Utility of panoramic radiographs in detecting cervical calcified carotid atheroma.

OBJECTIVE: The objective of this study was to determine the utility of panoramic radiographs for detecting extracranial calcified carotid atheroma and carotid luminal stenosis. STUDY DESIGN: Panoramic radiographs were obtained on 52 adult participants who had carotid ultrasound examination. Extent of carotid calcification and stenosis was determined by a cardiologist from ultrasound reports, which were considered gold standard assessments. A trained and calibrated oral and maxillofacial radiologist interpreted the radiographs for presence or absence of carotid calcifications. We examined the utility of panoramic radiographs to diagnose any carotid artery changes (diagnostic scheme 1) or only moderate to severe changes (scheme 2). Generalized estimating equations were used to account for clustering of observations within subjects. RESULTS: Under diagnostic schemes 1 and 2, radiographs had low sensitivity to detect carotid calcifications (31.1% and 25.0%, respectively) and stenoses (22.7% and 21.4%, respectively). CONCLUSIONS: When compared to ultrasonography, panoramic radiography is not a reliable means to detect carotid artery calcifications or stenoses.     

The significance of carotid artery atheromas on panoramic radiographs in the diagnosis of occult metabolic syndrome.

OBJECTIVE: Metabolic syndrome (MetS), the co-occurrence of abdominal obesity, hypertriglyceridemia, reduced HDL cholesterol, hypertension, and insulin resistance promotes carotid atherosclerosis and stroke. The objective of this study was to determine if the presence of calcified atheromas detected on panoramic radiographs of individuals free of overt vascular disease may herald occult MetS. STUDY DESIGN: Ninety-four individuals (mean age 65.6 years) with a calcified atheroma detected by a VA dental clinic were evaluated. A like-aged group was used for comparative analysis. RESULTS: Fifteen percent of individuals (mean age 64 years) with an atheroma had occult MetS. Mean waist circumference was 116 cm, BMI 32.7 kg/m2, triglycerides 250 mg/dL, HDL cholesterol 35 mg/dL, blood pressure 147/87 mm Hg, and glucose 117 mg/dL. Only 6% of controls had occult MetS but this difference in prevalence was not proven to be statistically significant (P = .059). CONCLUSION: Some individuals with a calcified atheroma may have undiagnosed MetS and should be referred to their physician because aggressive management may preclude a stroke.     

Correlation between carotid area calcifications and periodontitis: a retrospective study of digital panoramic radiographic findings in pretreatment cancer patients.

OBJECTIVES: The objective of this study was to examine the prevalence of carotid area calcifications retrospectively detected on digital panoramic radiographs of pretreatment cancer subjects, and to correlate the finding of such calcifications with radiographic evidence of periodontal bone loss in the same subjects. STUDY DESIGN: Digital panoramic radiographs of 201 subjects were evaluated for calcifications projected in the carotid artery bifurcation area as well as for alveolar bone loss as a result of periodontal disease. Inclusion criteria were unobscured carotid artery bifurcation regions bilaterally and sufficient index teeth present with a definable cemento-enamel junction and alveolar crest. Radiographs were independently observed for carotid area calcifications and for periodontal status. Image enhancements permitted for detection of calcifications projected in the carotid area included window/level, inverse, and emboss. Periodontal measurements were made on index teeth using proprietary imaging software and a mouse-driven measurement algorithm. A 3-factor analysis of variance was performed with 3 between-subjects comparisons. Percentage of bone loss was the dependent variable. Independent variables were age, subject sex, and the presence or absence of carotid area calcifications. RESULTS: Differences measured in percentage of bone loss between sexes were not statistically significant. While bone loss did increase with age, comparison of the mean bone loss of each age category revealed no statistical significance. There was a highly significant correlation between carotid artery area calcifications visible on panoramic radiographs and percent alveolar bone loss. Radiographs showing unilateral and bilateral calcifications had a mean percent bone loss of 24.2% +/- 12.6% and 25.7% +/- 13.0% respectively, compared to those with no calcification at 10.4% +/- 9.9%. CONCLUSIONS: Nearly 1 in 4 subjects in this study evidenced calcifications projected in the carotid bifurcation region. The finding of such calcifications was significantly related to the calculated percentage of alveolar bone loss.     

