Contrast enhanced ultrasound of carotid plaque in acute ischemic stroke (CUSCAS study).

INTRODUCTION: Carotid atherosclerosis represents 8 to 15% of ischemic strokes in relation to the concept of "vulnerable" plaque. Contrast enhanced ultrasound (CEUS) can detect moving microbubbles within the plaque corresponding to neovessels that constitute "precursors" of vulnerable plaque and intraplaque hemorrhage. CEUS was not studied specifically in acute ischemic strokes. The aim of this study is to analyse the prevalence of CEUS carotid plaque ipsilateral at the ischemic stroke as well as the main characteristics of contrast-plaques. METHOD: A single-centre prospective pilot study involving 33 consecutive patients with a stroke ≤10 days, diagnosed by an MRI with positive diffusion sequence and having a carotid plaque thickness ≥2.5mm with low or heterogeneous echogenicity, located in the ipsilateral carotid territory at the stroke. Plaque echogenicity was done by visual analysis and by measurement of the gray scale median (GSM). A transcranial Doppler monitoring was carried out in search of HITS. The contrast ultrasound was performed after 2.5 cc IV injection of SonoVue®. A video clip was recorded after injection which was used for interpretation by visual analysis in 3 grades, provided by two independent expert readers. RESULTS: The population consisted of 10 women and 23 men aged 73 on average. The topography of strokes in the carotid territory was located on the right in 11 (33%) cases and on the left in 22 (67%) cases. Seventeen patients had carotid stenosis between 0 and 49% according to the Nascet method and 16 patients had stenosis of 50 to 99%. The visual characterisation of the plaques had echolucent dominance (Type 1-2) in 18 cases and echogenic dominance (Type 3-4a) in 15 cases. Cardiovascular risk factors were common with no difference by sex. The inter-observer agreement of plaque enhancement was moderate in first reading (k=0.48) and excellent at consensus (k=0.91). Only one disagreement was found. Contrast agent enhancement of carotid plaque was observed in 11/32 patients, representing a prevalence of 34.4% - CI95% [17.9-50.9]. Variables associated with contrast plaque included the absence of antiplatelet drug (63.6% vs. 23.8%, P=0.05) and the presence of a regular edge on the plaque (91% vs. 48%, P=0.04). There was no difference in contrast enhancement for stenosis>or<50% in diameter and neither for the type of plaque. CONCLUSION: In a consecutive cohort of 33 patients, the prevalence of CEUS from an ipsilateral carotid plaque to a recent acute ischemic stroke was 34.4%. There was a statistically significant association between the contrast enhancement of the plaque and the absence of antiplatelet drug (P=0.05) and also the presence of a regular edge on the plaque (P=0.04). There was no correlation between plaque contrast and clinical and biological characteristics of patients or the presence of HITS.

[MRI can be prescribed in patients with implanted cardiac devices (pacemaker, defibrillator) to optimize radiotherapy planning]. / Une IRM peut être prescrite en situation de dispositif cardiaque implantable (pacemaker, défibrillateur), application à la radiothérapie.

PURPOSE: MRI is sometimes critical to optimal radiotherapy planning but may be contraindicated in increasing numbers of patients who carry an implantable cardiac device (ICD, pacemaker or defibrillator). MATERIAL AND METHODS: This literature search reviews studies of MRI in DCI patients, morbidity and procedures for the different types of ICD. RESULTS: Several retrospective studies and two recent large prospective studies have shown that the use of an ICD is not an absolute contraindication to MRI, given that specific DCI monitoring is performed under the tridisciplinary supervision of the oncologist, radiologist and cardiologist for MRI≤1.5T. The rate of major complications is less than 5% unless probe replacement is performed. When it can be anticipated, new MRI-compatible ICD can be implanted rather than conventional ICD, but probe replacement is not currently recommended. Data for MRI beyond 1.5T and in case of MRI repeatability in the context of MRI-Linac treatments are lacking. CONCLUSIONS: MRI may be performed in ICD patients, as the risk of morbidity is very low; provided that tridisciplinary evaluation is performed.

