Asymptomatic internal carotid artery stenosis and cerebrovascular risk stratification

Background The purpose of this study was to determine the cerebrovascular risk stratification potential of baseline degree of stenosis, clinical features, and ultrasonic plaque characteristics in patients with asymptomatic internal carotid artery (ICA) stenosis. Methods This was a prospective, multicenter, cohort study of patients undergoing medical intervention for vascular disease. Hazard ratios for ICA stenosis, clinical features, and plaque texture features associated with ipsilateral cerebrovascular or retinal ischemic (CORI) events were calculated using proportional hazards models. Results A total of 1121 patients with 50% to 99% asymptomatic ICA stenosis in relation to the bulb (European Carotid Surgery Trial [ECST] method) were followed-up for 6 to 96 months (mean, 48). A total of 130 ipsilateral CORI events occurred. Severity of stenosis, age, systolic blood pressure, increased serum creatinine, smoking history of more than 10 pack-years, history of contralateral transient ischemic attacks (TIAs) or stroke, low grayscale median (GSM), increased plaque area, plaque types 1, 2, and 3, and the presence of discrete white areas (DWAs) without acoustic shadowing were associated with increased risk. Receiver operating characteristic (ROC) curves were constructed for predicted risk versus observed CORI events as a measure of model validity. The areas under the ROC curves for a model of stenosis alone, a model of stenosis combined with clinical features and a model of stenosis combined with clinical, and plaque features were 0.59 (95% confidence interval [CI] 0.54-0.64), 0.66 (0.62-0.72), and 0.82 (0.78-0.86), respectively. In the last model, stenosis, history of contralateral TIAs or stroke, GSM, plaque area, and DWAs were independent predictors of ipsilateral CORI events. Combinations of these could stratify patients into different levels of risk for ipsilateral CORI and stroke, with predicted risk close to observed risk. Of the 923 patients with <70% stenosis, the predicted cumulative 5-year stroke rate was <5% in 495, 5% to 9.9% in 202, 10% to 19.9% in 142, and <20% in 84 patients. Conclusion Cerebrovascular risk stratification is possible using a combination of clinical and ultrasonic plaque features. These findings need to be validated in additional prospective studies of patients receiving optimal medical intervention alone. Copyright © 2010 by the Society for Vascular Surgery

Carotid body paraganglioma: review and surgical management

The term paraganglia best defines the spread in the body of clusters of cells with histological and cytochemical characteristics of neuroendocrine cells originating from the neural crest. with either sympathetic or parasympathetic function. Carotid body hyperplasia is associated with long-standing hypoxia as in native inhabitants in high altitude or in patients with chronic pneumonopathies. while carotid body paraganglioma is a rare parasympathetic tumor with significant morbidity. Tumor extension per se, associated cranial nerve involvement, and the estimated 3-10% malignant potential. particularly at a young: age, make early diagnosis and treatment of carotid body paraganglioma mandatory. Biopsy should be avoided, because of the accompanying incidence of hemorrhage, while it is essential in all cases to investigate both sides of the neck to exclude bilateral tumors. The modalities of therapy include preoperative embolization, preoperative and postoperative radiation with ambiguous results of both, and complete surgical removal which constitutes the definite therapy. The current stroke rate is less than 5%. The histological appearance of a carotid body paraganglioma is not a reliable guide to its propensity for malignant behavior and recurrences are most likely to appear in patients who have multiple paragangliomas or a family history of carotid body paraganglioma