Visualizing Carotid Bodies With Doppler Ultrasound Versus CT Angiography: Preliminary Study.

OBJECTIVE: The purpose of this article is to evaluate the utility of ultrasound in identifying carotid bodies (CBs) in patients with drug-resistant arterial hypertension. SUBJECTS AND METHODS: We enrolled 13 patients with drug-resistant hypertension into a trial for surgical CB excision. CT angiography (CTA) and Doppler ultrasound (DUS) of the cervical arteries were performed before surgery. CBs were identified in a blind manner at both CTA and DUS. CBs were defined at CTA as ovoid avidly enhancing structures at the inferomedial aspect of the carotid bifurcation. At DUS, CBs were defined as ovoid solid structures in the inferomedial aspect of the bifurcation. RESULTS: CBs were identified in 12 of 13 patients (23/26 sides) using CTA and in 11 of 13 patients (18/26 sides) using DUS. Identification of CB with DUS and CTA correlated in 17 of 18 cases; in one instance, CB was identified with DUS but not CTA. There was no statistically significant difference in size and volume of CB measured by both methods. CONCLUSION: Noncarcinogenic CBs can be visualized using DUS, with good correlation of size and location compared with CTA. The findings show that DUS can be reliably used to further examine the role of CBs in cardiovascular disorders and can be used in conjunction with therapies that target CBs.

Surgical management of carotid body tumor - Is Shamblin classification sufficient to predict surgical outcome?

Background The study aims to conduct a review of the surgical management of carotid body tumor. Methods Consecutive patients with CBT who received surgical interventions from January 1994 to January 2014 at our institution were reviewed. Clinical, operative, pathological and follow up information were reported. Results Twenty patients (four males; median age was 36) with 21 CBT operations were recorded during the period. One patient undertook sequential operations for bilateral CBTs. Patients had 19 neck mass, 1 incidental finding and 1 facial nerve palsy. Six CBTs (28.6%) were Shamblin class I, ten (47.6%) were class II and five (23.8%) were class III. Nine CBTs had preoperative conjunctive embolization. Two operations required internal carotid artery resection and reconstruction. Four patients received subtotal resections, while 17 achieved complete resection. Complications included two major strokes, three hoarse voice and two Horner's syndrome. Shamblin class was significant predictor of operative time, blood loss, and whether complete resection accomplished, but could not predict postoperative complication. With median follow up period of 94 months, there was no tumor recurrence found in those had complete resection. Conclusions This small cohort showed that Shamblin class was significant in predicting technical difficulties but could not predict occurrence of complications.

The volume of the carotid bodies and blood pressure variability and pulse pressure in patients with essential hypertension.

AIM: To assess the relationship between the volume of the carotid bodies (VrCB+lCB) examined by means of computed tomography angiography (CTA) and blood pressure variability and pulse pressure (PP) in 24-hour ambulatory blood pressure monitoring (ABPM) in patients with essential hypertension. MATERIALS AND METHODS: A group of 52 patients with essential hypertension was examined (mean age: 68.32±12.31 years), the sizes of carotid bodies were measured by means of carotid artery CTA, and 24-hour ABPM was carried out. The 24-hour ABPM established systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), PP, SBP variability (SBPV), and DBP variability (DBPV). RESULTS: SBP, MAP, and SBPV were significantly higher in the group of hypertension patients with VrCB+lCB equal to or above the median than in the group of hypertension patients with VrCB+lCB less than the median, as well as in the group of hypertension patients with oversized carotid bodies, than in the group of hypertension patients with normal VrCB+lCB. Moreover, the PP was statistically significantly higher in the group of hypertension patients with VrCB+lCB equal to or above the median than in the group of hypertension patients with VrCB+lCB less than the median. The existence of statistically significant positive linear relationships was revealed between VrCB+lCB and SBP, PP, and SBPV. A higher body mass index, older age, smoking, and higher VrCB+lCB are independent risk factors increasing SBPV in the research group. CONCLUSION: A positive relationship between the size of the carotid bodies and variability of the SBP and PP is observed in patients with essential hypertension.

Carotid body size on CTA: correlation with comorbidities.

