Aspirin vs anticoagulation in carotid artery dissection: a study of 298 patients

BACKGROUND: No randomized study has yet compared efficacy and safety of aspirin and anticoagulants in patients with spontaneous dissection of the cervical carotid artery (sICAD). METHODS: Prospectively collected data from 298 consecutive patients with sICAD (56% men; mean age 46 +/- 10 years) treated with anticoagulants alone (n = 202) or aspirin alone (n = 96) were retrospectively analyzed. Admission diagnosis was ischemic stroke in 165, TIA in 37, retinal ischemia in 8, and local symptoms and signs (headache, neck pain, Horner syndrome, cranial nerve palsy) in 80 patients, while 8 patients were asymptomatic. Clinical follow-up was obtained after 3 months by neurologic examination (97% of patients) or structured telephone interview. Outcome measures were 1) new cerebral ischemic events, defined as ischemic stroke, TIA, or retinal ischemia, 2) symptomatic intracranial hemorrhage, and 3) major extracranial bleeding. RESULTS: During follow-up, ischemic events were rare (ischemic stroke, 0.3%; TIA, 3.4%; retinal ischemia, 1%); their frequency did not significantly differ between patients treated with anticoagulants (5.9%) and those treated with aspirin (2.1%). The same was true for hemorrhagic adverse events (anticoagulants, 2%; aspirin, 1%). New ischemic events were significantly more frequent in patients with ischemic events at onset (6.2%) than in patients with local symptoms or asymptomatic patients (1.1%). CONCLUSIONS: Within the limitations of a nonrandomized study, our data suggest that frequency of new cerebral and retinal ischemic events in patients with spontaneous dissection of the cervical carotid artery is low and probably independent of the type of antithrombotic treatment (aspirin or anticoagulants).

Diabetic neuropathy is a more important determinant of baroreflex sensitivity than carotid elasticity in type 2 diabetes.

The object of this study was to evaluate the contribution of carotid distensibilty on baroreflex sensitivity in patients with type 2 diabetes mellitus with at least 2 additional cardiovascular risk factors. Carotid distensibility was measured bilaterally at the common carotid artery in 79 consecutive diabetic patients and 60 matched subjects without diabetes. Spontaneous baroreflex sensitivity assessment was obtained using time and frequency methods. Baroreflex sensitivity was lower in diabetic subjects as compared with nondiabetic control subjects (5.25+/-2.80 ms/mm Hg versus 7.55+/-3.79 ms/mm Hg; P<0.01, respectively). Contrary to nondiabetic subjects, diabetic subjects showed no significant correlation between carotid distensibility and baroreflex sensitivity (r2=0.08, P=0.04 and r2=0.04, P=0.13, respectively). In diabetic subjects, baroreflex sensitivity was significantly lower in subjects with peripheral neuropathy than in those with preserved vibration sensation (4.1+/-0.5 versus 6.1+/-0.4 ms/mm Hg, respectively; P=0.005). Age in nondiabetic subjects, diabetes duration, systolic blood pressure, peripheral or sensitive neuropathy, and carotid distensibility were introduced in a stepwise multivariate analysis to identify the determinants of baroreflex sensitivity. In diabetic patients, neuropathy is a more sensitive determinant of baroreflex sensitivity than the reduced carotid distensibility (stepwise analysis; F ratio=5.1, P=0.028 versus F ratio=1.9, P=0.16, respectively). In diabetic subjects with 2 additional cardiovascular risk factors, spontaneous baroreflex sensitivity is not related to carotid distensibility. Diabetic subjects represent a particular population within the spectrum of cardiovascular risk situations because of the marked neuropathy associated with their metabolic disorder. Therefore, neuropathy is a more significant determinant of baroreflex sensitivity than carotid artery elasticity in patients with type 2 diabetes.

Don't trust a vein graft to treat carotid aneurysm in patients with Behçet disease.

Extracranial carotid aneurysm is a rare vascular manifestation of Behçet disease. To our knowledge, only 32 cases have been reported. This article presents a complex case of a 28-year-old man who was first treated by vein graft reconstruction. At 12 months of follow-up, a nonanastomotic false aneurysm of the vein graft occurred and was treated by interposition of prosthetic graft. Two months later, an anastomotic pseudoaneurysm between the two grafts was excluded by two stent grafts. Based on our experience and a review of the literature, we compared the outcomes of prosthetic and autologous vein reconstructions and discussed the role of carotid ligation and immunosuppressive treatment.

Raeder's paratrigeminal syndrome due to spontaneous dissection of the cervical and petrous internal carotid artery.

