Do Carotid Plaque Ulcers Heal? Potential Detection of Carotid Artery Plaque Healing by Carotid Ultrasound Imaging.

OBJECTIVES: Carotid plaque ulcers confer an increased risk for stroke/ transient ischemic attacks in both symptomatic and asymptomatic carotid artery stenosis. Little is known about the healing rates of ulcers or the development of new ulcers. Carotid Duplex studies are noninvasive and easily repeatable tests to monitor progression of carotid stenosis and plaque morphology. Our aim was to determine the prevalence and healing rates of ultrasound-detected carotid plaque ulcers. METHODS: We retrospectively reviewed 5837 carotid Duplex studies performed in an outpatient ultrasound laboratory affiliated with the neurological department of an academic center. A total of 3215 patients underwent a first carotid ultrasound Duplex study, and 2622 follow-up studies were done. Carotid ulcer was defined as a 2 mm deep surface indentation in a carotid plaque with a well-defined back wall, as determined by multimodal ultrasound imaging techniques. RESULTS: The prevalence of carotid plaque ulcers among the 3215 patients with a first ultrasound study was 3% (82/3215). The mean follow-up was 42 ± 30 months, and the median number of follow-up studies was 6. Among patients with ulcers, follow-up studies were available in 65/82 patients. During the follow-up period, 28/65 (43%) ulcers healed. Among all 2622 follow-up studies, 45 patients developed a new ulcer. CONCLUSIONS: Duplex-detected carotid plaque ulcer prevalence is low. The carotid ulcers healed in approximately half of patients during follow-up. Factors associated with ulcer healing and development remain poorly understood.

Association of Menopausal Age with Unruptured Intracranial Aneurysm Morphology.

BACKGROUND: The prevalence of unruptured intracranial aneurysms (UIAs) increases rapidly in aging women compared with younger women. The impact of menopausal age on UIAs and treatment outcomes with endovascular therapy has not been well studied. We hypothesized that premenopausal age may have a protective effect on presentation size and treatment outcomes. OBJECTIVE: To evaluate the association of menopause with UIA size and outcome with endovascular therapy. METHODS: Retrospective analysis of consecutive female patients with UIAs treated with endovascular therapy at our academic tertiary care center. UIA characteristics, complications, and outcomes were recorded and compared. RESULTS: 117 patients were included: 23 patients in the premenopausal age (PRM) group and 94 in the postmenopausal age (POM) group. 93.6% of all aneurysms in the PRM group were in the internal carotid artery (ICA) segments (p < 0.05). Hence only ICA segment aneurysms were further studied. A total of 21 patients in the PRM group and 60 in the POM group were found to have ICA segment aneurysms. Baseline characteristics were similar between the 2 groups. The mean size of the aneurysms in the PRM group was 8.6 ± 3.9 versus 10.8 ± 5.6 mm in the POM group (p = 0.055). There was a trend to higher aneurysm neck size seen in the POM group (4.7 ± 2.5 vs. 3.7 ± 1.7 mm; p = 0.07). The number of aneurysm lobes was higher in the PRM group (1.23 ± 0.54 vs. 1.07 ± 0.31; p = 0.18). In multivariate analysis, the PRM group had a significantly higher number of UIA lobes. Complications and endovascular therapy outcomes were similar between the 2 groups. CONCLUSIONS: A trend to increased UIA maximal diameter and neck size was seen in the POM group compared to the PRM group. The PRM group had a significantly higher number of UIA lobes. Larger prospective trials are needed to confirm these findings.

Association of hypothyroidism with unruptured cerebral aneurysms: a case-control study.

OBJECTIVE Thyroid disorder has been known to affect vascular function and has been associated with aortic aneurysm formation in some cases; however, the connection has not been well studied. The authors hypothesized that hypothyroidism is associated with the formation of cerebral aneurysms. METHODS The authors performed a retrospective case-control study of consecutive patients who had undergone cerebral angiography at an academic, tertiary care medical center in the period from April 2004 through April 2014. Patients with unruptured aneurysms were identified from among those who had undergone 3-vessel catheter angiography. Age-matched controls without cerebral aneurysms on angiography were also identified from the same database. Patients with previous subarachnoid hemorrhage or intracranial hemorrhage were excluded. History of hypothyroidism and other risk factors were recorded. RESULTS Two hundred forty-three patients with unruptured cerebral aneurysms were identified and age matched with 243 controls. Mean aneurysm size was 9.6 ± 0.8 mm. Hypothyroidism was present in 40 patients (16.5%) and 9 matched controls (3.7%; adjusted OR 3.2, 95% CI 1.3-7.8, p = 0.01). Subgroup analysis showed that men with hypothyroidism had higher odds of an unruptured cerebral aneurysm diagnosis than the women with hypothyroidism, with an adjusted OR of 12.7 (95% CI 1.3-121.9) versus an OR of 2.5 (95% CI 1.0-6.4) on multivariate analysis. CONCLUSIONS Hypothyroidism appears to be independently associated with unruptured cerebral aneurysms, with a higher effect seen in men. Given the known pathophysiological associations between hypothyroidism and vascular dysfunction, this finding warrants further exploration.

Safety of Intraventricular rt-PA for Pan-Ventricular IVH Caused by a Ruptured AVM: A Case Report.