AIM: To test the hypothesis that computed tomographic angiography (CTA) can identify carotid body enlargement in patients with sympathetically mediated diseases. MATERIALS AND METHODS: A retrospective chart review of all patients obtaining CTAs of the cervical vasculature at University of Utah Health Sciences Center over a 6-month period was performed. Widest axial measurements of both carotid bodies were performed on a picture archiving and communication system (PACS). Statistical analysis was then performed to compare the mean carotid body size between control patients and patients with diabetes mellitus, hypertension, and congestive heart failure. RESULTS: Measurements were performed on 288 patients, with 134 controls. Of the remaining 154, 72 patients had diabetes mellitus, 46 had congestive heart failure, and 130 had hypertension. The control patients had a mean carotid body diameter of 2.3 mm. There was a statistically significant (p < 0.01) 20-25% increase in mean diameter with diabetes mellitus (2.8 mm), hypertension (2.7 mm), and congestive heart failure (2.7 mm; p < 0.01). CONCLUSIONS: This study found a 20-25% larger mean carotid body size in patients with diabetes mellitus, hypertension, and congestive heart failure relative to controls. However, this small enlargement should not mimic other carotid body diseases, such as a paraganglionoma. Moreover, these findings further support the proposed functional relationship between the carotid body and sympathetically mediated disease states.

CT angiography in the detection of carotid body enlargement in patients with hypertension and heart failure.

INTRODUCTION: The carotid body (CB) has previously been found to be enlarged and hyperactive in various disease states such as heart failure (HF), hypertension (HTN), and respiratory disease. Evaluation of CB size in these disease states using imaging has not been performed. The purpose of this case-control study was to compare CB sizes in patients with HF and HTN with those of controls using CT angiography. METHODS: A retrospective review was performed on 323 consecutive patients who had neck computed tomography angiography (CTA) exams in 2011. Following extensive review, 17 HF and HTN patients and 14 controls were identified. Two radiologists blinded to the patient disease status made consensus bilateral carotid body (CB) measurements on the CTA exams using a previously described standardized protocol. CB axial cross-sectional areas were compared between HF and HTN cases and controls using a paired t test. RESULTS: The right CB demonstrated a mean cross-sectional area of 2.79 mm(2) in HF and HTN patients vs. 1.40 mm(2) in controls (p = 0.02). The left CB demonstrated a mean cross-sectional area of 3.13 mm(2) in HF and HTN patients vs. 1.53 mm in controls (p = 0.03). CONCLUSION: Our results provide imaging evidence that the carotid bodies are enlarged in patients with HF and HTN. Our case-control series suggests that this enlargement can be detected on neck CTA.

Identification of internal carotid artery dissection by transoral carotid ultrasonography.

BACKGROUND AND PURPOSE: Conventional transsurface carotid ultrasonography (TSCU) via the cervical surface often fails to detect dissection of the extracranial internal carotid artery (ICA). The role of transoral carotid ultrasonography (TOCU) in the detection of ICA dissection was examined. METHOD: Patients with unilateral extracranial ICA dissection identified by digital subtraction angiography (DSA) from our database of patients with ischemic stroke or transient ischemic attack (TIA) were reviewed. Findings of dissection were compared between TSCU and TOCU. RESULTS: Eight patients (7 men, 37-69 years old), including 7 with ischemic stroke and 1 with TIA, had ICA dissection. By DSA, dissection was identified between the first and third vertebrae in 4 patients and from the third cervical vertebra to the intracranial level in the remaining 4. TOCU images revealed an intimal flap as definite evidence of dissection in all patients. In 7 patients, color flow signals were not seen in false lumens, indicating thrombosed lumens. Four patients showed morphological changes of dissection on follow-up TOCU, including a patient with recovery of color flow signals in false lumens. The diameter of the dissected ICA was 7.3 ± 0.7 mm and that of the contralateral ICA was 4.9 ± 0.6 mm (p = 0.008). In contrast, TSCU did not enable any conclusive findings of ICA dissection to be made in any patient. Six patients had intramural hematoma on T(1)-weighted MRI, and 2 had an intimal flap with a double lumen on magnetic resonance angiography. CONCLUSION: TOCU has advantages over TSCU in achieving an accurate diagnosis and follow-up evaluation of ICA dissection.

Aorticopulmonary Paraganglioma With Symptomatic Postoperative Bradycardia.

Aorticopulmonary paragangliomas are rare middle mediastinal masses that are often treated with surgery. In addition to the technical challenge of resection due to location near critical structures, these paragangliomas can have postoperative complications due to resection of cardiac sympathetic innervation. We present a patient with a nonfunctional aorticopulmonary paraganglioma who suffered from postoperative hypotension and heart block, with inability to tolerate his prior alpha and beta blockade on discharge.

