Skip to main content

Advertisement

SpringerLink
Log in

Non-stenosing carotid artery plaques in embolic stroke of undetermined source: a retrospective analysis

  • Original Article
  • Published:
Neurological Sciences Aims and scope Submit manuscript

Abstract

Background

We aim to identify the association between high-risk carotid plaques and their laterality to stroke in ESUS patient population. We also discuss recurrent stroke events and their laterality to the index stroke.

Methods

This was a retrospective study. We reviewed data for patients with ESUS between June 20, 2016, and June 20, 2021. Using computed tomography angiography, we analyzed plaque features that are associated with ESUS, and then, we identified the recurrent stroke events and characterized lateralization to the index stroke.

Results

Out of 1779 patients with cryptogenic ischemic stroke, we included 152 patients who met the criteria for ESUS. High-risk plaque features were found more often ipsilateral to the stroke side when compared contralaterally: plaque ulceration (19.08% vs 5.26%, p < .0001), plaque thickness > 3 mm (19.08% vs 7.24%, p = 0.001), and plaque length > 1 cm (13.16% vs 5.92%, p = 0.0218). There was also a significant difference in plaque component in which both components (soft and calcified) and only soft plaques were more prevalent ipsilaterally (42.76% vs 23.68% and 17.76% vs 9.21%, respectively, p < .0001). Of the 152 patients, 17 patients were found to have a recurrent stroke event, and 47% (n = 8) had an ipsilateral stroke to the index event. Moreover, stroke was bilateral in 41% of the patients (n = 7), and contralateral in 12% (n = 2).

Conclusion

High-risk plaque features studied here were more prevalent ipsilaterally to the stroke side in ESUS than contralaterally. Multicenter studies are needed to form precise prediction models and scoring systems to help guide treatment, i.e., choice of medical therapy and/or revascularization.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Data availability

All data are available from the corresponding author upon reasonable request.

Abbreviations

ESUS:

Embolic stroke of undetermined source

CTA:

Computed tomography angiography

TOAST:

Trial of Org 10172 in Acute Stroke Treatment

NASCET:

The North American Symptomatic Carotid Endarterectomy Trial

ECST:

European Carotid Surgery Trial

CEA:

Carotid endarterectomy

CAS:

Carotid artery stenting

CEA:

Carotid endarterectomy

CAS:

Carotid artery stenting

References

  1. Ferguson GG, Eliasziw M, Barr HW, Clagett GP, Barnes RW, Wallace MC et al (1999) The North American Symptomatic Carotid Endarterectomy Trial : surgical results in 1415 patients. Stroke 30(9):1751–1758. https://doi.org/10.1161/01.str.30.9.1751

    Article  CAS  Google Scholar 

  2. (1998) Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 351(9113):1379–87. PMID: 9593407

  3. Oddo M, Carrera E, Claassen J, Mayer SA, Hirsch LJ (2009) Continuous electroencephalography in the medical intensive care unit. Crit Care Med 37(6):2051–2056. https://doi.org/10.1097/CCM.0b013e3181a00604

    Article  Google Scholar 

  4. Rothwell PM, Eliasziw M, Gutnikov SA, Fox AJ, Taylor DW, Mayberg MR et al (2003) Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 361(9352):107–116. https://doi.org/10.1016/s0140-6736(03)12228-3

    Article  CAS  Google Scholar 

  5. Hart RG, Diener HC, Coutts SB, Easton JD, Granger CB, O’Donnell MJ et al (2014) Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol 13(4):429–438. https://doi.org/10.1016/s1474-4422(13)70310-7

    Article  Google Scholar 

  6. Hyafil F, Schindler A, Sepp D, Obenhuber T, Bayer-Karpinska A, Boeckh-Behrens T et al (2016) High-risk plaque features can be detected in non-stenotic carotid plaques of patients with ischaemic stroke classified as cryptogenic using combined (18)F-FDG PET/MR imaging. Eur J Nucl Med Mol Imaging 43(2):270–279. https://doi.org/10.1007/s00259-015-3201-8

