Multilevel Strip Pooling-Based Convolutional Neural Network for the Classification of Carotid Plaque Echogenicity.

Carotid plaque echogenicity in ultrasound images has been found to be closely correlated with the risk of stroke in atherosclerotic patients. The automatic and accurate classification of carotid plaque echogenicity is of great significance for clinically estimating the stability of carotid plaques and predicting cardiovascular events. Existing convolutional neural networks (CNNs) can provide an automatic carotid plaque echogenicity classification; however, they require a fixed-size input image, while the carotid plaques are of varying sizes. Although cropping and scaling the input carotid plaque images is promising, it will cause content loss or distortion and hence reduce the classification accuracy. In this study, we redesign the spatial pyramid pooling (SPP) and propose multilevel strip pooling (MSP) for the automatic and accurate classification of carotid plaque echogenicity in the longitudinal section. The proposed MSP module can accept arbitrarily sized carotid plaques as input and capture a long-range informative context to improve the accuracy of classification. In our experiments, we implement an MSP-based CNN by using the visual geometry group (VGG) network as the backbone. A total of 1463 carotid plaques (335 echo-rich plaques, 405 intermediate plaques, and 723 echolucent plaques) were collected from Zhongnan Hospital of Wuhan University. The 5-fold cross-validation results show that the proposed MSP-based VGGNet achieves a sensitivity of 92.1%, specificity of 95.6%, accuracy of 92.1%, and F1-score of 92.1%. These results demonstrate that our approach provides a way to enhance the applicability of CNN by enabling the acceptance of arbitrary input sizes and improving the classification accuracy of carotid plaque echogenicity, which has a great potential for an efficient and objective risk assessment of carotid plaques in the clinic.

Symptomatic nonstenotic carotid disease: Evaluation of a proposed classification scheme in a prospective cohort.

INTRODUCTION: Unraveling symptomatic nonstenotic carotid disease (SyNC) as a stroke etiology from other cryptogenic stroke may have important implications for defining natural history and for tailoring secondary prevention strategies. We aim to describe the characteristics of the plaques in a prospectively-collected cohort of patients with non-invasive imaging suggesting symptomatic carotid stenosis but whose DSA demonstrated nonstenotic atheromatous disease, and to evaluate the recurrence rate depending on the type of SyNC. METHODS: We reviewed prospectively-collected data for patients presenting with new neurologic events and non-invasive imaging suggestive of moderate or severe (≥50%) carotid stenosis between July 2016 and October 2018. Patients were included in the present study if the degree of stenosis on DSA was < 50%. We assigned these patients into groups based on a previously-proposed working definition of SyNC, and analyzed the rate of recurrent stroke in the following 6 months. RESULTS: 28 patients had DSA-confirmed < 50% stenosis and constituted the study cohort. The median age was 73 years and 64% were male; median presenting NIHSS was 1 (IQR 0-3). The great majority (86%) of carotid plaques had high-risk features including ulcerated plaque (n = 21, 75%) and plaque > 3 mm thick (n = 18, 64%). 17 of 28 patients (61%) met classification criteria for "definite" or "probable" SyNC. Three of five patients in the "definite SyNC" group experienced recurrent neurologic events. CONCLUSION: The majority of patients with non-invasive imaging suggesting carotid stenosis harbor symptomatic carotid disease per current classifications despite DSA stenosis < 50%. Current classification schema may allow for risk stratification of SyNC patients and these findings warrant further study.

Association between C-reactive protein and carotid plaque in mild-to-moderate idiopathic pulmonary fibrosis.