Prevalence in digital panoramic radiographs of carotid area calcification among Iraqi individuals with stroke-related disease.

OBJECTIVE: The purpose of this study was to determine the prevalence of carotid calcification on digital dental panoramic tomography in a group of the Iraqi population who have some stroke-related vascular and or metabolic disease. STUDY DESIGN: Digital dental panoramic tomographic images of 157 adult patients of age range 40-80 years having chronic illnesses such as coronary heart diseases, hypertension, type 2 diabetes, and hyperlipidemia and of 43 control subjects (age range 40-71 years, free of systemic diseases) were made and examined for the presence of carotid artery calcification adjacent or just below the intervertebral space between C3, C4, and C5 on both sides of patient's neck. The study group was subclassified into vascular, metabolic, and vascular-metabolic groups. Determinations were made of the prevalence, number, and distribution of carotid area calcifications. Forward stepwise logistic regression analysis was used to determine which risk factor is more liable to develop carotid artery area calcification. RESULTS: The statistical difference between patients with stroke-related diseases (vascular, metabolic, and vascular-metabolic groups) versus patients in the control group was highly significant concerning the prevalence of carotid area calcifications (P < .01). Carotid area calcification was identified in 38.8% of the study group. Bilateral calcifications were observed more than unilateral calcification for both genders (26.6% vs. 13.9% for men; 24.4% vs. 12.8% for women). CONCLUSION: People with stroke-related vascular and/or metabolic diseases have greater prevalence of calcified area calcifications seen on panoramic radiographs than people who are otherwise healthy.     

Can the presence of carotid artery calcification on panoramic radiographs predict the risk of vascular diseases among 80-year-olds?

OBJECTIVE: The purpose of this study was to evaluate whether subsequent vascular diseases and related death could be predicted by the presence of carotid artery calcification detected on panoramic radiographs among elderly persons. STUDY DESIGN: We evaluated 659 panoramic radiographs from 262 male and 397 female 80-year-old subjects and their general medical examination data to assess the relationship between the presence of carotid artery calcification and vascular disease risk at baseline examination. Of these subjects, the occurrence of vascular diseases within 5 years after baseline examination was examined in 191 subjects. Further, the causes of death were examined in 108 subjects who died within 5 years after baseline examination. RESULTS: There was a significant difference in the history of past vascular diseases among subjects with and without carotid artery calcifications; however, no significant difference in the occurrence of subsequent vascular diseases was found among them. Further, there was no significant difference in the occurrence of vascular disease-related death within 5 years after baseline examination among subjects with and without carotid artery calcifications (P = 0.719). CONCLUSION: Our results suggest that the presence of carotid artery calcifications on panoramic radiographs may be related to the history of past vascular diseases; however, this is not a useful marker for subsequent vascular diseases and related death among 80-year-olds.     

Panoramic radiographic atheromas portend adverse vascular events.

OBJECTIVE: This study sought to determine if calcified carotid artery atheromas (CCAA) imaged on panoramic radiographs portend an adverse vascular event. STUDY DESIGN: Medical records of 46 males (mean age 66) with a CCAA (Group 1) were reviewed for preimaging vascular risks and for cerebrovascular events subsequent to the radiograph. Matched controls (age, gender, ethnicity, and vascular risks) treated at the same hospital but never radiographed were identified (Group 2) and matched to their cohort. The medical records of Group 2 individuals were re-reviewed for development of vascular events occurring after the date of their cohort's radiograph. RESULTS: Twenty adverse vascular events (myocardial infarct, stroke, revascularization procedure, transient ischemic attack, angina requiring hospitalization) occurred in twelve Group 1 patients and 6 events occurred in five Group 2 patients (P = 0.006). CONCLUSION: The incidental finding of a CCAA portends significant risk of a future, adverse vascular event.     

Carotid artery calcification detected on panoramic radiographs in a group of Thai population.