    Article  Google Scholar 

  7. Altaf N, Daniels L, Morgan PS, Auer D, MacSweeney ST, Moody AR et al (2008) Detection of intraplaque hemorrhage by magnetic resonance imaging in symptomatic patients with mild to moderate carotid stenosis predicts recurrent neurological events. J Vasc Surg 47(2):337–342. https://doi.org/10.1016/j.jvs.2007.09.064

    Article  Google Scholar 

  8. Singh N, Moody AR, Panzov V, Gladstone DJ (2018) Carotid intraplaque hemorrhage in patients with embolic stroke of undetermined source. J Stroke Cerebrovasc Dis 27(7):1956–1959. https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.02.042

    Article  Google Scholar 

  9. Kamtchum-Tatuene J, Nomani AZ, Falcione S, Munsterman D, Sykes G, Joy T et al (2021) Non-stenotic carotid plaques in embolic stroke of unknown source. Front Neurol 12:719329. https://doi.org/10.3389/fneur.2021.719329

    Article  Google Scholar 

  10. Kasner SE, Lynn MJ, Chimowitz MI, Frankel MR, Howlett-Smith H, Hertzberg VS et al (2006) Warfarin vs aspirin for symptomatic intracranial stenosis: subgroup analyses from WASID. Neurology 67(7):1275–1278. https://doi.org/10.1212/01.wnl.0000238506.76873.2f

    Article  CAS  Google Scholar 

  11. Gupta A, Gialdini G, Lerario MP, Baradaran H, Giambrone A, Navi BB et al (2015) Magnetic resonance angiography detection of abnormal carotid artery plaque in patients with cryptogenic stroke. J Am Heart Assoc 4(6):e002012. https://doi.org/10.1161/jaha.115.002012

    Article  Google Scholar 

  12. Gupta A, Gialdini G, Giambrone AE, Lerario MP, Baradaran H, Navi BB et al (2016) Association between nonstenosing carotid artery plaque on MR angiography and acute ischemic stroke. JACC Cardiovasc Imaging 9(10):1228–1229. https://doi.org/10.1016/j.jcmg.2015.12.004

    Article  Google Scholar 

  13. Acampa M, Lazzerini PE, Manfredi C, Guideri F, Tassi R, Domenichelli C et al (2020) Non-stenosing carotid atherosclerosis and arterial stiffness in embolic stroke of undetermined source. Front Neurol 11:725. https://doi.org/10.3389/fneur.2020.00725

    Article  Google Scholar 

  14. Knight-Greenfield A, Quitlong Nario JJ, Vora A, Baradaran H, Merkler A, Navi BB et al (2019) Associations between features of nonstenosing carotid plaque on computed tomographic angiography and ischemic stroke subtypes. J Am Heart Assoc 8(24):e014818. https://doi.org/10.1161/jaha.119.014818

    Article  Google Scholar 

  15. Watase H, Canton G, Sun J, Zhao X, Hatsukami TS, Yuan C (2019) Four different carotid atherosclerotic behaviors based on luminal stenosis and plaque characteristics in symptomatic patients: an in vivo study. Diagnostics (Basel) 9(4):137. https://doi.org/10.3390/diagnostics9040137

    Article  Google Scholar 

  16. Demarco JK, Ota H, Underhill HR, Zhu DC, Reeves MJ, Potchen MJ et al (2010) MR carotid plaque imaging and contrast-enhanced MR angiography identifies lesions associated with recent ipsilateral thromboembolic symptoms: an in vivo study at 3T. AJNR Am J Neuroradiol 31(8):1395–1402. https://doi.org/10.3174/ajnr.A2213

