ArticlePDF Available

Carotid Imaging in 2023: Stenosis and Beyond

Authors:
Rodrigo A Salgado at Universitair Ziekenhuis Antwerpen
Rodrigo A Salgado
Download full-text PDF
Read full-text
Download citation

Abstract

In the last two decades, significant advances have been made in the further understanding of carotid atherosclerosis and stroke risk. While currently practical stratification regarding a surgical intervention in patients with symptomatic carotid disease is made based on the degree of luminal narrowing, several plaque features have been identified as independent risk factors for the development of downstream ischaemic events. Several of these plaque features can be readily identified on routine CT- and MR-examinations, and will be discussed during this lecture. Consequently, a contemporary radiology report must go beyond a mere description of the presence and degree of luminal narrowing, and must also provide information on plaque morphology and other vessel wall characteristics. This comprehensive approach will enable the referring clinical to better stratify their patients regarding current and future risk, leading to better patient management and clinical outcomes.
Available via license: CC BY 4.0
Content may be subject to copyright.
SHORT ABSTRACT
CORRESPONDING AUTHOR:
Rodrigo Salgado
Antwerp University Hospital &
Holy Heart Lier, Belgium
rodrigo.salgado@uza.be
KEYWORDS:
computed tomography
angiography; arterial disease,
carotid; magnetic resonance
angiography; Structured report
TO CITE THIS ARTICLE:
Salgado R. Carotid Imaging in
2023: Stenosis and Beyond.
Journal of the Belgian Society
of Radiology. 2023; 107(1):
96, 1–4. DOI: https://doi.
org/10.5334/jbsr.3380
Carotid Imaging in 2023:
Stenosis and Beyond
RODRIGO SALGADO
ABSTRACT
In the last two decades, significant advances have been made in the further
understanding of carotid atherosclerosis and stroke risk. While currently practical
stratification regarding a surgical intervention in patients with symptomatic carotid
disease is made based on the degree of luminal narrowing, several plaque features
have been identified as independent risk factors for the development of downstream
ischaemic events. Several of these plaque features can be readily identified on routine
CT- and MR-examinations, and will be discussed during this lecture. Consequently, a
contemporary radiology report must go beyond a mere description of the presence
and degree of luminal narrowing, and must also provide information on plaque
morphology and other vessel wall characteristics. This comprehensive approach will
enable the referring clinical to better stratify their patients regarding current and future
risk, leading to better patient management and clinical outcomes.
2Salgado Journal of the Belgian Society of Radiology DOI: 10.5334/jbsr.3380
1. INTRODUCTION
Stroke is a major cause of illness and death worldwide,
accounting for 5% of disability-adjusted life years lost
and more than 10% of deaths globally. In Europe and
the USA, the rate of stroke occurrence is approximately
200 per 100,000 people every year, with 80% of these
strokes being caused by ischemia [1].
Over the past two decades, significant progress has
been made to understand better the aetiology of carotid-
related strokes, particularly regarding the vulnerability of
some carotid plaques.
Previous concepts of atherosclerosis as a cause of
stroke, often limited to the effects of luminal narrowing
on downstream organ systems, are now being re-
evaluated. Over the years, investigators have identified
complex molecular and cellular processes influenced by
the endothelium which affect the overall health of vessel
walls. While early atherosclerotic processes usually lead
to a relatively predictable asymptomatic progression of
disease, it can later evolve into a more complex disease
state influenced by many factors with unpredictable
manifestations, which can possibly end in downstream
ischemic events [2]. Often, ischemic stroke events will be
unrelated to the degree of luminal stenosis but caused
by other plaque characteristics.
Fortunately, imaging techniques have improved,
enabling the evaluation of plaque composition and
morphological features associated with increased
vulnerability in addition to stenosis severity measurement.
Consequently, several societies have published consensus
statements on the current role of CT and MR imaging in
assessing carotid disease, highlighting the additional role
of plaque morphology in assessing stroke risk [3–5].
As a result, the current role of the radiologist in
evaluating carotid artery disease has evolved from a
mere evaluation of potential luminal obstruction to a
more comprehensive assessment of the underlying
plaque and its characteristics, identifying and reporting
additional risk factors of plaque instability. The result is
a more complete evaluation of both current disease and
future stroke risk, guiding medical treatment.
