The correlation of ultrasonic carotid plaque morphology and carotid plaque hemorrhage: clinical implications

doi:10.1067/msy.1998.91488

Surgery

Volume 124, Issue 4, October 1998, Pages 721-728

Presented at the Fifty-fifth Annual Meeting of the Central Surgical Association, Ann Arbor, Mich, March 5-7, 1998.

https://doi.org/10.1067/msy.1998.91488 Get rights and content

Abstract

Background: This study examined the importance of ultrasonic plaque morphology and its correlation to the presence of intraplaque hemorrhage and clinical implications. Methods: One hundred fifty-two carotid plaques associated with ≥50% internal carotid artery stenoses in 135 patients who had carotid endarterectomies were characterized ultrasonographically into irregular/ulcerative, smooth, heterogeneous, homogeneous, or not defined. All plaques were examined pathologically for the presence of intraplaque hemorrhage. Results: The ultrasonic morphology of the plaques included 63 with surface irregularity (41%), 48 smooth (32%), 59 heterogeneous (39%), 52 homogeneous (34%), and 41 not defined (27%). Intraplaque hemorrhage was present in 57 of 63 (90%) irregular plaques and 53 of 59 (90%) heterogeneous plaques, in contrast to 13 of 48 (27%) smooth plaques and 17 of 52 (33%) homogeneous plaques (P <.001). Fifty-three of 63 (84%) irregular plaques and 47 of 59 (80%) heterogeneous plaques had transient ischemic attack (TIA)/stroke symptoms, in contrast to 9 of 48 (19%) for smooth plaques and 15 of 52 (29%) for homogeneous plaques (P <.001). Conclusions: Irregular and/or heterogeneous carotid plaques are more often associated with intraplaque hemorrhage and neurologic events. Therefore, ultrasonic plaque morphology may be helpful in selecting patients for carotid endarterectomy. (Surgery 1988;124:721-8.)

Section snippets

Patients and methods

A total of 152 carotid plaques that were associated with ≥50% internal carotid artery stenoses by duplex ultrasonography in 135 patients who had carotid endarterectomies (17 bilateral) were analyzed. This study covered a 2-year period (July 1995 through June 1997) and included 78 males and 57 females with a mean age of 64 years (range, 42-87).

The hospital records, including duplex ultrasonogram, pathology reports, arteriograms, and operative reports, were reviewed. The demographic data, risk

Results

Indications for carotid endarterectomy included 91 for hemispheric TIA/strokes and 61 for nonhemispheric symptoms or asymptomatic stenoses. The ultrasonic morphology of the plaques included 63 irregular plaques (41%), 48 smooth plaques (32%), 59 heterogeneous plaques (39%), 52 homogeneous plaques (34%), and 41 plaques that were not defined (27%). Multiple intraplaque hemorrhages were present in 57 of 63 (90%) irregular plaques and 53 of 59 (90%) heterogeneous plaques, in contrast to 13 of 48

Discussion

This study examined the importance of ultrasonic plaque morphology, its correlation to the presence of intraplaque hemorrhage, and its clinical implications.

Duplex ultrasonogram studies have gained wide acceptance for their ability to identify the presence and degree of stenotic lesions in the extracranial carotid vessels. More recently there has been increased interest in the study of plaque morphology including ulceration using high-resolution duplex scanners. Several authors have studied the

