Mild or Intermediate Symptomatic Carotid Lesions: What we need to know about plaque

Ischemic stroke is the main reason behind disability in the world, and it is often followed by death.

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The rupture of carotid atherosclerotic plaque and its embolization are the main cause of this entity.

Different randomized studies have shown that carotid endarterectomy is beneficial in symptomatic patients with 70 to 99% carotid obstruction, but we still need to find evidence to establish the best treatment for mild and intermediate lesions.

The PARISK study, an observational multicenter prospective trial, included 238 patients with a history of transient ischemic attack (TIA) or monocular stroke, TIA or minor carotid stroke with mild to moderate ipsilateral carotid lesion.

Patients were looked at using magnetic resonance imaging (MRI) and computed tomography angiography (AngioTAC) to look at four carotid plaque properties: presence of intraplaque hemorrhage (MRI), (ulceration (AngioTAC), proportion of calcifications (AngioTAC), and total plaque volume (MRI).

Mean age was 69, 71% were men, 86% were hypertensive, 26% diabetic, 49% had a history of myocardial ischemia.

45% presented TIA, 44% stroke and 111% stroke or monocular TIA.

Carotid obstruction (ECST risk score) was 0 to 30% in 73% of patients, 30 to 49% in 23%, and 50 to 69% in the remaining 4%.

There was 39% intraplaque hemorrhage, 27% ulceration, 7.3% calcification and 1281.5 µL total plaque volume.

At 5 year-followup TIA or stroke was associated to presence and total volume of intraplaque hemorrhage (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 calcifications were not associated to events.

Conclusion

Intraplaque hemorrhage and total plaque volume are independent risk factor of TIA or recurrent ipsilateral stroke in patients with mild to moderate carotid stenosis. Plaque characteristics will improve decision making. Further study is required to validate plaque characteristics and its implementation in clinical scores.