Perspectives in Medicine (2012) 1, 108111

Bartels E, Bartels S, Poppert H (Editors):

New Trends in Neurosonology and Cerebral Hemodynamics an Update.
Perspectives in Medicine (2012) 1, 108111

journal homepage: www.elsevier.com/locate/permed

Early ultrasound imaging of carotid arteries in the

acute ischemic cerebrovascular patients
Maria Fabrizia Giannoni a,, Edoardo Vicenzini c, Enrico Sbarigia b,
Vittorio Di Piero c, Gian Luigi Lenzi c, Francesco Speziale b

a
Dept Paride Stefanini, Vascular Ultrasound Investigations Unit, Sapienza University of Rome, Italy
b
Dept Paride Stefanini Vascular Surgery, Italy
c
Dept Neurological Sciences, Sapienza, University of Rome, Italy

KEYWORDS Summary
Acute cerebral Background and purpose: The early identication of ischemic stroke pathophysiology may lead
ischemia; to different diagnostic and therapeutical strategies. In 1/3 of patients, stroke is related to
Unstable carotid carotid disease, when a vulnerable plaque evolves with surface rupture and local apposition of
plaques; highly embolic/thrombotic material. This being a rapidly evolving dynamic process, the value of
Ultrasonography; its early identication may be underestimated. With the diffusion of high-resolution ultrasound
Contrast enhanced equipments, the possibility of identifying these features of plaque vulnerability has become
ultrasound; easily available. These plaque characteristics have to be always considered in the patient man-
Carotid surgery; agement, in order to avoid further worsening of neurological conditions or to prevent recurrent
Timing of carotid events, and to choose the appropriate strategies.
surgery Methods: Early ultrasonography was performed with high frequency probes (9, 15, 18 MHz) in
patients admitted to emergency area for acute ischemic symptomatology from carotid stenosis.
Results: In 8 patients admitted to the emergency area few hours after the onset of neurologi-
cal symptoms, we detected peculiar plaque characteristics closely related to the neurological
events and at high risk of further embolic events with local thrombosis, surface plaque rupture
and carotid oating thrombi. All these cases were successfully submitted to emergency carotid
endarterectomy repair.
Conclusions: Timing of carotid endarterectomy has always been debated in stroke patients
clinical management, depending on several factors. All imaging techniques contribute to the
identication of plaque morphology features, but early admission of stroke patients to the emer-
gency areas and early US have a crucial leading role in detecting plaque rupture and dynamic
changes in real-time. Peculiar characteristics of high unstable plaques allow the identication
of those lesions at particularly high risk of further embolic events according to their fragile
characteristics that may benet from early surgery.
2012 Elsevier GmbH. Open access under CC BY-NC-ND license.

Corresponding author at: Dept Paride Stefanini, Vascular Ultrasound Investigation Unit, Vascular Surgery, Policlinico

Umberto I, Viale del Policlinico 155 00161 Rome, Italy. Tel.: +39 6 49970660; fax: +39 49970652.
E-mail address: mariafabrizia.giannoni@uniroma1.it (M.F. Giannoni).

2211-968X 2012 Elsevier GmbH. Open access under CC BY-NC-ND license.

