scholarly journals Carotid Plaque With High-Risk Features in Embolic Stroke of Undetermined Source

Stroke ◽  
2020 ◽  
Vol 51 (1) ◽  
pp. 311-314 ◽  
Author(s):  
Joseph Kamtchum-Tatuene ◽  
Alan Wilman ◽  
Maher Saqqur ◽  
Ashfaq Shuaib ◽  
Glen C. Jickling
Keyword(s):  
High Risk ◽  
Carotid Stenosis ◽  
Carotid Plaque ◽  
Stroke Risk ◽  
Meta Analysis ◽  
Random Effect ◽  
Embolic Stroke ◽  
Imaging Features ◽  
Luminal Narrowing ◽  
Carotid Plaque Imaging

Background and Purpose— An ipsilateral mild carotid stenosis, defined as plaque with <50% luminal narrowing, is identified in nearly 40% of patients with embolic stroke of undetermined source and could represent an unrecognized source of atheroembolism. We aimed to summarize data about the frequency of mild carotid stenosis with high-risk features in embolic stroke of undetermined source. Methods— We searched Pubmed and Ovid-Embase for studies reporting carotid plaque imaging features in embolic stroke of undetermined source. The prevalence of ipsilateral and contralateral mild carotid stenosis with high-risk features was pooled using random-effect meta-analysis. Results— Eight studies enrolling 323 participants were included. The prevalence of mild carotid stenosis with high-risk features in the ipsilateral carotid was 32.5% (95% CI, 25.3–40.2) compared with 4.6% (95% CI, 0.1–13.1) in the contralateral carotid. The odds ratio of finding a plaque with high-risk features in the ipsilateral versus the contralateral carotid was 5.5 (95% CI, 2.5–12.0). Conclusions— Plaques with high-risk features are 5 times more prevalent in the ipsilateral compared with the contralateral carotid in embolic stroke of undetermined source, suggesting a relationship to stroke risk.

Abstract WP177: Frequency of Carotid Plaque With High-Risk Features in Cryptogenic Stroke: Systematic Review and Meta-Analysis

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Joseph Kamtchum Tatuene ◽  
Alan Wilman ◽  
Maher Saqqur ◽  
Ashfaq Shuaib ◽  
Glen C Jickling
Keyword(s):  
High Risk ◽  
Carotid Plaque ◽  
Meta Analysis ◽  
Random Effect ◽  
Cryptogenic Stroke ◽  
Intraplaque Hemorrhage ◽  
Imaging Features ◽  
Anterior Circulation ◽  
Prevention Therapy ◽  
Pooled Prevalence

Background and Purpose: An ipsilateral non-obstructive carotid atherosclerosis (NOCA), defined as carotid plaque with <50% stenosis, is identified in 25% of cryptogenic strokes and could represent an unrecognized source of athero-embolism. We aimed to summarize available data regarding the frequency of NOCA with high-risk features in patients with cryptogenic stroke. Methods: A search of Pubmed and Ovid-Embase identified observational studies reporting carotid plaque imaging features in patients with cryptogenic stroke, from inception to July 15, 2019. The prevalence of NOCA with high-risk features in ipsilateral and contralateral carotid was determined by pooling study-specific estimates using a random-effect meta-analysis. Results: Six prospective studies enrolling a total of 255 participants with unilateral ischemic stroke in the anterior circulation were included. Carotid arteries were imaged with ultrasound, computed tomography or MRI to identify echolucency, ulceration, intraplaque hemorrhage, thrombus, or thickness ≥ 3 mm. The pooled prevalence of NOCA with high-risk features in the ipsilateral carotid was 34.0% (95% CI: 25.7 – 42.9) compared to 7.3 % (95% CI: 0.8 – 18.1) in the contralateral carotid. The odds ratio of finding a plaque with high-risk features in the ipsilateral versus the contralateral carotid was 4.1 (95% CI: 2.0 – 8.7). Conclusion: Plaques with high-risk features are four times more prevalent in the ipsilateral compared to the contralateral carotid artery in patients with cryptogenic stroke, suggesting a relationship to stroke risk. These features may aid in etiologic classification of stroke and risk stratification for secondary prevention therapy.

