Intraplaque hemorrhage in symptomatic and asymptomatic progressive internal carotid artery stenosis – a pilot study

Czech version

Authors: M. Roubec ^1,2; D. Školoudík ^1,2; T. Hrbáč ³; J. Havelka ⁴; T. Jonszta ⁴; R. Herzig ⁵
Authors‘ workplace: Neurologická klinika, Komplexní cerebrovaskulární centrum, LF Ostravské Univerzity a FN Ostrava ¹; Centrum vědy a výzkumu, Fakulta zdravotnických věd, UPOL, Olomouc ²; Neurochirurgická klinika LF Ostravské Univerzity a FN Ostrava ³; Radiologický ústav, FN Ostrava ⁴; Neurologická klinika, Komplexní cerebrovaskulární centrum, LF UK a FN Hradec Králové ⁵
Published in: Cesk Slov Neurol N 2019; 82(6): 638-643
Category: Original Paper
doi: https://doi.org/10.14735/amcsnn2019638

Overview

Aim: Intraplaque hemorrhage (IPH) belongs to potential mechanisms of plaque instability subsequently leading to ischemic stroke. Study aims to compare the IPH occurrence in patients with symptomatic (SS), asymptomatic stable (AS) and asymptomatic progressive (AP) internal carotid artery (ICA) stenosis ≥ 50%.

Materials and methods: Serial duplex ultrasound (DUS) in a 6-month period and MRI using axial 3DT1_MPRAGE sequence were used for IPH detection in patients with ICA stenosis. Stenoses in patients with ipsilateral ischemic stroke / transient ischemic attack within the previous 4 weeks or acute ischemic lesion on diffusion-weighted MRI sequencies were evaluated as symptomatic. Stenoses with progression of > 10% since last DUS examination were evaluated as progressive. Echolucent part of atherosclerotic plaque > 8 mm² on DUS and hyperintensity on 3DT1_MPRAGE-MRI were evaluated as IPH. Differences in IPH occurrence between SS, AS and AP ICA stenoses were statistically evaluated.

Results: A total of 52 patients (33 males, mean age 69.2 ± 9.0 years) with 59 ICA stenoses were enrolled in the prospective study during 15 months; 13 ICA stenoses were evaluated as SS, 27 as AS and 19 as AP. IPH was detected using DUS/ MRI in 6 (46%) / 4 (30%) of SS, 12 (44%) / 8 (30%) of AS, and 11 (58%) / 11 (58%) of AP ICA stenoses (P > 0.05 in all cases). IPH was detected using combination of both methods in 3 (23%) of SS, 4 (15%) of AS, and 7 (36%) of AP ICA stenoses (P > 0.05 in all cases).

Conclusion: IPH was more frequently detected in asymptomatic progressive than asymptomatic stable ICA stenoses. No significant differences were found between occurrence of IPH in symptomatic than in asymptomatic progressive ICA stenoses. A total of 200 patients will be enrolled in the ongoing study.

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE “uniform requirements” for biomedical papers.

有症状和无症状进行性颈内动脉狭窄的斑块内出血–一项初步研究

目的：斑块内出血(IPH)属于斑块不稳定进而导致缺血性卒中的潜在机制。该研究旨在比较有症状（SS），无症状稳定（AS）和无症状进行性（AP）颈内动脉（ICA）狭窄≥50％的患者的IPH发生率。

材料和方法：将6个月的串行双工超声（DUS）和使用轴向3DT1_MPRAGE序列的MRI用于ICA狭窄患者的IPH检测。将同侧缺血性卒中/前4周内短暂性缺血性发作或弥散加权MRI序列的急性缺血性病变的患者进行症状评估。自上次DUS检查以来进展> 10％的狭窄被评估为进展性。在DUS上动脉粥样硬化斑块的回声部分> 8 mm²和在3DT1_MPRAGE-MRI上的高强度被评估为IPH。统计评估SS，AS和AP ICA狭窄之间IPH发生的差异。

结果：前瞻性研究共纳入52例患者（33例男性，平均年龄69.2±9.0岁），其59例ICA狭窄在15个月内进入研究。 13种ICA狭窄评估为SS，27种评估为AS，19种评估为AP。使用DUS / MRI检测到IPH在SS的6（46％）/ 4（30％），AS的12（44％）/ 8（30％）和AP的11（58％）/ 11（58％）中被检测到ICA狭窄（在所有情况下P> 0.05）。使用这两种方法的组合，在3个SS中（23％），4个AS（15％）和7个（36％）AP ICA狭窄中检测到IPH（在所有情况下P> 0.05）。

结论：无症状进行性IPH比无症状稳定ICA狭窄更为常见。在有症状的IPH与无症状的进行性ICA狭窄之间发生IPH之间没有发现显着差异。共有200名患者将参加正在进行的研究。

