Journal of Regional Section of Serbian Medical Association in Zajecar
Year 2004     Volumen 29     Number 2
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UDK 616.133.073 ISSN 0350-2899, 29(2004) 2 p.80-82
   
Original paper

Clinical Significance of Ultrasound Classification Changes of Carotid Arteries
in Patients with Coronary Disease

Milan Đorić, Branko Lović, Ivan Tasić
Institut za prevenciju, lečenje i rehabilitaciju reumatičnih i kardiovaskularnih bolesti "Niška Banja"

 
 

 

 
  Summary: Atherosclerosis like mass non-infective disease with its progression of generalized changes represents pathoanatomic and patophyziologic substrate for manifestation of carotid and coronary disease. Pathoanatomic changes which evolutes in walls of big arteries, including carotid, are caracterized with diffuse changes of intima, hypertrophy and with forming of focal lesions-plaques. Different forms of necrosis, thrombosis, ulcerations and hemorrhagias are present in such atheromathosis plaques. Those complications are the main danger for embolisation in distal parts of arteries; moreover, they make the occlusion with consecutive clinical and neurological presentation even worse. We carried out ultrasonographic classification of plaques in carotid arteries in 32 patients with the detected coronary disease using Moore method. We got the following results grouped in the following way: A-7 patients, B-15 patients.,C-10 patients. In group A all patients were asymptomatic, in group B 7 patients already had TIA (transitory ischemic attack) without neurological sequels and in C group already 9 patients had neurological injuries with residual neurological defect.
Key words: carotid disease, atherosclerotic plaque, neurological defect

Note: summary in Serbian
Napomena: sažetak na srpskom jeziku

 
     
 

INTRODUCTION

Colour Doppler echosonography is the first method of choice for the evaluation of neck blood vessels, which significantly increases reabillity of diagnosis and decreases the number of invasive diagnostic procedures.
During the years of clinical investigation a certain need for examination of carotid disease has been established, as well as its connections with coronary disease in etiological, diagnostic and therapeutic aspect. According to the present experiences and literary data, those two locations are strongly connected. So, we can freely say that its material mistake is to ignore one in clear clinical manifestation of the other especially in the presence of multiple risk factors, which are more or less common for both localisations (1,2,3).
Cerebro vascular disease occupies a very important place in medicine and is very important on socio-economic level. Mortality is in the third place, right behind cardiovascular disease and neoplasms. Morbidity per year is about 160 on 100.000 of the examined, and it exponentially grows during the process of aging. Man got it 5 times more often than women.
Consequences of cerebrovascular insults are very serious: 71 % of the patients after the period of 6 months have neurological sequels and only 10% fully manage to recover and come back to previous social and professional life (4).
Anatomic changes which may cause cerebrovascular insult are in 56% located in bulbus, 10% in vertebral arteries, 9% in truncus brachiocephalicus and 9% in art.carotic communis (5, 6) .
According to the literary data and personal experiences as well as during the clinical observation of our patients we noticed that the size of atheromathosis plaques was an important factor for both diagnosis and treatment of those patients. Therefore, we started systematically to examine carotid arteries in patients with the detected coronary disease.

 
     
     
 

AIM

The aim of our study was to estimate the presence, relations and influence of the plaques on cerebrovascular events

 
     
     
 

MATERIAL AND METHOD

Our study group had 32 patients, all with angiographically detected coronary disease, 20 males and 12 females, the average age 62 7 years.
Colour Doppler echosonography of the main neck blood vessels on Aquson Sequoa C256 was performed on all our patients using linear transducer of 7 Mhertz and 50 mm deep slices. We examined intraluminal atherosclerotic changes with B mode way, defined intimo-medial thickness over 0,05cm and plaque like focal change of intima bigger than 2mm. Intimo-medial thickness was measured on the posterior wall of common carotid artery and we took 3 measures during diastole. The size of the plaques was determined by Moore's method:

  1. minimal arterial ulcerations or irregularities smaller than 10mm2
  2. significantly bigger ulcerations area 10 to 40mm2
  3. big, unhomogen ulcer, area more than 40mm2
 
     
     
 

RESULTS

 
  Among 32 examined patients we found minimal arterial ulcerations smaller than 10mm - group A in seven of them (22%), in 15 (48%) significantly bigger ulcerations area 10-40 mm was detected - group B whereas in 10(31%) patients big, unhomogen ulcer was present with area more than 40 mm2 -
group C10 (figure 1).
 