The combination of pain, ipsilateral oculosympathetic defect (ptosis and miosis), and ipsilateral trigeminal dysfunction constitutes Raeder's syndrome. We describe a patient with an acute presentation of Raeder's syndrome due to spontaneous internal carotid artery dissection. True trigeminal dysfunction due to carotid dissection is rare, and the potential mechanisms for its involvement are reviewed in this paper. Finally, we remind clinicians to consider dissection in the differential diagnosis of Raeder's syndrome because of its potential for ischemic cerebral neurologic sequelae and suggest early cranial and neck imaging in the evaluation of such patients.

Nonenhanced arterial spin labeled carotid MR angiography using three-dimensional radial balanced steady-state free precession imaging.

PURPOSE: To optimize and preliminarily evaluate a three-dimensional (3D) radial balanced steady-state free precession (bSSFP) arterial spin labeled (ASL) sequence for nonenhanced MR angiography (MRA) of the extracranial carotid arteries. MATERIALS AND METHODS: The carotid arteries of 13 healthy subjects and 2 patients were imaged on a 1.5 Tesla MRI system using an undersampled 3D radial bSSFP sequence providing a scan time of ∼4 min and 1 mm(3) isotropic resolution. A hybridized scheme that combined pseudocontinuous and pulsed ASL was used to maximize arterial coverage. The impact of a post label delay period, the sequence repetition time, and radiofrequency (RF) energy configuration of pseudocontinuous labeling on the display of the carotid arteries was assessed with contrast-to-noise ratio (CNR) measurements. Faster, higher undersampled 2 and 1 min scans were tested. RESULTS: Using hybridized ASL MRA and a 3D radial bSSFP trajectory, arterial CNR was maximized with a post label delay of 0.2 s, repetition times ≥ 2.5 s (P < 0.05), and by eliminating RF energy during the pseudocontinuous control phase (P < 0.001). With higher levels of undersampling, the carotid arteries were displayed in ≤ 2 min. CONCLUSION: Nonenhanced MRA using hybridized ASL with a 3D radial bSSFP trajectory can display long lengths of the carotid arteries with 1 mm(3) isotropic resolution. J. Magn. Reson. Imaging 2015;41:1150-1156. © 2014 Wiley Periodicals, Inc.

Thromboxane prostaglandin receptor antagonist and carotid atherosclerosis progression in patients with cerebrovascular disease of ischemic origin: a randomized controlled trial.

BACKGROUND AND PURPOSE: Thromboxane prostaglandin receptors have been implicated to be involved in the atherosclerotic process. We assessed whether Terutroban, a thromboxane prostaglandin receptor antagonist, affects the progression of atherosclerosis, as measured by common carotid intima-media thickness and carotid plaques. METHODS: A substudy was performed among 1141 participants of the aspirin-controlled Prevention of Cerebrovascular and Cardiovascular Events of Ischemic Origin with Terutroban in Patients with a History of Ischemic Stroke or Transient Ischemic Attack (PERFORM) trial. Common carotid intima-media thickness and carotid plaque occurrence was measured during a 3-year period. RESULTS: Baseline characteristics did not differ between Terutroban (n=592) and aspirin (n=549) treated patients and were similar as in the main study. Mean study and treatment duration were similar (28 and 25 months, respectively). In the Terutroban group, the annualized rate of change in common carotid intima-media thickness was 0.006 mm per year (95% confidence interval, -0.004 to 0.016) and -0.005 mm per year (95% confidence interval, -0.015 to 0.005) in the aspirin group. There was no statistically significant difference between the groups in the annualized rate of change of common carotid intima-media thickness (0.011 mm per year; 95% confidence interval, -0.003 to 0.025). At 12 months of follow-up, 66% of Terutroban patients had no emergent plaques, 31% had 1 to 2 emergent plaques, and 3% had ≥3 emergent plaques. In the aspirin group, the corresponding percentages were 64%, 32%, and 4%. Over time, there was no statistically significant difference in the number of emergent carotid plaques between treatment modalities (rate ratio, 0.91; 95% confidence interval, 0.77-1.07). CONCLUSIONS: Compared with aspirin, Terutroban did not beneficially affect progression of carotid atherosclerosis among well-treated patients with a history of ischemic stroke or transient ischemic attacks with an internal carotid stenosis <70%. CLINICAL TRIAL REGISTRATION URL: http://www.controlled-trials.com. Unique identifier: ISRCTN66157730.

Fast spin echo imaging of carotid artery dynamics.