High Dose of Pralidoxime Reverses Paraoxon-Induced Respiratory Toxicity in Mice.

OBJECTIVE: The efficiency of pralidoxime in the treatment of human organophosphates poisoning is still unclear. In a rat model, we showed that pralidoxime induced a complete but concentration-dependent reversal of paraoxon-induced respiratory toxicity. The aim of this study was to assess the efficiency of pralidoxime in a species other than rats. METHODS: A dose of diethylparaoxon corresponding to 50% of the median lethal dose was administered subcutaneously to male F1B6D2 mice. Ascending single pralidoxime doses of 10, 50-100 and 150 mg kg-1 were administered intramuscularly 30 min after diethylparaoxon administration. Ventilation at rest was assessed using whole-body plethysmography and mice temperature was assessed using infrared telemetry. Results are expressed as mean±SE. Statistical analysis used non-parametric tests. RESULTS: From 30 to 150 min post-injection, diethylparaoxon induced clinical symptoms and a decrease in respiratory frequency, which resulted from an increase in expiratory and inspiratory times associated with an increase in the tidal volume. In the 10-, 50- and 100-mg kg-1 pralidoxime groups, there was a trend towards a non-significant improvement of paraoxon-induced respiratory toxicity. The 150 mg kg-1 dose of pralidoxime induced a significant reversal of all respiratory parameters. CONCLUSION: In the present study, a toxic but non-lethal model of diethylparaoxon in awake, unrestrained mice was observed. By administering an equipotent dose of diethylparaoxon to rats, a 150 mg kg-1 dose of pralidoxime administered alone completely reversed diethylparaoxon-induced respiratory toxicity in mice. The dose dependency of reversal suggests that further studies are needed for assessing plasma concentrations of pralidoxime resulting in reversal of toxicity.

Carotid contrast-enhanced ultrasonography and multimodal imaging in a case of TIPIC syndrome.

Transient perivascular inflammation of the carotid artery (TIPIC) syndrome, previously referred to as 'carotidynia', is an unclassified clinicoradiological entity associating atypical acute neck pain, eccentric perivascular infiltration on imaging and improvement of symptoms either spontaneously or with anti-inflammatory treatment. This case report presents a patient with TIPIC syndrome who underwent five different types of imaging modality, including contrast-enhanced ultrasonography (CEUS) of the carotids, and describes the CEUS appearances of TIPIC syndrome.

[Contribution of contrast enhanced ultrasonography in the characterization of carotid lesions]. / Apport de l'échographie de contraste dans la caractérisation des lésions carotidiennes.

Harmonic mode ultrasound with injection of a contrast enhancement agent allows visualization of mobile microbubbles in the carotid plaque corresponding to neovessels secondary to an inflammation or hypoxia. These neovessels could be considered "precursor" markers of the vulnerable plaque. The aim of this work was to give an update on ultrasound contrast imaging acquisition in the exploration of carotid artery both for atheromatous lesions and for large vessel vasculitis. A precise description of the material to be used, the image acquisition methodology and the environmental conditions is discussed, emphasizing the pitfalls to be avoided as well as proper image interpretation. Microbubbles in a plaque are significantly associated with an increase in cardiovascular events (infarction and acute coronary syndrome) and ipsilateral cerebral ischemic events. Wall irregularities, microfissures and ulcer plaque detection are facilitated by the use of contrast compared to the CT scan. No studies have yet validated contrast enhanced ultrasound in the exploration of asymptomatic carotid stenosis. Contrast enhanced ultrasound also allows to detect vasculitis of the large vessels active phases by the presence of microbubbles in the carotid wall thickening and to monitor the regression under appropriate medical treatment. Future validation studies or even registries are needed to allow better use of this tool in everyday clinical practice.

Carotid diaphragm: Atypical fibromuscular dysplasia or atheromatous lesions?

