Uses of ultrasound in stroke prevention
1Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada.
Insights
Ultrasound imaging of carotid plaque burden effectively predicts cardiovascular risk and enables personalized stroke prevention strategies. Advanced ultrasound techniques also assess plaque vulnerability and detect microemboli for improved patient risk stratification.
Area of Science:
- Vascular Medicine
- Cardiovascular Imaging
- Stroke Prevention
Background:
- Carotid plaque burden, measured by total plaque area (TPA) or total plaque volume (TPV), is a superior cardiovascular risk predictor compared to intima-media thickness.
- Ultrasound plaque burden assessment is cost-effective, radiation-free, and comparable in predictive power to coronary calcium scores.
- Carotid plaque dynamics over months allow for a novel
- treating arteries instead of risk factors
- approach to vascular prevention.
Purpose of the Study:
- To highlight the multifaceted utility of ultrasound methods in stroke prevention.
- To emphasize the significance of carotid plaque burden measurement for risk stratification and personalized treatment.
- To introduce advanced ultrasound techniques for assessing plaque vulnerability and detecting microemboli.
Main Methods:
- Measurement of carotid plaque burden (TPA/TPV) using ultrasound.
- Assessment of plaque vulnerability through echolucency, ulceration, and texture analysis.
- Transcranial Doppler (TCD) for embolus detection and patent foramen ovale screening.
Main Results:
- High-risk patients with asymptomatic carotid stenosis (ACS) using the "treating arteries" approach showed >80% reduction in stroke and myocardial infarction over 2 years.
- TCD embolus detection clearly distinguished high-risk ACS patients (15.6% 1-year risk with ≥2 microemboli/hour) from lower-risk patients (1% risk without).
- TCD saline studies demonstrated higher sensitivity than trans-esophageal echocardiography for detecting patent foramen ovale and predicting recurrent stroke.
Conclusions:
- Ultrasound assessment of carotid plaque burden is a powerful tool for cardiovascular risk prediction and personalized vascular prevention.
- Monitoring carotid plaque changes enables a proactive treatment strategy focused on arterial health.
- Advanced ultrasound techniques, including TCD, significantly improve risk stratification in ACS patients, guiding intervention decisions and reducing stroke burden.
Abstract:
Ultrasound methods are useful in stroke prevention in several ways. Measurement of carotid plaque burden, as either total plaque area (TPA) or total plaque volume (TPV) are strong predictors of cardiovascular risk: much stronger than intima-media thickness, which does not represent true atherosclerosis, but a biologically and genetically distinct phenotype. Measurement of plaque burden is also useful for the study of genetics, and of new risk factors such as toxic products of the intestinal microbiome. Carotid plaque burden is highly correlated with and as predictive of risk as coronary calcium scores, but is less costly and does not require radiation. Furthermore, because carotid plaques change in time over a period of months, they can be used for a new approach to vascular prevention: "Treating arteries instead of treating risk factors". In high-risk patients with asymptomatic carotid stenosis (ACS), this approach, implemented in 2003 in our clinics, was associated with a >80% reduction of stroke and myocardial infarction over 2 years. "Treating arteries without measuring plaque would be like treating hypertension without measuring blood pressure". Ultrasound methods can also be used to assess plaque vulnerability, by detecting echolucency, ulceration and plaque inhomogeneity on assessment of plaque texture. Transcranial Doppler (TCD) embolus detection is useful for risk stratification in patients with ACS; patients with two or more microemboli in an hour of monitoring have a 1-year risk of 15.6%, vs. 1% without microemboli, so this very clearly distinguishes which patients with ACS could benefit from intervention. TCD saline studies are more sensitive than trans-esophageal echocardiography for detection of patent foramen ovale, and more predictive of recurrent stroke. These methods should be more widely used, to reduce the increasing burden of stroke in our aging populations.
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