Abstract WMP46: Frequency of High-Risk Features and Stroke Risk in Asymptomatic Carotid Atherosclerosis: Systematic Review and Meta-Analysis

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Joseph Kamtchum Tatuene ◽  
Alan Wilman ◽  
Maher Saqqur ◽  
Gina Sykes ◽  
Ashfaq Shuaib ◽  
...  
Keyword(s):  
High Risk ◽  
Carotid Atherosclerosis ◽  
Meta Analysis ◽  
Random Effect ◽  
Imaging Features ◽  
Plaque Imaging ◽  
Asymptomatic Carotid ◽  
Increased Risk ◽  
Ischemic Events ◽  
Annual Risk

Background: The recommended treatment of asymptomatic carotid atherosclerosis is best medical therapy since the 1% annual risk of stroke is lower than the risk of stroke from revascularization. Specific imaging features may identify patients at increased risk of stroke and optimize the risk-benefit ratio of carotid surgery. To assess the relevance and feasibility of such approach, we aimed to summarize available data on the frequency of high-risk features and the related risk of stroke in patients with asymptomatic carotid atherosclerosis. Methods: A search of Pubmed and Ovid-Embase identified prospective studies reporting findings of carotid plaque imaging and incidence of stroke in patients with asymptomatic carotid atherosclerosis. Prevalence of high-risk features and incidence of ipsilateral ischemic events were pooled using random-effect meta-analysis. Results: Thirty-five studies enrolling 5808 participants with asymptomatic carotid atherosclerosis of various grades were included. The pooled prevalence (95% CI) of high-risk features on plaque imaging was 28.8 (18.8 - 38.7). The prevalence of neovascularization was 53.5% (45.2 - 61.8), echolucency 40.0% (30.8 - 49.6), lipid-rich necrotic core 35.7% (24.1 - 48.1), thin or ruptured fibrous cap 27.5% (14.2 - 43.3), silent brain infarcts 27.0% (15.3 - 40.5), impaired cerebrovascular reserve 25.9% (10.3 - 45.5), intraplaque hemorrhage 19.2% (13.9 - 25.1), microembolic signals 14.4% (8.9 - 20.8), and ulceration 13.5% (1.3 - 34.0). In 15 cohort studies enrolling 4215 participants, the mean duration of follow-up was 3.5 years (2.0 - 4.6). The pooled incidence of ipsilateral ischemic events was 2.7 per 100 person-years (1.6 - 4.0). This incidence was higher in patients with a high-risk feature (4.9%, 2.3 - 8.2) than in those without (0.9%, 0.2 - 1.8) with an odds ratio of 4.6 (2.3 - 9.3). Conclusion: High-risk features on imaging are frequent in asymptomatic carotid atherosclerosis and associated with a fourfold increase in the annual risk of ipsilateral ischemic events. A risk-oriented selection of patients with asymptomatic carotid atherosclerosis prior to randomization in revascularization trials appears relevant and may be a strategy to prevent stroke in asymptomatic carotid atherosclerosis.

