Speakers - CIRWC 2024

Abstract

Cardiovascular disease is a serious public health problem and is the leading cause of morbidity and mortality worldwide. Over 70% of these deaths are atherosclerosis related, which is a systemic disease of the vessel wall that occurs in the aorta, carotid, coronary, and peripheral arteries and often causes stroke, myocardial infarction, and sudden death without prior symptoms. Stroke ranks third among all causes of death in Western countries, of all strokes, 87% are ischemic, and an estimated 20% are caused by carotid atherosclerotic disease. The microscopic alterations of the initial phase of this disease start during childhood, but usually carotid plaques remain asymptomatic until an advanced pathological stage is reached. In the last few years, the degree of carotid artery stenosis was considered the only determinant factor to address patients to treatment, that’s no longer the case in the meantime, several factors are considered potentially important markers for future cerebrovascular events, including plaque composition, presence and state of the fibrous cap (FC), intra-plaque haemorrhage, plaque ulceration and plaque location. All of these factors, therefore, need to be taken into account for a correct diagnostic and preventive approach aimed at risk stratification and treatment planning to reduce the incidence and severity of acute cerebrovascular disease. Three large multi-centric randomized studies, NASCET (North American Symptomatic Carotid Endarterectomy Trial), ECST (European Carotid Surgery Trial) and ACAS (Asymptomatic Carotid Athero-Sclerosis Group), provided cut-off values stenosis degree indicating possible benefits of carotid endarterectomy (CEA).
The most used methods to quantify the degree of carotid artery stenosis are North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST), both evaluating the degree of stenosis as the percentage reduction in the linear diameter of the artery. In addition, in both NASCET and ECST trials, stenosis degree was determined by conventional angiography, since Computed Tomography Angiography (CTA) and Magnetic Resonance Angiography (MRA) were not available at that time (3). Recently, the reference imaging technique in assessing the degree of carotid stenosis was only Digital Subtraction Angiography (DSA). However, it has been claimed that advanced non‐invasive imaging modalities including Doppler Ultrasound (DUS), MRA and CTA have progressively replaced the diagnostic role of DSA. This is mainly due to its high cost and greater risk. In addition, these in vivo techniques assist in analysing plaque morphology and its characteristics. This literature review will highlight the performance characteristics of contrast enhanced - MRA compared to other imaging modalities in the diagnosis of carotid artery stenosis.