Andreas Schindler1, Regina Schinner2, Nishaf Altaf3, Akram A Hosseini4, Richard J Simpson3, Lorena Esposito-Bauer5, Navneet Singh6, Robert M Kwee7, Yoshitaka Kurosaki8, Sen Yamagata8, Kazumichi Yoshida9, Susumu Miyamoto9, Robert Maggisano10, Alan R Moody6, Holger Poppert5, M Eline Kooi11, Dorothee P Auer12, Leo H Bonati13, Tobias Saam2. 1. Department of Radiology, University Hospital, LMU Munich, Munich, Germany; Department of Radiology, Trauma Center Murnau, Murnau, Germany. 2. Department of Radiology, University Hospital, LMU Munich, Munich, Germany. 3. Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom; Department of Vascular Surgery, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom. 4. Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom; Department of Neurology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom. 5. Department of Neurology, Technische Universität München, Munich, Germany. 6. Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. 7. Department of Radiology and Nuclear Medicine, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Radiology, Zuyderland Medical Center, Heerlen, the Netherlands. 8. Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan. 9. Department of Neurosurgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan. 10. Department of Vascular Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. 11. Department of Radiology and Nuclear Medicine, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands. 12. Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom; NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, United Kingdom. 13. Department of Neurology and Stroke Center, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland. Electronic address: leo.bonati@usb.ch.
Abstract
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.
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.
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