Update on Extracranial Carotid Stenosis

2016 ◽  
Vol 11 (1) ◽  
pp. 18 ◽  
Author(s):  
Tilman Reiff ◽  
Christoph Gumbinger ◽  
Sibu Mundiyanapurath ◽  
Peter A Ringleb ◽  
◽  
...  
Keyword(s):  
Risk Factor ◽  
High Risk ◽  
Carotid Artery ◽  
Ischaemic Stroke ◽  
Carotid Stenosis ◽  
Medical Therapy ◽  
Stroke Risk ◽  
Research Results ◽  
Carotid Artery Endarterectomy

Carotid stenosis is a risk factor of ischaemic stroke and has an increasing prevalence with age. Stroke risk under optimised medical therapy, as well as recommendations of carotid artery endarterectomy/stenting, as therapy in high risk carotid stenosis, are discussed in consideration of recent research results.

scholarly journals QuantiFERON-TB Gold In-Tube in Saudi Arabia benchmarked with other sites of the Middle East: A meta-analysis review

2018 ◽  
Vol 12 (09) ◽  
pp. 687-699
Author(s):  
Hawra Al-Ghafli ◽  
Sahal Al-Hajoj
Keyword(s):  
Saudi Arabia ◽  
High Risk ◽  
Middle East ◽  
Publication Bias ◽  
Meta Analysis ◽  
Skin Testing ◽  
Random Effect ◽  
Random Effect Model ◽  
Risk Groups ◽  
Tuberculin Skin Testing

Introduction: Screening for Latent Tuberculosis Infections (LTBI) constitutes a key step in health surveillance programs especially among adults of high-risk groups. To our knowledge, this is the first systematic and meta-analysis review that aims to critically assess and compare the agreement of QuantiFERON-TB Gold In-Tube (QFT-GIT) and Tuberculin Skin Testing (TST) among adults of high-risk groups in Saudi Arabia and compare results with other sites of the Middle East. Methodology: Kappa estimates were meta-analyzed using random effect model and several subgroup analyzes were performed to explain overall heterogeneity. Funnel plot, Begg’s and Egger’s tests were employed to assess overall publication bias. Results: 18 studies were meta-analyzed, comprising 5070 adults of high-risk groups. Pooled kappa estimates from Saudi Arabia (κ = 0.29, 95% CI: 0.16, 0.41) showed lower rate of agreement compared to other sites of the Middle East (κ = 0.33, 95% CI: 0.25, 0.41). However, a significant level of heterogeneity (I2 = 96.7%, p > 0.001) were identified across collected evidence. Begg’s and Egger’s tests confirmed absence of significant publication bias in this review (p = 0.49 and p = 0.16, respectively). Conclusion: This work revealed fair to poor agreement between TST and QFT-GIT, indicating that these two tests are not interchangeable in such settings. Substantial evidence is still needed before considering the sole use of QFT-GIT as an alternative to TST in these populations. Moreover, there is an urgent need for longitudinal studies in Saudi Arabia and the Middle East to accurately assess precision of LTBI diagnosis.

Supracardiac atherosclerosis in embolic stroke of undetermined source: the underestimated source

2020 ◽  
Author(s):  
George Ntaios ◽  
Max Wintermark ◽  
Patrik Michel
Keyword(s):  
Stroke Risk ◽  
Embolic Stroke ◽  
Future Research ◽  
Atherosclerotic Plaques ◽  
Imaging Features ◽  
Advanced Imaging ◽  
Randomized Controlled ◽  
Intracranial Arteries ◽  
Embolic Risk

Abstract The term ‘embolic stroke of undetermined source’ (ESUS) is used to describe patients with a non-lacunar ischaemic stroke without any identified embolic source from the heart or the arteries supplying the ischaemic territory, or any other apparent cause. When the ESUS concept was introduced, covert atrial fibrillation was conceived to be the main underlying cause in the majority of ESUS patients. Another important embolic source in ESUS is the atherosclerotic plaque in the carotid, vertebrobasilar, and intracranial arteries, or the aortic arch—collectively described as supracardiac atherosclerosis. There is emerging evidence showing that the role of supracardiac atherosclerosis is larger than it was initially perceived. Advanced imaging methods are available to identify plaques which high embolic risk. The role of novel antithrombotic strategies in these patients needs to be assessed in randomized controlled trials. This review presents the evidence which points towards a major aetiological association between atherosclerotic plaques and ESUS, summarizes the imaging features which may aid to identify plaques more likely to be associated with ESUS, discusses strategies to reduce the associated stroke risk, and highlights the rationale for future research in this field.