    Article  CAS  Google Scholar 

  17. Saba L, Saam T, Jäger HR, Yuan C, Hatsukami TS, Saloner D et al (2019) Imaging biomarkers of vulnerable carotid plaques for stroke risk prediction and their potential clinical implications. Lancet Neurol 18(6):559–572. https://doi.org/10.1016/s1474-4422(19)30035-3

    Article  Google Scholar 

  18. Yuan C, Zhang SX, Polissar NL, Echelard D, Ortiz G, Davis JW et al (2002) Identification of fibrous cap rupture with magnetic resonance imaging is highly associated with recent transient ischemic attack or stroke. Circulation 105(2):181–185. https://doi.org/10.1161/hc0202.102121

    Article  Google Scholar 

  19. Gupta A, Baradaran H, Kamel H, Pandya A, Mangla A, Dunning A et al (2014) Evaluation of computed tomography angiography plaque thickness measurements in high-grade carotid artery stenosis. Stroke 45(3):740–745. https://doi.org/10.1161/strokeaha.113.003882

    Article  Google Scholar 

  20. Kamtchum-Tatuene J, Noubiap JJ, Wilman AH, Saqqur M, Shuaib A, Jickling GC (2020) Prevalence of high-risk plaques and risk of stroke in patients with asymptomatic carotid stenosis: a meta-analysis. JAMA Neurol 77(12):1524–1535. https://doi.org/10.1001/jamaneurol.2020.2658

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurology, Henry Ford Hospital, Detroit, MI, USA

    Ammar Jumah, Omar Choudhury, Michael Fana, Mohammad Alkhoujah, Owais K. Alsrouji, Megan Brady, Alex Chebl & Daniel Miller

  2. Department of Vascular Neurology, Emory University School of Medicine, Atlanta, GA, USA

    Hassan Aboul Nour

  3. Department of Neuroradiology, Henry Ford Hospital, Detroit, MI, USA

    Osama Intikhab & Horia Marin

  4. Department of Neurology, Sparrow Hospital, Lansing, MI, USA

    Karam Gagi

  5. Department of Vascular Neurology, University of Toledo, Toledo, OH, USA

    Hisham Alhajala

  6. Jordan University of Science and Technology, Amman, Jordan

    Lara Eltous

  7. Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI, USA

    Lonni Schultz & Katie Latack

Authors
  1. Ammar Jumah
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Hassan Aboul Nour
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Osama Intikhab
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Omar Choudhury
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Karam Gagi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Michael Fana
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Hisham Alhajala
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Mohammad Alkhoujah
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Owais K. Alsrouji
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Lara Eltous
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Lonni Schultz
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Katie Latack
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Megan Brady
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Alex Chebl
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Horia Marin
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Daniel Miller
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Dr. Miller created the idea of the project, contributed to methodology and design, and supervised the project. Dr. Marin contributed to methodology, design, statistical planning, and project supervision. Dr. Jumah and Dr. Aboul Nour contributed to methodology and design, statistical planning, data extraction and cleaning, literature review. Dr. Eltous and Dr. Jumah contributed in manuscript writing. Dr. Alhajala contributed to methodology and design. Dr. Choudhury, Dr. Fana, Dr. Alsrouji, and Dr. Gagi contributed to data extraction and cleaning. Dr. Schultz and Dr. Latack contributed to statistical planning and execution. Ms. Brady contributed to data extraction and cleaning. All authors contributed to data interpretation, composition, and revision of the article. Dr. Chebl contributed to critical analysis and drafting of the manuscript.

Corresponding author

Correspondence to Ammar Jumah.

Ethics declarations

Ethical approval and consent to participate

The study was approved by the Institutional Review Board and the need for informed consent was waived due to the retrospective nature of the study.

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jumah, A., Aboul Nour, H., Intikhab, O. et al. Non-stenosing carotid artery plaques in embolic stroke of undetermined source: a retrospective analysis. Neurol Sci 44, 247–252 (2023). https://doi.org/10.1007/s10072-022-06425-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10072-022-06425-w

Keywords

Search

Navigation