2. QUANTIFICATION OF STENOSIS:
UNDERSTANDING THE MEASUREMENT
Current decisions regarding interventional treatment
of patients with symptomatic carotid disease are
pragmatically based on the degree of luminal narrowing.
This decision path is the result of the landmark NASCET
and ESCT trials, which demonstrated the ability of carotid
endarterectomy (CEA) to prevent strokes and death in
symptomatic patients with severe carotid stenosis [6,
7]. In these trials, the percentage degree of stenosis in
the internal carotid artery (ICA) was used as the main
parameter to guide a straightforward and repeatable
strategy for evaluating stroke risk in patients and
determining whether surgical or non-surgical treatment
options were appropriate.
When reporting numerical values of the degree
of stenosis, it is not only important to specify which
measurement method was used, but it is also
paramount to understand the significance of the
reported value. Currently, the most used measurement
of stenosis is based on the NASCET-trial calculation,
comparing the maximal degree of luminal narrowing to
a more distal disease-free post-bulbar vessel segment
using conventional angiography as the chosen two-
dimensional imaging modality. As opposed to the ESCT-
method, this calculation does not account for the normal
outward bulging of the carotid bulb, implicating that, for
example, a NASCET-calculated stenosis of 0% does not
equal no luminal narrowing. Also, some situations do not
allow formal calculation, as in a near-occlusion of the
carotid lumen.
Finally, caution must be taken when comparing
diameter-derived stenosis, as is customary in conventional
angiography as well as CT and MR angiography, with an
area stenosis as communicated in Doppler ultrasound
reports.
3. LOOKING BEYOND STENOSIS
Despite all the advances in plaque imaging, stenosis
severity remains the only available validated parameter
in current guidelines for treatment decision making
based on the 70% stenosis cut-off following the NASCET
method. As such, it remains one of the main components
of the radiology report and should be measured correctly.
However, additional information should be provided
on the morphological characteristics of the underlying
plaque, carotid vessel wall morphology and every other
evaluable plaque and vessel wall feature which may
improve stroke risk stratification and influence decision
making.
Plaque surface morphology is an easy-to-evaluate
and important morphological feature, as the presence of
contour irregularities is associated with the development
of ischemic neurological symptoms secondary to
plaque fragmentation and micro-embolic events.
Specifically, plaque ulceration is recognized as the
most important parameter among the possible luminal
surface irregularities, given its strong association with
cerebrovascular events. Its presence increases future
stroke risk independently of the degree of stenosis,
although this relationship is probably more complex [8, 9].
Another illustration of atherosclerosis having
significant effects beyond mere luminal narrowing is
the concept of arterial remodelling, which refers to a
change in vessel size (cross-sectional area) in reaction
3Salgado Journal of the Belgian Society of Radiology DOI: 10.5334/jbsr.3380
to atherosclerotic changes [10]. Arterial remodelling
can have many presentations, including plaque growth
beyond the normal outer diameters of the normal vessel
wall without a comparable effect on inward luminal
narrowing [11]. As such, a prominent plaque with positive
remodelling still represents significant atherosclerosis
despite NASCET-derived stenosis measurements within
non-interventional ranges.
Intraplaque haemorrhage is currently one of the most
important biomarkers of carotid plaque instability, which
can be detected through radiological means [12, 13]. The
most important imaging modality here is MR imaging,
which can visualise intraplaque blood degradation
products. While signal characteristics vary, intraplaque
bleeding is typically characterised as producing high
signal intensity on fat-suppressed T1-weighted images.
The importance of intraplaque hemaorrhague is further
illustrated by the knowledge that it is also more prevalent
in carotid arteries ipsilateral to embolic strokes of
unknown origin [14, 15].
Other important biomarkers like perivascular
inflammation, plaque neovascularisation and detailed
analysis of a possible lipid-rich necrotic core with thin fibrous
cap are in general not used in clinical practice for practical
reasons, their study often reserved for research labs.