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Diagnostic Accuracy of Optical Frequency Domain Imaging for Identifying Necrotic Cores with Intraplaque Hemorrhage in Advanced Human Carotid Plaques
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Although tissue characterization is different between native artery and the in-stent neointima, the OFDI signal attenuation rates were similar between the previous and current studies (smooth muscle cell with proteoglycan-rich myxomatous: 0.025 ± 0.009, calcium deposition: 0.023 ± 0.017, foam cell accumulation: 0.042 ± 0.014, and fibroatheroma/NC: 0.049 ± 0.012). Histologic analyses of extracted carotid plaques reported a strong relationship between the rupture of NCs and neurologic symptoms.13-15 These findings may indicate that the identification of a massive IPH and NC may predict future atheroembolic neurologic events.
This study investigated whether optical frequency domain imaging (OFDI) can identify carotid artery vulnerable plaque characteristics, focusing on lipid-rich necrotic core (NC) and intraplaque hemorrhage (IPH). Fourteen patients scheduled for carotid endarterectomy underwent OFDI scan during preoperative angiography. Atherosclerotic plaque specimens obtained from carotid endarterectomy were cut every 3–4 mm into 4-μm transverse cross-sections and stained with standard methods. Each cross-section was matched with OFDI, and histologically classified into either fibrous, calcific, pathological intimal thickening (PIT), and NC. Of 75 histologic cross-sections, 6 were categorized as fibrous (8%), 18 as calcific (24%), 9 as PIT (12%), and 42 as NC (56%). Tissues categorized as NC had significantly higher OFDI signal attenuation rates than the other tissues (p <0.001), followed by PIT, calcific, and fibrous tissues. The receiver operating characteristic analysis indicated that attenuation rates of >0.023 and >0.031 predicted the presence of NC and IPH with high areas under the curve of 0.91 and 0.88, respectively. OFDI provides potential capability for the detection of NCs with IPH of carotid artery plaques by quantitatively analyzing the attenuation rate.
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2021, Stroke: Pathophysiology, Diagnosis, and Management
Extracranial ultrasound assessment of the cervical arteries provides real-time, bedside evaluation of blood flow and vessel walls. Ultrasound examination is a non-invasive imaging modality of atherosclerosis in the extracranial arteries. For better yield of microembolic signals, power motion Doppler is superior to single-channel transcranial Doppler ultrasonography (TCD). TCD yields good-to-excellent results in detecting steno-occlusive intracranial lesions in the setting of acute cerebral ischemia when compared against computed tomographic angiography (CTA) or magnetic resonance angiography (MRA). Waveform pattern yields more information about thrombus location, hemodynamic significance of occlusion, and resistance in the distal vessels compared to velocity difference by itself. TCD is more sensitive than transthoracic echocardiogram for right-to-left shunt detection. Despite initial promising results of sonothrombolysis, the efficacy of ultrasound enhancement of thrombolysis has not been proven. Novel applications of ultrasound are molecular imaging, opening of the blood-brain barrier, and targeted drug delivery.
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Plaques may histologically be described as fibrosed, fibro-fatty, fatty, hemorrhagic, necrotic or calcified, with plaques that are necrotic or calcified being generally stable [71]. Although coronary IVUS (Fig. 7) and carotid US imaging have demonstrated that echolucent plaques may reflect lipid deposits, hemorrhage, necrotic debris [72], or inflammation [73] associated with an unstable clinical presentation [74], these imaging modalities have shown only modest accuracy [75]. Recent technical advances with radiofrequency signal analysis using VH-IVUS [76] (Fig. 7) enable radiographers to critically distinguish between the four different plaque components: fibrotic, fibro-fatty, necrotic, and dense calcium [77] (Tables 1 and 2).
The recent advancement of imaging modalities has made possible visualization of atherosclerosis disease in all phases of its development. Markers of subclinical atherosclerosis or even the most advanced plaque features are acquired by invasive (IVUS, OCT) and non-invasive imaging modalities (US, MRI, CTA). Determining plaques prone to rupture (vulnerable plaques) might help to identify patients at risk for myocardial infarction or stroke. The most accepted features of plaque vulnerability include: thin cap fibroatheroma, large lipid core, intimal spotty calcification, positive remodeling and intraplaque neovascularizations. Today, research is focusing on finding imaging techniques that are less invasive, less radiation and can detect most of the vulnerable plaque features. While, carotid atherosclerosis can be visualized using noninvasive imaging, such as US, MRI and CT, imaging plaque feature in coronary arteries needs invasive imaging modalities. However, atherosclerosis is a systemic disease with plaque development simultaneously in different arteries and data acquisition in carotid arteries can add useful information for prediction of coronary events.