Atypical fibromuscular dysplasia (FMD) is an underdiagnosed cause of ischemic stroke. The typical angiographic pattern of a septum on the posterolateral side of a carotid megabulb is highly suggestive of atypical FMD. We report here on two patients with this highly suggestive pattern of carotid atypical FMD, but which histological examination revealed to be atheromatous lesions. Interestingly, contrast-enhanced ultrasound of the carotid artery showed enhancement of the spur, which should never be the case with an FMD lesion, which has no vasa vasorum. Our findings suggest that the results of studies reporting stenting of atypical FMD in cervical arteries should be interpreted with caution.

[Ultrasound screening of abdominal aortic aneurysm: Lessons from Vesale 2013]. / Dépistage échographique de l'anévrisme de l'aorte abdominale - les enseignements de Vésale 2013.

Although aneurysm of the abdominal infra-renal aorta (AAA) meets criteria warranting B mode ultrasound screening, the advantages of mass screening versus selective targeted opportunistic screening remain a subject of debate. In France, the French Society of Vascular Medicine (SFMV) and the Health Authority (HAS) published recommendations for targeted opportunistic screening in 2006 and 2013 respectively. The SFMV held a mainstream communication day on November 21, 2013 in France involving participants from metropolitan France and overseas departments that led to a proposal for free AAA ultrasound screening: the Vesalius operation. Being a consumer operation, the selection criteria were limited to age (men and women between 60 and 75 years); the age limit was lowered to 50 years in case of direct family history of AAA. More than 7000 people (as many women as men) were screened in 83 centers with a 1.70% prevalence of AAA in the age-based target population (3.12% for men, 0.27% for women). The median diameter of detected AAA was 33 mm (range 20 to 74 mm). The prevalence of AAA was 1.7% in this population. Vesalius data are consistent with those of the literature both in terms of prevalence and for cardiovascular risk factors with the important role of smoking. Lessons from Vesalius to take into consideration are: screening is warranted in men 60 years and over, especially smokers, and in female smokers. Screening beyond 75 years should be discussed. Given the importance of screening, the SFMV set up a year of national screening for AAA (Vesalius operation 2014/2015) in order to increase public and physician awareness about AAA detection, therapeutic management, and monitoring. AAA is a serious, common, disease that kills 6000 people each year. The goal of screening is cost-effective reduction in the death toll.

[Contrast enhanced ultrasound can show symptomatic carotid lesions not visualized with magnetic resonance angiography]. / L'échographie avec contraste peut montrer des lésions carotidiennes symptomatiques non visualisées en angio-RM.

We report the cases of two patients who presented symptoms focused on a wall of the common carotid: carotidodynia in one patient and a transient ischemic attack in the other. The B-mode ultrasound showed an enlarged thickened medio-adventitial echostructure with a slightly heterogeneous and iso or hypoechoic appearance. There was no narrowing. Injection of ultrasound contrast led to significant enhancement in the wall reflecting neovascularization secondary to inflammation. Other imaging methods (MR and CT angiography) found no abnormality. At the 3-month follow-up visit, the surface area of the lesions was greatly decreased and the ultrasound contrast enhancement had disappeared. These two cases illustrate how focal lesions of the carotid wall missed on MR and CT angiography can be detected and visualized with B-mode ultrasound contrast enhancement. Contrast enhanced ultrasound leads to the concept of "active lesions" resulting from inflammatory processes that can be readily monitored without radiation.

[Detection of micro-embolic signals: a review of the literature]. / Détection de signaux micro-emboliques: revue de la littérature.

BACKGROUND: The detection of micro-embolic signals (MES), by transcranial Doppler sonography might be useful for risk stratification in patients with symptomatic and asymptomatic carotid or cerebral artery stenosis, dissections, aortic atheroma, interventional procedures, and right to left cardiac shunts. AIM: Review of the technique and clinical situations of MES detection. METHODS: PubMed search from 1990 to 2012. RESULTS: MES were found in 0,19, 48% versus 0,3, and 12% of patients with symptomatic and asymptomatic inferior than 30, 30 to 69, and 70 to 99% carotid stenosis, respectively. MES were related to the risk of recurrent stroke or transient ischemic attack (TIA). In the ACES study, the absolute annual risk of stroke or TIA after 2 years was 7% with vs 3% without MES. In patients with intracranial stenosis, the risk of stroke recurrence was 48% with vs 7% without MES at 13.6 months follow-up. MES were reported in 25% of the symptomatic versus none of the asymptomatic patients with intracranial stenosis. CONCLUSION: Detection of MES is feasible and reproducible for multicenter studies, using rigourous methodology and long lasting recordings. It may contribute to risk stratification, especially in patients with extra- or intracranial stenosis.

