Carotid Plaques From Symptomatic Patients With Mild Stenosis Is Associated With Intraplaque Hemorrhage

Nardi, Valentina; Benson, John C.; Bois, Melanie C.; Saba, Luca; Larson, Anthony S.; Ӧzcan, Ilke; Ahmad, Ali; Morse, David; Meyer, Fredric B.; Brinjikji, Waleed; Lanzino, Giuseppe; Lerman, Lilach O.; Savastano, Luis; Lerman, Amir

doi:10.1161/hypertensionaha.121.18128

Cited by 16 publications

(12 citation statements)

References 70 publications

(109 reference statements)

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“…31 Of all MR imaging biomarkers of plaque vulnerability, IPH has been most strongly associated with ipsilateral ischemia in patients with ESUS, even in cases of minimal luminal stenosis. 9,21,[32][33][34][35][36] In fact, our group has demonstrated that patients with ESUS with ipsilateral IPH had an annual recurrence rate of 9.5% compared with 2.5% in patients without IPH. 9 Perhaps the most convincing evidence to date comes from the aforementioned PARISK study, in which patients with MR imaging evidence of IPH were at higher risk of developing recurrent ischemic events at 5-year follow-up.…”

Section: Mr Imagingmentioning

confidence: 78%

Nonstenotic Carotid Plaques and Embolic Stroke of Undetermined Source: A Multimodality Review

Larson¹,

Brinjikji²,

Lekah³

et al. 2022

AJNR Am J Neuroradiol

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Symptomatic nonstenotic carotid artery disease has been increasingly recognized as a thromboembolic source in patients who would otherwise be classified as having embolic stroke of undetermined source. Evidence suggests that certain plaque features seen on sonography, CT, and MR imaging in nonstenotic carotid artery disease may predispose to recurrent stroke in patients with embolic stroke of undetermined source. We performed a focused literature review to further study plaque features in the context of embolic stroke of undetermined source and to determine which plaque features may be associated with ipsilateral ischemic events in such patients. Plaque thickness as seen on both ultrasound and CT appears to have a consistent association with ipsilateral stroke in patients with embolic stroke of undetermined source across multiple studies. Intraplaque hemorrhage as seen on MR imaging is now understood to have a strong association with ipsilateral stroke in patients with embolic stroke of undetermined source. Continued study of various plaque features as seen on different modalities is warranted to uncover other potential associations.ABBREVIATIONS: ESUS ¼ embolic stroke of undetermined source; IPH ¼ intraplaque hemorrhage; LRNC ¼ lipid-rich necrotic core; SyNC ¼ symptomatic nonstenotic carotid artery disease; US ¼ ultrasound U p to one-third of strokes have no established mechanism and are considered to be cryptogenic. 1 In 2014, the term "embolic stroke of undetermined source" (ESUS) was established as a clinical entity in patients with nonlacunar cryptogenic stroke in which an embolic source was thought to be most likely, despite an appropriate diagnostic evaluation with negative findings (Fig 1). 2 This term (along with "cryptogenic stroke") has also been used to define patients who may have multiple, competing stroke etiologies in which a definitive source cannot be determined. Patients with ESUS have been estimated to have a .4% risk of recurrent stroke per annum despite being on antiplatelet medication. 1 Subsequent thought was directed to the idea that anticoagulation may be beneficial in such patients, given the likelihood that emboli originated from various nonevident atheroembolic sources. 3 This premise provided the impetus for 2 large clinical trials that compared anticoagulation with aspirin alone in patients with ESUS. 4,5 Despite this plausible theory, no benefit of anticoagulation was observed. These results spurred continued interest in additional

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Section: Mr Imagingmentioning

confidence: 78%

Nonstenotic Carotid Plaques and Embolic Stroke of Undetermined Source: A Multimodality Review

Larson¹,

Brinjikji²,

Lekah³

et al. 2022

AJNR Am J Neuroradiol

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“…[19][20][21][22][23][24][25] There was a higher prevalence of intraplaque hemorrhage (IPH) in ipsilateral plaques 19,24,25 and in plaques with a lower degree of stenosis. 26 In particular, mildly stenotic carotid arteries in patients with ESUS had higher IPH compared with moderate and severe stenosis. 26 The pooled prevalence of ipsilateral high-risk carotid plaques across seven studies was 28% compared with 4% for contralateral plaques (Figure 2).…”

