Identifying which patients with asymptomatic carotid stenosis could benefit from intervention (original) (raw)
Related papers
2003
The Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) study is the largest natural history study on patients with 50-99% asymptomatic carotid stenosis (ACS). It included 1,121 ACS individuals with a follow-up between 6 and 96 months (mean: 48 months). During the last 15 years, several important ACSRS substudies have been published that have contributed significantly to the optimal management of ACS patients. These studies have demonstrated that specific baseline clinical characteristics and ultrasonic plaque features after image normalization (namely carotid plaque type, gray scale median, carotid plaque area, juxtaluminal black area without a visible echogenic cup, discrete white areas in an echolucent part of a plaque, silent embolic infarcts on brain computed tomography scans, a history of contralateral transient ischemic attacks/strokes) can independently predict future ipsilateral cerebrovascular events. The ACSRS study provided proof that by use of a computer program to normalize plaque images and extract plaque texture features, a combination of features can stratify patients into various categories depending on their stroke risk. The present review will discuss the various reported predictors of future ipsilateral cerebrovascular events and how these characteristics can be used to calculate individual stroke risk.
Stroke, 2005
Background and Purpose-Carotid endarterectomy clearly benefits patients with symptomatic severe stenosis (SCS), but the risk of stroke is so low for asymptomatic patients (ACS) that the number needed to treat is very high. We studied transcranial Doppler (TCD) embolus detection as a method for identifying patients at higher risk who would have a lower number needed to treat. Methods-Patients with carotid stenosis of Ն60% by Doppler ultrasound who had never been symptomatic (81%) or had been asymptomatic for at least 18 months (19%) were studied with TCD embolus detection for up to 1 hour on 2 occasions a week apart; patients were followed for 2 years. Results-319 patients were studied, age (standard deviation) 69.68 (9.12) years; 32 (10%) had microemboli at baseline (TCDϩ). Events were more likely to occur in the first year. Patients with microemboli were much more likely to have microemboli 1 year later (34.4 versus 1.4%; PϽ0.0001) and were more likely to have a stroke during the first year of follow-up (15.6%, 95% CI, 4.1 to 79; versus 1%, 95% CI, 1.01 to 1.36; PϽ0.0001). Conclusions-Our findings indicate that TCDϪ ACS will not benefit from endarterectomy or stenting unless it can be done with a risk Ͻ1%; TCDϩ may benefit as much as SCS if their surgical risk is not higher. These findings suggest that ACS should be managed medically with delay of surgery or stenting until the occurrence of symptoms or emboli.
2010
Background and Purpose-Carotid endarterectomy clearly benefits patients with symptomatic severe stenosis (SCS), but the risk of stroke is so low for asymptomatic patients (ACS) that the number needed to treat is very high. We studied transcranial Doppler (TCD) embolus detection as a method for identifying patients at higher risk who would have a lower number needed to treat. Methods-Patients with carotid stenosis of Ն60% by Doppler ultrasound who had never been symptomatic (81%) or had been asymptomatic for at least 18 months (19%) were studied with TCD embolus detection for up to 1 hour on 2 occasions a week apart; patients were followed for 2 years. Results-319 patients were studied, age (standard deviation) 69.68 (9.12) years; 32 (10%) had microemboli at baseline (TCDϩ). Events were more likely to occur in the first year. Patients with microemboli were much more likely to have microemboli 1 year later (34.4 versus 1.4%; PϽ0.0001) and were more likely to have a stroke during the first year of follow-up (15.6%, 95% CI, 4.1 to 79; versus 1%, 95% CI, 1.01 to 1.36; PϽ0.0001). Conclusions-Our findings indicate that TCDϪ ACS will not benefit from endarterectomy or stenting unless it can be done with a risk Ͻ1%; TCDϩ may benefit as much as SCS if their surgical risk is not higher. These findings suggest that ACS should be managed medically with delay of surgery or stenting until the occurrence of symptoms or emboli.
