Symptomatic carotid stenosis and stroke risk in patients with transient ischemic attack according to the tissue-based definition

Patients with symptomatic carotid stenosis benefit from revascularization. The risk of recurrent stroke is highest during the early period after a transient ischemic attack or stroke. Carotid endarterectomy and carotid stenting are options for treatment and should be considered within the first 2 weeks if feasible.

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Reduction in Early Stroke Risk in Carotid Stenosis With Transient Ischemic Attack Associated With Statin Treatment

Journal of Vascular Surgery ◽

10.1016/j.jvs.2013.12.010 ◽

2014 ◽

Vol 59 (2) ◽

pp. 555

Author(s):

Á. Merwick ◽

G.W. Albers ◽

E.M. Arsava

Keyword(s):

Carotid Stenosis ◽

Transient Ischemic Attack ◽

Stroke Risk ◽

Statin Treatment ◽

Ischemic Attack ◽

Early Stroke

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Carotid Stenosis and Recurrent Ischemic Stroke

Stroke ◽

10.1161/strokeaha.121.034089 ◽

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.

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Abstract 304: Association Between Plaque Morphology and Time Interval After the Neurologic Index Event in Patients With Symptomatic Carotid Stenosis

Arteriosclerosis Thrombosis and Vascular Biology ◽

10.1161/atvb.37.suppl_1.304 ◽

2017 ◽

Vol 37 (suppl_1) ◽

Author(s):

Pavlos Tsantilas ◽

Andreas Kuehnl ◽

Jaroslav Pelisek ◽

Lars Maegdefessel ◽

Carina Wendorff ◽

...

Keyword(s):

Carotid Stenosis ◽

Plaque Morphology ◽

Time Interval ◽

Symptomatic Carotid ◽

Index Event ◽

Plaque Removal ◽

Fibrous Cap ◽

Ordinal Regression Analysis ◽

Symptomatic Carotid Stenosis ◽

Ischemic Attack

Objectives: Instable plaques are more common in patients with symptomatic carotid stenosis compared to asymptomatic patients. Clinically symptomatic patients are at high risk for a recurrent stroke in the first days after a neurologic index event. Histopathologic plaque stabilisation or remodelling mechanisms of symptomatic plaques are unclear. Therefore, our study aimed to find changes of plaque morphology in dependence of time interval between neurologic index event and plaque removal. Methods: Plaques of patients that were removed from surgically treated patients with symptomatic carotid stenosis between 2004 and 2016 were included. Histological analyses of those carotid plaques were performed to assess the type of plaque (American Heart Association classification), the stability of plaque (thickness of the fibrous cap </>200μm), the extent of calcification, inflammation, neovascularization and the deposition of collagen and elastin. Statistical analysis was applied in form of an ordinal regression analysis, adjusted for common risk factors of atherosclerosis. Results: Out of 348 included plaques, the patients’ median age was 71 (Q1-Q3, 65 - 77) years and 69% were male. Median time interval between index event and plaque removal was 10 days (Q1-Q3, 4-28 days). Most common index event was a transient ischemic attack with 37% (128 of 348), followed by stroke in 28% (97 of 348), amaurosis fugax in 22% (76 of 348) and instable symptoms (crescendo transient ischemic attack, stroke in evolution) in 12% (43 of 348), respectively. The ordinal regression analysis revealed, that the time interval as continuous independent variable had no significant influence on plaque type, plaque stability, extent of calcification, inflammation or neovascularization and the deposition of collagen and elastin. Conclusions: The examined plaque morphology features of patients with symptomatic carotid stenosis showed no differences in relation to the time interval between neurologic index event and plaque removal. To find potential symptomatic plaque remodelling mechanisms, currently ongoing molecular and histomorphological analysis aim at identifying novel markers of apoptosis and cell fate-driven mechanisms in fibrous cap-enriched vascular smooth cells.

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Leukoaraiosis and Procedural Stroke Risk in Symptomatic Carotid Stenosis

World Neurosurgery ◽

10.1016/j.wneu.2014.01.010 ◽

2014 ◽

Vol 81 (3-4) ◽

pp. 455-457

Author(s):

Tarek Rayan ◽

Sepideh Amin-Hanjani

Keyword(s):

Carotid Stenosis ◽

Stroke Risk ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis

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Prolonged cerebral circulation time is more associated with symptomatic carotid stenosis than stenosis degree or collateral circulation

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013293 ◽

2017 ◽

Vol 10 (5) ◽

pp. 476-480 ◽

Cited By ~ 2

Author(s):

Yong-Sin Hu ◽

Wan-Yuo Guo ◽

I-Hui Lee ◽

Feng-Chi Chang ◽

Chung-Jung Lin ◽

...

Keyword(s):

Carotid Stenosis ◽

Cerebral Circulation ◽

Collateral Circulation ◽

Stroke Risk ◽

Circulation Time ◽

High Grade ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis ◽

The Difference ◽

Cerebral Circulation Time

Background and purposeCurrent practice of revascularization for carotid stenosis (CS) primarily relies on symptoms and degree of stenosis. Other parameters, such as collateral circulation and cerebral circulation time (CCT), might influence the stroke risk in CS. This study was conducted to (1) investigate whether CCT is more associated with symptomatic CS than degree of stenosis and (2) elucidate the associations among the degree of stenosis, collateral status, and CCT.MethodsFrom 2010 to 2016, 82 patients with unilateral CS were enrolled for DSA and divided into symptomatic and asymptomatic groups based on clinical presentation. CCT was defined as the difference between the time taken by the cavernous internal carotid artery and parietal vein to reach the maximal contrast medium intensities on lateral DSA. The degree of stenosis, collateral status, and CCT of the two groups were compared. Logistic regression analysis was performed to estimate the OR for symptomatic CS with the imaging variables.ResultsThe symptomatic group had a significantly higher degree of stenosis and longer CCT. CCT (OR 1.95, p=0.013) was more associated with symptomatic CS than the degree of stenosis (OR 1.03, p=0.229), after adjustment for potential confounders—namely, age, sex, antithrombotic use, and collateral status. Symptomatic high grade CS with collaterals had a non-significantly shorter CCT than those without collaterals.ConclusionsDSA derived CCT is more reflective of the hemodynamic differences between symptomatic and asymptomatic CS than degree of stenosis. Collaterals may not effectively reduce CCT in symptomatic high grade CS.

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