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Complicated Carotid Plaques and Risk of Recurrent Ischemic Stroke or TIA
Quick Takes
- Complicated carotid plaques are those with a ruptured fibrous cap, intraplaque hemorrhage, or associated mural thrombus.
- In this prospective cohort study, stroke patients with complicated carotid plaque had a higher risk of recurrent ischemic stroke or TIA than patients without. The risk was accentuated in patients with a cryptogenic stroke etiology.
- These data may help build a case for future clinical trials to address the best secondary stroke prevention strategy for patients with complicated carotid plaque. However, enthusiasm for such trials may be mitigated by the requirement for a contrasted MRI to diagnose most complicated carotid plaques, leading to considerable expense and decreased generalizability.
Study Questions:
Are complicated ipsilateral carotid artery plaques in stroke patients associated with recurrent ischemic stroke or transient ischemic attack (TIA)?
Methods:
Patients were eligible for this prospective observational study if they were ≥50 years of age, had a magnetic resonance imaging (MRI)-confirmed acute ischemic stroke within a single carotid artery territory within the prior 7 days, and unilateral or bilateral carotid artery plaque(s) with a thickness of ≥2 mm by carotid Doppler. Patients with ≥70% carotid stenosis and with competing potential stroke etiologies (e.g., intracranial atherosclerosis) were excluded. All patients underwent a carotid MRI within 10 days of stroke. Patients were followed for 3 years. The primary outcome was recurrent ischemic stroke or TIA. A secondary outcome was recurrent ipsilateral ischemic stroke or TIA.
Results:
A total of 196 patients were included in the final analysis: 56 had ipsilateral (to the qualifying stroke) complicated carotid plaque and 140 did not. The incidence rate of recurrent ischemic stroke or TIA was higher in patients with ipsilateral complicated carotid plaque than those without (hazard ratio [HR], 2.51; 95% confidence interval [CI], 1.03-6.11). When restricted to ipsilateral recurrent ischemic stroke or TIA, the risk was >3 times higher in the group with complicated carotid artery plaque (HR, 3.37; 95% CI, 1.21-9.38). When restricted to patients with cryptogenic stroke, the risk of recurrent ischemic stroke or TIA was >5 times higher in patients with ipsilateral complicated carotid plaque (HR, 5.60; 95% CI, 1.43-21.83).
Conclusions:
In this prospective cohort study, stroke patients with ipsilateral complicated carotid plaque had a higher risk of recurrent ischemic stroke or TIA than patients without. The risk was accentuated in patients with a cryptogenic stroke etiology.
Perspective:
These data help build a case for future clinical trials to address the best secondary stroke prevention strategy for patients with complicated carotid plaque. Should these patients receive different medical therapy compared to typical stroke patients? Should surgical intervention be considered? However, enthusiasm for such trials may be mitigated by the need for MRI with contrast to diagnose most complicated carotid plaques, leading to considerable expense and decreased generalizability.
Clinical Topics: Noninvasive Imaging, Prevention, Vascular Medicine, Magnetic Resonance Imaging
Keywords: Brain Ischemia, Carotid Arteries, Carotid Stenosis, Diagnostic Imaging, Hemorrhagic Stroke, Intracranial Arteriosclerosis, Ischemic Attack, Transient, Ischemic Stroke, Magnetic Resonance Imaging, Plaque, Atherosclerotic, Risk Factors, Secondary Prevention, Stroke, Thrombosis, Vascular Diseases
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