Outpatient clinics often see such examination reports, so is such a test necessary and how to deal with such results?
Carotid ultrasound report
Is carotid plaque screening necessary?
According to the 2015 China Cardiovascular Disease Report, stroke is currently the first cause of death for urban and rural residents in mainland China, and ischemic stroke accounts for about 80% of stroke patients, of which 25% to 30% of carotid artery stenosis is closely related to ischemic stroke. The main cause of carotid artery stenosis is atherosclerosis, which accounts for more than 90%.
Therefore, in 2014, the Health Management Branch of the Chinese Medical Association and the Chinese Journal of Health Management jointly released the "Expert Consensus on the Basic Project of Health Examination", which regards carotid ultrasound as a recommended project for screening the risk of cardiovascular disease in the physical examination population.
The "Management Measures for Early Screening and Comprehensive Intervention Projects for People at High Risk of Cardiovascular Diseases (Trial)" issued by the General Office of the Health and Family Planning Commission of the Mainland also regards carotid ultrasound as a screening project for people at high risk of cardiovascular disease.
Carotid plaque screening methods
Carotid plaque screening methods include angiography, transcranial Doppler, magnetic resonance, CTA, etc. Although angiography is the gold standard for diagnosis, carotid ultrasound is a non-invasive examination, low cost, high sensitivity, convenient, reproducible, and can be used as the preferred screening method.
Ultrasound can diagnose the location and extent of arterial stenosis or occlusion and determine the stability of the plaque.
01. Carotid artery stenosis ultrasound evaluation criteria
Note: Peak blood flow velocity during PSV systolic phase; end-diastolic blood flow velocity of EDV; ratio of PSV/PSVCCA internal carotid artery PSV to common carotid PSV
02. Determination of carotid plaque
At 1.0 to 1.5 cm near the end of the carotid artery at the carotid artery bifurcation, avoid carotid plaque, and the vertical distance from the intimal anterior margin to the outer membrane anterior margin is measured as the carotid intra-medial membrane thickness (IMT).
The carotid artery IMT ≥ 1.0 mm or IMT ≥ 1.2 mm at the bifurcation is thickened in the median membrane; when the IMT limit is ≥ 1.5 mm, greater than the surrounding normal IMT value is at least 0.5 mm, or more than 50% greater than the surrounding normal IMT value, and the local structural changes in the convex lumen can be defined as atherosclerotic plaque formation.
Measurement method of the thickness of the medial membrane of the carotid artery (vertical distance from the leading edge of the lumen of the carotid artery to the leading edge of the medial membrane-outer membrane surface)
Measurement method of plaque (longitudinal section in Figure 4A, cross-section in Figure 4B)
03. Determination of carotid plaque stability
The plaque is stable by morphology, internal echo, surface fiber cap integrity, etc. Taking the echo of the vascular wall as a reference, the content of tissue components in the plaque is different, and the carotid artery plaque can be divided into low echo, isoelic echo, strong echo and mixed echo plaque.
Strong echo plaque is more stable due to a large number of calcifications, corresponding to "hard plaque"; the plaque with uniform echo is mostly a simple fibrous plaque; the internal echo of unstable plaque is uneven, and when a large area of no echo or very low echo is seen, there may be ulcers, bleeding, large necrosis of lipid components, etc., with a tendency to rupture, prone to thrombosis and/or may rapidly develop into responsible lesions, closely related to ischemic cerebrovascular disease, also known as "vulnerable plaque", corresponding to "soft plaque".
Irregular (incomplete fibrous caps), neovascularization within plaques, and ulcerative plaques (fibrous caps rupture incompletely, forming a "crater sign", and colored blood flow Doppler shows blood flow ingress) are also vulnerable plaques.
Vulnerable plaques can be transformed into stable plaques with aggressive treatment, while otherwise, stable plaques that are not treated in time may also turn into vulnerable plaques, so effective assessment of plaque stability is critical to clinical decision-making.
Quantitative analysis of carotid plaque increases the predictive value of traditional cardiovascular disease risk factors in assessing cardiovascular disease risk. In patients with mild and moderate asymptomatic carotid artery stenosis, annual carotid ultrasound follow-up is recommended to dynamically assess plaque progression and stroke risk.
Strong echo plaque (shown by arrows)
Low echo plaque (as shown by arrows)
Mix echo plaques (as shown by arrows)
Clinical manifestations of carotid plaque
The disease tends to occur in middle-aged and elderly people, and most patients with early carotid artery stenosis/plaque have no clinical symptoms.
01. Asymptomatic carotid artery stenosis
There have been no transient ischemic attacks (TIAs), strokes, or other associated neurological symptoms due to carotid artery stenosis for the previous 6 months, and only clinical manifestations of dizziness or mild headache are considered asymptomatic carotid stenosis.
02. Symptomatic carotid artery stenosis
Carotid artery stenosis with one or more of the clinical symptoms of TIA, transient nibble, mild or non-disabling stroke due to intracranial vessels on the affected side (e.g., confusion of thought, postural vertigo, binocular blindness, ataxia, dizziness, vertigo, etc.) within the previous 6 months is called symptomatic carotid artery stenosis.
03. Physical examination
Carotid artery pulsation is weakened in some patients with carotid artery stenosis, and vascular bruits may be heard in some patients in bilateral cervical triangles and above the clavicle.
In general, high-pitched, long-duration murmurs indicate severe stenosis, but mild stenosis and complete occlusion can be preceded by slower blood flow without murmur. All patients with carotid artery stenosis require a neurological physical examination.
