Original Research
Prediction of Stroke Risk by Detection of Hemorrhage in Carotid Plaques: Meta-Analysis of Individual Patient Data

https://doi.org/10.1016/j.jcmg.2019.03.028Get rights and content
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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.

Key Words

carotid
cerebrovascular event
intraplaque hemorrhage
ischemic stroke
magnetic resonance imaging
NASCET

Abbreviations and Acronyms

AER
annualized event rate
AFx
amaurosis fugax
CI
confidence interval
HR
hazard ratio
IPH
intraplaque hemorrhage
MRI
magnetic resonance imaging
TIA
transient ischemic attack

Cited by (0)

Dr. Simpson has received grants from the UK Stroke Association during the conduct of the study. Dr. Esposito-Bauer has received grants from Technical University of Munich, Germany, KKF-Fond, during the conduct of the original study. Dr. Yoshida has received grants from the Japan Society for the Promotion of Science KAKENHI; grants and personal fees from Takeda Pharmaceutical Company, personal fees from Otsuka Pharmaceutical, AstraZeneca, and Kowa Pharmaceutical; and grants from Astellas Pharma Inc. and Pfizer Inc., outside the submitted work. Dr. Miyamoto has received grants from the Japan Society for the Promotion of Science KAKENHI, Otsuka Pharmaceutical, CSL Behring, Japan Medtronic, Philips Japan, Pfizer Inc., Siemens Healthineers Japan, Nihon Medi-Physics, Eisai, CHUGAI Pharmaceutical, SANOFI, Takeda Pharmaceutical, and MSD, outside the submitted work. Dr. Kooi has received grants from the Netherlands Heart Foundation during the conduct of the study. Dr. Auer has received grants and other from the UK Stroke Association; and grants from the National Institute of Health Research–Research for Patient Benefit during the conduct of the study. Dr. Bonati has received grants from the Swiss National Science Foundation (32003B-156658) and the Swiss Heart Foundation, during the conduct of the study; grants from Swiss National Science Foundation, Swiss Heart Foundation, and AstraZeneca; and personal fees from Amgen, Bayer, Bristol-Myers Squibb, and Claret Medical, outside the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Drs. Bonati and Saam are joint senior authors.