Carotid body paraganglioma.

Carotid body tumours are benign neoplasms. This case report describes two patients with this rare tumour with diagnostic workup and treatment options. The first case was a 36-year-old gentleman who presented with 6 months history of painless swelling on the left side of neck. The second patient was 60-years-old man who presented with slowly growing swelling on the right side of neck for the last 20 years. Both patients had transmitted pulsations over the swelling. On suspicion of a vascular lesion, a contrast enhanced CT scan and Doppler's ultrasound of neck was advised which suggested the diagnosis of a carotid body tumour. Magnetic Resonance Angiography (MRA) confirmed the diagnosis. Excision in collaboration with vascular surgeon was planned for the first case. The second case was subjected to radiation therapy due to the large size of tumour and the patient's age.

Carotid body enlargement in hypertension and other comorbidities evaluated by ultrasonography.

BACKGROUND: Carotid body hyperactivity is important for sympathetic-related diseases and carotid body volume may partly reflect carotid bodies' activity. Our objective was to identify the association between carotid body volume and hypertension or other sympathetic-related diseases. METHODS: Consecutive individuals, undergoing carotid ultrasonography, who were eligible for the inclusion criteria were included. The bilateral carotid bodies were detected and volumetric parameters were measured by carotid ultrasonography in clinical. Clinical data of included participants were collected and analysed. RESULTS: A total of 1226 consecutive individuals underwent carotid ultrasonography. Carotid bodies were detected as solid, pebble-shaped, hypoechoic structures and the overall carotid body detection rate was 78.7% (965/1226). Univariate and multivariate regression analyses indicated that hypertension, chronic heart failure (CHF), chronic lung disease, smoking and high BMI were positively associated with carotid body enlargement. Compared with controls (2.63 µl), carotid body volume was significantly elevated in simple hypertensive (3.11 µl, P < 0.001), simple CHF (3.27 µl, P = 0.004) and simple smoking (3.47 µl, P < 0.001) groups. Moreover, the individuals with three comorbidities (4.05 µl) had significantly larger carotid bodies than those with one (3.23 µl, P < 0.001) or two comorbidities (3.46 µl, P = 0.017), suggesting that there existed a cumulative effect of comorbidities on carotid body volume. CONCLUSION: Carotid body enlargement is strongly associated with hypertension and other sympathetic-related diseases or risk factors, and carotid body volume evaluated by carotid ultrasonography may be further explored as a promising screening and evaluation predictor for carotid body modulation therapy in patients with hypertension and other sympathetic-related diseases.

Carotid body size measured by computed tomographic angiography in individuals born prematurely.

PURPOSE: We tested the hypothesis that the carotid bodies would be smaller in individuals born prematurely or exposed to perinatal oxygen therapy when compared individuals born full term that did not receive oxygen therapy. METHODS: A retrospective chart review was conducted on patients who underwent head/neck computed tomography angiography (CTA) at the Mayo Clinic between 10 and 40 years of age (n = 2503). Patients were identified as premature ( < 38 weeks) or receiving perinatal oxygen therapy by physician completion or billing codes (n = 16 premature and n = 7 receiving oxygen). Widest axial measurements of the carotid body images captured during the CTA were performed. RESULTS: Carotid body visualization was possible in 43% of patients and 52% of age, sex, and body mass index (BMI)-matched controls but only 17% of juvenile preterm subjects (p = .07). Of the carotid bodies that could be visualized, widest axial measurements of the carotid bodies in individuals born prematurely (n = 7, 34 ±â€¯4 weeks gestation, birth weight: 2460 ±â€¯454 g; average size: 2.5 ±â€¯0.2 cm) or individuals exposed to perinatal oxygen therapy (n = 3, 38 ±â€¯2 weeks gestation, Average size: 2.2 ±â€¯0.1 cm) were not different when compared to controls (2.3 ±â€¯0.2 cm and 2.3 ±â€¯0.2 cm, respectively, p > 0.05). CONCLUSIONS: Carotid body size, as measured using CTA, is not smaller in adults born prematurely or exposed to perinatal oxygen therapy when compared to sex, age, and BMI-matched controls. However, carotid body visualization was lower in juvenile premature patients. The decreased ability to visualize the carotid bodies in these individuals may be a result of their prematurity.