Prevention and treatment of carotid plaques
01. Healthy lifestyle
Risk factors for carotid plaque include hypertension, smoking, diabetes, hyperlipidemia, etc., so a healthy lifestyle mainly includes a reasonable diet, physical activity, weight control, smoking cessation and alcohol restriction, etc., to reduce cardiovascular risk factors such as hypertension and hyperlipidemia. Non-fasting glycemic control is below 11.1 mmol/L, and glycosylated hemoglobin <7% during treatment.
02. Medication
Both asymptomatic and symptomatic carotid stenosis should be treated with drugs, of which antiplatelet therapy, antihypertensive therapy and statin therapy are the three cornerstones.
1) Antiplatelet therapy
Antiplatelet therapy is recommended for patients with moderate carotid artery stenosis and above, and the commonly used drugs are aspirin, and other drugs such as clopidogrel can be used for aspirin intolerants.
The target plaque is small and does not form a significant narrow (stenosis
2) Antihypertensive therapy
Hypertension is the most important risk factor for stroke, and antihypertensive therapy can be effective in reducing the risk of stroke. The goal of control in patients with common hypertension is
All kinds of antihypertensive drugs can be used, and calcium antagonists have certain advantages in preventing stroke.
3) Statin therapy
Statin therapy is not recommended in patients with simple carotid intimacy thickening, if the blood lipids are within the normal range and there is no coronary heart disease, cerebral infarction, diabetes, etc.;
Statin therapy is recommended for control of low-density lipoprotein cholesterol (LDL-C) in patients with unstable plaques of the carotid artery or plaques with stenosis of more than 50%, regardless of symptoms of ischemic stroke and abnormal lipids.
For carotid artery plaques with stenosis less than 50%, there are no symptoms of ischemic stroke, and blood lipids are within the normal range, and statins can be considered individually according to the stability of the plaque and the risk-benefit ratio of medication.
In patients with carotid plaque, if ischemic stroke has recently occurred, intensive statin therapy with low-density lipoprotein cholesterol (LDL-C) ≤ 1.8 mmol/L is recommended.
When statin monotherapy is not up to standard, other lipid-lowering drugs such as ezezermaebu may be used in combination. When patients with hypertriglyceridemia, niacin or fibrate lipid-lowering agents may be considered.
03. Vascular reconstruction
Carotid artery vascular reconstruction includes carotid endarterectomy (CEA) and carotid artery stenting (CAS). Guidelines recommend:
CEA or CAS may be considered in 70 to 99% of patients with symptomatic carotid artery stenosis;
CEA or CAS may also be considered in patients with symptomatic carotid artery stenosis 50 to 69 percent;
CEA or CAS may be considered in patients with nonsymptomatic carotid artery stenosis ≥ 70% of patients, with adequate assessment of the patient's surgical risk and benefit ratio, and when the perioperative disability or mortality rate can be controlled to less than 3%;
Patients treated with CAS should be given a combination of aspirin and clopidogrel preoperatively for at least 3 months after the procedure.
In summary, carotid atherosclerotic plaque is a manifestation of systemic arteriosclerosis in the carotid artery, so high-risk groups should be screened regularly and treated in time to reduce the incidence of cardiovascular and cerebrovascular events.
Typography: ly
Title image source: Stand Cool Helo
bibliography:
1. Consensus on the diagnosis and treatment of head and neck atherosclerosis in China. Neurology Branch of Chinese Medical Association Cerebrovascular Disease Group of Neurology Branch of Chinese Medical Association Journal of Neurology, Vol. 50, No. 8, 2017, pp. 572-578
2. Carotid artery ultrasonography specification for Chinese health examination population. Chinese Journal of Health Management, Issue 4, 2015, pp. 254-260
3. Expert consensus on several problems with head and neck vascular ultrasound (carotid part). National Health Commission Stroke Prevention and Control Expert Committee Vascular Ultrasound Professional Committee Chinese Society of Ultrasound Medical Engineering Superficial Organ and Peripheral Vascular Ultrasound Professional Committee et al. Chinese Journal of Cerebrovascular Diseases Vol. 17, No. 6, 346-352, 2020
4. Risk assessment and prevention strategies of carotid atherosclerotic plaque. Li Wei, Gong Tao, Chinese Journal of General Practitioners, Vol. 21, No. 2, 2022, pp. 101-104
5. Guidelines for the diagnosis and treatment of carotid artery stenosis. Chinese Journal of Vascular Surgery (Electronic Edition), Chinese Journal of Vascular Surgery, 2017, Vol. 9, No. 3, pp. 169-175
6. Method and standardized application of ultrasound for diagnosis of carotid atherosclerotic plaque. Li Yan Ren Junhong, Journal of Chinese General Practitioners, 2022, Vol. 21, No. 2, pp. 105-108
7. Chinese Guidelines for secondary prevention of ischemic stroke and transient ischemic attacks 2014. Neurology Branch of Chinese Medical Association Cerebrovascular Disease Group of Neurology Branch of Chinese Medical Association Chinese Journal of Neurology, Vol. 48, 2015, No. 4, pp. 258-273
8. Guidelines for the Diagnosis and Treatment of Endovascular Intervention in Ischemic Cerebrovascular Disease in China 2015. Chinese Journal of Neurology, Vol. 48, No. 10, pp. 830-837, Chinese Journal of Neurology, 2015, Neurological Branch, Neurology Branch, Chinese Medical Association, China Neurology Branch, 2015