However, as technology and post-processing mathematical
powers progress, they might become easier to detect in the
future. As with all novel biomarkers, it is important to also
develop a standardized reporting and validation system, as
well as guidelines on how to convert these new imaging
insights into practical clinical treatment decisions.
4. NON-ATHEROSCLEROTIC DISEASE
Despite the age-correlated prevalence of atherosclerotic
disease in the Western population, it is also important
to understand that important events can also occur
secondary to non-atherosclerotic disease. Knowledge
of the underlying conditions and their imaging
characteristics is critical to correctly diagnose and
manage these patients, which are often younger of
age, and prevent unnecessary downstream testing for
other conditions. Such conditions include embolic stroke
from non-carotid sources and carotid dissection, either
isolated or as a manifestation of fibromuscular dysplasia.
5. CONCLUSION
It has become clear that contemporary carotid imaging
with CT and MR goes beyond the mere reporting of
luminal narrowing. Plaque characteristics have become
an important and integral part of the radiology report,
delivering a more complete assessment of current and
future stroke risk and in determining patient management.
COMPETING INTERESTS
The author has no competing interests to declare.
AUTHOR AFFILIATIONS
Rodrigo Salgado, MD, PhD orcid.org/0000-0003-4060-1612
Department of Radiology, Antwerp University Hospital & Holy
Heart Lier, Belgium
REFERENCES
1. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease
and stroke statistics—2017 update. Circulation. 2017; 135:
e146–e603.
2. Danese MD, Pemberton-Ross P, Catterick D, et al.
Estimation of the increased risk associated with recurrent
events or polyvascular atherosclerotic cardiovascular
disease in the United Kingdom. Eur J Prev Cardiol. 2020; 28:
335–343. DOI: https://doi.org/10.1177/2047487319899212
3. Saba L, Antignani PL, Gupta A, et al. International
Union of Angiology (IUA) consensus paper on imaging
strategies in atherosclerotic carotid artery imaging: From
basic strategies to advanced approaches. Atherosclerosis.
2022; 354: 23–40. DOI: https://doi.org/10.1016/j.
atherosclerosis.2022.06.1014
4. Saba L, Loewe C, Weikert T, et al. State-of-the-art CT and
MR imaging and assessment of atherosclerotic carotid
artery disease: standardization of scanning protocols
and measurements—a consensus document by the
European Society of Cardiovascular Radiology (ESCR). Eur
Radiol. 2023; 33: 1063–1087. DOI: https://doi.org/10.1007/
s00330-022-09024-7
5. Saba L, Loewe C, Weikert T, et al. State-of-the-art CT and
MR imaging and assessment of atherosclerotic carotid
artery disease: the reporting—a consensus document
by the European Society of Cardiovascular Radiology
(ESCR). Eur Radiol. 2023; 33: 1088–1101. DOI: https://doi.
org/10.1007/s00330-022-09025-6
6. Group ECSTC. Randomised trial of endarterectomy for
recently symptomatic carotid stenosis: Final results of the
MRC European Carotid Surgery Trial (ECST). Lancet. 1998;
351: 1379–1387. DOI: https://doi.org/10.1016/S0140-
6736(97)09292-1
7. Collaborators NASCET, Barnett HJM, Taylor DW,
et al. Beneficial effect of carotid endarterectomy in
symptomatic patients with high-grade carotid stenosis.
N Engl J Med. 1991; 325: 445–453. DOI: https://doi.
org/10.1056/NEJM199108153250701
8. Eliasziw M, Streifler JY, Fox AJ, et al. Significance of
plaque ulceration in symptomatic patients with high-grade
carotid stenosis. North American Symptomatic Carotid
Endarterectomy Trial. Stroke. 2018; 25: 304–308. DOI:
https://doi.org/10.1161/01.STR.25.2.304
4Salgado Journal of the Belgian Society of Radiology DOI: 10.5334/jbsr.3380
TO CITE THIS ARTICLE:
Salgado R. Carotid Imaging in 2023: Stenosis and Beyond. Journal of the Belgian Society of Radiology. 2023; 107(1): 96, 1–4. DOI:
https://doi.org/10.5334/jbsr.3380
Submitted: 02 October 2023 Accepted: 12 October 2023 Published: 08 December 2023
COPYRIGHT:
© 2023 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0
International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original
author and source are credited. See http://creativecommons.org/licenses/by/4.0/.
