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Detection of calcifications within the course of internal carotid artery as incidental findings in CBCT scans. Is it important for patients?

Heraldo Luis Dias Da Silveira

Professor of Oral Radiology, Department Surgery and Orthopedics, Rio Grande do Sul Federal University – UFRGS, Brazil

E-mail : bhuvaneswari.bibleraaj@uhsm.nhs.uk

DOI: 10.15761/DOCR.1000205

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Stroke was the second most frequent cause of death after coronary artery disease in 2013, accounting around 6.4 million deaths (12% of the total). About 3.3 million deaths resulted from ischemic stroke [1]. A study embedded in the population-based Rotterdam Study that has comprised 2521 persons (mean age 69.7 ± 6.8 years) that underwent an MDCT scan has used multivariable logistic regression to investigate the associations of calcification in the internal carotid artery (ICA) with presence of stroke. It was found a strong and graded association of prevalent stroke with ICA calcification, independent of cardiovascular risk factors [2].

Calcification in atherosclerotic plaques is a marker of atherosclerosis and is related to cardiovascular disease [3]. The severity of intracranial artery calcification on brain CT is significantly correlated with coronary artery calcium scores as determined by CT coronary angiography among patients previously believed free of atherosclerotic heart disease [4]. Several non-invasive imaging technologies now make it possible to identify subclinical atherosclerosis before symptoms appear or major vascular events occur. These include B-mode ultrasound to measure carotid intima-media thickness, CT to measure coronary artery calcification, and high-resolution magnetic resonance imaging to evaluate plaque size and composition [5].

Many risk factors for atherosclerosis are known: diabetes, dyslipoproteinemia, tobacco smoking, dietary habits and elevated serum C-reactive protein concentrations [6,7]. Stroke risk is modifiable through many risk factors, one being healthy dietary habits. A study assessed the association between intake of total fiber and fiber sources and stroke incidence on 69,677 healthy Swedish adults (aged 45-83 y). During 10.3 y of follow-up, 3680 incident stroke cases were ascertained. The findings indicate that intake of dietary fiber, especially fruit and vegetable fibers, is inversely associated with risk of stroke [8].

Although several modifiable cardiovascular risk factors are associated with carotid calcification growth, a time and baseline calcification load remain the most important determinants of calcification development [9]. Face to these data and the high cost of treatment of stroke, preventive strategies should be thought [10].

Studies show that the quality of carotid atherosclerosis visualization by conventional CT does not differ from that of CBCT [11,12]. A study that evaluated the incidence of extracranial calcifications in course of ICA (ExCICA) and intracranial calcification in ICA (InCICA) on cone beam computed tomography scans shows that the possibility of detectable ExCICAs and InCICAs increases with increasing age; this is more prominent for InCICAs. The possibility of detecting ExCICAs and InCICAs in the 60-69 age group increased, respectively, up to 12.46 and 20.32 times compared with the 40-49 group [13]. Other study with CBCT scans reveals that the identification of certain anatomic landmarks enables the detection of calcifications as incidental findings along the course of the segments of the ICA, including the extracranial C1 segment and the intracranial petrous (C2), lacerum (C3), cavernous (C4), clinoid (C5), and ophthalmic (C6) segments. Furthermore, carries that the stringency of calcification increases with increasing age, especially in the C1, C4, and C5/ C6 segments [14].

The CBCT imaging protocol should include the smallest FOV necessary and available [15]. However, in several situations, patients are undergone larger FOV for dental purposes, as in cases of implants placement in both dental arcs and mostly for orthognathic surgery planning. Either way all CBCT volumes, regardless of clinical application, should be evaluated for signs of abnormalities systematically [15]. Oral radiologists should be attent and aware that ICA calcification is a serious incidental finding that should unquestionably involve referring of these patients to physicians for further evaluation [16].

Thus, knowing the chance of calcifications detection in the intra and extracranial segments of the ICA according to the age group, the magnitude and location more frequent in each intracranial segment, can make identification easier by oral and maxillofacial radiologists. Finally, we can assume that CBCT is an opportunity for the early identification of calcifications in the ICA and this way to contribute unequivocally to more accurate medical treatment strategies.

