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Variations in the position of the bifurcation of the common carotid artery (CCA) and the origin or branching pattern of the external carotid artery are uncommon. Variations in transformation of the embryonic aortic arch system are the genesis of these variations. A 70-year-old female presented with history of sudden onset dizziness followed by right hemiparesis showed a trifurcation of CCA on carotid duplex ultrasound (CDU) scan. Computed tomography angiography (CTA) of the extracranial neck vessels confirmed our sonological findings and it was determined that the third vessel originating from the CCA was an aberrant superior thyroid artery (STA). Knowledge of variant terminations of the CCA is important to prevent inadvertent vascular injury during radical neck dissection, cervical discectomy, and carotid artery catheterization and a CDU is a prudent screening tool for the same.

Background & objectives: Early atherosclerosis and vascular complication have been described in thalassaemia patients. There is lack of data or guidelines regarding monitoring of vascular health in thalassaemia. This study was conducted to compare carotid artery structural and functional indices such as carotid artery intima-media thickness (CIMT), stiffness index (SI) and Young's elastic modulus (YEM) in β-thalassemia patients with age and sex matched controls, and to correlate these parameters with serum ferritin, cardiac iron, and hepatic iron. Methods: This cross-sectional study included 53 β-thalassaemia patients receiving regular blood transfusions. Carotid artery indices such as CIMT, SI, and YEM were calculated by duplex ultrasound and colour Doppler. Serum ferritin levels were measured by chemiluminescence. Cardiac and hepatic iron estimation were done using MRI T2* sequences analyzed by a special thalassaemia software. Results: Mean CIMT of cases and controls were 0.48 ± 0.04 and 0.44±0.02 mm, respectively and these were significantly different (P<0.001). Similarly significant differences were noted in SI and YEM of cases (2.45±0.79 and 96.12±34.85, respectively) as compared to controls (1.98±0.54 and 68.60±24.29, respectively) (p<0.001). There was significant inverse correlation between stiffness index and cardiac iron overload assessed by MRI cardiac T2* (p=0.03). Mean SI and YEM of cases were (2.1736 ± 0.2986 and 107.3± 41.6, respectively) significantly higher among non-splenectomized patients compared to splenectomized patients (2.0136 ± 0.263 and 86.9 ± 25.2, respectively) (p<0.05). Interpretation & conclusions: CIMT and arterial stiffness indices were significantly increased in β-thalassaemia patients compared to controls which was indicative of early atherogenic changes. This study supports the hypothesis that iron overload is a risk factor for early atherosclerosis and cardiovascular disease.

The risky working environments of divers and pilots, and the possible role of extreme ambient pressure in carotid stenosis, make ischemic stroke an important occupational concern among these professionals. In this study, we aimed to evaluate the association of being exposed to hyperbaric or hypobaric conditions with carotid artery stenosis by comparing common carotid intima-media thickness (CCIMT) and blood flow velocities of cerebral arteries in divers and pilots using carotid duplex ultrasound (CDUS) and transcranial Doppler (TCD). CDUS and transtemporal TCD were performed in 29 divers, 36 pilots and 30 control participants. Medical history, blood pressure, lipid profile and blood sugar were recorded to control the previously well-known risk factors of atherosclerosis. Findings of the CDUS and TCD [including: CCIMT and blood flow velocities of internal carotid artery (ICA), common carotid artery (CCA), and middle cerebral artery (MCA)] of divers and pilots were compared with those of the control group using regression analysis models. Both right and left side CCIMT were significantly higher in divers ( P  < 0.05) and pilots ( P  < 0.05) in comparison with the control group. Carotid index [peak systolic velocity (PSV) of ICA/PSV of CCA) of divers and pilots were also higher than the control group. TCD findings were not significantly different between divers, pilots, and the control group. Increased CCIMT and carotid index in diver and pilot groups appear to be suggestive of accelerated atherosclerosis of carotid artery in these occupational groups.