doi:10.1016/j.permed.2012.02.045
Early ultrasound imaging of carotid arteries in the acute ischemic cerebrovascular patients
Introduction
Vulnerable atherosclerotic plaque rupture with surface
apposition of thrombotic material is the predominant
pathological substrate of acute cerebrovascular events,
accounting for 30% of all strokes [1]. In acute ischemic stroke
patients, in addition to standard imaging techniques aimed
at the decision whether to perform thrombolysis, early
ultrasound investigation is fundamental to detect potential
embolic carotid source in order to avoid further emboliza-
tion by means of carotid surgery.
The aim of this report is to evaluate the possibility of
early detection of these carotid plaque features with ultra-
sound and to discuss the implications of this diagnosis in
order to plan the most appropriate strategy in acute cere-
brovascular ischemic patients.
Material and methods
All patients referred to the emergency area for the onset
of acute ischemic neurological symptoms were subjected
to Duplex Ultrasonography (DUS) (Siemens Sequoia 512 and
Siemens S2000 apparatus), according to the conventional
methodology and standard AHA and European Guidelines
with high-resolution probes (9, 15, 18 MHz), Tissue Harmon-
ics and Spatial Compound. DUS was performed immediately
after brain imaging. No patients with ipsilateral (middle
cerebral artery) occlusion or an ischemic area > 1/3 of the
Middle Cerebral Artery area underwent carotid endarterec-
tomy.
Results
We report 8 patients (M: 6, F: 2, mean age 64.7 yrs, range
5378 yrs), referred to the emergency area for the onset
of acute neurological symptoms occurred no more than 6 h
before, in whom we detected with US immediately per-
formed after brain CT scan, plaque features of high risk
Figure 1 Left side MRI: cerebral ischemic lesion. Right side: intraoperative macroscopic ndings ultrasound imaging of the ruptured
plaque with the mobile ap (Clip 1).
109
of further embolic events, as mobile thrombus over plaque
ruptures.
Symptoms included: hemiparesis (n = 5), amaurosis fugax
(n = 3), language impairment (n = 3). Three patients had a
combination of the symptoms.
Mean NIHSS on admission was 4 (min: 0, max: 8). Cere-
bral Magnetic Resonance Imaging with diffusion-weighted
sequences documented the presence of ischemic areas in
7 patients in the corresponding omolateral carotid territory.
All patients presented hemodynamic internal carotid
stenosis consistent with the clinical symptoms. Hetero-
geneous, mostly hypoechoic, complicated plaques were
detected in all cases. Moreover, high-resolution B-Mode
imaging performed with high frequency probes and spatial
compound to better visualize plaque surface and texture,
demonstrated an extensive rupture of the surface with
structure ssurations (Fig. 1), intraoperatively conrmed.
Ultrasound B-Mode imaging also allowed the detection of
an abnormal motion of the soft parts of the plaques,
in particular nearby the sites of plaque rupture. In two
cases, real-time B-Mode imaging demonstrated an endothe-
lial oating ap represented by the ruptured cap of the
plaque, mobile in the lumen, and thus conrming the high
potential embolic risk of these lesions (Fig. 2). Mobile clots
were also visualized from the surface at the site of plaque
rupture in two cases (Fig. 3). Contrast ultrasound imag-
ing detected a high density of microvessels in the plaque
tissue consisting with relevant neoangiogenesis, as already
described elsewhere [2,3] in acute symptomatic plaques.
Furthermore, contrast ultrasound allowed a better visu-
alization of the plaque extension and surface, better
demonstrating the rupture extended deeply from the sur-
face to the core of the plaque. In one case, a small ulceration
with a mobile clot was also identied.
All patients were immediately and successfully submitted
to CEA: mean NIHSS at discharge was 2 (min: 0, max: 4).
Discussion
Stroke remains a leading cause of disability and death world-
wide [4]. About one-third of ischemic strokes arise from
110
Figure 2 Ultrasonography: hypoechoic, mobile thrombus in
the distal anterior part of the plaque (right side of the image)
(Clip 2).
carotid atherosclerotic plaques, embolization representing
the main pathophysiological explanation. For this reason,
the identication of vulnerable lesions represents the fun-
damental step to select patients at risk of cerebrovascular
ischemic events from carotid disease where the surgical pro-
cedure is indicated. This is a particularly relevant hot topic
in literature since optimal management of asymptomatic
carotid stenosis still remains controversial [5], while the
benecial effect of CEA is recognized worldwide in symp-
tomatic patients for hemodynamic stenosis. However, the