Journal of the Belgian Society of Radiology is a peer-reviewed open access journal published by Ubiquity Press.
9. Gils MJ van, Homburg PJ, Rozie S, et al. Evolution of
atherosclerotic carotid plaque morphology: Do ulcerated
plaques heal? A serial multidetector CT angiography study.
Cerebrovasc Dis. 2011; 31: 263–270. DOI: https://doi.
org/10.1159/000322152
10. Glagov S, Weisenberg E, Zarins CK, et al. Compensatory
enlargement of human atherosclerotic coronary arteries.
New Engl J Medicine. 1987; 316: 1371–1375. DOI: https://
doi.org/10.1056/NEJM198705283162204
11. Ward MR, Pasterkamp G, Yeung AC, et al. Arterial
remodeling. Circulation. 2000; 102: 1186–1191. DOI:
https://doi.org/10.1161/01.CIR.102.10.1186
12. Chu B, Ferguson MS, Chen H, et al. Cardiac magnetic
resonance features of the disruption-prone and the
disrupted carotid plaque. JACC: Cardiovasc Imaging.
2009; 2: 883–896. DOI: https://doi.org/10.1016/j.
jcmg.2009.03.013
13. Saba L, Moody AR, Saam T, et al. Vessel wall–imaging
biomarkers of carotid plaque vulnerability in stroke prevention
trials: A viewpoint from The Carotid Imaging Consensus
Group. JACC: Cardiovasc Imaging. 2020; 13: 2445–2456. DOI:
https://doi.org/10.1016/j.jcmg.2020.07.046
14. Singh N, Moody AR, Panzov V, et al. Carotid intraplaque
hemorrhage in patients with embolic stroke of undetermined
source. J Stroke Cerebrovasc Dis. 2018; 27: 1956–1959. DOI:
https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.02.042
15. Kopczak A, Schindler A, Bayer-Karpinska A, et al.
Complicated carotid artery plaques as a cause of
cryptogenic stroke. J Am Coll Cardiol. 2020; 76: 2212–2222.
DOI: https://doi.org/10.1016/j.jacc.2020.09.532
ResearchGate has not been able to resolve any citations for this publication.
State-of-the-art CT and MR imaging and assessment of atherosclerotic carotid artery disease: the reporting-a consensus document by the European Society of Cardiovascular Radiology (ESCR)
Article
Full-text available
  • Oct 2022
  • EUR RADIOL
The European Society of Cardiovascular Radiology (ESCR) is the European specialist society of cardiac and vascular imaging. This society’s highest priority is the continuous improvement, development, and standardization of education, training, and best medical practice, based on experience and evidence. The present intra-society consensus is based on the existing scientific evidence and on the individual experience of the members of the ESCR writing group on carotid diseases, the members of the ESCR guidelines committee, and the members of the executive committee of the ESCR. The recommendations published herein reflect the evidence-based society opinion of ESCR. The purpose of this second document is to discuss suggestions for standardized reporting based on the accompanying consensus document part I. Key Points • CT and MR imaging-based evaluation of carotid artery disease provides essential information for risk stratification and prediction of stroke. • The information in the report must cover vessel morphology, description of stenosis, and plaque imaging features. • A structured approach to reporting ensures that all essential information is delivered in a standardized and consistent way to the referring clinician.