scholarly journals Oxygen Extraction Fraction and Stroke Risk in Patients with Carotid Stenosis or Occlusion: A Systematic Review and Meta-Analysis

2013 ◽  
Vol 35 (2) ◽  
pp. 250-255 ◽  
Author(s):  
A. Gupta ◽  
H. Baradaran ◽  
A. D. Schweitzer ◽  
H. Kamel ◽  
A. Pandya ◽  
...  
Keyword(s):  
Systematic Review ◽  
Carotid Stenosis ◽  
Stroke Risk ◽  
Meta Analysis ◽  
Oxygen Extraction Fraction ◽  
Oxygen Extraction ◽  
Extraction Fraction

scholarly journals Tenecteplase in Pulmonary Embolism Patients: A Meta-Analysis and Systematic Review

2021 ◽  
Author(s):  
Zhu Zhang ◽  
Linfeng Xi ◽  
Shuai Zhang ◽  
Yunxia Zhang ◽  
Guohui Fan ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Meta Analysis ◽  
Random Effect ◽  
Random Effect Model ◽  
Bleeding Risk ◽  
Effect Model ◽  
High Bleeding Risk

Abstract OBJECTIVE: To assess the efficacy and safety of tenecteplase in patients with pulmonary embolism (PE). METHODS: We completed the literature search on May 31, 2021 using PubMed, EMBASE and the Web of Science. Analyses were conducted according to PE risk stratification, study design and duration of follow-up. The pooled risk ratios (RRs) and its 95% confident intervals (CIs) for death and major bleeding were calculated using a random-effect model.RESULTS: A total of six studies, with four randomized controlled trials (RCTs) and two cohort studies, were included in this study out of the 160 studies retrieved. For patients with high-risk PE, tenecteplase increased 30-day survival rate (16% vs 6%; P=0.005) and did not increase the incidence of bleeding (6% vs 5%; P=0.73). For patients with intermediate-risk PE, four RCTs suggested that tenecteplase reduced right ventricular insufficiency at 24h early in the onset and the incidence of hemodynamic failure without affecting mortality in a short/long-term [<30 days RR=0.83, 95% CI (0.47, 1.46);≥30 days RR=1.04, 95% CI (0.88, 1.22)]. However, tenecteplase was associated with high bleeding risk [<30 days RR=1.79, 95% CI (1.61, 2.00); ≥30 days RR=1.28, 95% CI (0.62, 2.64)].CONCLUSIONS: Tenecteplase may represent a promising candidate for patients with intermediate/high risk PE. Furthermore, tenecteplase may be preferable in the COVID-19 pandemic due to its all-at-once administration.

scholarly journals Carotid Stenosis and Recurrent Ischemic Stroke

Stroke ◽  
2021 ◽  
Author(s):  
Shadi Yaghi ◽  
Adam de Havenon ◽  
Sara Rostanski ◽  
Alexandra Kvernland ◽  
Brian Mac Grory ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
High Risk ◽  
Carotid Stenosis ◽  
Transient Ischemic Attack ◽  
Stroke Risk ◽  
Hazard Ratio ◽  
Minor Ischemic Stroke ◽  
Increased Risk ◽  
Ischemic Stroke Risk ◽  
Ischemic Attack