Intraventricular recombinant tissue plasminogen activator (IVT rt-PA) has improved outcomes for intraventricular hemorrhage (IVH). Patients with suspected or untreated arteriovenous malformations (AVMs) have been excluded from clinical trials. We present a patient with IVH secondary to a ruptured AVM safely treated with IVT rt-PA. A 48-year-old Hispanic male with a history of dermatomyositis presented to the emergency department with sudden left-sided weakness. En route to computed tomography (CT), he became lethargic. Computed tomography revealed extensive IVH with acute hydrocephalus, which was treated with the placement of external ventricular drain with clinical improvement. Computed tomography angiogram performed did not reveal AVM. Cerebral digital subtraction angiogram (DSA) was planned due to suspicion of AVM. Prior to DSA, patient became acutely lethargic. Computed tomography imaging revealed worsening hydrocephalus. External ventricular drain was noted to be draining. Repeat CT revealed improved hydrocephalus but with left lateral ventricle dilatation. Risks and benefits of IVT rt-PA were discussed with the family and a decision was made to treat. Three doses of 1 mg IVT rt-PA were administered with resolution of midline blood and lateral ventricular dilatation with clinical improvement. Digital subtraction angiogram revealed early draining vein on right internal carotid artery injection draining into the inferior sagittal sinus representing ruptured AVM without clear nidus. Repeat DSA with possible embolization was planned after discharge. In spite of additional in-hospital complications, the patient gradually improved and was ultimately discharged home. Our case supports the idea that the use of IVT rt-PA following an IVH caused by an underlying AVM could be further explored in carefully designed clinical trials.

Medical and Revascularization Therapies for Asymptomatic Carotid Stenosis.

Asymptomatic internal carotid artery stenosis increases with age and is more common in men. Carotid endarterectomy and stenting have reduced stroke rates in patients with asymptomatic carotid stenosis in clinical trials. A variety of risk stratification methods are available for selection of patients with carotid stenosis for revascularization. In the past decade, there is increasing evidence that the rate of stroke declined with the use of aggressive multi-modal medical therapy. These developments have led to new clinical trials to compare revascularization versus aggressive medical therapy in patients with asymptomatic carotid stenosis.

Posterior communicating and vertebral artery configuration and outcome in endovascular treatment of acute basilar artery occlusion.

BACKGROUND: We aimed to evaluate if vertebrobasilar anatomic variations impact reperfusion and outcome in intra-arterial therapy (IAT) for basilar artery occlusion (BAO). METHODS: Consecutive BAO patients with symptom onset <24 h treated with IAT were included. Vertebral artery (VA) V3 and posterior communicating artery (PCoA) diameters were measured (CT angiography or MR angiography). The presence of PCoA atresia, VA hypoplasia, VAs that end in the posterior inferior cerebellar artery (PICA), and extracranial VA occlusion was recorded. RESULTS: 38 BAO patients were included. Mean age was 63±15 years; 52% were men. Baseline National Institutes of Health Stroke Scale score was 21±9, and mean/median time from symptom onset to IAT were 10/7 h. First generation thrombectomy devices were mostly used. Overall Treatment in Cerebral Ischemia 2b-3 reperfusion was 68.4%. Good outcome (modified Rankin Scale score ≤2) was observed in 17.8% and mortality in 64.3% of cases at 90 days. 55% of patients had an atretic PCoA while 47% had a hypoplastic VA. The mean sum of the bilateral PCoA and VA diameters were 2.3±1.2 and 5.2±5.2 mm, respectively. VAs that end in the PICA was noted in 23% of patients, and extracranial VA occlusion in 42%. BAO was proximal/mid/distal in 36%/29%/34%. Multivariate linear regression analysis indicated hypertensive disease (ß=2.97; 95% CI 1.15 to 4.79; p<0.01) and reperfusion rate (ß=-0.40; 95% CI -0.74 to -0.70; p=0.02) independently associated with outcome. Multivariate analysis for predictors of reperfusion failed to identify other associations. A trend for better reperfusion with stent retrievers was noted (ß=1.82; 95% CI -0.24 to 3.88; p=0.08). CONCLUSIONS: Reperfusion emerged as a predictor of good outcome in patients that underwent IAT for BAO. Angioarchitectural variations of the posterior circulation were not found to impact reperfusion or clinical outcome.

FLAIR distal hyperintense vessels as a marker of perfusion-diffusion mismatch in acute stroke.

BACKGROUND AND PURPOSE: Distal hyperintense vessels (DHV) on MRI FLAIR sequences in acute brain ischemia are thought to represent leptomeningeal collateral flow. We hypothesized that DHV are more common in acute stroke patients with perfusion-diffusion weighted mismatch (PDM) than in those without. METHODS: We performed a retrospective study of consecutive anterior circulation stroke patients who underwent multimodal MRI within 8 hours of onset. We correlated DHV occurrence with the presence or absence of PDM, and analyzed DHV correlates when angiography was available. RESULTS: Twenty-one patients with PDM and 28 without were included. On univariate analysis, there was no significant difference regarding demographic variables between the two groups, with the exception of a higher frequency of atrial fibrillation (33% vs. 7%; P = .02) and intravenous tissue plasminogen activator use (57% vs 25%; P = .03) in the PDM patients. The PDM group more commonly had DHV (85% vs 25%; P < .001). On multivariate analysis, DHV presence (odds ratio, 6.01; 95% confidence-interval, 1.08-33.29; P = .04) and vessel occlusion site (odds ratio, 3.17; 95% confidence-interval, 1.21-8.31; P = .01) were the only variables independently associated with PDM. Conventional angiography was useful correlating DHV presence and collateral flow in a subset of patients. CONCLUSIONS: DHV may be a surrogate marker for PDM in patients with hyperacute ischemic stroke.