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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 307-311

Three-dimensional hemodynamic study of carotid bulb in patients with evolving stroke


1 Department of Vascular Surgery, Faculty of Medicine (for Girls), Al Azhar University, Cairo, Egypt
2 Department of General Surgery, Faculty of Medicine (for Girls), Al Azhar University, Cairo, Egypt

Date of Submission26-Apr-2019
Date of Acceptance02-Jun-2019
Date of Web Publication2-Oct-2020

Correspondence Address:
Maisa A Abdel Wahab
Department of Vascular Surgery, Faculty of Medicine (for Girls), Al Azhar University, El Obour City, Cairo 11828
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjamf.sjamf_44_19

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  Abstract 


Objectives Determining carotid stenosis severity, monitoring of carotid plaque, and identification of vulnerable plaques are important in identifying patients who would benefit from carotid endarterectomy (CEA). Our work aimed to evaluate the role of three-dimensional (3D) hemodynamic study in patient with evolving stroke.
Patients and methods The study enrolled 20 patients diagnosed with forebrain stroke selected from our university hospital from March 2017 to February 2019. The severity of stenosis and the length and type of plaques were quantified by 3D ultrasound (US). Overall, 17 patients underwent CEA. The follow-up after operation was done by 3D US with measuring the free lumen area and the operated artery.
Results There are significant increases in postoperative peak systolic velocity and free lumen area in all patients with stenosis or occlusion, with P value 0.001 and 0.0001, respectively, in most critical cases of the soft plaques. Moreover, there is a higher significant P value (0.003) regarding peak systolic velocity related to carotid end-arterectomy (CEA) with patching than nonpatching.
Conclusion 3D US imaging is a recent tool for improving the visualization and quantification of complex anatomy and pathology as well as monitoring progression of atherosclerosis.

Keywords: carotid, carotid endarterectomy, stroke, three-dimensional ultrasound


How to cite this article:
Sakr AK, Sadek YK, Mostafa AA, Abdel Wahab MA. Three-dimensional hemodynamic study of carotid bulb in patients with evolving stroke. Sci J Al-Azhar Med Fac Girls 2020;4:307-11

How to cite this URL:
Sakr AK, Sadek YK, Mostafa AA, Abdel Wahab MA. Three-dimensional hemodynamic study of carotid bulb in patients with evolving stroke. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Oct 31];4:307-11. Available from: http://www.sjamf.eg.net/text.asp?2020/4/3/307/296944




  Introduction Top


The development of plaques in the carotid artery has been carefully investigated [1].

It is now recognized that plaque properties other than size and degree of obstruction are important for the identification of patients at high risk of ischemic events [2].

Conventional two-dimensional (2D) ultrasound (US) has been used in the assessment of plaque morphology. However, owing to insufficient image contrast and to the variability of conventional 2D US examinations, accurate assessments of morphological plaque changes are difficult such as volume and surface irregularity. Because it is difficult to reposition the 2D image of the plaque, monitoring the changes in the development of the plaque over long periods of time using conventional 2D US is problematic [3].

In addition, the reconstruction of a 3D impression of the vascular anatomy and the plaque using multiple 2D images is time consuming and prone to variability and inaccuracy. Noninvasive and reproducible 3D imaging techniques that allow for the direct visualization and quantification of plaque development are becoming more important in serial monitoring of disease progression and deterioration [4].

The characterization of carotid plaques in three dimensions will potentially improve investigations into the changes of surface morphology, plaque geometry, and plaque distribution, and these can provide important information about the effects of antiatherosclerotic therapies [5].

The aim of this study was to examine the accuracy of a three-dimensional (3D) US system for quantitation of stenotic lesions and to evaluate changes in regional vessel volume and cross-sectional area after carotid endarterectomy (CEA), and also it has been applied to study carotid plaque morphology, surface, and volume during atherosclerosis progression. This technique was used in conditions different than carotid stenosis, such as bifurcation anatomy changes of the caliber and vessel course modifications.


  Patients and methods Top


Study design

This is a prospective study.

Study participants

This study enrolled 20 patients diagnosed with forebrain stroke selected from our university hospital from March 2017 to February 2019.

Inclusion criteria

All patients who presented with brain stroke were not included in the exclusion criteria.

Exclusion criteria

Patients with congestive heart failure, decompensated liver cell failure, totally occluded internal carotid artery (ICA), nonobstructing carotid lesions, inefficient brain circulation, and cognitive dysfunction were excluded from our study.

