US Images of Asymptomatic Carotid Plaques Predict Stroke

OBJECTIVES: It has been suggested that a juxtaluminal black (hypoechoic) area (JBA) in ultrasonic images of asymptomatic carotid artery plaques is associated with a lipid core close to the lumen or a thrombus on the plaque surface. The aim of our study was to test the hypothesis that the presence and size of JBA predicts future ipsilateral ischemic stroke.


METHODS: JBA was defined as an area of pixels with gray scale value <25 adjacent to the lumen without a visible echogenic cap, after image normalization. The size of a JBA was measured in the carotid plaque images of 1,121 patients with asymptomatic carotid stenosis 50-99% in relation to the bulb (ACSRS study), followed-up for up to 8 years.

RESULTS: JBA had a linear association with future stroke rate. The area under the ROC curve was 0.816. Using Kaplan Meier curves, the mean annual stroke rate was 0.4% in 706 patients with JBA <4 mm2; it was 1.4% in 171 patients with JBA 4-8 mm2, 3.2% in 46 patients with JBA 8-10 mm2 and 5% in 198 patients with JBA >10 mm2 (p<.001). In a Cox model with ipsilateral ischemic events (AF, TIA or stroke) as the dependent variable, JBA (<4, 4-8, >8) was still significant after adjusting for other plaque features known to be associated with increased risk (stenosis, GSM, presence of discrete white areas without acoustic shadowing (DWA) indicating neovascularization, plaque area and history of contralateral TIA or stroke. Plaque area and gray scale median (GSM) were not significant. Using the significant variables (stenosis, DWA, JBA and history of contralateral TIA or stroke), this model predicted the annual risk of stroke (range 0.5-10.0%). The average annual stroke risk was <1% in 734 patients, 1-1.9% in 94, 2-3.9% in 134, 4-5.9% in 125 and 6-10% in 34.

CONCLUSIONS: The size of JBA is linearly related to the risk of stroke and can be used in risk stratification models. These findings need to be confirmed in future prospective studies or in the medical arm of randomized controlled studies in the presence of optimal medical therapy.

NHÂN CA GIANT CELL ARTERITIS of the BREAST TẠI MEDIC

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Giant cell arteritis (GCA) from the above article

Although giant cell arteritis is a systemic disease, on rare occasions the breast may be the primary organ of manifestation. In a review of the English medical literature up to 2008, Kadotani et al identified 20 reported cases, all of which were postmenopausal elderly women. Single or multiple lumps due to arteritis were present in 80% (16 of 20 patients), and redness and tenderness in the absence of lumps were present in 10%. Breast involvement was bilateral in 50% of the patients. Spontaneous breast pain and tenderness were presenting features in 85% of the patients. Systemic symptoms such as low-grade fever, arthralgia, myalgia, and those suggestive of polymyalgia rheumatica were present in 65% of the patients.

There have been no reports of mass lesions or other distinctive findings by mammography or ultrasonography. In a recent case report of a patient presenting with a lump in her breast and a negative mammogram, ultrasound of a stringlike thickening in the right axillary tail of the breast revealed a “halo sign” (hypoechoic circumferential wall thickening indicating edema), which, compared with biopsy, has been reported to have a sensitivity of 69% and a specificity of 82% for diagnosis of arteritis. In most cases reported in the medical literature, the diagnosis was made after excisional biopsy (a considerable amount of tissue is required to make the diagnosis of giant cell arteritis). In rare cases, the diagnosis was established before biopsy on the basis of systemic symptoms and ultrasound findings. Pathology shows fragmentation of the elastica in association with giant cell infiltration, intimal proliferation, and narrowing of the vascular lumina. Inflammatory cancer was suspected in four of seven cases reported by Kadotani et al.

Prednisone is the treatment of choice. It has been shown to improve both general symptoms and breast-specific manifestations of giant cell arteritis.

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