1. Analysis of cerebral atherosclerosis and risk factors of stroke using 64-slice computed tomography 64 排電腦斷層應用在頸動脈血管硬化和 腦中風危險因子之分析

3. Cerebral aneurysm

11. Carotid atherosclerosis

12. Albers, G. W. et al. Chest 2004;126:483S-512S The most frequent sites of arterial and cardiac abnormalities causing ischemic stroke

16. AHA Classification of Atherosclerotic Plaque ( Circulation. 2002;106:1368.) Type I: initial lesion with foam cells Type I–II: near-normal wall thickness, no calcification Type II: fatty streak with multiple foam cell layers Type III: preatheroma with extracellular lipid pools Type III: diffuse intimal thickening or small eccentric plaque with no calcification Type IV: atheroma with a confluent extracellular lipid core Type IV–V: plaque with a lipid or necrotic core surrounded by fibrous tissue with possible calcification Type V: fibroatheroma Type VI: complex plaque with possible surface defect, hemorrhage, or thrombus Type VI: complex plaque with possible surface defect, hemorrhage, or thrombus Type VII: calcified plaque Type VII: calcified plaque Type VIII: fibrotic plaque without lipid core Type VIII: fibrotic plaque without lipid core and with possible small calcifications

18. Type IV-V

19. Type VI

22. Plaques thickness

23. ulcerated plaques

29. Plaques with mobile components

31. 鈣化指數計量 (CACS)

33. 鈣化指數計量與冠心病 Mayo Clinic Proceedings, 1999 Carr JJ, et. Al, AJR 2000 鈣化指數 (1,2) 涵義 冠心病的危險度 0 無法偵測到斑塊 非常低，通常低於 5% 1 - 10 可偵測到微細斑塊 不見得會有，低於 10% 11 - 100 很確定 , 至少有輕度粥樣硬化斑塊 可能會有輕度或微量冠狀動脈狹窄 101 - 400 很確定 , 至少有中度粥樣硬化斑塊 非常可能有輕度冠狀動脈狹窄，可能會有有意義的狹窄 401 or Higher 廣泛性粥樣硬化斑塊 會有至少一條冠狀動脈有意義狹窄的高度可能

37. EVIDENCE-BASED MEDICINE

39. How effective is a carotid endarterectomy in someone with moderate carotid stenosis?

40. Step I P atient or Problem Step II I ntervention Step III C omparison Intervention Step IV O utcome Description of the patient or the target disorder of interest Could include: · Exposure · Diagnostic test · Prognostic factor · Therapy · Patient perception etc. Relevant most often when looking at therapy questions Clinical outcome of interest to you and your patient

41. P atient or Problem I ntervention C omparison Intervention O utcome 65 year old man with stroke and moderate carotid stenosis Carotid endarterectomy Medical therapy Stroke or outcome of death In a 65 year old man with stroke and moderate carotid stenosis, can carotid endarterectomy decrease the risk of stroke or outcome of death compared with medical therapy?

46. Relative Number needed to Risk Production Treat Relative with Primary Secondary Risk factor Risk Treatment Prevention Prevention Hypertension Atrial fibrillation Diabetes Smoking Hyperlipidemia Asymptomatic carotid stenosis Symptomatic carotid stenosis (70-99%) Symptomatic carotid stenosis (50-69%) 2-5 1.8-2.9 1.8-6 1.8 1.8-2.6 2.0 38% 68% warfarin 21% aspirin No proven effect 50%at 1 year, baseline risk at 5 years post cessation 10-29% 46-53% 65% at 2 years 29% at 5 years 100-300 20-83 85 N/A N/A 50-100 13 N/A 12 77

50. Statins and Atheroma

52. REVERSAL: Method For Measurement Of Intravascular Ultrasound Images Nissen et al. Am J Cardiol . 2005;96(suppl):61F

53. 2.7 * Pravastatin Significant atherosclerotic progression from baseline -0.4 † Atorvastatin No significant change from baseline; atherosclerotic progression was stopped Primary end point: Percent change in total atheroma volume Change in TAV (%) -1 0 1 2 3 *Progression vs baseline ( P =0.001); †No change vs baseline ( P =0.98) P =0.02

54. REVERSAL The Need for Intensive LDL-C Lowering: Relationship Between Degree of LDL-C Reduction and Change in Atheroma Volume The solid blue line indicates the relationship between mean change in LDL-C and change in atheroma volume from linear regression analysis. The dashed green lines indicate the upper and lower 95% confidence limits for the mean values. Nissen S et al JAMA 2004;291:1071–1080. % Change in LDL-C Change in atheroma volume (mm 3 ) – 15 – 10 – 5 0 5 10 15 20 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 0 10 20 N=502

55. -1 -0.5 0 0.5 1 1.5 2 50 60 70 80 90 100 110 120 ASTEROID 3 rosuvastatin A-Plus 2 placebo ACTIVATE 1 placebo CAMELOT 4 placebo REVERSAL 5 pravastatin REVERSAL 5 atorvastatin Mean LDL-C (mg/dL) The relationship between mean LDL-C and change in percent atheroma volume (PAV) in IVUS studies † Change in Percent Atheroma Volume* (%) † ASTEROID and REVERSAL investigated active statin treatment; A-PLUS, ACTIVATE AND CAMELOT investigated non-statin therapies but included placebo arms who received background statin therapy (62%, 80% and 84% respectively). *Median change in PAV from ASTEROID and REVERSAL; LS mean change in PAV from A-PLUS, ACTIVATE AND CAMELOT 1 Nissen S et al. N Engl J Med 2006;354:1253-1263 . 2 Tardif J et al. Circulation 2004;110:3372-3377. 3 Nissen S et al. JAMA 2006;295 (13):1556-1565 4 Nissen S et al . JAMA 2004;292: 2217–2225. 5 Nissen S et al. JAMA 2004; 291 : 1071–1080 Progression Regression

58. Cardiovascular Disease (CAD) Versus Cerebrovascular Disease (CAD)

65. 動脈硬化的基因與蛋白質

68. Hp expression in human aorta with atherosclerosis SMC FC A B C D Early stage Late stage

69. Macrophage cells Hp protein

70. Relative Number needed to Risk Production Treat Relative with Primary Secondary Risk factor Risk Treatment Prevention Prevention Hypertension Atrial fibrillation Diabetes Smoking Hyperlipidemia Asymptomatic carotid stenosis Symptomatic carotid stenosis (70-99%) Symptomatic carotid stenosis (50-69%) 2-5 1.8-2.9 1.8-6 1.8 1.8-2.6 2.0 38% 68% warfarin 21% aspirin No proven effect 50%at 1 year, baseline risk at 5 years post cessation 10-29% 46-53% 65% at 2 years 29% at 5 years 100-300 20-83 85 N/A N/A 50-100 13 N/A 12 77