OBJECTIVE: To determine the prevalence of carotid artery calcification (CAC) detected on panoramic radiographs in a Thai population. STUDY DESIGN: The panoramic radiographs of the patients 50 and older (N = 1,370) visiting Mahidol University from January 1998 through September 2004 were retrospectively reviewed for CAC. The medical records of the positive subjects were then reviewed. RESULTS: Thirty-four (2.5%) of the 1,370 patients, 16 men and 18 women, with a mean age of 69 and a range of 50 to 87 years, had 1 or more CACs. These calcifications were unilateral in 25 (73.5%) and bilateral in 9 (26.5%) subjects. Of those positive subjects, 18 reported hypertension, 10 reported diabetes mellitus, and 5 reported hyperlipidemia. CONCLUSIONS: Although it is uncommon to find CAC in the Thai population, dentists should be aware of this calcification on the routine panoramic radiographs and promptly refer for cerebrovascular and cardiovascular evaluation.     

Intrathoracic carotid bifurcation in Klippel-Feil syndrome

Intrathoracic carotid bifurcation is rare with only five other cases reported. This anatomic variant with posteromedial origin of the internal carotid artery (ICA) appears to be part of the Klippel-Feil syndrome, a rare congenital defect characterized by fusion of the cervical vertebrae. Caution is advised when planning thoracic and cervical vascular procedures. Angiography carries higher risk of unintentional ICA catheterization due to the short common carotid artery length. The intrathoracic location of the carotid bifurcation makes endarterectomy difficult and patients may do better with carotid artery stenting. Ultrasound can be confusing in these patients and MRA may be preferable.     

Relationship between oxidative stress parameters and atherosclerotic signs in the carotid artery of stable renal transplant patients

Reactive oxygen species (ROS) may participate in atheroma plaque formation, which may be noninvasively diagnosed by Doppler ultrasound of carotid artery. We sought to determine the relationship between the presence of carotid artery lesions and oxidative parameters to identify factors that may influence these lesions in renal transplant patients. Fifty renal transplanted patients with stable renal function and without diabetes mellitus were studied for more than 1 year posttransplantation. Echo Doppler examination of the carotid artery was performed to assess the intimal media thickness (IMT), atheroma plaques, calcification, and stenosis. Data were collected on oxidative parameters: malondialdehyde (MDA), glutathione peroxidase (GPx), catalase, superoxide dismutase (SOD), glutathione reductase (GR), and lipid profile. The serum GPx level among patients without atheroma plaques, calcification, or stenosis was higher than in those with ultrasound signs. The LDL cholesterol fraction was lower in patients with no ultrasound signs of atherosclerotic lesions; total cholesterol values showed the same behavior. In conclusion, transplanted patients with atheromatous plaques, calcification, and carotid stenosis have a greater degree of hypercholesterolemia and lower antioxidant activity (lower GPx). Recipient age was the principal risk factor for the presence of increased IMT, atheroma plaque, calcification, and/or stenosis of carotid artery in renal transplant patients.     

Mobile atheroma of the aortic arch and the risk of carotid artery disease.

BACKGROUND: Mobile atheromas of the aortic arch are associated with otherwise unexplained strokes and transient ischemic attacks (TIA). They are associated with increased perioperative strokes in patients undergoing coronary artery bypass surgery. Peripheral embolization is an additional risk. Transesophageal echocardiography (TEE) accurately identifies mobile atheroma. Anticoagulant therapy may have therapeutic considerations in the management of this condition. However, the risk of significant carotid artery disease associated with mobile atheromas is unknown. METHODS: Between March 1994 and July 1998, 40 patients with mobile atheromas by TEE and evidence of embolization were studied. All patients were captured prospectively in a vascular registry and were retrospectively reviewed. Carotid artery disease was evaluated using carotid duplex imaging in an accredited vascular laboratory. All patients with significant carotid disease, 70% or greater stenosis, underwent arteriography. Patients with significant carotid artery stenosis then underwent carotid endarterectomy. All patients with mobile atheromas were maintained on anticoagulation. RESULTS: Forty patients with mobile atheromas of the aortic arch were diagnosed with TEE. All 40 patients had evidence of embolization. Patient age ranged from 57 to 73 years (mean 68.4). There were 22 men and 18 women. Twenty of 40 (50%) patients presented with symptoms of TIA. Eleven of 40 (28%) patients presented with diffuse atheroembolization (lower extremity embolization and renal insufficiency). Six of 40 (15%) patients presented with a completed stroke. Three of 20 (7%) patients presented with acute extremity ischemia secondary to a peripheral embolus. Twenty-three of 40 (58%) of patients had significant carotid artery stenosis, 70% or greater stenosis. These 23 patients underwent both arteriography and carotid endarterectomy without complication. All patients were treated with anticoagulation and have remained anticoagulated. Clinical follow-up between 2 to 48 months (mean 18) has demonstrated no further evidence of systemic embolization in these 40 patients. Repeat TEE was performed in 6 of 40 patients. These follow-up studies no longer visualized mobile atheromas. CONCLUSIONS: Mobile atheromas are recognized sources for embolization. Routine carotid duplex imaging should be performed in patients found to have mobile atheromas of the aortic arch. Carotid endarterectomy appears to be safe in patients who have combined carotid artery stenosis and mobile atheromas. Anticoagulation may have therapeutic considerations in the management of this condition.     