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Citation Excerpt :
These morphological characteristics include surface ulcerations, inflammation, microvascular formation, presence of a thin fibrous cap over the lipid core, and/or intraplaque hemorrhage [9]. Several studies have shown that the morphology of the plaque itself may play a critical role in the incidence of ischemic neurological events [12, 15]. Any of these interruptions of vascular flow to the brain can cause permanent injuries.
Cerebrovascular (CVA) accidents are the second leading cause of death worldwide and their numbers are increasing. Strokes can arise from several causes, with extracranial carotid artery atherosclerosis (CAS) being one of the leading causes. CAS causes these strokes either by diminishing blood flow distal to the diseased stenotic segment of the artery or, as more recently discovered, by a thromboembolic event of material from the plaque site itself. The specific etiology of CAS is unknown, but causative factors in the formation of atherosclerotic plaque of the carotid arteries have been linked to specific morphological areas within the plaque that may be vulnerable to rupture, leading to thromboemboli into the cerebrovascular circulation.
The current means for imaging and reporting CAS is through the measurement of the severity of luminal diameter stenosis caused by atherosclerotic disease. Recent developments in medical imaging techniques have expanded the role of early imaging and detection of CAS. Although current practice uses luminal narrowing as the surrogate marker to assess CAS, it has been recently discovered that plaque morphology and composition may help predict the clinical behavior of CAS and better determine the necessary medical intervention or risk of stroke. Although a single optimized imaging modality for standard CAS imaging has not been established or agreed on, various modalities can provide key elements to a successful exam. This review article will evaluate the most commonly used methods for CAS imaging along with the new and upcoming uses, advantages, and limitations for advanced CAS imaging.
Les accidents vasculaires cérébraux (AVC) sont la deuxième cause de mortalité au monde et leur nombre est en progression. UN AVC peut avoir plusieurs causes : l’athérosclérose de l’artère carotide extracrânienne (AAC) est l’une des principales. L’AAC cause des AVC en diminuant le flux sanguin dans la portion distale du segment sténosé de l’artère affectée ou, comme on l’a constaté récemment, par un événement thromboembolique de matériel du site même de la plaque. L’étiologie spécifique de l’AAC est inconnue, mais les facteurs de causalité de la formation de la plaque d’athérosclérose des artères carotides ont été reliés à des secteurs morphologiques spécifiques de la plaque qui peuvent s’avérer vulnérables à une rupture, conduisant à la formation d’un embole dans la circulation cérébrovasculaire.
La méthode actuelle d’imagerie et de présentation de l’AAC passe par la mesure de la gravité de la sténose du diamètre luminal causé par l’athérosclérose. Les développements récents dans les techniques d’imagerie médicale ont élargi le rôle de l’imagerie et de la détection précoces de l’AAC. Bien que la pratique actuelle utilise le rétrécissement luminal comme marqueur de substitution pour l’évaluation de l’AAC, on a récemment découvert que la morphologie et la composition de la plaque pourraient aider à prédire le comportement clinique de l’AAC et à mieux déterminer l’intervention médicale nécessaire ou le disque d’AVC. Bien qu’une modalité d’imagerie optimisée unique pour l’imagerie standard de l’AAC n’ait pas encore été établie ou convenue, différentes modalités peuvent fournir des éléments clés d’un examen réussi. Cet article d’examen bibliographique évaluera les méthodes couramment utilisées pour l’imagerie de l’AAC ainsi que les utilisations nouvelles et à venir, les avantages et les limites de l’imagerie avancée de l’AAC.
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Original Articles from the Central Surgical AssociationThe correlation of ultrasonic carotid plaque morphology and carotid plaque hemorrhage: clinical implications*

Abstract

Section snippets

Patients and methods

Results

Discussion

Am J Surg

J Am Coll Cardiol

J Vasc Surg

Ultrasound Med Biol

Ann Vasc Surg

Surg Clin North Am

J Vasc Surg

The vascular laboratory: diagnosis and management of cerebrovascular disease

Correlation of B-mode ultrasound imaging and arteriography with pathologic findings at carotid endarterectomy

Arch Surg

Tissue characterization of atheromatous plaques: correlation between ultrasound image and histological findings

J Clin Ultrasound

Ultrasonographic correlates of carotid atherosclerosis in transient ischemic attack and stroke

Stroke

Original Articles from the Central Surgical Association
The correlation of ultrasonic carotid plaque morphology and carotid plaque hemorrhage: clinical implications*