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Embolic Stroke of Undetermined Source and Carotid Intraplaque Hemorrhage on MRI

A Systemic Review and Meta-Analysis

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Abstract

Background

Embolic stroke of undetermined source (ESUS) has traditionally discounted the significance of internal carotid artery stenosis of <50%; however, recent studies have examined the role of carotid artery intraplaque hemorrhage (IPH) as an etiology in nonstenotic carotid arteries. We performed a systemic review of the literature to determine the prevalence of carotid artery IPH on magnetic resonance imaging (MRI) of the vessel wall in patients with ESUS.

Methods

We used PubMed, Epub ahead of print, Ovid MEDLINE in-process and other non-indexed citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane central register of controlled trials, Ovid Cochrane database of systematic reviews and Scopus. Our study consisted of all case series with >10 patients with IPH and ESUS published through October 2018. Additionally, we included 123 patients from an institutional database from 2015–2019. Random effects meta-analysis was used for pooling across studies. Meta-analysis results were expressed as odds ratio (OR) with respective 95% confidence intervals (CI).

Results

A total of 7 studies with 354 patients were included. The mean age was 67.5 years old. The overall prevalence estimate for prevalence of IPH ipsilateral to the ischemic lesion was 25.8% (95% CI 13.1–38.5). The odds of having IPH on the ipsilateral side versus the contralateral side was 6.92 (95% CI 3.04–15.79).

Conclusion

Patients with ESUS have IPH in the carotid artery ipsilateral to the ischemic stroke in 25.8% of cases. Carotid artery vessel wall MRI should be considered as part of the standard work-up in patients with ESUS.

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Authors and Affiliations

  1. Department of Radiology, Mayo Clinic, 200 1st St. SW, 55905, Rochester, MN, USA

    Ian T. Mark, John Huston, Vance T. Lehman & Waleed Brinjikji

  2. Department of Neurology, Mayo Clinic, Rochester, MN, USA

    Deena M. Nasr & Alejandro A. Rabinstein

  3. Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA

    Lucio de Maria & Paolo de Sanctis

  4. Department of Radiology, University of Cagliari, Cagliari, Italy

    Luca Saba

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  1. Ian T. Mark
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Correspondence to Waleed Brinjikji.

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Conflict of interest

I.T. Mark, D.M. Nasr, J. Huston, L. de Maria, P. de Sanctis, V.T. Lehman, A.A. Rabinstein, L. Saba and W. Brinjikji declare that they have no competing interests.

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Mark, I.T., Nasr, D.M., Huston, J. et al. Embolic Stroke of Undetermined Source and Carotid Intraplaque Hemorrhage on MRI. Clin Neuroradiol 31, 307–313 (2021). https://doi.org/10.1007/s00062-020-00921-2

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