An association between C-reactive protein (CRP) levels and carotid plaque has never been investigated in idiopathic pulmonary fibrosis (IPF). The aim of this study was to evaluate the extent of carotid atherosclerosis in mild-to-moderate IPF and to assess its relationship to serum CRP. This observational retrospective case-control study included 60 consecutive IPF patients (73.8 ± 6.6 years, 45 males) and 60 matched controls, examined between Sep 2017 and Jan 2019. All patients underwent CRP assessment and a carotid Doppler ultrasonography. CRP levels were significantly higher in IPF patients than controls (0.2 ± 0.09 mg/dl vs 0.09 ± 0.04 mg/dl, p < 0.0001). A total of 46 plaques were detected, with higher prevalence in IPF patients than controls (38 vs 8, p < 0.0001). On univariate logistic regression the main variables independently associated with carotid plaque were: age (HR 1.09, 95% CI 1.03-1.16, p = 0.006), hypertension duration (HR 1.05, 95% CI 1.01-1.09, p = 0.01), diabetes duration (HR 1.09, 95% CI 1.01-1.18, p = 0.03), LDL-cholesterol (HR 1.07, 95% CI 1.04-1.10, p < 0.0001) and finally CRP levels (HR 1.73, 95% CI 0.59-5.00, p < 0.0001). Multivariate logistic regression analysis revealed that LDL-cholesterol (HR 1.05, 95% CI 1.01-1.08, p = 0.009) and CRP levels (HR 1.43, 95% CI 0.39-5.19, p < 0.0001) retained statistical significance. Common carotid artery-intima media thickness was significantly correlated with CRP levels in IPF patients (r = 0.86). SerumCRP might represent both an early marker and a potential therapeutic target for carotid atherosclerosis in mild-to-moderate IPF.

Endovascular Recanalization of Symptomatic Nonacute Intracranial Internal Carotid Artery Occlusion: Proposal of a New Angiographic Classification.

BACKGROUND AND PURPOSE: The optimal treatment for symptomatic nonacute intracranial ICA occlusion is uncertain, and endovascular recanalization remains a technical challenge. Our purpose was to report multicenter clinical results of endovascular recanalization for medically refractory, nonacute, intracranial ICA occlusion and to propose a new angiographic classification to explore which subgroups of patients are most amenable to this treatment. MATERIALS AND METHODS: From January 2015 to December 2019, thirty-six consecutive patients who underwent endovascular recanalization for refractory, nonacute, atherosclerotic intracranial ICA occlusion at 3 stroke centers were analyzed retrospectively. The patients were divided into 3 types according to an angiographic classification. Rates of technical success, periprocedural complications, and any stroke or death within 30 days along with follow-up results were evaluated. RESULTS: The overall technical success rate was 80.6% (29/36), and the rate of any stroke or death within 30 days was 16.7% (6/36). The recanalization success rate gradually decreased from type I to type III in the 3 classification groups (92.9%, 81.3%, and 50%, P = .038), and the opposite was true of the perioperative complication rates (7.1%, 18.8%, and 50%, P = .038). Type I lesions showed favorable recanalization effects, 92.9% technical success rates, and 7.1% perioperative complications. CONCLUSIONS: Endovascular recanalization for nonacute atherosclerotic intracranial ICA occlusion is technically feasible, especially in patients with type I lesions, and could offer an alternative option for patients with recurrent ischemic symptoms despite aggressive medical therapy. The angiographic classification proposed is conducive to the selection of suitable patients and difficulty in grading.

Bradycardia and Asystole in Patients Undergoing Symptomatic Chronically Occluded Internal Carotid Artery Recanalization.

BACKGROUND: Reports have emerged describing the successful endovascular recanalization of the chronically occluded internal carotid artery (COICA). The impact this restoration of flow has on the sensitive carotid sinus baroreceptors has not been previously described. In this manuscript, we present the largest COICA surgical series to date, with a specific focus on perioperative heart rate abnormalities. METHODS: Patient demographics were obtained, and the COICAs were radiographically classified based on the anatomic distribution of the stenosis and collateral flow. Thirty-six patients had a total of 37 COICA revascularization procedures. RESULTS: A total of 23 patients had intraprocedural bradycardia during balloon angioplasty. Three patients went into transient asystole during the procedure, and 2 of these patients had symptomatic bradycardia with ischemic cerebral changes, 1 of which required permanent pacemaking. All other patients had immediate resolution of their bradycardia, asystole, and neurologic symptoms immediately following balloon deflation and pharmaceutical management. There was a statistically significant difference in the observed proportion of bradycardic patients among COICA classifications (P = 0.014). There was no statistically significant difference in mean age between patients with bradycardia and those without (aged 63.36 vs. 67.71 years, P = 0.2265). CONCLUSIONS: Bradycardia associated with angioplasty of the carotid bulb was observed in the majority of patients receiving COICA revascularization. A small percentage of these patients were symptomatic. Our results suggest that carotid sinus baroreceptors remain active while residing in a complete arterial occlusion, and close monitoring is necessary during balloon angioplasty of the proximal COICA.