  Figure 1. Percentage distribution in study group  
     
     
  In group A all our patients were subjectively and clinically asymptomatic, which brings us to conclusion that smaller plaques doesn't significantly impact the brain function.
In group B 7 patients already got transitor ischemic attack without neurological defects.
In C group 9 patients had hemi paresis with residual sequels. All changes are located on contra lateral side and their number is account of all particularly.
Such relation shows us the dominant influence of size and type of atheromathosis plaques on evolution of cerebrovascular disease.
 
     
     
 

DISCUSSION

The problem of atheromathosis and stenotic lesions of carotid arteries is clinically significant, not only like isolated carotid disease but it is connected with some other diseases which require medicament or surgical treatment (cardiovascular disease, strictly controlled diabetes, big intra abdominal surgery, transplantations, even some orthopaedic procedures) (7, 8).
It is well-known that brain of healthy, young adult has circulation of about 800-1000ml/min.Brain consumes 15 % of volumen, 20%of calories, 20% of blood and about 20% of oxygen consumption.
Brain flow is directly connected with pressure and resistance in blood vessels. Further more, structural changes of vessels and changes in blood viscosity have direct impact on cerebral perfusion although brain is capable of auto regulating mechanisms in orderto keep perfusion on a certain level. Changes of blood pressure, frequency and volumen have direct influence on perfusion of other organs. This is possible due to the permanent accommodation in small cerebral arteries, arteriolas and capilars so, brain flow is last which is compromited in cardial and peripheral circulatory insufficiency.
Serious compromitation of cerebral auto-regulation is present after certain period of unregulated hypertension, prolonged hypotension and acidosys. The loss of cerebral auto regulations is present after 20 minutes of hypoxia, and is re-established after 6-7 hours of regular oxygenation. Brain circulation is constant and doesn't change with changes of systemic blood pressure if its between 60-170 mmHg. Chromnic hypertension is getting auto regulating mechanisms on higher levels.
Moor and his assistant showed a direct correlation between stenosis, size and characteristics of plaques. Therefore, we should identified the risk groups among asymptomatic patients which have stenosis with degeneration of plaques, according to the previous authors. Doppler result is 94 % of the patients sensitive to intrapalqual hemorrhagic, while it is specific in 88%. Embolism from exulcerated plaques brings up the transitor ischemic attack or cerebrovascular insult and if the silent zones of brain are affected it can pass by like clinically unrecognised.
Symptomatic ulcerogened lesion, although homodynamic insignificant is nowadays an absolute indication of endartherectomy (8).
Our results are fully in accordance with the references and states from literature. Therefore, such results make us very confident in our efforts to promote this Moore method as a practical one, not only in routine clinical praxis but in further scientific examinations of coronary disease as well.

 
     
     
 

CONCLUSION

  1. Colour Doppler echosonography of carotid arteries offers detection and estimation of pathoanatomical and pathophysiological changes in carotid arteries of coronary patients.
  2. Using Moores method of classification of severity and significance of carotid arteries plaques is important for the evaluation of cerebrovascular sypthomatology and proper treatment.
  3. This method is non-invasive, reproducible and should be a part of diagnostic algorithm for every proved coronary patient.
 
     
 

REFERENCES

  1. WOSCOPS (West of Scotland Coronary Prevention Study): Implications for clinical practice. Euro Heart Journal. 1996 ,17: 163-164
  2. Assman G.Lipid metabolism disorders and coronary heart disease ed G.Assman, Munich.MV Medizin Verlag, 1998; 143-143
  3. Consensus Group, Consensus statement on the management of patients with asymptomatic atherosclerotic carotid bifurcation lesions ,International Angiology1995, Vol 14 N0 1-.92-104
  4. Dawber TR.The Framingham Study. The epidemiology of atherosclerotic disease. Cambridge: Harward Universiti press, 1980.;143-65
  5. Rodney A. White, Atherosclerosis and arteriosclerosis, CRC, Florida,1996.;29-33
  6. Born GVR, Richardson PD:Mechanical properties of human atherosclerotic lesions. In pathology of the Human Atherosclerotic Plaque edited by Glasgov S, Newman WP, Shaffer SA.New York; Springer 1998;68-79
  7. Fuster V. Syndromes of atherosclerosis .Correlation of Clinical Imaging and pathology, American Heart Association,1996;1.;44-67
  8. Gross,W.S., Verta, M.J. et all . Comparation of non-invasive diagnostic techniques in carotid artery occlusive disease, Surgery, 1997;87-271
 
     
  Corresponding Address:
Milan Đorić,
Petra Velebita 13, 18000 Niš,
tel: 018-337-083, 063-433-795
e-mail: mdjoric@EUnet.yu
 
     
  Paper received: 15. 04. 2004.
Paper accepted: 10. 06. 2004
Published online: 05. 08. 2004.
 
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