Bilateral vessel-outlining carotid artery calcifications in panoramic radiographs: an independent risk marker for vascular events.

BACKGROUND: In odontology, panoramic radiographs (PRs) are regularly performed. PRs depict the teeth and jaws as well as carotid artery calcifications (CACs). Patients with CACs on PRs have an increased risk of vascular events compared to healthy controls without CACs, but this association is often caused by more vascular events and risk factors at baseline. However, the risk of vascular events has only been analyzed based on the presence of CACs, and not their shape. Thus, this study determined if the shape of CACs in PRs affects the risk of future vascular events. METHODS: The study cohort included 117 consecutive patients with CACs in PRs and 121 age-matched controls without CACs. CAC shape in PRs was dichotomized into bilateral vessel-outlining CACs and other CAC shapes. Participants were followed prospectively for an endpoint of vascular events including myocardial infarction, stroke, and vascular death. RESULTS: Patients with bilateral vessel-outlining CACs had more previous vascular events than those with other CAC shapes and the healthy controls (p < 0.001, χ2). The mean follow-up duration was 9.5 years. The endpoint was reached in 83 people. Patients with bilateral vessel-outlining CACs had a higher annual risk of vascular events (7.0%) than those with other CAC shapes (4.4%) and the controls (2.6%) (p < 0.001). In multivariate analysis, bilateral vessel-outlining CACs (hazard ratio: 2.2, 95% confidence interval: 1.1-4.5) were independent risk markers for the endpoint. CONCLUSIONS: Findings of bilateral vessel-outlining CACs in PRs are independent risk markers for future vascular events.

Atherosclerotic Calcification Detection: A Comparative Study of Carotid Ultrasound and Cone Beam CT.

BACKGROUND AND AIM: Arterial calcification is often detected on ultrasound examination but its diagnostic accuracy is not well validated. The aim of this study was to determine the accuracy of carotid ultrasound B mode findings in detecting atherosclerotic calcification quantified by cone beam computed tomography (CBCT). METHODS: We analyzed 94 carotid arteries, from 88 patients (mean age 70 ± 7 years, 33% females), who underwent pre-endarterectomy ultrasound examination. Plaques with high echogenic nodules and posterior shadowing were considered calcified. After surgery, the excised plaques were examined using CBCT, from which the calcification volume (mm3) was calculated. In cases with multiple calcifications the largest calcification nodule volume was used to represent the plaque. Carotid artery calcification by the two imaging techniques was compared using conventional correlations. RESULTS: Carotid ultrasound was highly accurate in detecting the presence of calcification; with a sensitivity of 88.2%. Based on the quartile ranges of calcification volumes measured by CBCT we have divided plaque calcification into four groups: <8; 8-35; 36-70 and >70 mm3. Calcification volumes ≥8 were accurately detectable by ultrasound with a sensitivity of 96%. Of the 21 plaques with <8 mm3 calcification volume; only 13 were detected by ultrasound; resulting in a sensitivity of 62%. There was no difference in the volume of calcification between symptomatic and asymptomatic patients. CONCLUSION: Carotid ultrasound is highly accurate in detecting the presence of calcified atherosclerotic lesions of volume ≥8 mm3; but less accurate in detecting smaller volume calcified plaques. Further development of ultrasound techniques should allow better detection of early arterial calcification.

Ultrasound screening for asymptomatic carotid stenosis in subjects with calcifications in the area of the carotid arteries on panoramic radiographs: a cross-sectional study.