timing of surgery in acute cerebrovascular events is still
controversial. At present, early CEA is indeed the most
appropriate strategy to prevent further carotid cerebrovas-
cular events.
Moreover, in particular, the aim of this short report is to
focus on the utility of evaluating acute symptomatic lesions
in the early phase, due to the possible detection of pecu-
liar morphological aspects: plaque rupture is an unstable,
very common event, detected in our experience in all cases
admitted to the emergency area few hours from onset of
symptomatology.
The behavior of acute symptomatic plaques in the early
phase is often underestimated, while an early and accu-
rate evaluation may be helpful to plan the most appropriate
strategy to prevent further cerebrovascular events. Further
efforts have to be performed to make a greater awareness
in patients so that they arrive in specialized areas as soon
as possible: this is a crucial node. The onset of neurolog-
ical symptomatology must be considered as an emergency
condition.
Advances of arterial imaging, through conventional radi-
ological imaging (CT and MR Angiography) [6,7] as well as
with ultrasonography [8], converge to achieve more detailed
information regarding the identication of these plaques.
Summarizing, peculiar plaque characteristics such as severe
M.F. Giannoni et al.
Figure 3 Ultrasonography: hypoechoic, mobile thrombus in
the proximal part of the plaque (left side of the image) (Clip 3).
degree of stenosis, low GSM and surface ulceration are
important predictors of plaque vulnerability and there are
clear evidences that acute symptomatic plaques are always
complicated, with low echogenicity and with relevant sur-
face alterations. However, acute symptomatic plaques in
the very early phase have peculiar characteristics that are
possible to detect with careful US investigations. Their inci-
dence is often underestimated while an accurate evaluation
may be helpful to plan the most appropriate strategy to
prevent further cerebrovascular events. Acute symptomatic
lesions have specic morphological aspects, and plaque rup-
ture is a true adverse extremely unstable and common
event in our experience in early phase. Data collected from
recent studies indirectly conrm this condition: in the very
acute stroke phase or in patients with transient ischemic
attacks, the risk of recurrency is signicantly higher and
CEA signicantly reduces the absolute risk of ipsilateral
ischemic stroke [9,10]. As recently indicated by Wardlow
et al. [11], increasing delays to endarterectomy prevented
fewer strokes. In our experience, early ultrasonography
performed with high resolution B-Mode imaging in real-time,
quickly revealed in all these symptomatic plaques harm-
ful characteristics, different from surface irregularities and
chronic ulcerations, or low echogenicity or low GSM.
Early admission to emergency-specic areas represents
the early care in hospitalized centers and the 24 h availabil-
ity of diagnostic facilities and operating rooms and vascular
teams is a fundamental step to get a signicant improvement
of acute stroke patients prognosis. In conclusion, ultrasound
vascular imaging is a key component of the evaluation of
early ischemic carotid diseases. Acute symptomatic plaques
are a well-dened entity that require early and accurate
real-time evaluation, mandatory to thoroughly assess their
unstable behavior, rare, but highly risk condition. US imag-
ing, with high-resolution probes, harmonic imaging and
spatial compound, has the unique capability to assess these
particular features in real-time, where immediate surgery
may reduce further stroke risk.
Early ultrasound imaging of carotid arteries in the acute ischemic cerebrovascular patients
Conclusions
Timing of carotid endarterectomy has always been debated
in stroke patients clinical management, depending on sev-
eral factors, i.e. blood-brain-barrier breaking, neurological
severity, entity of cerebral damage. All imaging techniques
contribute to the identication of plaque morphology unsta-
ble features, but early US has a crucial leading role in
detecting plaque rupture and dynamic changes in real-time,
allowing the identication of those lesions at particularly
high risk of further embolic events for their fragile charac-
teristics and that may benet from CEA performed early.
Acute symptomatic plaques require early and accurate
real-time evaluation, mandatory to thoroughly assess their
unstable behavior and successfully treat them.
Appendix A. Supplementary data
Supplementary data associated with this arti-
cle can be found, in the online version, at
doi:10.1016/j.permed.2012.02.045.
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