Intracranial Blood Flow Changes in Patients with High-Grade Severe Carotid Artery Stenosis After Stenting.

OBJECTIVE: We investigated whether the cerebral hemodynamic changes of pre- and poststenting in patients with severe carotid stenosis differ by stenosis grades. METHODS: We prospectively recruited patients who underwent carotid artery stenting (CAS) after acute ischemic stroke from June 2014 to December 2015. We compared the mean relative cerebral blood flow (rCBF) changes (measured by whole-brain computed tomography perfusion) pre- and poststenting in patients with high-grade severe stenosis (HGSS) (90%-99%) versus patients with low-grade severe stenosis (LGSS) (70%-89%). RESULTS: Among 24 patients included in the study (mean age, 66.2 ± 7.2 years; 91.7% men), 62.5% (15/24) were in the HGSS group and 37.5% (9/24) were in the LGSS group. In the HGSS group, rCBF increased in territories of the anterior cerebral artery (P = 0.021), middle cerebral artery (P < 0.001), posterior cerebral artery (P = 0.001), and basil ganglia (P = 0.003) after stenting. Of the patients with HGSS, 53.3% (8/15) had collateral flow through anterior communicating artery (AcomA) prestenting. After stenting, all the AcomA collaterals in HGSS reverted to normal (P = 0.002). CONCLUSIONS: The improvement of brain perfusion combined with the normalization of collateral flow through the circle of Willis after CAS was observed only in patients with HGSS.

Definition of common carotid wall thickness affects risk classification in relation to degree of internal carotid artery stenosis: the Plaque At RISK (PARISK) study.

BACKGROUND: Mean or maximal intima-media thickness (IMT) is commonly used as surrogate endpoint in intervention studies. However, the effect of normalization by surrounding or median IMT or by diameter is unknown. In addition, it is unclear whether IMT inhomogeneity is a useful predictor beyond common wall parameters like maximal wall thickness, either absolute or normalized to IMT or lumen size. We investigated the interrelationship of common carotid artery (CCA) thickness parameters and their association with the ipsilateral internal carotid artery (ICA) stenosis degree. METHODS: CCA thickness parameters were extracted by edge detection applied to ultrasound B-mode recordings of 240 patients. Degree of ICA stenosis was determined from CT angiography. RESULTS: Normalization of maximal CCA wall thickness to median IMT leads to large variations. Higher CCA thickness parameter values are associated with a higher degree of ipsilateral ICA stenosis (p < 0.001), though IMT inhomogeneity does not provide extra information. When the ratio of wall thickness and diameter instead of absolute maximal wall thickness is used as risk marker for having moderate ipsilateral ICA stenosis (>50%), 55 arteries (15%) are reclassified to another risk category. CONCLUSIONS: It is more reasonable to normalize maximal wall thickness to end-diastolic diameter rather than to IMT, affecting risk classification and suggesting modification of the Mannheim criteria. TRIAL REGISTRATION: Clinical trials.gov NCT01208025 .

Resultados a corto y medio plazo en el tratamiento de estenosis carotídea sintomática mediante «stenting» versus endarterectomía carotídea / Early and mid-term results after stenting and endarterectomy in the treatment of symptomatic carotid stenosis