Genetically determined enlargement of carotid body evaluated using computed angiotomography.

It has recently been established that carotid bodies play a significant role in the regulation of activities of the cardiovascular system as well as in the pathogenesis of arterial hypertension, heart failure and diabetes. Aim of study was to determinate the influence of polymorphisms within genes of the renin-angiotensin-aldosterone system (RAAS) on the volume of the carotid bodies (CB) in patients with hypertension (HTA). The study group consisted of 77 patients with HTA. All patients were genotyped for single-nucleotide polymorphisms of genes coding for: angiotensinogen: rs4762, rs5049, rs5051 and rs699; angiotensin-converting enzyme: rs4343; angiotensin receptor type 1 gene (AGTR1): rs5182 and rs5186; and the aldosterone synthase: rs1799998. The estimation of volumes of CB (VrCB+lCB) was based on computed tomography angiography. Among individuals with essential hypertension certain relationships were documented between rs5182 and rs5186 polymorphisms of AGTR1 gene and rs1799998 polymorphism of CYP11B2 gene on one hand and the volume of carotid bodies on one other. Patients carrying the C alleles within the rs5182 and rs5186 of AGTR1 gene was associated with higher values of VrCB+lCB. The carriage of the T allele in the rs5182 locus of the AGTR1 gene determine lower values of VrCB+lCB. In summary, in patients with HTA a higher volume of CB may be resulted from the presence of specific genotypes in RAAS.

Impact of sleep disordered breathing on carotid body size.

We tested the hypotheses that: (1) carotid body size can be measured by computed tomographic angiography (CTA) with high inter-observer agreement, and (2) patients with sleep apnea exhibit larger carotid bodies than those without sleep apnea. A chart review was conducted from patients who underwent neck CTA and polysomnography at the Mayo Clinic between January 2000 and February 2015. Widest axial measurements of the carotid bodies, performed independently by two radiologists, were possible in 81% of patients. Intra-class correlation coefficients ranged from 0.93 to 0.95 (Right carotid body: 0.93; Left: 0.94; Average: 0.95). Widest axial measurements of the carotid bodies were greater in patients with sleep apnea (n=32) compared to controls (n=46, P-value range 0.02-0.04). After adjusting for age, no differences in carotid body size were observed between the patient groups (P-value range 0.45-0.59). We conclude carotid body size can be detected by CTA with high inter-observer agreement; however, carotid body size is not increased in patients with sleep apnea.

Increased urinary dopamine excretion in association with bilateral carotid body tumours-- clinical, biochemical and genetic findings.

This report describes a rare case of a patient with increased urinary dopamine excretion in association with bilateral carotid body tumours. Excretion of adrenaline, noradrenaline, metadrenaline, normetadrenaline and 4-hydroxy-3-methoxymandelic acid (HMMA) were within the reference ranges, and an (123)I-meta-iodobenzylguanidine (MIBG) scan showed uptake in the neck masses, with no other abnormal uptake anywhere else in the body. The patient is being managed conservatively as the tumours are not amenable to resection on account of their size and vascularity. There are only four previous case reports of dopamine-secreting tumours of the carotid body described in the literature, all of whom were women. The tumours were unilateral in three cases and bilateral in the fourth case. Familial cases of carotid body tumours have a higher prevalence of bilateral tumours than non-familial cases. Recent reports in the literature have suggested that a significant number of patients with extra-adrenal catecholamine-secreting paragangliomas have a genetic mutation in one of the identified susceptibility genes for catecholamine-secreting tumours, despite having no other affected family members, and a mutation has been found in the succinate dehydrogenase gene for this patient.

The Quality of Imaging of the Carotid Body by the Standard Protocol for Computed Tomography Angiography of the Carotid Arteries.

