Complicated carotid artery plaques present underrecognized risk for recurrent stroke
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Among patients with cryptogenic stroke, ipsilateral complicated carotid artery plaque detected by MRI was associated with elevated risk for recurrent ischemic stroke or transient ischemic attack, data show.
“To our knowledge, there are no studies that have related the presence of complicated carotid artery plaques or intraplaque hemorrhage as assessed in the first days after stroke to recurrent ischemic stroke or TIA,” Martin Dichgans, MD, professor of neurology and director of the Institute for Stroke and Dementia Research at the Medical Center of the University of Munich, and colleagues wrote in the Journal of the American College of Cardiology. “Such information is needed, particularly for patients with nonstenosing carotid artery plaques and no recognizable cause of stroke (cryptogenic stroke), to optimize strategies for risk prediction and potentially also for stratifying patients into future secondary prevention trials.”
Prospective stroke data
Dichgans and colleagues analyzed data from 196 patients aged 49 years or older enrolled in CAPIAS, an observational, prospective study conducted in four tertiary care centers in Germany that recruited patients with ischemic stroke restricted to a single carotid artery. Complicated carotid artery plaques, defined as American Heart Association lesion type VI, were assessed by multisequence, contrast-enhanced carotid MRI obtained within 10 days from stroke onset. Recurrent events were assessed after 3, 12, 24 and 36 months. The primary outcome was recurrent ischemic stroke or TIA.
Within the cohort, 104 patients had cryptogenic stroke and nonstenosing carotid artery plaque. During a mean follow-up of 30 months, 16 patients experienced recurrent ischemic stroke and five patients experienced TIA.
The 3-year incidence rate for the primary outcome was higher among patients with ipsilateral complicated carotid artery plaque (9.5 per 100 patient-years) compared with patients without ipsilateral complicated carotid artery plaque (3.61 per 100 patient-years; log-rank P = .025).
In models adjusted for age and sex, ipsilateral complicated carotid artery plaques were associated with a 2.5-fold increased risk for recurrent ischemic stroke or TIA over 3 years (HR = 2.51; 95% CI, 1.03-6.11; P =.043). Results persisted after restricting analyses to ipsilateral recurrent ischemic stroke or TIA (HR = 3.37; 95% CI, 1.21-9.38; P = .02).
Researchers also found that the presence of a ruptured fibrous cap at baseline (HR = 4.91; 95% CI, 1.31-18.45; P = .018) and intraplaque hemorrhage (HR = 4.37; 95% CI, 1.2-15.97; P = .026) were the largest drivers of increased risk for recurrent events in patients with cryptogenic stroke.
The researchers noted that study participants were selected for the presence of carotid artery plaque and were mildly affected, as reflected by the NIH Stroke Scale score at baseline.
“This, together with the relatively large CIs for recurrence rates, emphasizes the need for additional studies,” the researchers wrote. “We envision the next step to be a multicenter study determining the precise prevalence of intraplaque hemorrhage and associated recurrence rates in unselected patients with anterior circulation stroke. Such a study would enable analyses in relevant subgroups to prepare for future prevention trials.”
Role of vulnerable carotid plaque
In a related editorial, Joshua Z. Willey, MD, MS, of the department of neurology at Columbia University Irving Medical Center, and Gerard Pasterkamp, MD, of the Central Laboratory of Diagnostics at University Medical Center Utrecht, the Netherlands, wrote that the study highlights the importance of considering substenotic atherosclerotic plaques as a cause of ischemic stroke and the subsequent risk for recurrence.
“Whether these patients require different medical treatment and whether a subsequent cardioembolic source does not need to be as extensively ruled out with higher-cost cardiac imaging or implantable loop recorders remain to be answered by future studies,” Willey and Pasterkamp wrote.
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