and morphology can affect cardiovascular prognosis. We evaluate both the importance of echographically assessed carotid artery plaque geometry and morphology as predictors of death in hospitalised cardiological patients. Methods 541 hospitalised patients admitted in a cardiological division (age = 66 ± 11 years, 411 men), have been studied through ultrasound Duplex carotid scan and successively followed-up for a median of 34 months. Echo evaluation assessed plaque severity and morphology (presence of heterogeneity and profile). Results 361 patients showed carotid stenosis (67% with <50% stenosis, 18% with 50–69% stenosis, 9% with >70% stenosis, 4% with near occlusion and 2% with total occlusion). During the follow-up period, there were 83 all-cause deaths (15% of the total population). Using Cox's proportional hazard model, age (RR 1.06, 95% CI 1.03–1.09, p = 0.000), ejection fraction > 50% (RR = 0.62, 95% CI 0.4–0.96, p = 0.03), treatment with statins (RR = 0.52, 95% CI 0.29–0.95, p = 0.34) and the presence of a heterogeneous plaque (RR 1.6; 95% CI, 1.2 to 2.14, p = 0.002) were independent predictors of death. Kaplan – Meier survival estimates have shown the best outcome in patients without plaque, intermediate in patients with homogeneous plaques and the worst outcome in patients with heterogeneous plaques (90% vs 79% vs 73%, p = 0.0001). Conclusion In hospitalised cardiological patients, carotid plaque presence and morphology assessed by ultrasound are independent predictors of death. Non-invasive carotid artery ultrasound is a well established and valid method which allows to both visualize and quantify atherosclerotic lesions. Ultrasound and autopsy studies have shown that the presence and extent of carotid atherosclerosis correlates with atherosclerosis elsewhere in the circulation, including coronary arteries [1-4]. Several studies have found that the presence of carotid stenosis is a strong predictor of death in the general population [5,6]. Moreover, there is evidence that ultrasonographic B-mode characterization of plaque morphology may be useful in the assessment of the vulnerability of the atherosclerotic lesions [7-10]. Atherosclerotic plaque composition appears to be more important than plaque size in determining adverse events [11]. In particular, lipids and haemorrhages are associated with a more active plaque [12,13], which appear to be more vulnerable to rupture. Ultrasonically assessed plaque morphology provides an insight into the plaque composition and structure as shown by both in vitro [14-18] and in vivo [19-23] studies. Echo-lucent carotid plaques are lipid-rich and have a greater potential for clinical complications [7,10]. Heterogeneous plaques have a hypoechoic component and are associated with the presence of intra-plaque haemorrhage, ulceration and lipids, more likely to result in adverse events [8,21,22]. Home | Cardiovascular Ultrasound Volume 4 Viewing options:  Abstract  Full text  PDF (332KB) Associated material:  Readers' comments      Pre-publication history  PubMed record Related literature:  Articles citing this article  Other articles by authors  Related articles/pages Tools:  Download citation(s)  Download XML  Email to a friend  Order reprints  Post a comment Post to:       Citeulike  Connotea  Del.icio.us  Facebook  Twitter Browse articles | Search | Weblinks | Submit article | My Cardiovascular Ultrasound | About Cardiovascular Ultrasound on Google Scholar on PubMed Central CAROTID PLAQUES From histopathologic and vascular biologic studies, plaque composition and vulnerability, rather than degree of stenosis, have emerged as crucial factors leading to sudden rupture of the plaque surface, usually with superimposed thrombosis, which underlies the majority of acute occlusions. The link between echo plaque structure and prognosis do not appear to be limited to the carotid arteries but may apply to virtually all vascular districts G.Marcucci Research Christina Petersen      , Patricia B Peçanha      , Lucia Venneri      , Emilio Pasanisi      , Lorenza Pratali      and Eugenio Picano      CNR, Institute of Clinical Physiology, Pisa, Italy      author email      corresponding author email Cardiovascular Ultrasound 2006, 4:16doi:10.1186/1476-7120-4-16 The electronic version of this article is the complete one and can be found online at: http://www.cardiovascularultrasound.com/content/4/1/16 Received: 11 January 2006 Accepted: 24 March 2006 Published: © 2006 Petersen et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Echo-lucency is associated with lipid-rich plaques CAROTID PLAQUES Heterogeneous plaques have been correlated with the presence of intra-plaque haemorrhage, ulceration and loose stroma containing lipids, cholesterol and proteinaceous deposits Echo-lucency is associated with lipid-rich plaques G.Marcucci