BACKGROUND: Directed ultrasonic screening for carotid stenosis is cost-effective in populations with > 5% prevalence of the diagnosis. Occasionally, calcifications in the area of the carotid arteries are incidentally detected on odontological panoramic radiographs. We aimed to determine if directed screening for carotid stenosis with ultrasound is indicated in individuals with such calcifications. METHODS: This was a cross-sectional study. Carotid ultrasound examinations were performed on consecutive persons, with findings of calcifications in the area of the carotid arteries on panoramic radiography that were otherwise eligible for asymptomatic carotid endarterectomy. RESULTS: Calcification in the area of the carotid arteries was seen in 176 of 1182 persons undergoing panoramic radiography. Of these, 117 fulfilled the inclusion criterion and were examined with carotid ultrasound. Eight persons (6.8%; 95% CI 2.2-11.5%) had a carotid stenosis--not significant over the 5% pre-specified threshold (p = 0.232, Binomial test). However, there was a significant sex difference (p = 0.008), as all stenoses were found in men. Among men, 12.5% (95%CI 4.2-20.8%) had carotid stenosis--significantly over the 5% pre-specified threshold (p = 0.014, Binomial test). CONCLUSIONS: The incidental finding of calcification in the area of the carotid arteries on panoramic radiographs should be followed up with carotid screening in men that are otherwise eligible for asymptomatic carotid endarterectomy. TRIAL REGISTRATION: The study was registered at http://www.clinicaltrials.gov; NCT00514644.

Calcifications in the neck region of patients with carotid artery stenosis: a computed tomography angiography study of topographic anatomy.

OBJECTIVES: The aim of this study was to map the vertical locations of calcified carotid plaques (CCPs), osseous anatomic structures, and calcified soft tissues in the area of the carotid artery, determine to what extent CCPs are superimposed on the cervical spine in coronal images, and analyze the differences between men and women. STUDY DESIGN: Computed tomography angiography (CTA) scans of 79 patients were studied. CCPs were discovered in 152 of the total 158 neck sides. Evaluations were performed by using sagittal and coronal reformatted CTA images with maximum intensity projection. RESULTS: Most of the calcified anatomic structures studied, including the carotid bifurcation, were found in close relationship to the level of the third and fourth cervical vertebrae. In the coronal view, all or most of the areas of the CCPs were superimposed on the cervical spine in 22 of 44 (50%) neck sides with CCP in women and in 37 of 108 (34.2%) in men (P = .070). CONCLUSIONS: The carotid bifurcation is in close proximity to various calcified anatomic structures. This should be taken into account when diagnosing CCPs in panoramic radiographs. In the coronal view, CCPs and the cervical spine are often superimposed; thus, coronal images are not recommended for confirmation of putative carotid calcifications diagnosed on the basis of panoramic radiographs.

Carotid calcification in panoramic radiographs: radiographic appearance and the degree of carotid stenosis.

OBJECTIVES:: Approximately 7% of patients examined with panoramic radiographs (PRs) for odontological reasons, and with incidental findings of carotid artery calcification (CAC), have significant (≥50%) carotid stenosis (SCS). The aim of this study was to determine if the radiographic appearance of CACs in PRs could be categorized such that we could improve the positive-predictive value (PPV) for SCS detection. METHODS:: This cross-sectional study included 278 patients with CACs identified by PRs, 127 with SCS and 151 without SCS. CACs were categorized based on the following appearances: (1) single, (2) scattered or (3) vessel-outlining. Correlates were derived for each category according to positivity or not for SCS in the corresponding neck sides. For a representative adult population (in dentistry) presenting with CACs in PRs, PPVs for SCS prediction were then calculated for three subgroups based on different combinations of appearances (2) and/or (3). RESULTS:: Vessel-outlining CACs corresponded to 65% of neck sides with SCS vs 47% without SCS (p < 0.001). Single CACs corresponded to 15% of neck sides with SCS vs 27% without SCS (p = 0.006). Scattered CACs corresponded to 20% of neck sides with SCS vs 26% without SCS (p = 0.127). In the representative population, the PPVs for SCS detection were comparable (7.2-7.8%) for all three subgroups and when the presence of a CAC is the sole criterion (7.4%). CONCLUSIONS:: Stratifying the radiographic appearance of CACs in PRs does not improve the PPV for SCS detection. Whether different radiographic appearances are associated with future risk of stroke, or other cardiovascular events, remains unknown.

