Carotid Plaque Inflammation Is Associated With Cerebral Microembolism in Patients With Recent Transient Ischemic Attack or Stroke

Moustafa, Ramez Reda; Izquierdo‐Garcia, David; Fryer, Tim D.; Graves, Martin J.; Rudd, James H.F.; Gillard, Jonathan H.; Weissberg, Peter L.; Baron, Jean‐Claude; Warburton, Elizabeth A.

doi:10.1161/circimaging.110.938225

Cited by 79 publications

(44 citation statements)

References 45 publications

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“…FDG uptake can distinguish between culprit carotid and vertebral lesions in patients presenting with posterior circulation stroke [52]. Carotid artery FDG uptake has been shown to correlate with microembolic signals on transcranial Doppler ultrasound after TIA [55].…”

Section: Clinical Studies With Fdg-petmentioning

confidence: 99%

Vascular imaging with positron emission tomography

Joshi

Rosenbaum

Bordes

et al. 2011

Journal of Internal Medicine

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Atherosclerosis is an inflammatory disease that causes most myocardial infarctions, strokes and acute coronary syndromes. Despite the identification of multiple risk factors and widespread use of drug therapies, it still remains a global health concern with associated costs. Although angiography is established as the gold standard means of detecting coronary artery stenosis, it does not image the vessel wall itself, reporting only on its consequences such as luminal narrowing and obstruction. MRI and computed tomography provide more information about the plaque structure, but recently positron emission tomography (PET) imaging using [ 18 F]-fluorodeoxyglucose (FDG) has been advocated as a means of measuring arterial inflammation. This results from the ability of FDG-PET to highlight areas of high glucose metabolism, a feature of macrophages within atherosclerosis, particularly in high-risk plaques. It is suggested that the degree of FDG accumulation in the vessel wall reflects underlying inflammation levels and that tracking any changes in FDG uptake over time or with drug therapy might be a way of getting an early efficacy readout for novel anti-atherosclerotic drugs. Early reports also demonstrate that FDG uptake is correlated with the number of cardiovascular risk factors and possibly even the risk of future cardiovascular events. This review will outline the evidence base, shortcomings and emerging applications for FDG-PET in vascular imaging. Alternative PET tracers and other candidate imaging modalities for measuring vascular inflammation will also be discussed.

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Section: Clinical Studies With Fdg-petmentioning

confidence: 99%

Vascular imaging with positron emission tomography

Joshi

Rosenbaum

Bordes

et al. 2011

Journal of Internal Medicine

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show abstract

“…53,58,66 FDG imaging of carotid plaques shows the most promise when used as an adjunct to other imaging modalities, especially MRI. A number of investigators have examined the value of the combination of FDG-PET to detect active inflammation and MRI to identify worrisome morphological features for the optimization of risk stratification.…”

mentioning

confidence: 99%

Contemporary carotid imaging: from degree of stenosis to plaque vulnerability

Brinjikji¹,

Huston²,

Rabinstein

et al. 2016

JNS

291

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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“…Studies with FDG-PET in patients with carotid plaque have shown that patients with microemboli are more likely to have inflammation within the plaque (Moustafa, Izquierdo-Garcia et al 2010). Plaque specimens in patients undergoing endarterectomy have shown that presence of microemboli is strongly associated with plaque fissuring and luminal thrombosis (Sitzer, Siebler et al 1995).…”

Section: Application Of Microemboli Monitoring In Carotid Artery and mentioning

confidence: 99%

“…Microemboli have been associated with carotid plaque inflammation (Moustafa, Izquierdo-Garcia et al 2010), coagulopathies (Seok, Kim et al 2010) and platelet activation markers (Ritter, Jurk et al 2009). Adding information on basic disease mechanisms may improve our understanding of the complex pathophysiology of acute embolic stroke as defined by MES monitoring.…”

Section: Uncertainties and Future Directivesmentioning

confidence: 99%