Background and Purpose: Randomized trials demonstrated the benefit of dual antiplatelet therapy in patients with minor ischemic stroke or high-risk transient ischemic attack. We sought to determine whether the presence of carotid stenosis was associated with increased risk of ischemic stroke and whether the addition of clopidogrel to aspirin was associated with more benefit in patients with versus without carotid stenosis. Methods: This is a post-hoc analysis of the POINT trial (Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke) that randomized patients with minor ischemic stroke or high-risk transient ischemic attack within 12 hours from last known normal to receive either clopidogrel plus aspirin or aspirin alone. The primary predictor was the presence of ≥50% stenosis in either cervical internal carotid artery. The primary outcome was ischemic stroke. We built Cox regression models to determine the association between carotid stenosis and ischemic stroke and whether the effect of clopidogrel was modified by ≥50% carotid stenosis. Results: Among 4881 patients enrolled POINT, 3941 patients met the inclusion criteria. In adjusted models, ≥50% carotid stenosis was associated with ischemic stroke risk (hazard ratio, 2.45 [95% CI, 1.68–3.57], P <0.001). The effect of clopidogrel (versus placebo) on ischemic stroke risk was not significantly different in patients with <50% carotid stenosis (adjusted hazard ratio, 0.68 [95% CI, 0.50–0.93], P =0.014) versus those with ≥50% carotid stenosis (adjusted hazard ratio, 0.88 [95% CI, 0.45–1.72], P =0.703), P value for interaction=0.573. Conclusions: The presence of carotid stenosis was associated with increased risk of ischemic stroke during follow-up. The effect of added clopidogrel was not significantly different in patients with versus without carotid stenosis. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03354429.

Carotid Intraplaque Hemorrhage Is Associated with Cardiovascular Risk Factors

2020 ◽  
Vol 49 (4) ◽  
pp. 355-360
Author(s):  
Anthony S. Larson ◽  
Waleed Brinjikji ◽  
Luis E. Savastano ◽  
John Huston III ◽  
John C. Benson
Keyword(s):  
Risk Factors ◽  
Cardiovascular Risk ◽  
Cardiovascular Risk Factors ◽  
Carotid Stenosis ◽  
Carotid Plaque ◽  
Intraplaque Hemorrhage ◽  
Plaque Imaging ◽  
Male Sex ◽  
Artery Disease ◽  
Carotid Plaque Imaging

Introduction: Intraplaque hemorrhage (IPH) is a known predictor of symptomatic cervical carotid artery disease. However, the association between IPH and modifiable cardiovascular risk factors, patient demographics, and pertinent laboratory values has not been extensively studied. Methods: A retrospective review was performed of consecutive patients who have undergone dedicated carotid plaque imaging over a 3-year period. Patients were excluded if the MR examination did not include high-resolution carotid plaque imaging. Intraplaque hyperintense signal on carotid plaque images was presumed to represent IPH. The presence or absence of IPH was compared to various demographic and clinical variables. Multivariable regression analysis was performed in order to determine an independent association between variables and IPH. Results: Of 643 included patients, 114 patients (17.7%) had IPH in one or both carotids, 529 patients (82.3%) did not; 39.5% of patients with IPH had coronary artery disease compared to 23.1% of patients without (p = 0.0003). Patients with IPH also had higher proportions of hypertension (77.2 vs. 60.7%, p = 0.009), hyperlipidemia (HLD; 89.5 vs. 62.4%, p < 0.0001), diabetes mellitus (29.0 vs. 18.7%, p = 0.01), and a history of tobacco smoking (63.2 vs. 52.6%, p = 0.003). Patients without IPH had, on average, higher high-density lipoprotein levels (46.1 vs. 56.7%, p = 0.003). Factors independently associated with IPH were advanced age (odds ratio [OR]: 1.1, 95% CI: [1.0–1.05], p <0.0001), male sex (OR: 2.5, 95% CI: [1.4–4.4], p = 0.0001), presence of carotid stenosis (OR: 8.4, 95% CI: [4.6–15.3], p < 0.0001), and HLD (OR: 2.6, 95% CI: [1.3–5.2], p = 0.009). Conclusions: IPH is associated with multiple cardiovascular risk factors, in particular advanced age, male sex, presence of carotid stenosis, and HLD. Such risk factors likely play a role in the development of IPH and may provide insight into the pathophysiology of unstable carotid plaques.

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