Calcium quantity in carotid plaques: detection in panoramic radiographs and association with degree of stenosis.

OBJECTIVE: To determine calcium volume in extirpated carotid plaques, analyze correlations between calcium volume and degree of stenosis, and analyze whether calcium volume influences the possibility of detecting stenosis in panoramic radiographs. STUDY DESIGN: Ninety-seven consecutive patients with ultrasonography-verified carotid stenosis were examined with panoramic radiography before surgery. Extirpated carotid plaques (n = 103) were analyzed for calcium volume by cone beam computed tomography (CBCT). Panoramic radiographs were analyzed for carotid calcifications. RESULTS: The median calcium volume was 45 mm(3) (first quartile subtracted from the third quartile [IQR], 14-98 mm(3)). We observed no correlation between calcium volume and degree of stenosis. Seventy-eight stenoses were situated within the region included in the panoramic radiographs, and their volumes ranged from 0 to 509 mm(3). Of these, 99% revealed carotid calcifications on panoramic radiographs. CONCLUSIONS: We found no association between calcium volume and degree of carotid stenosis. Calcium volume did not influence the possibility of detecting carotid calcifications in panoramic radiographs.

Carotid calcifications on panoramic radiographs: a 5-year follow-up study.

OBJECTIVE: The aim of this study was to determine whether people with calcifications in the area of the carotid arteries on panoramic radiographs (CALPANs) have an increased prevalence of vascular risk factors or an increased risk of future vascular events. MATERIALS AND METHODS: We included 113 consecutive patients with CALPANs and 116 gender- and age-matched controls without CALPANs. Vascular risk factors were generally known in the study population, since it was recorded in a population-based community-screening program. RESULTS: Patients with CALPANs had a higher prevalence of vascular risk factors than controls independent of previous vascular events. During the 5.4-year follow-up, patients with CALPANs had a higher risk of a combined endpoint of vascular events (5.6%/yr) compared with the controls (2.4%/yr) (P = .004 by log rank test; unadjusted hazard ratio (HR) 2.4; 95% CI 1.3-4.3). This difference was not significant when previous vascular events and risk factors were taken into account (adjusted HR; 1.2; 95% CI 0.6-2.3; P = .62; Cox regression). CONCLUSIONS: People with CALPANs are very likely to have vascular risk factors, but these factors might be unknown when CALPANs are detected. Accordingly, patients with CALPANs should be advised to have their vascular risk factors regularly checked in order to receive advice on preventive lifestyle modifications and medical treatment when indicated. However, it remains unknown whether CALPANs add information about the independent risk of future vascular events. Therefore, further studies are warranted to investigate whether the detection of CALPANs indicates a need for additional or more intense vascular treatment.

Detection of calcifications in panoramic radiographs in patients with carotid stenoses ≥50%.

OBJECTIVE: Carotid stenoses ≥50% are associated with increased risk for stroke that can be reduced by prophylactic carotid endarterectomy (CEA). Calcifications in arteries can be detected in panoramic radiographs (PRs). In a cross-sectional study, we analyzed (1) extirpated plaques for calcification, (2) how often PRs disclosed calcified plaques, (3) how often patients with stenoses ≥50% presented calcifications in PRs, and (4) the additional value of frontal radiographs (FRs). STUDY DESIGN: Patients (n = 100) with carotid stenosis ≥50% were examined with PRs and FRs before CEA. Extirpated carotid plaques were radiographically examined (n = 101). RESULTS: It was found that 100 of 101 (99%) extirpated plaques were calcified, of which 75 of 100 (75%) were detected in PRs; 84 of 100 (84%) patients presented carotid calcifications in the PRs, in 9.5% contralateral to the stenosis ≥50%. CONCLUSIONS: Carotid calcifications are seen in PRs in 84% of patients with carotid stenosis ≥50%, independent of gender. FRs do not contribute significantly to this identification.