Ischemic leukoaraiosis (ILA) is associated with cognitive decline and aging. Its pathophysiology is believed to be ischemic in origin due to its association with cerebrovascular risk factors and similarity in location to lacunar infarctions. ILA diagnosis is still based on magnetic resonance imaging (MRI) as well as exclusion of other causes of white matter hyperintensities. So far, there are no known confirming diagnostic tests of ILA. Ultrasound studies have recently shown increased large artery stiffness, increased cerebrovascular resistance, and lower cerebral blood flow in patients with ILA. Increased arterial stiffness and decreased blood flow could have a synergistic effect, and their ratio could be a useful diagnostic index of ILA. In this post hoc analysis, we introduced new ILA indices (ILAi) that are ratios of the carotid stiffness parameters (pulse wave velocity beta [PWVβ], pressure-strain elasticity modulus [Ep], β index), and diastolic and mean blood flows in the internal carotid artery: Q-ICAd and Q-ICAm. We compared the ILAi of 52 patients with ILA and 44 sex- and risk factor-matched controls with normal MRI of the head. ILA diagnosis was based on MRI and exclusion of other causes of white matter hyperintensities. The diagnostic significance of ILAi for the prediction of ILA was analyzed. All ILAi significantly differed between the groups; the most significant were PWVβ/Q-ICAd (ILA group: 1.96±0.64 vs control group: 1.56±0.40, P=0.001) and PWVβ/Q-ICAm (ILA group: 1.13±0.32 vs control group: 0.94±0.25, P=0.003). All ILAi were significantly associated with ILA (P<0.01) and were significant independent predictors of ILA. All ILAi were also sensitive and specific for predicting ILA (area under the curve: 0.632-0.683, P<0.05). The new ultrasound indices significantly differed between patients with ILA and the control group and were significant predictors of ILA. A combination of lower carotid blood flow and increased carotid stiffness represented as ILAi probably has a diagnostic value in patients with ILA.

In the past few decades, imaging has been developed to a high level of sophistication. Improvements from one-dimension (1D) to 2D images, and from 2D images to 3D models, have revolutionized the field of imaging. This not only helps in diagnosing various critical and fatal diseases in the early stages but also contributes to making informed clinical decisions on the follow-up treatment profile. Carotid artery stenosis (CAS) may potentially cause debilitating stroke, and its accurate early detection is therefore important. In this paper, the technical development of various CAS diagnosis imaging modalities and its impact on the clinical efficacy is thoroughly reviewed. These imaging modalities include duplex ultrasound (DUS), computed tomography angiography (CTA) and magnetic resonance angiography (MRA). For each of the imaging modalities considered, imaging methodology (principle), critical imaging parameters, and the extent of imaging the vulnerable plaque are discussed. DUS is usually the initial recommended CAS diagnostic examination. However, for the therapeutic intervention, either MRA or CTA is recommended for confirmation, and for added information on intracranial cerebral circulation and aortic arch condition for procedural planning. Over the past few decades, the focus of CAS diagnosis has also shifted from pure stenosis quantification to plaque characterization. This has led to further advancement in the existing imaging tools and development of other potential imaging tools like Optical coherence tomography (OCT), photoacoustic tomography (PAT), and infrared (IR) thermography.

PurposeDiagnosing carotid near-occlusion (CNO) with colour duplex ultrasound (CDU) is challenging. We hypothesised that CNO is associated with a reduced distal internal carotid artery (ICA) velocity and aimed to assess if distal velocity is able to diagnose CNO accurately. If not, we aimed to develop CDU rule-out and rule-in criteria to diagnose CNO.MethodsThis is a prospective cross-sectional study in consecutive participants with suspected ≥ 50% carotid stenosis on CT angiography (CTA). CDU velocities in the common carotid artery, the stenosis and distal to the stenosis were examined. CTAs were assessed for CNO, serving as a reference test. If no CDU parameter was both sensitive and specific for CNO, rule-out (98% sensitive) and rule-in (99% specific) criteria were created.ResultsOf the 315 included participants with ≥ 50% stenosis, 190 (60%) were conventional ≥ 50% stenosis and 125 (40%) CNO. No CDU parameter was both sensitive and specific for CNO. The best exclusion criteria were stenosis end diastolic velocity (EDV) ≤ 63 cm/s and/or distal peak systolic velocity (PSV) > 23 cm/s, seen in 115 (38%) participants. The best rule-in criteria were stenosis EDV ≥ 280 cm/s and/or distal PSV ≤ 23 cm/s, seen in 35 (12%) participants. Of the remaining participants, 143 (47%) were uncertain (74 CNOs) and 9 (3%) were misdiagnosed as carotid occlusion (all CNOs).ConclusionsCDU alone cannot diagnose CNO but can rule in or rule out CNO in half of participants with ≥ 50% stenosis. These criteria are intended for inclusion in an algorithm, sorting cases needing further exams, such as CTA and/or phase-contrast magnetic resonance angiography.

