The size of juxtaluminal hypoechoic area in ultrasound images of asymptomatic carotid plaques predicts the occurrence of stroke

Kakkos, Stavros K.; Griffin, Maura; Nicolaides, Andrew; Kyriacou, Efthyvoulos; Sabetai, Michael M.; Tegos, Thomas; Makris, Gregory C.; Thomas, Dafydd J.; Geroulakos, George

doi:10.1016/j.jvs.2012.09.045

Cited by 173 publications

(154 citation statements)

References 32 publications

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“…Alternatively, studies could be conducted in ‘enriched' patient populations at high risk of cerebrovascular events with medical therapy alone, since such patients could potentially benefit from invasive revascularization procedures [34]. The identification of such individuals could be based on prognostic risk models that combine patient information with the results of specialized imaging tests [35,36,37,38]. …”

Section: Discussionmentioning

confidence: 99%

Asymptomatic Carotid Artery Stenosis Treated with Medical Therapy Alone: Temporal Trends and Implications for Risk Assessment and the Design of Future Studies

Hadar¹,

Raman²,

Moorthy³

et al. 2014

Cerebrovasc Dis

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Background: The rate of adverse clinical outcomes among patients with asymptomatic carotid stenosis receiving medical therapy alone can be used to guide clinical decision-making and to inform future research. We aimed to investigate temporal changes in the incidence rate of clinical outcomes among patients with asymptomatic carotid stenosis receiving medical therapy alone and to explore the implications of these changes for the design of future comparative studies. Summary: We searched MEDLINE, the Cochrane Central Register of Controlled Trials, US Food and Drug Administration documents, and reference lists of included studies (last search: December 31, 2012). We selected prospective cohort studies of medical therapy for asymptomatic carotid artery stenosis and we extracted information on study characteristics, risk of bias, and outcomes. We performed meta-analyses to estimate summary incidence rates, meta-regressions to assess trends over time, and simulations to explore sample size requirements for the design of future studies comparing new treatments against medical therapy. The main outcomes of interest were ipsilateral stroke, any stroke, cardiovascular death, death, and myocardial infarction. We identified 41 studies of medical therapy for patients with asymptomatic carotid stenosis (last recruitment year: 1978-2009). The summary incidence rate of ipsilateral carotid territory stroke (25 studies) was 1.7 per 100 person-years. This incidence rate was significantly lower in recent studies (last recruitment year from 2000 onwards) as compared to studies that ended recruitment earlier (1.0 vs. 2.3 events per 100 person-years; p < 0.001). The incidence rates of any territory stroke (17 studies), cardiovascular death (6 studies), death (13 studies), and myocardial infarction (5 studies) were 2.7, 4.1, 4.6, and 1.8 per 100 person-years, respectively. Simulations showed that future studies would need to enroll large numbers of patients with a relatively high incidence rate under medical therapy, and evaluate interventions with large effect sizes, to have adequate power to reliably detect treatment effects. Key Messages: Improved prognosis under medical therapy alone has narrowed the potential range of risk reduction attainable with new treatments for asymptomatic carotid stenosis. Future comparative studies will need to enroll large numbers of patients to assess treatment effectiveness.

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Section: Discussionmentioning

confidence: 99%

Asymptomatic Carotid Artery Stenosis Treated with Medical Therapy Alone: Temporal Trends and Implications for Risk Assessment and the Design of Future Studies

Hadar¹,

Raman²,

Moorthy³

et al. 2014

Cerebrovasc Dis

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“…Ultrasound is sensitive in detecting plaque echolucency with a detection rate up to 90% (64). Detection of the size and site of "juxtaluminal echolucency" which represents either a LRNC or IPH is important because a large LRNC near the lumen is associated with increased risk of stroke and clinical ischemic events (65,66).…”

Section: Intraplaque Echolucencymentioning

confidence: 99%

Current status of carotid ultrasound in atherosclerosis

Ho¹

2016

Quant. Imaging Med. Surg.

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“…Though various sonographically determined plaque features have been proposed to aid in the identification of high-risk plaque such as plaque ulceration [57] or stenosis progression [58], perhaps the most well-studied [59,60,61,62,63,64,65,66,67] risk marker for which there is level 2a evidence [68] is the presence of predominantly echolucent plaque. Histopathologic investigations [69,70] suggest that predominantly echolucent plaque may contain a relatively high proportion of lipid-rich necrotic core or intraplaque hemorrhage, which are the known constituents of more advanced, complicated atherosclerotic plaque [37,38].…”

Section: Plaque Vulnerability For Stroke Risk Assessmentmentioning

confidence: 99%

Moving Beyond Luminal Stenosis: Imaging Strategies for Stroke Prevention in Asymptomatic Carotid Stenosis

Gupta¹,

Marshall

2015

Cerebrovasc Dis

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Background: With progressive improvements in medical therapy and resultant reductions in stroke risk, luminal stenosis criteria are no longer adequate to inform decisions to pursue surgical revascularization in patients with asymptomatic carotid artery stenosis. Summary: In this evidence-based review, we discuss the imaging-based risk stratification strategies that take into account factors beyond luminal stenosis measurements, including cerebral hemodynamics and plaque composition. The existing literature lends support to the use of certain imaging tests in patients with asymptomatic carotid stenosis including cerebrovascular reserve testing, MRI of plaque composition, ultrasound of plaque echolucency, and transcranial Doppler evaluation for microemboli. The highest quality evidence thus far in the literature includes only systematic reviews and meta-analyses of cohort studies with no randomized trials having yet been performed to show how these newer imaging biomarkers could be used to inform treatment decisions in asymptomatic carotid stenosis. Beyond the need for randomized trials, there are additional important steps needed to improve the relevance of evidence supporting risk assessment strategies. Imaging studies evaluating the risk of stroke in carotid disease should clearly define asymptomatic versus symptomatic disease, use uniform definitions of clearly defined outcome measures such as ipsilateral stroke, ensure that imaging interpretations are performed in a manner blinded to treatments and other risk factors, and include cohorts which are on modern intensive medical therapy. Such studies of risk stratification for asymptomatic carotid stenosis will be most valuable if they can integrate multiple high-risk features (including clinical risk factors) into a multi-factorial risk assessment strategy in a manner that is relatively simple to implement and generalizable across a wide range of practice settings. Key Messages: Together, modern imaging strategies allow for a more mechanistic assessment of stroke risk in carotid disease compared to luminal stenosis measurements alone, which, with further validation in randomized controlled trials, may improve current efforts at stroke prevention in asymptomatic carotid stenosis.

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The size of juxtaluminal hypoechoic area in ultrasound images of asymptomatic carotid plaques predicts the occurrence of stroke

Cited by 173 publications

References 32 publications

Asymptomatic Carotid Artery Stenosis Treated with Medical Therapy Alone: Temporal Trends and Implications for Risk Assessment and the Design of Future Studies

Asymptomatic Carotid Artery Stenosis Treated with Medical Therapy Alone: Temporal Trends and Implications for Risk Assessment and the Design of Future Studies

Current status of carotid ultrasound in atherosclerosis

Moving Beyond Luminal Stenosis: Imaging Strategies for Stroke Prevention in Asymptomatic Carotid Stenosis

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