关键词：颈内动脉–狭窄–超声–斑块内出血

Keywords:

ultrasound – internal carotid artery – Stenosis – intraplaque hemorrhage

Sources

Thrift AG, Thayabaranathan T, Howard .G et al. Global stroke statistics. Int J Stroke 2017; 12(1): 13–32. doi: 10.1177/ 1747493016676285.
Phan TG, Beare RJ, Jolley D et al. Carotid artery anatomy and geometry as risk factors for carotid atherosclerotic disease. Stroke 2012; 43(6): 1596–1601. doi: 10.1161/ STROKEAHA.111.645499.
Aboyans V, Ricco JB, Bartelink ME et al. 2017 ESC Guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS): document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity. Eur Heart J 2018; 39(9): 763–816. doi: 10.1093/ eurheartj/ ehx095.
Kešnerová P, Viszlayová D, Školoudík D. Detekce nestabilního karotického plátu v prevenci ischemické cévní mozkové příhody. Cesk Slov Neurol N 2018; 81/ 114(4): 378–391. doi: 10.14735/ amcsnn2018378.
Treiman GS, McNally JS, Kim SE et al. Correlation of carotid intraplaque hemorrhage and stroke using 1.5 T and 3 T MRI. Magn Reson Insights 2015; 8 (Suppl 1): 1–8. doi: 10.4137/ MRI.S23560.
Roubec M, Školoudík D, Herzig R et al. Intraplaque hemorrhage in symptomatic and asymptomatic progressive carotidartery stenosis – pilot study. Eur J Neurol 2018; 25 (Supp 1): P12.
North American Symptomatic Carotid Endarterectomy Trial. Methods, patient characteristics, and progress. Stroke 1991; 22(6): 711–720. doi: 10.1161/ 01.str.22.6.711.
Herzig R, Urbánek K, Vlachová I et al. The role of chronic alcohol intake in patients with spontaneous intracranial hemorrhage: a carbohydrate-deficient transferrin study. Cerebrovasc Dis 2003; 15(1–2): 22–28. doi: 10.1159/ 000067118.
Puppini G, Furlan F, Cirota N et al. Characterisation of carotid atherosclerotic plaque: comparison between magnetic resonance imaging and histology. Radiol Med 2006; 111(7): 921–930. doi: 10.1007/ s11547-006-0091-7.
den Hartog AG, Bovens SM, Koning W et al. Current status of clinical magnetic resonance imaging for plaque characterisation in patients with carotid artery stenosis. Eur J Vasc Endovasc Surg 2013; 45(1): 7–21. doi: 10.1016/ j.ejvs.2012.10.022.
Reilly LM, Lusby RJ, Hughes L et al. Carotid plaque histology using real-time ultrasonography. Clinical and therapeutic implications. Am J Surg 1983; 146(2): 188–193. doi: 10.1016/ 0002-9610(83)90370-7.
Altaf N, Daniels L, Morgan PS et al. Detection of intraplaque hemorrhage by magnetic resonance imaging in symptomatic patients with mild to moderate carotid stenosis predicts recurrent neurological events. J Vasc Surg 2008; 47(2): 337–342. doi: 10.1016/ j.jvs.2007.09.064.
Lusby RJ, Ferrell LD, Ehrenfeld WK et al. Carotid plaque hemorrhage. Its role in production of cerebral ischemia. Arch Surg 1982; 117(11): 1479–1488. doi: 10.1001/ archsurg.1982.01380350069010.
Lovett JK, Gallagher PJ, Hands LJ et al. Histological correlates of carotid plaque surface morphology on lumen contrast imaging. Circulation 2004; 110(15): 2190–2197. doi: 10.1161/ 01.CIR.0000144307.82502.32.
Singh N, Moody AR, Gladstone DJ, et al. Moderate carotid artery stenosis: MR imaging – depicted intraplaque hemorrhage predicts risk of cerebrovascular ischemic events in asymptomatic men. Radiology 2009; 252(2): 502–508. doi: 10.1148/ radiol.2522080792.
Howard DP, van Lammeren GW, Rothwell PM et al. Symptomatic carotid atherosclerotic disease: correlations between plaque composition and ipsilateral stroke risk. Stroke 2015; 46(1): 182–189. doi: 10.1161/ STROKE AHA.114.007221.
Nosáľ V, Kurča E, Turčanová-Koprušáková M et al. Nestabilný karotický plát. Neurológia 2009; 4(1): 31–34.
Bots ML, Breslau PJ, Briet E et al. Cardiovascular determinants of carotid artery disease. The Rotterdam Elderly Study. Hypertension 1992; 19 (6 Pt 2): 717–720. doi: 10.1161/ 01.hyp.19.6.717.
Mathiesen EB, Joakimsen O, Bonaa KH. Prevalence of and risk factors associated with carotid artery stenosis: the Tromsø Study. Cerebrovasc Dis 2001; 12: 44–51. doi: 10.1159/ 000047680.
O’Leary DH, Polak JF, Kronmal RA et al. Distribution and correlates of sonographically detected carotid artery disease in the Cardiovascular Health Study. The CHS Collaborative Research Group. Stroke 1992; 23(12): 1752–1760. doi: 10.1161/ 01.str.23.12.1752.