Abstract
Mobile plaque is associated with increased risk of ischemic stroke, but definitions have remained unclear. We have previously reported that carotid ultrasonography can detect the mobile component of the carotid plaque surface, which rises and falls in a manner inconsistent with arterial pulsatile wall motion (Jellyfish sign). However, clinical and pathological features of Jellyfish sign remain unclear. The subjects comprised of 165 patients with carotid plaque and degree of area stenosis ≥50% on ultrasonography. Using magnetic resonance imaging, we quantified intraplaque hemorrhage (IPH) and defined ischemic stroke in each patient. Fifteen surgical specimens were obtained by carotid endarterectomy, and pathological features (area of fibrous cap and intraplaque atheromatous lesion) were compared with ultrasonographic plaque surface movement rate. Carotid plaques with IPH were seen in 78 cases, with Jellyfish sign in 31 cases. Jellyfish sign was not detected in patients without IPH. In these 15 patients, the fibrous cap covered the atheromatous lesion, and cap thickness correlated negatively with Jellyfish-positive plaque surface movement rate. Kaplan–Meier and Cox multiple regression analysis demonstrated that the most important predictor of ischemic stroke during follow-up is Jellyfish sign, not IPH. Stroke events in patients with Jellyfish sign repeated within a short interval after diagnosis. Jellyfish sign on ultrasonography is a sign of high-risk plaque vulnerability, suggesting rupture of the fibrous cap associated with the release of thrombogenic factors into the arterial lumen, and resulting in repeated ischemic stroke during a short interval after diagnosis.
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Acknowledgements
The authors thank Masuki Kobayashi, M.D., Junichi Kanazawa, M.D., Seiichirou Hibino, M.D., Chie Mihara, M.D. (Hibino Hospital), and Akihiro Toyota, M.D. (Chugoku Rosai Hospital), for the collection of follow-up data and helpful comments.
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Dorothea Miller, Ulrich Sure, Essen, Germany
Kume and colleagues demonstrated in this article how ultrasonography might help in predicting the risk of ischemic stroke in patients with carotid stenosis.
Ultrasound was performed to determine plaque morphology in cases of carotid stenosis. Ultrasound features with focus on plaque surface movement (Jellyfish sign) were compared with pathological features in 15 surgical specimens. Moreover, MRI was used to quantify intraplaque hemorrhage, as well as ischemic stroke.
The authors could show that Jellyfish sign was only detected in cases with intraplaque hemorrhage on MRI. Jellyfish sign was negatively correlated to fibrous cap thickness in surgical specimens. Statistical analysis revealed Jellyfish sign as the most important predictor of ischemic stroke during follow-up.
The idea that unstable or ruptured atheromatous plaques bear an increased risk of stroke is not new. However, little has been published on ultrasound diagnostics of unstable plaques, as well as its predictive value for ischemic stroke. Carotid ultrasonography is an inexpensive and widely available diagnostic tool. Thus, the study presented by the authors is highly relevant for clinical practice.
However, there are some limitations of the study. The authors do not correlate signs of plaque rupture directly on ultrasound and MRI. Correlations with pathological specimens could only be performed in a small number of cases.
Thus, the ultrasound feature termed “Jellyfish sign” by the authors could be an important predictive sign in patients at risk of stroke, although further validation of the methodology will still be necessary.
Kazunori Arita, Kagoshima, Japan
The development of ultrasonographic scanning of the carotid artery has provided valuable information on the pathophysiologic nature of atheromatous plaques of the cervical carotid arteries. Ultrasonographically identified floating plaques are a well-known risk factor for ischemic stroke. The authors describe the rise and fall motion of the carotid plaque surface that is inconsistent with arterial pulsatile wall motion. This, a finding different from floating plaque, they name the “Jellyfish sign”. They found that this movement predicts the early recurrence of stroke and postulate that the Jellyfish sign is a result of plaque rupture associated with the continuous release of thrombogenic factors into the arterial lumen. Their findings may contribute significantly to the proper management of carotid artery stenosis. They also suggest that the early surgical treatment of plaques exhibiting the Jellyfish sign is justified, especially in patients with recurrent ischemic stroke during a short period of time.
As the authors indicate, their current findings must be confirmed in large cohorts that include patients with less than 50% stenosis. Changes in the Jellyfish sign in the long run and the response to medical treatment with, for example, statins, may be the next study targets.
Electronic supplementary materials
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Digital video of plaque surface motion of Jellyfish sign in Case 1. Arrow shows the Jellyfish sign-positive part. CCA common carotid artery, ICA internal carotid artery. (MPG 1307 kb)
Digital video of plaque surface motion of Jellyfish sign in Case 2. Arrow shows the Jellyfish sign-positive part. CCA common carotid artery, ICA internal carotid artery. (MPG 546 kb)
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Kume, S., Hama, S., Yamane, K. et al. Vulnerable carotid arterial plaque causing repeated ischemic stroke can be detected with B-mode ultrasonography as a mobile component: Jellyfish sign. Neurosurg Rev 33, 419–430 (2010). https://doi.org/10.1007/s10143-010-0270-9
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DOI: https://doi.org/10.1007/s10143-010-0270-9