CAROTID PLAQUES All of the heterogeneous plaques have a echo-lucent component (lipid, haemorrhage, thrombi) A hypo-echoic appearance can also be associated with intra-plaque haemorrhage, which may be the result of intra-plaque neo-vascularization. G.Marcucci

G.Marcucci

CAROTID PLAQUES These small, fragile vessels could represent the underlying anatomic and pathologic changes leading to intramural haemorrhages and rupture. Lipid lakes and intra-plaque haemorrhage are more frequently found in vulnerable plaques, with greater potential for evolution and complication, and are the dominant substrate of hypoechoic and heterogeneous plaques G.Marcucci

“VULNERABLE PLAQUE” Cardiovascular Research 2002; 54:36-41 G.Marcucci

Atheroembolization atheroembolization results from disruption of endothelial surface and fibrous cap platelet and erytrocyte aggregation to the subendothelial layer distal embolization of the thrombus and debris from the plaque G.Marcucci

CEREBRAL EMBOLIZATION DURING CEA AND CAS Perioperative cerebral embolization during CEA or CAS is a potentially devastting complication It is correlated with: - embolic potential of the plaque - during surgical dissection - during CAS procedure - postoperative embolization (technical problems) G.Marcucci

Carotid endarterectomy In the course of monitoring CEA’s with TCD ultrasonography, it became apparent that during all stages of this operation, signals identical to the qualities of embolic transients could be noticed G.Marcucci

an association between multiple cerebral microemboli during dissection and new white matter lesions on magnetic resonance images (MRI) of the brain made after surgery However, in the majority of these patients the new MRI lesions were clinically silent JANSEN Stroke, 1994 G.Marcucci

microemboli that appeared during but…… microemboli that appeared during dissection and particularly during wound closure were statistically significantly associated with permanent cerebral deficits, i.e. intraoperative stroke ACKERSTAFF R. Stroke, 2000 G.Marcucci

Carotid Artery Stenting CAS has been criticized on the grounds that the risk of cerebral embolism during the procedure may be greater than CEA G.Marcucci

In contrast to coronary and peripheral artery angioplasty and stenting, which have been widely adopted, the concern for cerebral embolisation originally resulted in a understandable reluctance to use these techniques in the carotid artery territory. During these peripheral procedures, the risk of embolisation, estimated by myocardial infarction and clinical distal arterial emboli, ranges from 4% to 5% CRAWLEY Stroke, 1997 G.Marcucci

true incidence of asymptomatic embolisation may be much higher, and emboli of a size that are asymptomatic in the coronary and peripheral arterial circulations may cause neurological deficits in the cerebral circulation The National Heart LaBIR N Engl J Med, 1988 G.Marcucci

during stent deployment squeezes plaque material from the vessel wall microembolization G.Marcucci

and neurological event rate but…… utilization of neuroprotection devices has the potential to reduce the intraprocedural cerebral embolic load and neurological event rate G.Marcucci

Our aim is not to prove superiority of one technique over other In conclusion, Our aim is not to prove superiority of one technique over other CEA is a safe and effective procedure CAS of the carotid bifurcation is a feasible alternative to CEA, particularly in patients with medical or surgical contraindications to surgery Nevertheless, CAS results in a significant higher cerebral embolic load and the number of clinically silent lesions on MRI is greater than in CEA G.Marcucci