INTRODUCCIÓN: La estenosis de la arteria carótida interna de origen aterosclerótico es una de las principales causas de los ictus isquémicos. La tromboendarterectomía (TEA) carotídea es el tratamiento clásico para disminuir el riesgo de recurrencia de un nuevo ictus. Las técnicas endovasculares, como el stenting carotídeo están en auge. OBJETIVO: Describir nuestra experiencia en el tratamiento de estenosis carotídea sintomática mediante TEA carotídea y el implante de stent carotídeo. Nuestros objetivos principales son comparar: eventos neurológicos, infarto de miocardio y muerte a los 30 días postintervención. El objetivo secundario es reportar la incidencia de reestenosis severa (≥70%), reintervencion carotídea y mortalidad durante el seguimiento. MÉTODOS: Realizamos un estudio descriptivo de pacientes tratados entre los años 2008 y 2012. Analizamos un total de 86 pacientes, 61,6% (n = 53) recibieron TEA carotídea y 38,4% (n = 33) stent carotídeo. El diagnóstico de estenosis carotídea fue con ecografía-doppler, confirmado mediante arteriografía en el grupo con stent. RESULTADOS: Se registraron 2 casos de ictus en el grupo TEA carotídea frente a 4 en el grupo con stent (3,2 versus 12,1%, respectivamente). Aconteció un solo caso de infarto agudo de miocardio, no letal, en el grupo de TEA carotídea. La mortalidad a los 30 días fue de 1,9% (n = 1) en el grupo TEA carotídea en comparación con 3,0% (n = 1) en el grupo stent. Se registraron 7 casos de reestenosis crítica en el grupo de stent carotídeo, ninguno en el de TEA (p = 0,006). La mediana de seguimiento fue de 38,5 meses en el grupo TEA y 37,5 meses en grupo endovascular. CONCLUSIONES: Nuestra experiencia reporta mejores resultados en el corto y medio plazo, a favor de la TEA carotídea. Así, pensamos que la TEA carotídea debería seguir siendo el tratamiento de elección en pacientes con estenosis carotídea sintomáticos

INTRODUCTION: Atherothrombotic stenosis of the internal carotid artery is a common cause of stroke. Carotid endarterectomy (CEA) is the most common treatment for secondary stroke prevention. Carotid artery stenting is an alternative treatment. OBJECTIVE: To describe our experience of treating symptomatic carotid artery stenosis with CEA or carotid artery stenting. The primary outcomes were: 30-day stroke, myocardial infarction, or death. The secondary outcomes were severe restenosis (>70%), re-intervention, and death during mid-term follow-up. METHODS: Retrospective cohort study including patients treated between 2008 and 2012. A total of 86 patients were included, of which 61.6% (n = 53) received CEA, and a CAS technique in the remaining 38.4% (n = 33). Diagnosis was established by echo-Doppler, and confirmed with selective arteriography in the carotid artery stenting group. RESULTS: Two strokes were recorded in the CEA group, and 4 cases in the carotid artery stenting group (3.21 vs. 12.12%). There was one case of non-lethal myocardial infarction in the CEA group. The 30-day mortality rate was 1.9% (n = 1) in the CEA group, and 3.0% (n = 1) in the carotid artery stenting group. There were 7 cases of severe restenosis in the carotid artery stenting group, with no cases being reported in the CEA group (p=.006). The median follow-up was 38.5 months in the CEA group and 37.5 months in the carotid artery stenting group. CONCLUSION: Our study reports better results in the early and mid-term after CEA. Thus, it is concluded that CEA should remain the reference-standard treatment in symptomatic patients

[Diagnostic value of carotid atherosclerosis score for ischemic stroke].

OBJECTIVE: To discuss the diagnostic value of carotid atherosclerosis score for ischemic stroke. METHODS: In the study, 151 patients with ischemic stroke were enrolled, who were diagnosed by cranial CT scan or cranial MRI scan, and examined with carotid duplex ultrasound, and 151 healthy check-up cases matched by age and sex were chosen as control group, who were excluded ischemic stroke by cranial CT scan or cranial MRI scan. All the control cases were examined with carotid duplex ultrasound also. Intima-media thickness (IMT), the number of carotid plaques, the size of each plaque, the location of the plaque and each plaque's echo, texture, surface regularity were estimated by carotid duplex ultrasound. RESULTS: The IMT of the case group and the control group were (0.946±0.185) mm and (0.863±0.148) mm, and there were significant differences (P<0.001); The parameters of arterial plaque correlated with ischemic stroke were plaque's echo, texture and surface regularity, however the plaque size and location were not correlated with ischemic stroke. The median and quartile of carotid artery plaque score were 3 and 2 respectively in case group, 1 and 2 respectively in control group, and there were significant differences (P<0.001); The parameters of carotid arterial atherosclerosis associated with ischemic stroke were carotid artery plaque score,carotid stenosis degree and IMT, but not the number of carotid plaques. The median and quartile of carotid arterial atherosclerosis score were 5 and 4 respectively in case group, 2 and 4 respectively in control group, and there were significant differences (P<0.001); The area under the curve (AUC) for IMT, the number of carotid plaques, carotid artery plaque score and carotid arterial atherosclerosis score were 0.679, 0.677, 0.704 and 0.805,respectively (P<0.001). The accuracy of carotid atherosclerosis score was the highest. CONCLUSION: Carotid artery plaque score and carotid atherosclerosis score can be used for the diagnosis of ischemic stroke, and the accuracy of carotid atherosclerosis score is higher.