Asymptomatic carotid stenosis and risk stratification
2019
Carotid endarterectomy in patients with asymptomatic carotid stenosis (ACS) is controversial. Researchers focus on identification of the vulnerable carotid plaque to improve patients' selection for surgery. However, there is no consensus on a specific algorithm. Also, most studies analyse static plaque measurements, despite carotid plaques being dynamic structures. The aims of this thesis were to determine the association of clinical parameters and ultrasonic plaque characteristics with stroke and mortality risk; also, stroke risk in terms of time. The final endpoint was to provide new methods of stroke and mortality stratification and assess new features of plaque instability, in patients with ACS. In a natural history study of 1121 patients with ACS, a high-risk subgroup with annual stroke risk of 7.2%, based on clinical parameters, was identified. Independent stroke predictors were creatinine, severity of stenosis, history of contralateral neurological events and progression of stenosis. A model based on six computer-extracted plaque texture features, predicting cerebrovascular events in the first two years, was developed. Finally, a subgroup of patients with 100% 5-year cardiovascular mortality was identified. Independent predictors of cardiovascular mortality were male gender, age, diabetes, stenosis >80%, not taking aspirin, cardiac failure and left ventricular hypertrophy. In the final part of the thesis, quantification of discordant plaque motion and its relationship to symptoms was evaluated. In a cross-sectional study, involving 116 patients (58 symptomatic and 58 asymptomatic), discordant motion was associated with a high prevalence of symptomatic carotid plaques. A method of objective computerised measurements for identification and quantification of discordant plaque motion was developed. The optimal predictor and a cutoff point for discordant motion were found. Plaque motion analysis is a potential tool in stroke risk stratification. It should be tested, in combination with other plaque features, in prospective studies of patients with ACS. mortality. Predicting CV mortality 5.5 Discussion CHAPTER 6: Plaque motion analysis study. Association of visual classification of plaque motion with symptoms-An objective measurement of discordant motion and its relationship to symptoms Glossary
Prediction of Stroke Risk by Detection of Hemorrhage in Carotid Plaques
JACC: Cardiovascular Imaging, 2019
OBJECTIVES The goal of this study was to compare the risk of stroke between patients with carotid artery disease with and without the presence of intraplaque hemorrhage (IPH) on magnetic resonance imaging. BACKGROUND IPH in carotid stenosis increases the risk of cerebrovascular events. Uncertainty remains whether risk of stroke alone is increased and whether stroke is predicted independently of known risk factors. METHODS Data were pooled from 7 cohort studies including 560 patients with symptomatic carotid stenosis and 136 patients with asymptomatic carotid stenosis. Hazards of ipsilateral ischemic stroke (primary outcome) were compared between patients with and without IPH, adjusted for clinical risk factors. RESULTS IPH was present in 51.6% of patients with symptomatic carotid stenosis and 29.4% of patients with asymptomatic carotid stenosis. During 1,121 observed person-years, 66 ipsilateral strokes occurred. Presence of IPH at baseline increased the risk of ipsilateral stroke both in symptomatic (hazard ratio [HR]: 10.2; 95% confidence interval [CI]: 4.6 to 22.5) and asymptomatic (HR: 7.9; 95% CI: 1.3 to 47.6) patients. Among patients with symptomatic carotid stenosis, annualized event rates of ipsilateral stroke in those with IPH versus those without IPH were 9.0% versus 0.7% (<50% stenosis), 18.1% versus 2.1% (50% to 69% stenosis), and 29.3% versus 1.5% (70% to 99% stenosis). Annualized event rates among patients with asymptomatic carotid stenosis were 5.4% in those with IPH versus 0.8% in those without IPH. Multivariate analysis identified IPH (HR: 11.0; 95% CI: 4.8 to 25.1) and severe degree of stenosis (HR: 3.3; 95% CI: 1.4 to 7.8) as independent predictors of ipsilateral stroke. CONCLUSIONS IPH is common in patients with symptomatic and asymptomatic carotid stenosis and is a stronger predictor of stroke than any known clinical risk factors. Magnetic resonance imaging might help identify patients with carotid disease who would benefit from revascularization.
Journal of Cerebral Blood Flow & Metabolism, 2019
The relationship between plaque morphology, cerebral micro-embolic signals (MES) and platelet biomarkers in carotid stenosis patients warrants investigation. We combined data from two prospective, observational studies to assess carotid plaque morphology and relationship with cerebral MES and platelet biomarkers in patients with recently symptomatic (≤4 weeks of transient ischaemic attack (TIA)/ischaemic stroke) versus asymptomatic carotid stenosis. Plaque morphology on ultrasound was graded with Grey-Scale Median (GSM) and Gray–Weale (GW) scoring. Bilateral transcranial Doppler ultrasound classified patients as ‘MES+ve’ or ‘MES-ve’. Full blood counts were analysed and flow cytometry quantified CD62P and CD63 expression, leucocyte-platelet complexes and reticulated platelets. Data from 42 recently symptomatic carotid stenosis patients were compared with those from 36 asymptomatic patients. There were no differences in median GSM scores between symptomatic and asymptomatic patients (...