Section: Carotid Atherosclerosismentioning

confidence: 89%

“…26 In particular, mildly stenotic carotid arteries in patients with ESUS had higher IPH compared with moderate and severe stenosis. 26 The pooled prevalence of ipsilateral high-risk carotid plaques across seven studies was 28% compared with 4% for contralateral plaques (Figure 2).…”

Section: Carotid Atherosclerosismentioning

confidence: 89%

Magnetic resonance imaging for diagnostic workup of embolic stroke of undetermined source: A systematic review

Khenkina

Aimo

Fabiani

et al. 2023

International Journal of Stroke

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Background Embolic stroke of undetermined source, or ESUS, refers to ischemic stroke where the underlying cause of thromboembolism cannot be found despite the recommended diagnostic workup. Unidentified source of emboli hinders clinical decision-making and patient’s management with detrimental consequences on long-term prognosis. Rapid development and versatility of MRI make it an appealing addition to the diagnostic routine of patients with ESUS for the assessment of potential vascular and cardiac embolic sources. Aims to review the use of MRI in the identification of cardiac and vascular embolic sources in ESUS and to assess the reclassification value of MRI examinations added to the conventional workup of ESUS Summary of review we reviewed the use of cardiac and vascular MRI for the identification of a variety of embolic sources associated with ESUS, including atrial cardiomyopathy, left ventricular pathologies, and supracervical atherosclerosis in carotid and intracranial arteries and in distal thoracic aorta. The additional reclassification after MRI examinations added to the workup of patients with ESUS ranged from 6.1 up to 82.3% and varied depending on the combination of imaging modalities. Conclusion MRI techniques allow to identify additional cardiac and vascular embolic sources and may further decrease the prevalence of patients with the diagnosis of ESUS.

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“…109 Intraplaque hemorrhage is another strong indicator of symptomatic plaque and is associated with stroke reoccurrence. 110 Histopathologic studies of extracranial cervical artery specimens have validated intraplaque hemorrhage as plaques with high-signal intensity on T1 weighted images. 111 Unlike in vivo validation of plaque characteristics for carotid atherosclerosis due to sample availability from carotid endarterectomy, in vivo validation for intracranial arteries remains a challenge.…”

Section: Imaging In Icadmentioning

confidence: 99%

Epidemiology, Pathophysiology, and Imaging of Atherosclerotic Intracranial Disease

Chen,

Spagnolo-Allende,

Yang

et al. 2024

Stroke

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Intracranial atherosclerotic disease (ICAD) is one of the most common causes of stroke worldwide. Among people with stroke, those of East Asia descent and non-White populations in the United States have a higher burden of ICAD-related stroke compared with Whites of European descent. Disparities in the prevalence of asymptomatic ICAD are less marked than with symptomatic ICAD. In addition to stroke, ICAD increases the risk of dementia and cognitive decline, magnifying ICAD societal burden. The risk of stroke recurrence among patients with ICAD-related stroke is the highest among those with confirmed stroke and stenosis ≥70%. In fact, the 1-year recurrent stroke rate of >20% among those with stenosis >70% is one of the highest rates among common causes of stroke. The mechanisms by which ICAD causes stroke include plaque rupture with in situ thrombosis and occlusion or artery-to-artery embolization, hemodynamic injury, and branch occlusive disease. The risk of stroke recurrence varies by the presumed underlying mechanism of stroke, but whether techniques such as quantitative magnetic resonance angiography, computed tomographic angiography, magnetic resonance perfusion, or transcranial Doppler can help with risk stratification beyond the degree of stenosis is less clear. The diagnosis of ICAD is heavily reliant on lumen-based studies, such as computed tomographic angiography, magnetic resonance angiography, or digital subtraction angiography, but newer technologies, such as high-resolution vessel wall magnetic resonance imaging, can help distinguish ICAD from stenosing arteriopathies.

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Carotid Plaques From Symptomatic Patients With Mild Stenosis Is Associated With Intraplaque Hemorrhage

Cited by 16 publications

References 70 publications

Nonstenotic Carotid Plaques and Embolic Stroke of Undetermined Source: A Multimodality Review

Nonstenotic Carotid Plaques and Embolic Stroke of Undetermined Source: A Multimodality Review

Magnetic resonance imaging for diagnostic workup of embolic stroke of undetermined source: A systematic review

Epidemiology, Pathophysiology, and Imaging of Atherosclerotic Intracranial Disease

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