Complicated Non-Stenotic Carotid Plaques: A Light in the Diagnosis of Cryptogenic Stroke?

Stroke is one of the leading causes of death and disability. It produces great morbidity by causing marked post-event cognitive impairment. Recurrence of an ischemic event may vary according to the cause of the stroke. Complicated non-stenotic carotid plaque (CCP) type VI (according to the American Heart Association [AHA] classification) has been described as an under-recognized cause in the diagnosis of stroke.

Placas carotídeas complicadas no estenosantes ¿una luz en el diagnóstico del ACV criptogénico?

CCP is defined as plaque with a ruptured fibrous cap, intraplaque hemorrhage (IPAH), or mural thrombosis. It can be accurately diagnosed by carotid magnetic resonance angiography (dark blood technique).

The AHA classifies it into type I-II (normal thickness, without calcification), type III (diffuse intimal thickening, without calcification), type IV/V (plaque with lipid or necrotic core surrounded by fibrous tissue with possible calcification), type VI (complicated plaque with surface defects or thrombus), type VII (calcified plaque), and type VIII (fibrotic plaque without lipid core and with small calcifications).

Currently, there are no studies that have assessed its search in the first days after stroke (acute stage), especially in patients labeled as cryptogenic stroke.

The CAPIAS (carotid plaque imaging in acute stroke) is an observational, prospective, multicenter study conducted in Germany, looking to define the role of CCP in the recurrence of ischemic stroke or transient ischemic attack (TIA) compared with patients without CCP.

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Researchers included patients older than 49 years, within 10 days after an ischemic stroke, with a single area involved (attributable to carotid artery), with carotid plaque ≥2 mm. Patients with carotid stenosis ≥70% or dissection were excluded. The primary endpoint (PEP) was a composite of recurrent ischemic stroke or TIA. Secondary endpoints (SEP) were recurrent ischemic stroke and ipsilateral recurrent ischemic stroke or TIA.

Data were obtained from 196 patients, of whom 104 had been diagnosed with cryptogenic stroke. Twenty-nine percent had a baseline ipsilateral CCP. On average, 21 patients had recurrence of ischemic stroke or TIA.

The incidence rate of the PEP was significantly higher in patients with ipsilateral CCP (9.50 per 100 patient-years) compared with patients without CCP (3.61 per 100 patient-years; p = 0.025). Adjusted for age and sex, ipsilateral CCP was associated with 2.5 times higher risk of recurrence at 3 years (hazard ratio [HR]: 2.51; 95% confidence interval [CI]: 1.03-6.11; p = 0.043).

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When analyzing the characteristics of CCPs by MRI, the presence of ruptured fibrous cap was mostly associated with ischemic events (HR: 2.61; 95% CI: 1.01-7.05; p = 0.041), whereas the presence of intraplaque hemorrhage was associated with an increased risk of events in patients with cryptogenic stroke (HR: 4.37; 95% CI: 1.20-15.97; p = 0.026).


This study showed that ipsilateral CCP detected by MRI angiography within 10 days of stroke was associated with an increased risk of recurrent stroke or TIA. These findings were mainly in patients diagnosed with cryptogenic stroke. Whether the treatment of these patients should include more aggressive medical treatment or carotid interventions has not been studied, but from the data shown on recurrence in this research it should be considered as a field to be developed.

Dr. Omar Tupayachi

Dr. Omar Tupayachi.
Member of the Editorial Board of

Original Title: Complicated Carotid Artery Plaques and Risk of Recurrent Ischemic Stroke or TIA.

Reference: Kopczak, Anna et al. “Complicated Carotid Artery Plaques and Risk of Recurrent Ischemic Stroke or TIA.” Journal of the American College of Cardiology vol. 79,22 (2022): 2189-2199. doi:10.1016/j.jacc.2022.03.376.

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