Searching the perfect ultrasonic classification in assessing carotid artery stenosis: comparison and remarks upon the existing ultrasound criteria.

Doppler ultrasound scanning is the first line investigation for quantifying the internal carotid artery stenosis. Nevertheless, the lack of internationally accepted ultrasound criteria for describing the degree of stenosis has contributed to the different and confusing measurements ranges. The use of two different angiographic methods, the North American Symptomatic Carotid Endoarterectomy Study and the European Carotid Surgery Trial was probably the major initial source of confusion in deriving valid and reliable duplex ultrasound criteria worldwide. The consensus proposed in 2003 by the Society of Radiologists in Ultrasound has been a great attempt to create a conformity document, establishing grey scale and Doppler criteria in considering the different degrees of stenosis. According to this attempt, in 2010, the multi-parametric Deutsche Gesellschaft für Ultraschall in der Medizin ultrasound criteria have been proposed with a precise differentiation between main and additional criteria and depicted a different peak systolic velocity (PSV) threshold. In 2012, these criteria have been implemented, focusing on the multi-parametric approach, re-defining the PSV values and clearly introducing the concept of PSV average. Despite these attempts, a wide range of practice patterns still exists, with consistent disparities in patients' care. This paper collects these previous experiences and summarizes their strengths and weaknesses, to give a contribution in the carotid artery stenosis grading standardization using ultrasonic methods. Carotid ultrasound as the only diagnostic tool for the selection of patients for carotid surgery or stenting will be possible only with internationally accepted criteria.

Reimbursement Policies for Carotid Duplex Ultrasound that are Based on International Classification of Diseases Codes May Discourage Testing in High-Yield Groups.

BACKGROUND: To curb increasing volumes of diagnostic imaging and costs, reimbursement for carotid duplex ultrasound (CDU) is dependent on "appropriate" indications as documented by International Classification of Diseases (ICD) codes entered by ordering physicians. Historically, asymptomatic indications for CDU yield lower rates of abnormal results than symptomatic indications, and consensus documents agree that most asymptomatic indications for CDU are inappropriate. In our vascular laboratory, we perceived an increased rate of incorrect or inappropriate ICD codes. We therefore sought to determine if ICD codes were useful in predicting the frequency of abnormal CDU. We hypothesized that asymptomatic or nonspecific ICD codes would yield a lower rate of abnormal CDU than symptomatic codes, validating efforts to limit reimbursement in asymptomatic, low-yield groups. MATERIAL AND METHODS: We reviewed all outpatient CDU done in 2011 at our institution. ICD codes were recorded, and each medical record was then reviewed by a vascular surgeon to determine if the assigned ICD code appropriately reflected the clinical scenario. CDU findings categorized as abnormal (>50% stenosis) or normal (<50% stenosis) were recorded. Each individual ICD code and group 1 (asymptomatic), group 2 (nonhemispheric symptoms), group 3 (hemispheric symptoms), group 4 (preoperative cardiovascular examination), and group 5 (nonspecific) ICD codes were analyzed for correlation with CDU results. RESULTS: Nine hundred ninety-four patients had 74 primary ICD codes listed as indications for CDU. Of assigned ICD codes, 17.4% were deemed inaccurate. Overall, 14.8% of CDU were abnormal. Of the 13 highest frequency ICD codes, only 433.10, an asymptomatic code, was associated with abnormal CDU. Four symptomatic codes were associated with normal CDU; none of the other high frequency codes were associated with CDU result. Patients in group 1 (asymptomatic) were significantly more likely to have an abnormal CDU compared to each of the other groups (P < 0.001, P < 0.001, P = 0.020, P = 0.002) and to all other groups combined (P < 0.001). CONCLUSIONS: Asymptomatic indications by ICD codes yielded higher rates of abnormal CDU than symptomatic indications. This finding is inconsistent with clinical experience and historical data, and we suggest that inaccurate coding may play a role. Limiting reimbursement for CDU in low-yield groups is reasonable. However, reimbursement policies based on ICD coding, for example, limiting payment for asymptomatic ICD codes, may impede use of CDU in high-yield patient groups.

