Carotid Plaque Characteristics Predict Recurrent Ischemic Stroke and TIA: The PARISK (Plaque At RISK) Study
PARISK Study Group
(2022) JACC. Cardiovascular imaging, volume 15, issue 10, pp. 1715 - 1726
(Article)
Abstract
Background: Patients with symptomatic carotid stenosis are at high risk for recurrent stroke. The decision for carotid endarterectomy currently mainly relies on degree of stenosis (cutoff value >50% or 70%). Nevertheless, also, patients with mild-to-moderate stenosis still have a considerable recurrent stroke risk. Increasing evidence suggests that carotid plaque composition
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rather than degree of stenosis determines plaque vulnerability; however, it remains unclear whether this also provides additional information to improve clinical decision making. Objectives: The PARISK (Plaque At RISK) study aimed to improve the identification of patients at increased risk of recurrent ischemic stroke using multimodality carotid imaging. Methods: The authors included 244 patients (71% men; mean age, 68 years) with a recent symptomatic mild-to-moderate carotid stenosis in a prospective multicenter cohort study. Magnetic resonance imaging (carotid and brain) and computed tomography angiography (carotid) were performed at baseline and after 2 years. The clinical endpoint was a recurrent ipsilateral ischemic stroke or transient ischemic attack (TIA). Cox proportional hazards models were used to assess whether intraplaque hemorrhage (IPH), ulceration, proportion of calcifications, and total plaque volume in ipsilateral carotid plaques were associated with the endpoint. Next, the authors investigated the predictive performance of these imaging biomarkers by adding these markers (separately and simultaneously) to the ECST (European Carotid Surgery Trial) risk score. Results: During 5.1 years follow-up, 37 patients reached the clinical endpoint. IPH presence and total plaque volume were associated with recurrent ipsilateral ischemic stroke or TIA (HR: 2.12 [95% CI: 1.02-4.44] for IPH; HR: 1.07 [95% CI: 1.00-1.15] for total plaque volume per 100 µL increase). Ulcerations and proportion of calcifications were not statistically significant determinants. Addition of IPH and total plaque volume to the ECST risk score improved the model performance (C-statistics increased from 0.67 to 0.75-0.78). Conclusions: IPH and total plaque volume are independent risk factors for recurrent ipsilateral ischemic stroke or TIA in patients with mild-to-moderate carotid stenosis. These plaque characteristics improve current decision making. Validation studies to implement plaque characteristics in clinical scoring tools are needed.
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Keywords: Aged, Calcinosis/complications, Carotid Arteries/pathology, Carotid Stenosis/complications, Cohort Studies, Constriction, Pathologic/complications, Female, Hemorrhage/complications, Humans, Ischemic Attack, Transient/complications, Ischemic Stroke, Magnetic Resonance Imaging/methods, Male, Plaque, Atherosclerotic, Predictive Value of Tests, Prospective Studies, Risk Factors, Stroke/complications, recurrent stroke risk, computed tomography angiography (CTA), plaque imaging, carotid atherosclerosis, magnetic resonance imaging (MRI), symptomatic carotid artery disease, Cardiology and Cardiovascular Medicine, Radiology Nuclear Medicine and imaging, Research Support, Non-U.S. Gov't, Multicenter Study, Journal Article
ISSN: 1936-878X
Publisher: Elsevier Inc.
Note: Funding Information: The authors thank S.L.M. Bakker, G.A.J.C. Crombag, G.J. de Borst, M.P.M. de Maat, A.A.J. de Rotte, K. Dilba, A.P. Hoeks, P.A.M. Hofman, B. Hussain, L.J. Kappelle, M. Kassem, A.G. Korten, J.R. de Kruijk, N.D. Kruyt, M. Limburg, C. Lucci, B.J. Meems, M.T. Mulder, A.J. Nederveen, K.P.H. Nies, R. Saxena, A.H.C.M.L. Schreuder, J.P.L. Slenders, H.M. Spronk, J. Steinbuch, H. ten Cate, S.C. Tromp, H.M.M. van Beusekom, A.C. van Dijk, C.M. van Egmond, A.M. van Hattem, R.H.M. van Hoof, N.P. van Orshoven, T.J. van Velzen, J.C.B. Verhey, W. Weisfelt, J.E. Wildberger, A.D. Wijnhoud, and T. Zadi for their contribution to the PARISK study; and Rob J. van der Geest for providing VesselMASS software and Elucid Bioimaging for providing VascuCAP. Funding Information: This work was supported by the Dutch Heart Foundation (grant number DHF2008-T094) and was performed within the framework of the Center for Translational Molecular Medicine, project PARISK (Plaque At RISK; grant number 01C-202). The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Publisher Copyright: © 2022 The Authors
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