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O. MARTINELLI

O. MARTINELLI. La valutazione della performance della diagnostica mediante US in patologia carotidea. Ombretta Martinelli UOC di Chirurgia Vascolare e di Chirurgia Vascolare d’Urgenza Università degli Studi di Roma “Sapienza”.

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O. MARTINELLI

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  1. O. MARTINELLI

  2. La valutazione della performance della diagnostica mediante US in patologia carotidea Ombretta Martinelli UOC di Chirurgia Vascolare e di Chirurgia Vascolare d’Urgenza Università degli Studi di Roma “Sapienza”

  3. With the widespread use of the screening methods an increasing number of patients, mostly asymptomatic, received diagnosis of carotid plaques inherent with the problem of how to manage these lesions ?

  4. For nearly 25 years, as a result of several landmark randomised clinical trials, the treatment of carotid plaques has been dictated by the degree of carotid stenosis and by the clinical presentation (symptomatic or asymptomatic)

  5. “it may be important to look beyond the degree of stenosis”

  6. US examination has become well established for assessment of carotid stenosis stenosis degree wall shear stress cap disruption

  7. Measurements of only luminal stenosis may give incomplete information about the plaque burden because low-grade stenosis can cause brain ischemia since Atheromatous plaque is dynamic structure undergoing continous changes of its morphology which has to be defined in order to assess the related risk of stroke

  8. The carotid plaquemorphology is now the “holy gral” of carotid diagnosis and management

  9. Characterization of the vulnerable plaques in terms of: lipid-rich necrotic core (LRNC) a thin fibrous cap inflammatory cell infiltrate intraplaque content motion a rich ‘vasavasorum’ network intraplaquehaemorrage is an essential component for the management of the carotid plaques Schaar JA, Eur Heart J 2004 Abela GS Am J Cardiol. 2010 Abela GS J Clin Lipidol. 2010 Altaf N Radiology. 2011

  10. Severalfeaturesofplaquevulnerability can beassessedby ultrasound examination: • etherogenity: iuxtaluminal location of echolucent areas • plaque echolucenty (>40% of area) • plaque area • discrete white areas (DWAs) • thin cap/disruption • intraplaque content motion Falkowski A Med Scienc Mon 2007 Nicolaides An J Vasc Surg 2011 Makris GC Atherosclerosis 2011 Kashiwazaki D J Neurosurg 2112 Byrnes KR Int J Vasc Med 2012

  11. Plaque structure and surface features: agreement between visual CDU and intraoperative specimen Our experience: 384 cases

  12. Plaque structure and surface features: agreement between visual CDU and intraoperative specimen Our experience: 384 cases

  13. Visual classification of vulnerable plaques on ultrasound is subjective This may explain the relatively poor reproducibility data concerning plaque morphology

  14. New computer-aided methods of ultrasonic imaging can make the US assessment of carotid plaque features more accurate Extraction” computed –aided system : plaque images were automatically ature contoured and color-coded.: pixels with gray values 0 to 24 were colored black, 25 to 49 in blue, 50 to 74 in green, 75 to 99 in yellow, 100 to 124 in orange, pixels reater than 124 in red Plaque vulnerabiliy Hashimoto T .Cerebrovasc Dis 2009 Sanches, J. Ultrasound Imaging: Advances and Applications., 2012.

  15. The computer–aided US systems automatically calculate the following features of vulnerability: • echolucenty • plaque area • iuxtaluminal location of an echolucent region • discrete white areas (areas with pixels having grayscale values >124 not producing acoustic shadowing)

  16. Kakkos et al. Angiology 2011: plaques were classified according to a modified Geroulakos types

  17. ACSRS J Vasc Surg 2010

  18. New approaches in plaque-ultrasound-image analysis include: ContrastEnhanchedUltraSound – CEUS toidentifyintraplaqueinflammation and/or neovascularization Giannoni MF EJVES 2009 Staub D,. Stroke. 2010; Owen DR,. Radiology. 2010; Faggioli GL Eur J Vascular and Endovascular Surgery. 2011 Clevert DA Eur J Radiology. 2011

  19. Emerging approaches in plaque-imaging also include the 3D ultrasound to assess: • plaque volume • plaque surface • plaque content motion Spence JD, Ultrasonics 2006 Egger M, Ultrasound in Medicine & Biology 2007 Makris GC Atherosclerosis 2011 Close Chiu B. Physics in Medicine and Biology 2013

  20. The Motion of Intraplaque Content (MIC)is one of the findings of vulnerable plaques. The MIC is more useful in predicting the risk of stroke

  21. Conclusive remarks and future directions • visualclassificationofcarotidplaques on US istoosubjectivewithpoorreproducibilityresults • CEUS and computer-aidedmethodshasbeenshownto • result in a more accurate US assessmentofplaque • burden • the future developmentofvery accurate 3-D/4-D systems • willprovidefurther data toidentifyvulnerableplaques

  22. Thesenew US technologieswillprovide a more accurate multimodalitynoninvasive system tostratify the riskofstroke and toredefine the indicationsforcarotidrevascularizationwithregardto the increasedeffectivenessof the best medicaltherapy

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