View
State-of-the-art CT and MR imaging and assessment of atherosclerotic carotid artery disease: standardization of scanning protocols and measurements-a consensus document by the European Society of Cardiovascular Radiology (ESCR)
Article
Full-text available
  • Oct 2022
  • EUR RADIOL
The European Society of Cardiovascular Radiology (ESCR) is the European specialist society of cardiac and vascular imaging. This society’s highest priority is the continuous improvement, development, and standardization of education, training, and best medical practice, based on experience and evidence. The present intra-society consensus is based on the existing scientific evidence and on the individual experience of the members of the ESCR writing group on carotid diseases, the members of the ESCR guidelines committee, and the members of the executive committee of the ESCR. The recommendations published herein reflect the evidence-based society opinion of ESCR. We have produced a twin-papers consensus, indicated through the documents as respectively “Part I” and “Part II.” The first document (Part I) begins with a discussion of features, role, indications, and evidence for CT and MR imaging-based diagnosis of carotid artery disease for risk stratification and prediction of stroke (Section I). It then provides an extensive overview and insight into imaging-derived biomarkers and their potential use in risk stratification (Section II). Finally, detailed recommendations about optimized imaging technique and imaging strategies are summarized (Section III). The second part of this consensus paper (Part II) is focused on structured reporting of carotid imaging studies with CT/MR. Key Points • CT and MR imaging-based evaluation of carotid artery disease provides essential information for risk stratification and prediction of stroke. • Imaging-derived biomarkers and their potential use in risk stratification are evolving; their correct interpretation and use in clinical practice must be well-understood. • A correct imaging strategy and scan protocol will produce the best possible results for disease evaluation.
View
Complicated Carotid Artery Plaques as a Cause of Cryptogenic Stroke
Article
Full-text available
  • Nov 2020
  • J AM COLL CARDIOL
Background The underlying etiology of ischemic stroke remains unknown in up to 30% of patients. Objectives This study explored the causal role of complicated (American Heart Association−lesion type VI) nonstenosing carotid artery plaques (CAPs) in cryptogenic stroke (CS). Methods CAPIAS (Carotid Plaque Imaging in Acute Stroke) is an observational multicenter study that prospectively recruited patients aged older than 49 years with acute ischemic stroke that was restricted to the territory of a single carotid artery on brain magnetic resonance imaging (MRI) and unilateral or bilateral CAP (≥2 mm, NASCET [North American Symptomatic Carotid Endarterectomy Trial] <70%). CAP characteristics were determined qualitatively and quantitatively by high-resolution, contrast-enhanced carotid MRI at 3T using dedicated surface coils. The pre-specified study hypotheses were that that the prevalence of complicated CAP would be higher ipsilateral to the infarct than contralateral to the infarct in CS and higher in CS compared with patients with cardioembolic or small vessel stroke (CES/SVS) as a combined reference group. Patients with large artery stroke (LAS) and NASCET 50% to 69% stenosis served as an additional comparison group. Results Among 234 recruited patients, 196 had either CS (n = 104), CES/SVS (n = 79), or LAS (n = 19) and complete carotid MRI data. The prevalence of complicated CAP in patients with CS was significantly higher ipsilateral (31%) to the infarct compared with contralateral to the infarct (12%; p = 0.0005). Moreover, the prevalence of ipsilateral complicated CAP was significantly higher in CS (31%) compared with CES/SVS (15%; p = 0.02) and lower in CS compared with LAS (68%; p = 0.003). Lipid-rich and/or necrotic cores in ipsilateral CAP were significantly larger in CS compared with CES/SVS (p < 0.05). Conclusions These findings substantiate the role of complicated nonstenosing CAP as an under-recognized cause of stroke. (Carotid Plaque Imaging in Acute Stroke [CAPIAS]; NCT01284933)
View
Heart Disease and Stroke Statistics—2017 Update: A Report From the American Heart Association
Article
Full-text available
  • Jan 2017
Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together in a single document the most upto-date statistics related to heart disease, stroke, and the factors in the AHA's Life's Simple 7 (Figure1), which include core health behaviors (smoking, physical activity [PA], diet, and weight) and health factors (cholesterol, blood pressure [BP], and glucose control) that contribute to cardiovascular health. The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions. Cardiovascular disease (CVD) and stroke produce immense health and economic burdens in the United States and globally. The Update also presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure (HF), valvular disease, venous disease, and peripheral arterial disease) and the associated outcomes (including quality of care, procedures, and economic costs). Since 2006, the annual versions of the Statistical Update have been cited >20000 times in the literature. In 2015 alone, the various Statistical Updates were cited '4000 times.
