Carotid plaque hemorrhage on magnetic resonance imaging strongly predicts recurrent ischemia and stroke
Version of Record online: 4 JUN 2013
© 2013 American Neurological Association
Annals of Neurology
Volume 73, Issue 6, pages 774–784, June 2013
How to Cite
Hosseini, A. A., Kandiyil, N., MacSweeney, S. T. S., Altaf, N. and Auer, D. P. (2013), Carotid plaque hemorrhage on magnetic resonance imaging strongly predicts recurrent ischemia and stroke. Ann Neurol., 73: 774–784. doi: 10.1002/ana.23876
- Issue online: 18 JUL 2013
- Version of Record online: 4 JUN 2013
- Accepted manuscript online: 6 MAR 2013 12:39AM EST
- Manuscript Accepted: 22 FEB 2013
- Manuscript Revised: 23 JAN 2013
- Manuscript Received: 14 AUG 2012
- National Institute for Health Research (NIHR). Grant Number: PB-PG-0107-11438
There is a recognized need to improve selection of patients with carotid artery stenosis for carotid endarterectomy (CEA). We assessed the value of magnetic resonance imaging (MRI)-defined carotid plaque hemorrhage (MRIPH) to predict recurrent ipsilateral cerebral ischemic events, and stroke in symptomatic carotid stenosis.
One hundred seventy-nine symptomatic patients with ≥50% stenosis were prospectively recruited, underwent carotid MRI, and were clinically followed up until CEA, death, or ischemic event. MRIPH was diagnosed if the plaque signal intensity was >150% that of the adjacent muscle. Event-free survival analysis was done using Kaplan–Meier plots and Cox regression models controlling for known vascular risk factors. We also undertook a meta-analysis of reported data on MRIPH and recurrent events.
One hundred fourteen patients (63.7%) showed MRIPH, suffering 92% (57 of 62) of all recurrent ipsilateral events and all but 1 (25 of 26) future strokes. Patients without MRIPH had an estimated annual absolute stroke risk of only 0.6%. Cox multivariate regression analysis proved MRIPH as a strong predictor of recurrent ischemic events (hazard ratio [HR] = 12.0, 95% confidence interval [CI] = 4.8–30.1, p < 0.001) and stroke alone (HR = 35.0, 95% CI = 4.7–261.6, p = 0.001). Meta-analysis of published data confirmed this association between MRIPH and recurrent cerebral ischemic events in symptomatic carotid artery stenosis (odds ratio = 12.2, 95% CI = 5.5–27.1, p < 0.00001).
MRIPH independently and strongly predicts recurrent ipsilateral ischemic events, and stroke alone, in symptomatic ≥50% carotid artery stenosis. The very low stroke risk in patients without MRIPH puts into question current risk–benefit assessment for CEA in this subgroup. ANN NEUROL 2013;73:774–784