PURPOSE: We propose the use of a retrospectively gated cine fast spin echo (FSE) sequence for characterization of carotid artery dynamics. The aim of this study was to compare cine FSE measures of carotid dynamics with measures obtained on prospectively gated FSE images. METHODS: The common carotid arteries in 10 volunteers were imaged using two temporally resolved sequences: (i) cine FSE and (ii) prospectively gated FSE. Three raters manually traced a common carotid artery area for all cardiac phases on both sequences. Measured areas and systolic-diastolic area changes were calculated and compared. Inter- and intra-rater reliability were assessed for both sequences. RESULTS: No significant difference between cine FSE and prospectively gated FSE areas were observed (P = 0.36). Both sequences produced repeatable cross-sectional area measurements: inter-rater intraclass correlation coefficient (ICC) = 0.88 on cine FSE images and 0.87 on prospectively gated FSE images. Minimum detectable difference (MDD) in systolic-diastolic area was 4.9 mm(2) with cine FSE and 6.4 mm(2) with prospectively gated FSE. CONCLUSION: This cine FSE method produced repeatable dynamic carotid artery measurements with less artifact and greater temporal efficiency compared with prospectively gated FSE. Magn Reson Med 74:1103-1109, 2015. © 2014 Wiley Periodicals, Inc.

Assessment of intima-media complex in carotid, femoral and right subclavian arteries for early investigation of atherosclerosis in HIV-infected patients

Objective To compare automatic and manual measurements of intima-media complex (IMC) in common carotid, common femoral and right subclavian arteries of HIV-infected patients in relation to a control group, taking into consideration the classical risk factors for atherosclerosis. Materials and Methods The study sample comprised 70 HIV-infected patients and 70 non-HIV-infected controls paired according sex and age. Automatic (gold standard) and manual measurements of IMC were performed in the carotid arteries. Manual measurements were also performed in common femoral and right subclavian arteries. Bland-Altman graphs were utilized in the comparison and the adopted level significance was 5%. Results Intima-media complex alterations were not observed in any of the individuals as the mean automatic measurement in the right common carotid (RCC) artery was considered as the gold standard. As the gold standard was compared with the manual measurements (mean, maximum and minimum), no clinically significant alteration was observed. As the gold standard was compared with other sites, the difference was statistically and clinically significant at the origin of right subclavian artery (RCC: 0.51 mm vs. 0.91 mm) (p < 0.001). Conclusion HIV-infected individuals are not at higher risk for atherosclerosis than the control population.

Reliability of digital panoramic radiography in the diagnosis of carotid artery calcifications

Objective The present study evaluated the reliability of digital panoramic radiography in the diagnosis of carotid artery calcifications. Materials and Methods Thirty-five patients under high-risk for development of carotid artery calcifications who had digital panoramic radiography were referred to undergo ultrasonography. Thus, 70 arteries were assessed by both methods. The main parameters utilized to evaluate the panoramic radiography reliability in the diagnosis of carotid artery calcifications were accuracy, sensitivity, specificity and positive predictive value of this method as compared with ultrasonography. Additionally, the McNemar's test was utilized to verify whether there was a statistically significant difference between digital panoramic radiography and ultrasonography. Results Ultrasonography demonstrated carotid artery calcifications in 17 (48.57%) patients. Such individuals presented with a total of 29 (41.43%) carotid arteries affected by calcification. Radiography was accurate in 71.43% (n = 50) of cases evaluated. The degree of sensitivity of this method was 37.93%, specificity of 95.12% and positive predictive value of 84.61%. A statistically significant difference (p < 0.001) was observed between the methods evaluated in their capacity to diagnose carotid artery calcifications. Conclusion Digital panoramic radiography should not be indicated as a method of choice in the investigation of carotid artery calcifications.

Study of carotid disease in patients with peripheral artery disease

Objective: To study the stenosis of the carotid arteries in patients with symptomatic peripheral arterial disease.Methods: we assessed 100 consecutive patients with symptomatic peripheral arterial disease in stages of intermittent claudication, rest pain or ulceration. Carotid stenosis was studied by echo-color-doppler, and considered significant when greater than or equal to 50%. We used univariate analysis to select potential predictors of carotid stenosis, later taken to multivariate analysis.Results: The prevalence of carotid stenosis was 84%, being significant in 40% and severe in 17%. The age range was 43-89 years (mean 69.78). Regarding gender, 61% were male and 39% female. Half of the patients had claudication and half had critical ischemia. Regarding risk factors, 86% of patients had hypertension, 66% exposure to smoke, 47% diabetes, 65% dyslipidemia, 24% coronary artery disease, 16% renal failure and 60% had family history of cardiovascular disease. In seven patients, there was a history of ischemic cerebrovascular symptoms in the carotid territory. The presence of cerebrovascular symptoms was statistically significant in influencing the degree of stenosis in the carotid arteries (p = 0.02 at overall assessment and p = 0.05 in the subgroups of significant and non-significant stenoses).Conclusion: the study of the carotid arteries by duplex scan examination is of paramount importance in the evaluation of patients with symptomatic peripheral arterial disease, and should be systematically conducted in the study of such patients.

