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Common carotid intima-media features determine distal disease phenotype and vulnerability in asymptomatic patients
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
Umeå University, Faculty of Medicine, Department of Radiation Sciences.
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2015 (English)In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 196, 22-28 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: There is a growing awareness of the importance of carotid plaque features evaluation in stroke prediction. Carotid intima-media thickness (IMT) and recently its echogenicity were used for stroke prediction, although their clinical relevance was not well determined. The aim of this study was to assess the relationship between common carotid artery (CCA) ultrasound markers of atherosclerosis and distal, bifurcation and internal carotid artery (ICA), plaque features. Methods: We analyzed 137 carotid arteries in 87 asymptomatic patients with known carotid disease (mean age 69 +/- 6 year, 34.5% females). Intima media thickness (IMT) and its gray scale median (IM-GSM) were measured at the CCA. Plaque textural features including gray scale median (GSM), juxtaluminal black area (JBA-mm(2)) without a visible cap, and plaque coarseness, at bifurcation and ICA were also determined. CCA measurements were correlated with those of the distal plaques. Results: An increased IMT in CCA correlated with plaque irregularities in the bifurcation and ICA (r = 0.53, p < 0.001), while IM-GSM was closely related to plaque echogenicity (GSM) (r = 0.76, p < 0.001), and other textural plaque features. Both, IMT and IM-GSM correlated weakly with stenosis severity (r = 0.27, p = 0.001 and r = -0.18, p = 0.026) respectively. Conclusion: In asymptomatic patients, measurements of CCA reflect distal, bifurcation and ICA disease, with IMT reflecting plaque irregularities and IM-GSM as markers of textural plaque abnormalities. Integrating measurements of both IMT and IM-GSM in a model could be used as a better marker of disease vulnerability over and above each measure individually. 

Place, publisher, year, edition, pages
2015. Vol. 196, 22-28 p.
Keyword [en]
Carotid atherosclerosis, Intima-media thickness, Intima-media-gray scale median, Plaque features, aque vulnerability
National Category
URN: urn:nbn:se:umu:diva-107150DOI: 10.1016/j.ijcard.2015.05.168ISI: 000358314300005PubMedID: 26070179OAI: diva2:850729
Available from: 2015-09-02 Created: 2015-08-19 Last updated: 2015-12-04Bibliographically approved
In thesis
1. Patterns of non-invasive imaging of carotid atherosclerosis
Open this publication in new window or tab >>Patterns of non-invasive imaging of carotid atherosclerosis
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Atherosclerosis is an inflammatory disease that can be generalized, affecting more than one arterial bed simultaneously, or localized, manifested in one system. Ultrasound based measurements of plaque textural features, such as low grey scale median (GSM), echolucent (hypoechoic) plaque types and juxtaluminal black (hypoechoic) area (JBA) are manifestation of potentially unstable lesions. Conventional carotid IMT (intima media thickness) and the recently introduced IM-GSM (echogenicity of the intima media complex) are important measures of subclinical atherosclerosis and are used to predict future ischemic events.

The aims of this thesis were to study, in detail, the systemic nature of atherosclerosis by evaluating the carotid disease burden contralateral to symptomatic arteries, determining the relationship between proximal (subclinical atherosclerosis) and distal segments (well established disease) of the same artery and comparing local plaque features with systemic burden of atherosclerosis disease. In addition, the effect of statins on carotid plaque echogenicity was evaluated in a systematic review and meta-analysis.


We have measured ultrasound-based textural carotid plaque features (GSM, JBA, entropy, coarseness), surface morphology, as well as IMT and IM-GSM. An in-house custom developed research software package was used for plaque feature extraction. For the meta-analysis we used Comprehensive Meta-Analysis version 3 software.


Study 1. In 39 patients, the carotid plaques contralateral to symptomatic arteries had similar morphological and textural features to those in the symptomatic arteries and are more vulnerable than those in asymptomatic arteries; more often mildly or markedly irregular with more vulnerable textural plaque features (lower GSM and larger JBA).

Study 2. In 87 asymptomatic patients, an increased IMT in CCA correlated with plaque irregularities in the bifurcation and ICA while IM-GSM was closely related to plaque echogenicity (GSM), and other textural plaque features.

Study 3. In the same cohort in study 2, patients with previous disease in the coronary arteries had higher IMT and lower IM-GSM and those with prior stroke had lower IM-GSM. Neither IMT nor IM-GSM was different between patients with and without previous lower extremity disease. IM-GSM decreases significantly with increasing number of arterial territories p<0.001 (asymptomatic vs symptoms in one vs multiple arterial systems) but conventional IMT was not different between groups p=0.49.

Study 4. In a meta-analysis of 9/580 identified studies including 566 patients with 7.2 months follow-up, a consistent increase in the carotid plaques echogenicity after statin therapy, was reported. The perpetual (over 12 months) effects of which were shown in a meta-regression analysis to be related to changes in hsCRP.


Symptomatic patients have similar plaque morphology and textural features of vulnerability in the contralateral carotid system, compared with asymptomatic ones. In the latter, measurements of proximal disease reflect distal pathology and the number of affected arteries. Finally, statin therapy and the drop of LDL cholesterol result in better plaque stability and optimum control of arterial inflammation, shown by arterial wall echogenicity and hsCRP changes, respectively.

Place, publisher, year, edition, pages
Umeå: Umeå University, 2015. 87 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1759
National Category
Cardiac and Cardiovascular Systems
Research subject
urn:nbn:se:umu:diva-110969 (URN)978-91-7601-363-2 (ISBN)
Public defence
2015-11-25, hörsal B, Unod T9, Umeå, 09:00 (English)
Available from: 2015-11-04 Created: 2015-11-01 Last updated: 2015-11-06Bibliographically approved

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