Repeatability of in vivo quantification of atherosclerotic carotid artery plaque components by supervised multispectral classification.

OBJECTIVE: To evaluate the agreement and scan-rescan repeatability of automated and manual plaque segmentation for the quantification of in vivo carotid artery plaque components from multi-contrast MRI. MATERIALS AND METHODS: Twenty-three patients with 30-70% stenosis underwent two 3T MR carotid vessel wall exams within a 1 month interval. T1w, T2w, PDw and TOF images were acquired around the region of maximum vessel narrowing. Manual delineation of the vessel wall and plaque components (lipid, calcification, loose matrix) by an experienced observer provided the reference standard for training and evaluation of an automated plaque classifier. Areas of different plaque components and fibrous tissue were quantified and compared between segmentation methods and scan sessions. RESULTS: In total, 304 slices from 23 patients were included in the segmentation experiment, in which 144 aligned slice pairs were available for repeatability analysis. The correlation between manual and automated segmented areas was 0.35 for lipid, 0.66 for calcification, 0.50 for loose matrix and 0.82 for fibrous tissue. For the comparison between scan sessions, the coefficient of repeatability of area measurement obtained by automated segmentation was lower than by manual delineation for lipid (9.9 vs. 17.1 mm(2)), loose matrix (13.8 vs. 21.2 mm(2)) and fibrous tissue (24.6 vs. 35.0 mm(2)), and was similar for calcification (20.0 vs. 17.6 mm(2)). CONCLUSION: Application of an automated classifier for segmentation of carotid vessel wall plaque components from in vivo MRI results in improved scan-rescan repeatability compared to manual analysis.

Carotid Plaque Morphological Classification Compared With Biomechanical Cap Stress: Implications for a Magnetic Resonance Imaging-Based Assessment.

BACKGROUND AND PURPOSE: Two approaches to target plaque vulnerability-a histopathologic classification scheme and a biomechanical analysis-were compared and the implications for noninvasive risk stratification of carotid plaques using magnetic resonance imaging were assessed. METHODS: Seventy-five histological plaque cross sections were obtained from carotid endarterectomy specimens from 34 patients (>70% stenosis) and subjected to both a Virmani histopathologic classification (thin fibrous cap atheroma with <0.2-mm cap thickness, presumed vulnerable) and a peak cap stress computation (<140 kPa: presumed stable; >300 kPa: presumed vulnerable). To demonstrate the implications for noninvasive plaque assessment, numeric simulations of a typical carotid magnetic resonance imaging protocol were performed (0.62×0.62 mm(2) in-plane acquired voxel size) and used to obtain the magnetic resonance imaging-based peak cap stress. RESULTS: Peak cap stress was generally associated with histological classification. However, only 16 of 25 plaque cross sections could be labeled as high-risk (peak cap stress>300 kPa and classified as a thin fibrous cap atheroma). Twenty-eight of 50 plaque cross sections could be labeled as low-risk (a peak cap stress<140 kPa and not a thin fibrous cap atheroma), leading to a κ=0.39. 31 plaques (41%) had a disagreement between both classifications. Because of the limited magnetic resonance imaging voxel size with regard to cap thickness, a noninvasive identification of only a group of low-risk, thick-cap plaques was reliable. CONCLUSIONS: Instead of trying to target only vulnerable plaques, a more reliable noninvasive identification of a select group of stable plaques with a thick cap and low stress might be a more fruitful approach to start reducing surgical interventions on carotid plaques.