References

  1. GBD 2013 Mortality and Causes of Death, Collaborators (2015) Global, regional and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet 385: 117-171. [Crossref]
  2. Elias-Smale SE, Odink AE, Wieberdink RG, Hofman A, Hunink MGM, et al. (2010) Carotid, aortic arch and coronary calcification are related to history of stroke: The Rotterdam Study. Atherosclerosis 212: 656-660. [Crossref]
  3. Bos D, Ikram MA, Elias-Smale SE, Krestin GP, Hofman A, et al. (2011) Calcification in major vessel beds relates to vascular brain disease. Arterioscler Thromb Vasc Biol 31: 2331-2337.
  4. Ahn SS, Nam HS, Heo JH, Kim YD, Lee S-K, et al. (2013) Ischemic stroke: measurement of intracranial artery calcifications can improve prediction of asymptomatic coronary artery disease. Radiology 268: 842-849. [Crossref]
  5. Santos RD, Nasir K (2009) Insights into atherosclerosis from invasive and non-invasive imaging studies: Should we treat subclinical atherosclerosis? Atherosclerosis 205: 349-356. [Crossref]
  6. Kumar V, Abbas AK, Aster J (2013) Robbins Basic Pathology, 9th ed., Elsevier Health Sciences.
  7. Narain VS, Gupta N, Sethi R, Puri A, Dwivedi SK, et al. (2008) Clinical correlation of multiple biomarkers for risk assessment in patients with acute coronary syndrome. Indian Heart J 60: 536-542. [Crossref]
  8. Larsson SC, Akesson A, Wolk A (2014) Healthy diet and lifestyle and risk of stroke in a prospective cohort of women. Neurology 83: 1699-1704. [Crossref]
  9. Van Gils MJ,  Bodde MC, Cremers LG, Dippel DW, Van Der Lugt A (2013) Determinants of calcification growth in atherosclerotic carotid arteries; a serial multi-detector CT angiography study. Atherosclerosis 227: 95-99. [Crossref]
  10. Mackay J, Mensah GA, Mendis S, Greenlund K (2004) The atlas of heart disease and stroke. World Health Organization.
  11. Heiland M, Pohlenz P, Blessmann M, Habermann CR, Oesterhelweg L, et al. (2007) Cervical soft tissue imaging using a mobile CBCT scanner with a flat panel detector in comparison with corresponding CT and MRI data sets. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 104: 814-820. [Crossref]
  12. Kasraie N, Mah P, Keener CR, Clarke GD (2014) Characterization of atherosclerotic plaque: a contrast-detail study using multidetector and cone-beam computed tomography. J Appl Clin Med Phys 15: 290-302. [Crossref]
  13. Da Silveira HL, Damaskos S, Arús NA, Tsiklakis K, Berkhout WER (2016) The presence of calcifications along the course of internal carotid artery in Greek and Brazilian populations: a comparative and retrospective cone beam CT data analysis. Oral Surg Oral Med Oral Pathol Oral Radiol 121: 81-90. [Crossref]
  14. Damaskos S, Da Silveira HL, Berkhout WER (2016) Severity and presence of atherosclerosis signs within the segments of internal carotid artery: CBCT's contribution. Oral Surg Oral Med Oral Pathol Oral Radiol 122: 89-97. [Crossref]
  15. Tyndall DA, Price JB, Tetradis S, Ganz SD, Hildebolt C, et al. (2012) Position statement of the American Academy of Oral and Maxillofacial Radiology on selection criteria for the use of radiology in dental implantology with emphasis on cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol 113: 817-826. [Crossref]
  16. Schulze R, Friedlander AH (2013) Cone beam CT Incidental findings: intracranial carotid artery calcification—a cause for concern. Dentomaxillofac Radiol 42: 20130347. [Crossref]

Editorial Information

Editor-in-Chief

Shigeru Watanabe
Meikai University

Article Type

Editorial

Publication history

Received date: February 04, 2017
Accepted date: February 16, 2017
Published date: February 20, 2017

Copyright

© 2017 Da Silveira HLD. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Da Silveira HLD (2017) Detection of calcifications within the course of internal carotid artery as incidental findings in CBCT scans. Is it important for patients? Dent Oral Craniofac Res 3: DOI: 10.15761/DOCR.1000205

Corresponding author

Heraldo Luis Dias Da Silveira

Professor of Oral Radiology, Department Surgery and Orthopedics, Rio Grande do Sul Federal University – UFRGS, Brazil

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