Postangioplasty restenosis: a practical model in the porcine carotid artery

Transluminal coronary angioplasty is a routine therapeutic intervention in coronary heart disease. Despite the high rate of primary success, restenosis continues to be its major limitation. Porcine models have been considered to be the most adequate experimental models for studying restenosis. One limitation of porcine models is the need for radiological guidance and the expenses involved. The objective of the present study was to adapt an experimental model of angioplasty in the porcine carotid artery that does not require radiological equipment. Eight animals were used to develop the technique of balloon injury to the common carotid artery by dissection without radiological guidance. This technique was then employed in six other animals. Under anesthesia, the left common carotid artery was dissected and incised at the carotid sinus for insertion of an over-the-wire angioplasty balloon towards the aorta. Overstretch injury of the carotid artery was performed under direct visualization. After 30 days, the arteries were excised and pressure-fixated. Uninjured carotid arteries from 3 additional animals were used as controls. A decreased luminal area associated with intimal hyperplasia and medial reaction was observed in all injured arteries. Immunohistochemistry identified the intimal hyperplastic cells as smooth muscle cells. Computerized morphometry of the ballooned segments revealed the following mean areas: lumen 2.12 mm2 (± 1.09), intima 0.22 mm2 (± 0.08), media 3.47 mm2 (± 0.67), and adventitia 1.11 mm2 (± 0.34). Our experimental model of porcine carotid angioplasty without radiological guidance induced a vascular wall reaction and permitted the quantification of this response. This porcine model may facilitate the study of vascular injury and its response to pharmacological interventions

The carotid body of the spontaneous insulin-dependent diabetic rat

The carotid bodies from adult spontaneous insulin-dependent diabetic rats (strain BB/S) were perfusion-fixed at normal arterial blood pressure with 3% phosphate-buffered glutaraldehyde and compared with the organs from control rats (strain BB/Sc) prepared in the same way. Serial 5-µm sections were cut, stained, and using an interactive image analysis system, were analysed to determine the volumes of the carotid body and its vascular and extravascular compartments. There was no evidence of systemic arterial disease in the carotid stem arteries in either group of animals, and the microvasculature of the organs appeared normal by light microscopy. The volume of the carotid body was unchanged 3 months after the onset of diabetes but was increased at 6 months. The total vascular volume of the organ was unchanged, but the volume of the small vessels (5-12 µm) was increased. In the control group the small vessels comprised 5% of the total volume of the carotid body, or about 44% of the vascular compartment. The percentage of small vessels increased at 3 months in the diabetic group, but had returned to normal at 6 months. The extravascular volume followed the same pattern as the total carotid body volume and so did not change appreciably when expressed as a percentage of the total volume of the organ. The increase in size of the carotid body in diabetic rats is due, therefore, to an augmented extravascular volume. In one diabetic specimen the carotid sinus nerve showed signs of diabetic neuropathy, axonal swelling and intramyelinic oedema. The clinical implications of these results are discussed.

Quantitative studies of the vasculature of the carotid body in the chronically hypoxic rat

The carotid bodies of rats made chronically hypoxic by breathing 12% O2 in a normobaric chamber (inspired PO2 91 mmHg) were compared with those of controls. Serial 5-µm sections of the organs were examined using an interactive image analysis system. The total volume of the carotid bodies was increased by 64%. The total vascular volume rose by 103% and was likely due to an increase in size of the large vessels (>12 µm lumen diameter) because the small vessel (5-12 µm lumen diameter) volume did not increase significantly while the small vessel density tended to decrease. The extravascular volume was increased by 57%. Expressed as a percentage of the total volume of the organ, the total vascular volume did not change, but the small vessel volume was significantly decreased from 7.83 to 6.06%. The large vessel volume must therefore have been increased. The proportion occupied by the extravascular volume was virtually unchanged (84 vs 82%). In accordance with these findings, the small vessel endothelial surface area per unit carotid body volume was diminished from 95.2 to 76.5 mm-1, while the extravascular area per small vessel was increased from 493 to 641 µm2 or by 30%. In conclusion, the enlargement of the carotid body in chronic hypoxia is most likely due to an increase in total vascular volume, mainly involving the "large" vessels, and to an increase in extravascular volume. This is in contrast to our previously published findings indicating that in the spontaneous insulin-dependent diabetic rat the enlargement of the carotid body is due solely to an increase in extravascular volume.