Ethical considerations

The study was conducted according to the World Medical Association Declaration of Helsinki for studies on human subjects. It was approved by the Institutional Review Board of our institution and a written informed consent was obtained from all patients.

Assessment and procedures

All patients were subjected to a detailed medical history, clinical examination, 3D carotid duplex US, and laboratory investigations.

Medical history

It included demographic data, risk factors, and history of previous cerebro-vascular stroke (CVS) and residual neurological deficit (stroke en evolution) or attacks of transient ischemic attack (TIAs) (crescendo TIAs).

Clinical examination

This included carotid pulsation, thrill, and neurological examination.

Laboratory investigations

Complete blood count (CBC), liver and kidney functions, blood glucose level, lipid profile, and coagulation profile were investigated.

Three-dimensional carotid duplex ultrasound

General Electric logic 9 machine (UK) using linear 7 MHz probe was used to detect anatomical site of the lesion, wave forms, peak systolic velocity (PSV) and PSV ratio, diameter reduction, plaques morphology, and free lumen area.

Procedures

CEA was done with or without patching using synthetic poly-tetra-fluoro-ethelene (PTFE) or Dacron graft. Follow-up program included clinical assessment for both neurological deficit and recurrent stenosis after 1 and 6 months to assess PSV and free lumen area using 3D duplex US, as illustrated in [Figure 1],[Figure 2],[Figure 3],[Figure 4].
Figure 1 Preoperative 70–75% hard plaque in internal carotid artery (ICA) with significant diameter reduction by ∼70%.

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Figure 2 Postoperative carotid endarterectomy result, with improvement of diameter free lumen.

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Figure 3 Postoperative carotid endarterectomy result, with improvement of peak systolic velocity.

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Figure 4 Postoperative carotid endarterectomy result, with increased peak systolic velocity and free lumen.

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Statistical methods

Statistical analysis was carried out with the software IBM SPSS 20 (IBM SPSS Inc., Chicago, Illinois, USA). The quantitative data are presented as mean and SD or as the mean SE. For testing the statistical hypothesis, the significance level of 0.05 was selected. t-Test was used. For testing the statistical hypothesis about the independence of two variables, the χ2-test was used.


  Results Top


The study included 20 (16 males and four females) patients aged from 52 to 70 years, with a mean±SD age of 63.2±5.28 years.

Demographic and clinical characteristics for the cases are described in [Table 1].
Table 1 Demographic and clinical characteristics (N=20)

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There were five (25%) patients with soft (unstable) plaque noticed during preoperative assessment, which increased the risk of showering stroke in perioperative periods, and the others with calcified plaque (stable plaque) or stenosis, as described in [Table 2].
Table 2 Lesion characteristic by duplex ultrasound (N=20)

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One case died postoperatively and two cases were not suitable for operation owing to lacunar infarction and inefficient brain reserve.

There are significant increases in postoperative PSV and free lumen area in all patients of stenosis or occlusion, as shown in [Table 3].
Table 3 Comparisons between three-dimensional duplex ultrasound parameters before and after carotid endarterectomy (N=17)

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Moreover, there is a higher significant P value (0.0001 and 0.0473, respectively) regarding PSV improvement and free lumen area related to CEA with patching than nonpatching, as shown in [Table 4].
Table 4 Comparison between patching and nonpatching maneuver regarding improvement of peak systolic velocity

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  Discussion Top


Angiography is widely used for evaluation of carotid artery stenosis and selection of patients for CEA. However, carotid angiography is an invasive procedure with non-negligible complications and periprocedural risk [6].

MR and computed tomography angiography of the carotid artery have been investigated as well. Both techniques are expensive, and neither is available at bedside. The latter also requires contrast injection. Therefore, their application is limited in daily practice. 3D US is able to overcome some of the drawbacks of the aforementioned techniques [7].

3D US has several advantages. First, it is noninvasive and portable and can be performed in various clinical settings. Second, it may minimize the discomfort of the patient by reducing the examination time and probe manipulation. A 3D dataset can be collected within 2 s, with the probe held in a fixed position. Close examination of the carotid artery can be achieved offline, and images of the carotid artery can be reconstructed in unrestricted directions from the 3D dataset. Third, it provides volumetric information of not only the free lumen of the carotid artery but also the plaques, the vessel wall, and the adjacent tissue and structures, such as the jugular vein [8].

Information of the shape and distribution of plaques and the degree of calcification may be helpful in clinical management of the patients, such as selection of appropriate interventional methods. Lastly, 3D US permits volume quantification of either a plaque or a segment of free lumen or original vessel lumen [9].