[Diagnostic value of clinical signs and clinical scoring for deep vein thrombosis after hip and knee arthroplasty]. / Dépistage clinique de la thrombose veineuse profonde après prothèse de hanche et de genou. Proposition d'un score de prédiction pour guider l'indication de l'échographie-Doppler veineux.

AIM: To assess the most accurate clinical signs and clinical scoring for selecting patients who could benefit from duplex sonography screening of deep venous thrombosis (DVT) after total hip replacement (THR) and total knee replacement (TKR). METHODS: Four hundred and eighty consecutive patients with THR or TKR were included. Post-operative physical examination and venous duplex sonography (day 6-10) were performed in all of them. DVT was diagnosed in presence of at least 3mm thick and 3 cm long incomplete venous compressibility. Clinical prediction scores were built from clinical parameters, which were significantly associated with DVT in univariate analysis, one of them weighted from logistic multivariate regression coefficients. RESULTS: Recent DVT was diagnosed in 74 patients (15.7%) (29.6% after TKR and 8.4% after THR). There was no isolated proximal DVT and extensive DVTs were very rare (TKR 1.2% vs. THR 1%). Two TKR patients developed pulmonary embolism (1.2%). One died (0.6%). Univariate analysis showed significant association between provoked localized limb pain, pitting edema and difference in calf circumference (DCC), and DVT (P<0.0001). DCC> 3 cm was significantly associated with DVT (32.4% vs. 16.6%, OR 2.4 [1.3-4.2] ; P=0.001). In multivariate analysis the only two clinical manifestations independently associated with DVT were provoked localized limb pain (adjusted OR 2.3 [1.3-4.1] ; P<0.01) and DCC> 3 cm (adjusted OR 2.0 [1.1-3.8] ; P=0.04). A clinical score value greater or equal to 4 was associated with a risk of DVT of 34%, and a value<4 with a risk of 9%. CONCLUSIONS: After THR or TKR, DCC> 3 cm or a clinical risk score greater or equal to 4 could be used as an accurate and easy clinical test for assessing the need for further DVT screening by sonography.

[Quality standards for ultrasound assessment (CW-Doppler, Duplex US) of the lower limb arteries in vascular medicine. Report of the French Society for Vascular Medicine]. / Standards de qualité pour la pratique des examens Doppler et écho-Doppler artériel des membres inférieurs en médecine vasculaire. Rapport de la Société française de médecine vasculaire (SFMV).

The quality standards of the French Society of Vascular Medicine for the ultrasound assessment of lower limb arteries in vascular medicine practice are based on the principle that these examinations have to meet two requirements: technical know-how (knowledge of devices and methodologies); medical know-how (level of examination matching the indication and purpose of the examination, interpretation and critical analysis of results). OBJECTIVES OF THE QUALITY STANDARDS: To describe an optimal level of examination adjusted to the indication or clinical hypothesis; to homogenize practices, methodologies, terminologies, results description and report; to provide good practice reference points and to promote a high quality process. THEMES OF THE QUALITY STANDARDS: The three levels of examination, indications and objectives for each level; the reference standard examination (level 2) and its variants according to indications; the minimal content of the exam report, the medical conclusion letter to the corresponding physician (synthesis, conclusion and management suggestions); commented glossary (anatomy, hemodynamics, signs and symptoms); technical basis. Device settings. Here, we discuss CW-Doppler and Duplex ultrasound in various indications for lower limbs arteries assessment.