颈椎软骨终板钙化与颈椎间盘退变和椎体骨赘形成的关系

目的：研究颈椎软骨终板钙化与颈椎间盘退变和颈椎椎体骨赘形成的关系。方法：应用组织学方法观察颈前路环锯手术切下的18例脊髓型颈椎病和4例颈椎过伸性损伤致颈椎间盘突出患者的颈椎间盘及相邻的上下椎体标本,研究不同退变程度颈椎间盘软骨终板和椎间盘的形态学变化及椎体骨赘形成过程。结果：退变程度较轻或基本正常的颈椎间盘软骨终板结构良好,潮标清晰,退变程度较重的颈椎间盘软骨终板发生明显纤维化,潮标前移,钙化软骨和软骨下骨板增厚,退变颈椎间盘周边软骨终板潮标明显前移,钙化和骨化层增厚,形成突向外侧的椎体边缘的骨赘。结论：颈椎软骨终板的不断钙化和骨化导致颈椎间盘营养发生障碍可能是启动颈椎间盘退变的关键因素,退变椎体周边软骨终板的不断钙化和骨化是椎体骨赘形成的根本原因。     

Effect of lipid modification on progression of coronary calcification

Coronary artery calcification (CAC) reflects the anatomic presence of coronary atherosclerosis and the relative burden of coronary artery disease (CAD). Higher levels of CAC are seen in the presence of CAD risk factors, older age, and chronic kidney disease. The lipid profile (primarily low HDL cholesterol, elevated triglycerides, elevated LDL cholesterol, and elevated total cholesterol) are important factors in the calcification process. The annual progression of CAC can be reduced from 25 to 30% to 0 to 6% with LDL cholesterol reduction caused by statins and possibly sevelamer. At treated LDL cholesterol levels somewhere below 100 mg/dl, several sources of data suggest the anatomic burden of CAD, including CAC, regresses. Additional supportive studies indicate that carotid intimal medial thickness and the volume of coronary atheroma also can be reduced by LDL cholesterol reduction in concert with elevation of HDL cholesterol. This article reviews the data in support of altering the natural history of CAC with lipid modification.     

Artery-to-artery embolism due to ruptured calcified carotid plaque

Calcified carotid plaques are thought to be less likely to be symptomatic than non-calcified plaques. We present a patient with an unusual cerebral embolism that appeared as very high density on CT and was ascertained to derive from a calcified plaque. This 46-year-old male was admitted within 1 hr of sudden aphasia onset. The admission CT scan showed multiple high-intensity lesions that appeared like calcification. They were high intensity on MRI FLAIR images. MRA showed occlusion of the posterior trunk of the middle cerebral artery. As we considered cerebral embolism, the patient received heparin followed by warfarin. Routine MRA and DSA detected no abnormality, however, a carotid echogram showed a hyperechoic plaque at the left carotid bifurcation. As the NASCET method indicated 6.5% stenosis, carotid endarterectomy was not indicated. However, the thrombus at the bifurcation gradually enlarged despite adequate medical treatment (PT-INR 2.2 - 2.7) and we decided to surgically remove the calcified plaque, thought to be the embolus source. We removed the plaque content through a defect in the plaque membrane. Intraoperatively we found that the rapidly enlarging lesion was the plaque content rather than a thrombus. Pathologically, calcification was more dominant than atherosclerosis. His postoperative course was good and he required only aspirin. This case was peculiar in that the calcification mimicked a hyperdensity embolus and that the lesion derived from a calcified plaque which is usually stable. Repeat carotid ultrasonography is easy and useful when routine investigation fails to reveal the embolic source.     