The Revised Sonographic NASCET Index: A New Hemodynamic Parameter for the Assessment of Internal Carotid Artery Stenosis.

PURPOSE: A previously described Doppler parameter, the sonographic NASCET index (SNI), was derived to be more directly analogous to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) methodology for assessing carotid artery stenosis. However, this index does not account for complex changes affecting the Doppler waveform. We propose a revised SNI (rSNI) in an effort to improve predicting carotid stenosis. MATERIALS AND METHODS: 25 carotid bifurcations with stenoses ranging from 40 - 92 % were analyzed. For each vessel, the rSNI and original SNI were calculated. The peak systolic velocity (PSV), rSNI, and original SNI were correlated with angiography using linear regression analysis and relative accuracies were compared at two thresholds. RESULTS: A correlation between rSNI and angiography was found to be significantly better than that between PSV or internal carotid artery-common carotid artery (ICA-CCA) peak velocity ratio and angiography (r² = 0.47 vs. 0.22; r² = 0.47 vs. 0.16). The accuracy of PSV in predicting high-grade stenosis was 68% and 72%, compared with 80% and 88% for rSNI, at each of two thresholds. The original SNI better correlated with angiography compared to the rSNI (r² = 0.55 vs. 0.47), but with slightly lower accuracy in predicting high-grade stenosis (76% vs. 80%). CONCLUSION: The revised SNI correlates more closely with angiographic stenosis than either the PSV or the ICA-CCA ratio, and is more accurate in predicting high-grade stenosis. However, it is overall comparable to the original SNI, suggesting that the previously unaccounted for effects over the remainder of the cardiac cycle do not significantly improve the ability to sonographically predict significant stenosis.

Early atherosclerosis detection in asymptomatic patients: a comparison of carotid ultrasound, coronary artery calcium score, and coronary computed tomography angiography.

BACKGROUND: Detailed multimodality assessment of subclinical atherosclerosis in asymptomatic subjects referred for risk stratification has not been performed. We analyzed the detection of early atherosclerosis using 3 imaging modalities: coronary artery calcium (CAC) scoring, carotid ultrasound (US), and coronary computed tomography angiography (CCTA). METHODS: Asymptomatic subjects free of known vascular disease scheduled to undergo a carotid US for risk stratification were invited to undergo CCTA/CAC. Subjects taking lipid-lowering medication were excluded. All images were assessed by experienced core laboratory personnel. Carotid intima media thickness ≥ 75th percentile for age and sex, CAC > 0, and detection of either carotid or coronary artery plaque were indicators of atherosclerosis. RESULTS: Fifty patients were included with a median age of 53 years. Atherosclerosis was observed in 28%, 78%, and 90% of subjects using CAC, CCTA, and carotid US, respectively. All subjects showed atherosclerosis on at least 1 modality. In 36 patients with a CAC score = 0, 69% and 86% had atherosclerosis on CCTA and carotid US, respectively. CONCLUSIONS: In this detailed analysis, all subjects identified to warrant further risk stratification had subclinical atherosclerosis on at least 1 imaging modality. Concordance between modalities was highly variable, dependent on the specific definition of atherosclerosis used. Carotid US and CCTA detection of plaque were significantly more sensitive than CAC > 0 in this middle-aged population. Considering the prevalence of subclinical disease on carotid US and CCTA, the threshold at which to treat warrants further research.

Automatic active contour-based segmentation and classification of carotid artery ultrasound images.

