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Multiparametric ultrasound evaluation with CEUS and shear wave elastography for carotid plaque risk stratification

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Abstract

Purpose

To assess the diagnostic effectiveness of Multiparametric ultrasound (MPUS), which includes color Doppler ultrasound (CDUS), CEUS and Shear wave elastography (SWE), for evaluating carotid plaque as compared with CT-angiography (CTA) and histology.

Materials and methods

Forty-three consecutive patients scheduled to undergo carotid endarterectomy underwent MPUS. Then, after periods ranging from 2 days to 2 weeks, all underwent CTA. Each plaque was classified by means of dedicated scores for CEUS and SWE as compared with CTA features. At surgery, each plaque was removed in a single fragment to facilitate histological analysis, which evaluated 4 features: extension of the lipid core, thickness of the fibrous cap, inflammatory infiltrate (CD68 + and CD3 + markers) and the presence of intraplaque microvessels. For the CEUS, SWE and CTA, the following values for identifying plaque vulnerability were evaluated: sensitivity, specificity, accuracy, negative predictive value (NPV), positive predictive value (PPV) and Area under the curve (AUC). Cohen’s kappa was used to evaluate the concordance between measurements in the different imaging methods. A p < 0.05 was considered statistically significant.

Results

At histology, 31 out of 43 plaques were identified as vulnerable because of the presence of at least one of the following criteria: fibrous cap < 200 μm, lipid core, intraplaque hemorrhage, inflammatory infiltrate or intraplaque neovascularization. CTA showed a sensitivity of 87.1%, a specificity of 100%, a PPV of 100%, an NPV of 75% and an AUC of 93.5%. SWE showed a sensitivity of 87.1%, a specificity of 66.7%, a PPV of 87.1%, an NPV of 66.7% and an AUC of 76.9%. CEUS showed a sensitivity of 87.1%, a specificity of 58.3%, a PPV of 84.4%, an NPV of 63.6% and an AUC of 72.7%.

Conclusions

Multiparametric ultrasound is an effective modality to obtain comprehensive information on carotid plaques. Further studies are needed to determine whether it can be considered a diagnostic standard.

Sommario

Scopo

Valutare l’efficacia diagnostica della CEUS e dell’elastografia Shear Wave (SWE), nella valutazione della placca carotidea in comparazione con l’angiografia-TC (CTA) e la valutazione istologica.

Materiali e Metodi

Quarantatre pazienti consecutivi candidati ad endoarteriectomia carotidea sono stati sottoposti ad esame ecografico completo di valutazione CEUS e SWE e quindi, in un periodo compreso tra due giorni e due settimane, a CTA.Ogni placca è stata classificata mediante scale di valutazione dedicate per la CEUS e la SWE in comparativa con la CTA. In fase di intervento ogni placca è stata rimossa come singolo frammento in modo da facilitarne l’analisi istologica, che ha preso in considerazione quattro caratteristiche: estensione del nucleo lipidico, spessore del cappuccio fibroso, presenza di infiltrato infiammatorio (tramite markers per i CD68 + ed i CD3 +) e presenza di vascolarizzazione intraplacca. Per la CEUS, la SWE e la CTA sono stati calcolati la sensibilità, la specificità, l’accuratezza, i valori predittivi positivo e negativo (PPV e NPV rispettivamente) e l’area sottesa alla curva (AUC) per l’identificazione della vulnerabilità di placca. Per valutare la concordanza tra i valori delle differenti metodiche di imaging è stato utilizzato il K di Cohen. Un valore di p < 0.05 è stato considerato statisticamente significativo.

Risultati

Alla valutazione istologica 31 delle 43 placche sono state idetificate come vulnerabili per la presenza di almeno una delle seguenti caratteristiche: cappuccio fibroso di spessore < 200 µm, presenza di nucleo lipidico, di infiltrato infiammatorio o di vascolarizzazione intraplacca. La CTA ha dimostrato una sensibilità del 87.1%, una specificità del 100%, un PPV of 100%, un NPV of 75% e una AUC del 93.5%. La SWE ha dimostrato una sensibilità del 87.1%, una specificità del 66.7%, un PPV del 87.1%, un NPV del 66.7% e una AUC del 76.9%. La CEUS ha dimostrato una sensibilità del 87.1%, una specificità del 58.3%, un PPV del 84.4%, un NPV del 63.6% e una AUC del 72.7%.

Conclusioni

La CEUS e la SWE sono metodiche efficaci per ottenere informazioni sia qualitative che quantitative sulle placche carotidee. Ulteriori studi sono necessari per determinare se possano essere accettate come metodiche diagnostiche standard.

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Authors and Affiliations

  1. Dipartimento di Scienze Radiologiche, Oncologiche e Anatomopatologiche, Policlinico Umberto I Roma, Viale del Policlinico 155, 00161, Rome, RM, Italy

    N. Di Leo, V. de Soccio, V. Forte, G. Alagna, M. Caratozzolo, D. Messineo, C. Di Gioia, D. Fresilli, G. Pugliese, V. Cantisani & F. D’Ambrosio

  2. Department of Surgery “Pietro Valdoni”, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy

    L. Venturini & L. Di Marzo

  3. Department of Public Health and Infectious Diseases, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy

    P. Lucchetti & C. De Vito

  4. Biomedicine and Prevention Department, University Tor Vergata of Rome, Rome, Italy

    G. Cerone

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  1. N. Di Leo
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Corresponding author

Correspondence to N. Di Leo.

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Conflict of interest

Vito Cantisani has been lecturer for Toshiba, Samsung and Bracco. The other authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical standard statement

The authors declare that this study has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.

Informed consent

Informed consent was obtained from all patients for being included in the study.

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Di Leo, N., Venturini, L., de Soccio, V. et al. Multiparametric ultrasound evaluation with CEUS and shear wave elastography for carotid plaque risk stratification. J Ultrasound 21, 293–300 (2018). https://doi.org/10.1007/s40477-018-0320-7

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