Usefulness of three-dimensional CT angiography (3D-CTA) with a single bolus injection of contrast material for the examination of intracranial and cervical arteries in cerebrovascular disease screening]

Three-dimensional CT angiography (3D-CTA) has been gaining wide acceptance as a clinically useful tool in the field of neurosurgery. The great diagnostic value of 3D-CTA for cerebral aneurysm or other cerebrovascular diseases has been well established. However, images of the intracranial and cervical arteries have not been obtained simultaneously because of the limitation of the scanning area and the need for contrast material. In order to use 3D-CTA to screen for cerebrovascular disease, we used a helical CT scan with an intravenous single bolus injection of contrast material to perform 3D-CTA of the intracranial and cervical arteries simultaneously. A spiral computed tomographic scan was performed with a Hispeed Advantage RP (General Electric). After injection of 150 ml of nonionized contrast material at a rate of 3 mm/sec in an antecubital vein, an axial computed tomographic scan (120 kV, 200 mA) of the cranial region was performed with a delay of 20-25 seconds after starting the injection. Section thickness was 1 mm with table increments of 1 mm per rotation. The scan volume included 20-30 mm above and below the sella turcica. An axial computed tomographic scan (120 kV, 190 mA) of the cervical region was performed with a delay of 30 seconds after completion of cranial CTA. Section thickness was 3 mm with table increments of 3 mm per rotation. Image reconstruction was carried out through surface rendering and maximum intensity projection processing. From November 1995 to August 1998, we used this technique to screen 218 consecutive outpatients for cerebrovascular disease. Unruptured cerebral aneurysms were found in 20 cases (9.2%). Atherosclerotic diseases of the cervical carotid artery were found in 58 cases (26.6%), as follows: carotid artery occlusion in 2 cases, carotid bifurcation stenosis in 22 cases, and intramural calcification of the internal carotid artery in 50 cases. Atherosclerotic diseases of the intracranial artery were found in 99 cases (45.4%), as follows: middle cerebral artery occlusion in 2 cases, middle cerebral artery stenosis in 21 cases, internal carotid artery stenosis in 2 cases, and calcification of the carotid siphon in 78 cases. Although our method has various technical problems that require further improvement, we conclude that it is a useful and noninvasive diagnostic modality for screening patients for cerebral aneurysms and other cerebrovascular diseases.     

软骨终板钙化与椎间盘退变关系的实验研究

目的　研究椎体软骨终板钙化与椎间盘退变的关系。　方法　通过切除２０ 只兔颈椎棘上、棘间韧带及分离颈椎后旁两侧肌肉造成颈椎力学上的失稳而诱导了颈椎间盘退变动物模型。在形态学上评定颈椎间盘退变程度,测定不同退变程度椎间盘软骨终板钙化层与非钙化层厚度。　结果　软骨终板钙化层厚度与椎间盘退变程度呈高度正相关性（ｒ＝ ０－９２） 。　结论　软骨终板的钙化可能是椎间盘退变的启动和促进因素     

Radiological evaluation of the styloid process in young adults resident in Turkey's Yeditepe University faculty of dentistry.

OBJECTIVES: This study evaluated and classified the radiographic appearance of the styloid process (SP) patterns of calcification according to subject gender. The relationship between SP length and the limits of mandibular protrusion was studied. STUDY DESIGN: The panoramic radiographs of 55 young adults were analyzed. Elongated SPs were classified with the radiographic appearance based on length, morphology, and calcification pattern. The data were analyzed by using chi-squared and 1-way ANOVA with significance set at P < .05. RESULTS: "Elongated" (Type I) SP with "calcified outline" was the most frequent SP type and calcification pattern. No correlation was found between SP type and calcification pattern and subject gender. No differences were proven based on laterality of the SP. A relationship between mandibular protrusive movement and SP calcified length was not proven. CONCLUSION: Elongation of calcification of SP in young adults is common with no correlation to gender, laterality, or mandibular protrusive limitation. "Type I" with "calcified outline" of the SP was observed most frequently in the population studied.     