To assess the incidence and clinical significance as well as predictors of in-stent restenosis (ISR) after carotid artery stenting (CAS) diagnosed with serial duplex sonography investigations. We analyzed 215 CAS procedures that had clinical and serial carotid duplex ultrasound investigations. The incidence of in-stent restenosis (ISR) and periprocedural as well as long-term clinical complications were recorded. The influence of an ISR on clinical complication was analyzed using Kaplan-Meier curves and clinical risk factors for the development of an ISR with multivariate logistic regression. During a median follow-up time of 33.4 months (interquartile range 15.3–53.7) an ISR of ≥70% was detected in 12 (6.1%) of 215 arteries (mean age of 68.1 ± 9.8 years, 71.6% male). The combined stroke and death rate during long-term follow-up was significantly higher in the group with an ISR [odds ratio (OR): 3.59, 95% confidence interval (CI): 1.50–8.59, p  = 0.004]. After applying multivariate logistic regression analysis contralateral carotid occlusion (OR 10.11, 95% CI 2.06–49.63, p  = 0.004), carotid endarterectomy (CEA) restenosis (OR 8.87, 95% CI 1.68–46.84, p  = 0.010) and postprocedural carotid duplex ultrasound with a PSV ≥120 cm/s (OR 6.33, 95% CI 1.27–31.44, p  = 0.024) were independent predictors of ISR. ISR after CAS during long-term follow-up is associated with a higher proportion of clinical complications. A close follow-up is suggested especially in those patients with the aforementioned independent predictors of an ISR. Against the background of a lacking established treatment of ISR, these findings should be taken into account when offering CAS as a treatment alternative to CEA.

We evaluated the feasibility of the Framingham stroke risk score (FSRS) and atherosclerotic cardiovascular disease (ASCVD) risk scores for asymptomatic carotid stenosis (ACS). In addition, we developed novel risk prediction models for ischemic stroke and composite outcomes by combining ultrasonographic parameters and conventional cardiovascular risk scores. We retrospectively enrolled 612 patients with ACS greater than 50% over 7 years and evaluated them using transcranial Doppler and carotid duplex ultrasonography. In total, 150 patients were included in the analysis. During the mean 5-year follow-up, 6 ischemic strokes and 25 composite events were detected. Among all ultrasonographic parameters, only a higher peak-systolic velocity/end-diastolic velocity ratio was detected and significantly associated with an increased risk of relevant ischemic stroke (hazard ratio: 1.502, 95% confidence interval: 1.036–1.968). The C-statistics of the FSRS and ASCVD risk scores were 0.646 and 0.649, respectively, for relevant ischemic stroke, and 0.612 and 0.649, respectively, for composite outcomes. C-statistics of the FSRS and ASCVD risk scores combined with ultrasonographic parameters increased to 0.937 and 0.941, respectively, for ischemic stroke, and 0.856 and 0.886, respectively, for composite outcomes. The study suggests that inclusion of ultrasonographic parameters in conventional cardiovascular scores helps identify the risk of further vascular events in ACS patients.

Background: Duplex ultrasonography (DUS) of the extracranial arteries is essential for the primary and secondary prevention of ischemic stroke and the diagnosis of other cerebrovascular pathologies. The aim of the Italian Society for Vascular Investigation (SIDV) is to provide a standardised approach for the ultrasound evaluation of extracranial arterial disease. Methods: A multidisciplinary SIDV expert panel conducted a comprehensive literature search and performed a narrative review of the recent medical literature; the updated operative procedures were subsequently developed through a consensus-driven process that included dedicated meetings and national congress sessions for discussion and validation. Results: This document outlines a comprehensive approach to the ultrasound evaluation of extracranial arteries, detailing techniques such as Brightness Mode (B-mode), Colour Doppler, Power Doppler, contrast-enhanced ultrasound (CEUS), micro-vascular flow imaging (MVFI), and Three-Dimensional (3D) ultrasound. The text provides an in-depth discussion of clinical indications, technical protocols, plaque characterisation, stenosis quantification, and hemodynamic criteria. Emerging technologies are also examined for their potential to improve cerebrovascular risk stratification. Conclusions: The updated SIDV operative procedures for the ultrasound evaluation of extracranial cerebrovascular disease are intended to serve as a valuable reference for clinicians and vascular laboratories.

The ultrasonography of carotid arteries plays a key role in evaluating cerebrovascular disease. There are some useful considerations to perform it correctly in the intensive care unit, such as using different kind of transducer, Doppler mode optimization, and the correct interpretation of the findings.