[The best of vascular medicine in 2004]. / L'essentiel de 2004 en médecine vasculaire.

The wealth of information in vascular pathology merits close examination. The French Cardiology Society vascular group turned its attention to arteries, veins, hypertension and a more fundamental investigation to analyse the results from some illuminating studies which appeared in 2004, despite some pertinent therapeutic doubts. Examination of the trials discussed here shows the importance, as much in vascular pathology as elsewhere, of founding our practice on evidence based medicine.

Influence of ploidy and metal-metal interactions on the accumulation of Ag, Cd, and Cu in oysters Crassostrea gigas thunberg.

The present study was designed to compare the response to contaminants in diploid with triploid specimens of the oyster Crassostrea gigas. The reproduction investment in bivalve molluscs has priority on somatic growth. Thus, genetic sterilization by triploidy induction enables the energy flux to be directed toward somatic growth and glucide storage. Bioaccumulation was examined for Ag (10 microg/L), Cd (10 microg/L), and Cu (30 microg/L) to determine if the response to metals follows similar patterns in diploid (2n) and triploid (3n) groups. The effect of ploidy was also evaluated as a function of dry weight of soft tissue and condition index. Moreover, the reciprocal influence of these metals on their incorporation was studied. The results showed that the major factor governing the degree of metal bioaccumulation by oysters is the nature of the metal introduced in the experimental medium. Thus, the uptake of Cd is proportionally more important than in the case of Ag and even more in Cu. For Cu-treated samples, the influence of ploidy on weight and metal body burden (and Cu concentration) was not significant, whereas for Ag and Cd, significant differences according to genetic type were evidenced by higher tissue weight and lower concentrations in triploid than diploid specimens. Metal-metal interactions study especially showed a reciprocal antagonism between Ag and Cu.

Aroma of fresh oysters Crassostrea gigas: composition and aroma notes.

In contrast to many foods, very little is known about the aroma of fresh oysters. This study deals with the relationship between extracted volatiles of oysters and their olfactory properties. Nearly 50 volatiles were identified: most of them were principally related to fatty acid oxidation (86%) and particularly to n-3 polyunstaturated fatty acid oxidation (66%). Only one volatile arose from amino acid degradation. Panelists detected 42 odors by sniffing. Among them, only 12 odors were definitely attributed to identified volatile. These odors were green/sulfur/crustacean, mushroom/citrus, and marine/cucumber notes and were attributed to dimethyl sulfide, 1-penten-3-one, hexanal, (2,4)-E,E-heptadienal, 1-octen-3-one, 1-octen-3-ol, 6-methyl-5-hepten-3-one, octanal, (E,Z)-2,6-nonadienal, (E)-2-octenal, and decanal, respectively.

Influence of parentage upon growth in Ostrea edulis: evidence for inbreeding depression.

Genetic variability for growth was analysed in three populations of Ostrea edulis, selected for resistance to the protozoan parasite Bonamia ostreae. This study was undertaken first to determine the potential for selection for growth in populations that have never been selected for this character, and second to estimate heterosis versus inbreeding depression. Growth was monitored in culture for 10 months. The selected populations (namely S85-G3, S891-G2 and S89W-G2), their crossbred population and a control population were composed of full-sib families whose parents were already genotyped using five microsatellite markers. This genotyping allowed the estimation of genetic relatedness among pairs of parents. The parents' relatedness was then correlated with the growth performance of their offspring within each of the three populations, and inbreeding depression was estimated. The population effect for growth was highly significant, with the crossbred population having the highest growth rate, followed by S891-G2 and S89W-G2, S85-G3 and the control population. The within-populations family effect was also highly significant, indicating, as well as the high value for heritability at the family level (between 0.57 and 0.92), that a potential for a further selection for growth still exists within the three populations. Estimates of inbreeding depression (relative to the mean, for complete inbreeding) were high (1 for S891-G2, 0.44 for S89W-G2 and between 0.02 and 0.43 for S85-G3), which correlates with the apparent heterosis for growth observed in the crossbred population. These results are discussed in the context of the future management of the selected populations.