In this paper, we present automatic image segmentation and classification technique for carotid artery ultrasound images based on active contour approach. For early detection of the plaque in carotid artery to avoid serious brain strokes, active contour-based techniques have been applied successfully to segment out the carotid artery ultrasound images. Further, ultrasound images might be affected due to rotation, scaling, or translational factors during acquisition process. Keeping in view these facts, image alignment is used as a preprocessing step to align the carotid artery ultrasound images. In our experimental study, we exploit intima-media thickness (IMT) measurement to detect the presence of plaque in the artery. Support vector machine (SVM) classification is employed using these segmented images to distinguish the normal and diseased artery images. IMT measurement is used to form the feature vector. Our proposed approach segments the carotid artery images in an automatic way and further classifies them using SVM. Experimental results show the learning capability of SVM classifier and validate the usefulness of our proposed approach. Further, the proposed approach needs minimum interaction from a user for an early detection of plaque in carotid artery. Regarding the usefulness of the proposed approach in healthcare, it can be effectively used in remote areas as a preliminary clinical step even in the absence of highly skilled radiologists.

Understanding symptomatology of atherosclerotic plaque by image-based tissue characterization.

Characterization of carotid atherosclerosis and classification into either symptomatic or asymptomatic is crucial in terms of diagnosis and treatment planning for a range of cardiovascular diseases. This paper presents a computer-aided diagnosis (CAD) system (Atheromatic) that analyzes ultrasound images and classifies them into symptomatic and asymptomatic. The classification result is based on a combination of discrete wavelet transform, higher order spectra (HOS) and textural features. In this study, we compare support vector machine (SVM) classifiers with different kernels. The classifier with a radial basis function (RBF) kernel achieved an average accuracy of 91.7% as well as a sensitivity of 97%, and specificity of 80%. Thus, it is evident that the selected features and the classifier combination can efficiently categorize plaques into symptomatic and asymptomatic classes. Moreover, a novel symptomatic asymptomatic carotid index (SACI), which is an integrated index that is based on the significant features, has been proposed in this work. Each analyzed ultrasound image yields on SACI number. A high SACI value indicates that the image shows symptomatic and low value indicates asymptomatic plaques. We hope this SACI can support vascular surgeons during routine screening for asymptomatic plaques.

[Arterial heterogeneity]. / Artériopathie et hétérogénéité artérielle.

More and more clinical observations and trials support the concept of heterogeneity of atheroma according to the arterial bed. In a pilot study named "Étude Comparative des Lésions Athéromateuses" (ECLA), we have shown that carotid and femoral plaques possess different characteristics. Carotid arteries display increased lipid content compared to femoral arteries whereas femoral arteries are more prone to calcify and to develop osteoid metaplasia. These observations should lead the researcher and the clinician to look at the cellular and molecular mechanisms governing the heterogeneity of atheromas. At last, a better understanding of the characteristics of plaques should help us to determine plaque stability, to prevent cardiovascular events and to choose the best medical, endovascular or surgical option.

Asymptomatic carotid artery stenosis: identification of subgroups with different underlying plaque characteristics.

OBJECTIVES: Optimal surgical treatment of patients with asymptomatic carotid artery stenosis (ACAS) remains a matter of debate. Established definitions of ACAS include: (1) patients who never suffered from ipsilateral cerebrovascular events (group 1) or (2) patients who suffered from ipsilateral cerebrovascular events more than 6 months prior to revascularisation (group 2). Cerebrovascular symptoms are closely related to underlying carotid plaque composition and therefore we investigated potential plaque differences between these definition-based subgroups. DESIGN: Cross-sectional analysis of a longitudinal prospective biobank study. MATERIAL AND METHODS: Carotid atherosclerotic plaques from 264 asymptomatic patients were harvested during endarterectomy, and subjected to histopathological examination. Patients were divided into two groups: group 1: truly asymptomatic (n = 182), and group 2: patients with ipsilateral events more than 6 months before carotid endarterectomy (CEA) (n = 82). RESULTS: Patients in group 1 had relatively more stable plaque characteristics as compared with patients in group 2, with a higher median plaque smooth muscle cell content (2.1 (0.0-18.7) vs. 1.6 (0.0-14.4); P = 0.036), a higher proportion of heavily calcified plaques (67.7% (123/182) vs. 48.8% (40/82); P = 0.005) and less frequently intraplaque haemorrhages (11.5% (21/182) vs. 30.5% (25/82); P = 0.001). CONCLUSION: Different plaque characteristics within subgroups of ACAS patients can be identified based on reported past ipsilateral events, which might result in adjusted future treatment strategies.