View
International Union of Angiology (IUA) consensus paper on imaging strategies in atherosclerotic carotid artery imaging: From basic strategies to advanced approaches
Article
  • Jun 2022
  • Atherosclerosis
Cardiovascular disease (CVD) is the leading cause of mortality and disability in developed countries. According to WHO, an estimated 17.9 million people died from CVDs in 2019, representing 32% of all global deaths. Of these deaths, 85% were due to major adverse cardiac and cerebral events. Early detection and care for individuals at high risk could save lives, alleviate suffering, and diminish economic burden associated with these diseases. Carotid artery disease is not only a well-established risk factor for ischemic stroke, contributing to 10%–20% of strokes or transient ischemic attacks (TIAs), but it is also a surrogate marker of generalized atherosclerosis and a predictor of cardiovascular events. In addition to diligent history, physical examination, and laboratory detection of metabolic abnormalities leading to vascular changes, imaging of carotid arteries adds very important information in assessing stroke and overall cardiovascular risk. Spanning from carotid intima-media thickness (IMT) measurements in arteriopathy to plaque burden, morphology and biology in more advanced disease, imaging of carotid arteries could help not only in stroke prevention but also in ameliorating cardiovascular events in other territories (e.g. in the coronary arteries). While ultrasound is the most widely available and affordable imaging methods, computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), their combination and other more sophisticated methods have introduced novel concepts in detection of carotid plaque characteristics and risk assessment of stroke and other cardiovascular events. However, in addition to robust progress in usage of these methods, all of them have limitations which should be taken into account. The main purpose of this consensus document is to discuss pros but also cons in clinical, epidemiological and research use of all these techniques.
View
View
Estimation of the increased risk associated with recurrent events or polyvascular atherosclerotic cardiovascular disease in the United Kingdom
Article
  • Jan 2020
Aims The aims of this study were to re-estimate the international REduction of Atherothrombosis for Continued Health (REACH) risk equation using United Kingdom data and to distinguish different relative hazards for specific atherosclerotic cardiovascular disease event histories. Methods and results Patients in the UK Clinical Research Practice Datalink (CPRD) were included as of 1 January 2005 if they were 40 years or older, had 2 or more years of prior data, received one or more moderate or high-intensity statin in the previous year, and had a history of myocardial infarction, ischemic stroke, or other atherosclerotic cardiovascular disease. Patients were followed until a composite endpoint of myocardial infarction, ischemic stroke or cardiovascular death, loss to follow-up, or end of observation. We re-estimated the REACH risk equation hazard ratios (HRs) using CPRD data (re-estimated REACH model). Our event history model replaced the REACH vascular bed variables with more specific event histories. There were 60,838 patients with 5.25 years of mean follow-up. In the validation model, HRs were in the same direction, and generally greater than REACH. In the event history model, HRs compared to other atherosclerotic cardiovascular disease alone included: recurrent myocardial infarction (HR 1.19, 95% confidence interval (CI) 1.05–1.34), recurrent ischemic stroke (HR 1.36, 95% CI 1.03–1.80), myocardial infarction and other atherosclerotic cardiovascular disease (HR 1.31, 95% CI 1.23–1.38), ischemic stroke and other atherosclerotic cardiovascular disease (HR 1.40, 95% CI 1.23–1.60), myocardial infarction and ischemic stroke (HR 1.94, 95% CI 1.23–3.04), and myocardial infarction, ischemic stroke and other atherosclerotic cardiovascular disease (HR 1.93, 95% CI 1.47–2.54). Conclusion A detailed cardiovascular event history may be useful for estimating the relative risk of future cardiovascular events.
View
Carotid Intraplaque Hemorrhage in Patients with Embolic Stroke of Undetermined Source
Article
  • Mar 2018
  • J Stroke Cerebrovasc Dis
Background: Many embolic strokes are of undetermined source (ESUS). Carotid artery intraplaque hemorrhage (IPH), an unstable component of atherosclerosis, may be an under-recognized etiology in patients with ESUS. We investigated the prevalence of carotid IPH detected noninvasively by magnetic resonance imaging (MRI). Methods: This pilot study analyzed data from a prospective cohort of patients with a recent ESUS who underwent MRI for carotid IPH assessment. All patients had carotid artery stenosis of less than 50%. The primary outcome was the presence of carotid IPH ipsilateral to the cerebral ischemic event. Results: The cohort comprised 35 consecutive patients with a recent carotid-territory ESUS who underwent carotid MRI (mean age 74.3 ± 9.6 years). We found ipsilateral and contralateral IPH in 7 of 35 patients (20.0%) and in 3 of 35 patients (8.6%), respectively (P = .005). Conclusions: In this sample of patients with ESUS, 1 in 5 had carotid IPH ipsilateral to their acute infarct, as detected by MRI of the vessel wall. Further studies are warranted to investigate carotid IPH as an etiology of ESUS.