Extraskeletal osteochondromas of the wrist

Extraskeletal osteochondromas of the wrist are described in two patients. They both had painless, slow-growing wrist masses, one palmar and one dorsal. Radiographs demonstrated the presence of an extraskeletal, radiopaque mass. Excisional biopsy showed extraskeletal, firm, calcified masses. Histologic examination revealed mature hyaline cartilage, with extensive ossification consistent with the diagnosis of extraskeletal osteochondroma. The ambiguous nomenclature for this cartilage lesion and the differential diagnosis of extraskeletal calcification are reviewed.     

Anatomical variations of the common carotid artery bifurcation

BACKGROUND: The correlation of the common carotid artery (CCA) bifurcation and its surrounding structures is poorly described. The aim of this study was to describe the anatomy of the CCA bifurcation relative to its surrounding structures. METHOD: We dissected a total of 67 carotid specimens from 36 embalmed cadavers. CCA bifurcation occurred at the superior border of thyroid cartilage in 39% and at the body of hyoid bone in 40% of specimens. RESULTS: The superior thyroid artery arose more commonly from the CCA (52.3%) than the external carotid artery (46.2%). The vagus nerve was posterior to the carotid bifurcation in 40 (60%), posterior-lateral in 24 (36%), posterior-medial in 2 (3%) and anterior-lateral in 1 specimen (1.5%). The hypoglossal nerve was closer to the CCA bifurcation when the CCA bifurcated at the level of the hyoid bone than when it bifurcated at the superior border of the thyroid cartilage (P < 0.05). The correlation of the common facial vein and the carotid artery was highly variable. CONCLUSION: The presence of a high CCA bifurcation should caution surgeons that the hypoglossal nerve lies in closer proximity and is more vulnerable. Preoperatively documenting the level of the CCA bifurcation may be helpful in identifying those patients at increased risk of iatrogenic injury.     

Cervical radiculomyelopathy caused by deposition of calcium pyrophosphate dihydrate crystals in the ligamenta flava. Case report

A case of cervical radiculomyelopathy caused by multiple calcified nodules in the ligamenta flava is presented. Roentgenological examination of the cervical spine showed radiopaque nodular lesions, 7 x 7 x 5 mm in size, located in the paramedian portion of the posterior spinal canal. The nodules were removed surgically and they were confirmed to be calcifications of ligamenta flava. Microscopic examination of the nodules with the polarized light revealed extensive deposition of crystals. By x-ray diffraction study, the crystal was determined as calcium pyrophosphate dihydrate (CPPD: Ca2P2O7 . 2H2O). Although CPPD deposition in the cartilage has been known as pseudo-gout syndrome, deposition in the ligament has been reported only in a few cases. This is the first case with radiopaque calcified nodules in the ligamenta flava causing spinal cord compression, the composition of which proved to be CPPD.     

Computed tomographic evaluation of extracranial carotid artery disease

Axial computed tomographic (CT) scans after intravenous contrast infusion were used to image the cervical carotid arteries of patients with cerebral ischemic symptoms. Standard transfemoral cervical carotid and cerebral angiography was the principal diagnostic modality used in all patients studied. The angiographic results were compared to the CT images and to the gross and microscopic endarterectomy pathological specimens, when available. Examples of the various types of abnormalities that can be visualized using CT scans are presented. The CT scan was useful for determining the presence of degenerative atheromatous changes including carotid artery calcification, subintimal hemorrhage, carotid occlusion, carotid segmental occlusion, and carotid pseudoocclusion, as well as carotid artery dissection. The scans were particularly useful for identification of atheromatous carotid artery disease when the carotid angiogram appeared nearly normal and for identifying the cause of postoperative carotid stenosis. CT scanning allows visualization of the carotid artery wall and lumen rather than just the lumen and, consequently, can sometimes add helpful information about the pathological processes affecting this artery.