The study by Enrico et al. [10] found that there was good correlation on comparison between 3D US and carotid angiography in 14 patients with carotid stenosis regarding plaque length and volume measurements before and after surgery.

Another research study also identified a change in carotid plaque burden by repeated measurement of plaque volume with 3D US on 10 patients with carotid stenosis. The lumen and outer wall boundaries were outlined in cross-sectional images 1-mm apart [11].

The study by Johann et al. [12] examined 37 patients with 43 internal carotid artery stenosis (ICAS) and emphasize superiority of 3D US in a direct comparison with 2D US.

This study showed significant increase in postoperative PSV and free lumen area in all patients of stenosis or occlusion, with P values of 0.001 and 0.0001, respectively, in most critical cases of the soft plaques.

This study found that PSV shows a highly significant improvement related to carotid end-arterectomy (CEA) with patching than nonpatching, with P value of 0.003.

This is in agreement with a study that demonstrated no significant changes in segmental vessel volume and average cross-sectional area of the operated artery after surgery in patients with suture closure. However, a significant increase in segmental vessel volume was obtained in patients with polyfluoroethylene patches applied to the surgical opening of the artery [13].


  Conclusion Top


The 3D US imaging is a recent tool for improving the visualization and quantification of complex anatomy and pathology as well as monitoring progression of atherosclerosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Skagen K, Skjelland M, Zamani M, Russell D. Unstable carotid artery plaque: new insights and controversies in diagnostics and treatment. Croat Med J 2016; 57:311–320.  Back to cited text no. 1
    
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Stefanadis C, Antoniou CK, Tsiachris D, Pietri P. Coronary atherosclerotic vulnerable plaque: current perspectives. J Am Heart Assoc 2017; 6:e005543.  Back to cited text no. 2
    
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Calogero E, Fabiani I, Pugliese NR, Santini V, Ghiadoni L, Di Stefano R et al. Three-dimensional echographic evaluation of carotid artery disease. J Cardiovasc Echogr 2018; 28:218–227.  Back to cited text no. 3
    
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Liang Y, Wang F, Treanor D, Magee D, Teodoro G, Zhu Y, Kong J. 3D primary vessel reconstruction framework with serial microscopy images. Med Image Comput Comput Assist Interv 2015; 9351:251–259.  Back to cited text no. 4
    
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Picano E, Paterni M. Ultrasound tissue characterization of vulnerable atherosclerotic plaque. Int J Mol Sci 2015; 16:10121–10133.  Back to cited text no. 5
    
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Huang X, Zhang Y, Meng L, Abbott D, Qian M, Wong KKL et al. Evaluation of carotid plaque echogenicity based on the integral of the cumulative probability distribution using gray-scale ultrasound images. PLoS One 2017; 12:e0185261.  Back to cited text no. 6
    
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Naim C, Douziech M, Therasse E, Robillard P, Giroux MF, Arsenault F et al. Vulnerable atherosclerotic carotid plaque evaluation by ultrasound, computed tomography angiography, and magnetic resonance imaging: an overview. Can Assoc Radiol J 2014; 65:275–286.  Back to cited text no. 7
    
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Tigabu A, Bethelehem A, Tarekegn T, Berhe N. Review on diagnostic approach of ultrasound in veterinary practice. Int J Adv Res Biol Sci 2017; 4:134–142.  Back to cited text no. 8
    
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Park TH. Evaluation of carotid plaque using ultrasound imaging. J Cardiovasc Ultrasound 2016; 24:91–95.  Back to cited text no. 9
    
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Enrico C, Iacopo F, Nicola R, Veronica S, Lorenzo G, Rossella D et al. Three-dimensional echographic evaluation of carotid artery disease. J Cardiovasc Echogr 2018; 28:218–227.  Back to cited text no. 10
    
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AlMuhanna K, Hossain MM, Zhao L, Fischell J, Kowalewski G, Dux M et al. Carotid plaque morphometric assessment with three-dimensional ultrasound imaging. J Vasc Surg 2015; 61:690–697.  Back to cited text no. 11
    
12.
Johann O, Anna W, Thomas K, Dorothee S. Evaluation of freehand B-mode and power-mode 3D ultrasound for visualization and grading of internal carotid artery stenosis. PLoS One 2017; 12:XX.  Back to cited text no. 12
    
13.
Ahmed M, Sayed K. Axillary thoracotomy for open heart surgical closure of atrial septal defects in children. J Egypt Soc Cardiothorac Surg 2013; 21:1–4.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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Abstract
Introduction
Patients and methods
Results
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