View
Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST) *
Article
  • May 1998
  • LANCET
Background Our objective was to assess the risks and benefits of carotid endarterectomy, primarily in terms of stroke prevention, in patients with recently symptomatic carotid stenosis. Methods This multicentre, randomised controlled trial enrolled 3024 patients. We enrolled men and women of any age, with some degree of carotid stenosis, who within the previous 6 months had had at least one transient or mild symptomatic ischaemic vascular event in the distribution of one or both carotid arteries. Between 1981 and 1994, we allocated 1811 (60%) patients to surgery and 1213 (40%) to control (surgery to be avoided for as long as possible). Follow-up was until the end of 1995 (mean 6·1 years), and the main analyses were by intention to treat. Findings The overall outcome (major stroke or death) occurred in 669 (37·0%) surgery-group patients and 442 (36·5%) control-group patients. The risk of major stroke or death complicating surgery (7·0%) did not vary substantially with severity of stenosis. On the other hand, the risk of major ischaemic stroke ipsilateral to the unoperated symptomatic carotid artery increased with severity of stenosis, particularly above about 70–80% of the original luminal diameter, but only for 2–3 years after randomisation. On average, the immediate risk of surgery was worth trading off against the long-term risk of stroke without surgery when the stenosis was greater than about 80% diameter; the Kaplan-Meier estimate of the frequency of a major stroke or death at 3 years was 26·5% for the control group and 14·9% for the surgery group, an absolute benefit from surgery of 11·6%. However, consideration of variations in risk with age and sex modified this simple rule based on stenosis severity. We present a graphical procedure that should improve the selection of patients for surgery. Interpretation Carotid endarterectomy is indicated for most patients with a recent non-disabling carotid-territory ischaemic event when the symptomatic stenosis is greater than about 80%. Age and sex should also be taken into account in decisions on whether to operate.
View
Evolution of Atherosclerotic Carotid Plaque Morphology: Do Ulcerated Plaques Heal A Serial Multidetector CT Angiography Study
Article
  • Feb 2011
  • CEREBROVASC DIS
Atherosclerotic carotid plaque rupture may lead to thromboembolization, causing transient ischemic attack or ischemic stroke. Carotid plaque ulceration on angiography is associated with plaque rupture. Although healing of ruptured plaques has been described in coronary arteries, little is known about the natural development of plaque ulcerations in carotid arteries. We therefore explored the evolution of carotid plaque surface morphology with serial multidetector CT angiography (MDCTA). From a registry of patients with transient ischemic attack or minor ischemic stroke, we selected 83 patients who had undergone serial MDCTA of the carotid arteries. Arteries subjected to revascularization procedures between the two scans were excluded (n = 11). Plaque surface morphology was classified as smooth, irregular or ulcerated on both baseline and follow-up MDCTA. Progression (i.e. development of irregularities or ulceration) and regression (i.e. disappearance of irregularities or ulceration) in morphology were evaluated. The mean time interval between the MDCTA scans was 21 ± 13 months. At baseline, 28 (18%) arteries were normal, 124 (80%) contained atherosclerotic plaque and 3 (2%) were occluded. Plaque surface morphology was smooth in 86 arteries (55%), irregular in 23 (15%) and ulcerated in 15 (10%). At follow-up, surface morphology was unchanged in 88% of arteries, had progressed in 8% and regressed in 4%. Most importantly, plaque morphology remained unchanged in most ulcerated plaques (10/15; 67%). One ulcerated plaque had progressed, whereas 4 had regressed. New ulcerations had developed in 2 nonulcerated plaques. MDCTA allows evaluation of temporal changes in atherosclerotic carotid plaque morphology. Plaque surface morphology remained unchanged in most arteries. Carotid ulcerations persist for a long time, and may remain a potential source of thromboembolism.
View