BACKGROUND: The clinical significance of the carotid body (CB) has been increasing. Currently, research connected with the CB is focused on establishing the significance of chronically increased activity of the CB in the progression of heart failure and in the genesis of hypertension. Moreover, it has been suggested that cardiac hypertrophy may be associated with an increase in CB volume. OBJECTIVES: The aim of study was to assess the quality of imaging the CB by following the standard protocol for computed tomography angiography (CTA) of the carotid arteries. MATERIAL AND METHODS: The analysis includes 50 consecutive CTA examinations of the carotid arteries. A retrospective assessment of the quality of imaging both the right and left CB (rCB and lCB) was carried out for all the CTA examinations of the carotid arteries. RESULTS: The rCB was exposed in 62% and the lCB in 56% of the CTA examinations. None of the CTA examinations analyzed resulted in good or very good quality visualization of the CB. Only 22% of the CTA examinations provided a medium quality rCB image. An even lower ratio of medium-quality visualizations of the lCB was noted: only 14% of the analyzed examinations. In the male sample group, the CB was exposed significantly more often than in the female group. CONCLUSIONS: The standard protocol for CTA examinations of the carotid arteries appears to be insufficient for use in assessing the CB.

Resection of a large carotid paraganglioma in Carney-Stratakis syndrome: a multidisciplinary feat.

A 39-year-old man was referred to the vascular surgeons with a right-sided cervical mass, palpitations, headaches and sweating. He had presented with abdominal discomfort 12 months earlier. Investigations had revealed a gastrointestinal stromal tumour (GIST) and left adrenalectomy. CT of the neck with contrast demonstrated a large right carotid paraganglioma, extending superiorly from below the carotid bifurcation to encase the internal carotid artery. Genetic screening confirmed the diagnosis of Carney-Stratakis syndrome, an SDH-D germline mutation leading to GIST and multifocal paragangliomas. Successful surgical excision required considerable multidisciplinary teamwork between neuroendocrinologists, anaesthetists and surgeons. The tumour was highly vascular and involved the right carotid body, hypoglossal and vagus nerves. Access was challenging and maxillofacial surgical expertise were required for division of the mandible. The patient made a good recovery following speech and swallowing rehabilitation.

Localization and treatment of familial malignant nonfunctional paraganglioma with iodine-131 MIBG: report of two cases.

Two cases of familial, malignant, nonfunctional paraganglioma are reported. Uptake of iodine-131 metaiodobenzylguanidine ([131I]MIBG) by the tumors and metastases was demonstrated. In the first case, with multicentric and locally invasive disease, [131I]MIBG correctly localized a right carotid body paraganglioma which had been missed arteriographically. In the second case, with widespread, symptomatic metastatic disease, a therapeutic dose of [131I]MIBG produced palliation of bone pain after the failure of radio- and chemotherapy. Uptake of [131I]MIBG by paragangliomas does not correlate with catecholamine secretory activity. Iodine-131 MIBG should be considered as a therapeutic option in unresectable, malignant paragangliomas which take up this radiopharmaceutical.

Anatomical reconstruction of carotid bifurcation with a branched non-reversed saphenous vein.

A large carotid body tumor surrounding the entire carotid bifurcation of a 17-year-old female was completely resected with the carotid bifurcation. Anatomical reconstruction was attempted, using a branched non-reversed saphenous vein, the valve cusps of which were incised by a valvulotome. Postoperative angiogram showed smooth, satisfactory flow from the common carotid artery to both internal and external carotid arteries. The postoperative course has been uneventful for the 16 months since the operation. We conclude that the branched non-reversed saphenous vein is an excellent graft for anatomical reconstruction of the carotid bifurcation.

Fine-needle aspiration diagnosis of carotid body tumor: report of a case and review of experience with cytologic features in four cases.

A 45-yr-old female presented with a left upper cervical swelling of 4 yr duration. The clinical suspicion of carotid body tumor (CBT) was confirmed by imaging findings, fine-needle aspiration (FNA) cytology, and histology of the resected tumor. Review of our experience with four cases including the present one during 10 yr (1984-1994) showed that the age of the patients ranged from 35 to 45 yr with a mean of 40.8 yr. All four cases were females and had left-sided upper cervical swelling. Clinically one case was diagnosed as cervical lymphadenopathy and there was clinical suspicion of CBT in two cases. Findings of digital subtraction angiogram in four cases and ultrasonography including Doppler ultrasound vascular imaging in three cases were consistent with CBT. The cytodiagnosis was CBT in three cases and inadequate (blood only) in one case. The analysis of detailed cytologic features in three cases revealed blood-rich aspirate with poor to moderate cellularity, indistinct cell outline, and acinar formation. Giant bare nuclei, spindle-shaped tumor cells, and cytoplasmic granulations were observed in two cases each. Histopathology of the resected tumors in two cases confirmed the cytodiagnosis of CBT. FNA cytology played a useful role in arriving at a tissue diagnosis of this rare neoplasm.