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Stroke Prevention with Extracranial Carotid Artery Disease

  • Stroke (DL Tirschwell, Section Editor)
  • Published:
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Abstract

Purpose of Review

Carotid artery stenosis is a major risk factor for ischemic stroke. Although effective treatment options exist, careful assessment of benefits and risks for individual patients is needed in clinical decision-making. This article reviews contemporary treatments for carotid artery stenosis, the underlying evidence, and areas of uncertainties.

Recent Findings

Specific recommendations are available to guide the standard of care of carotid artery stenosis. Nonetheless, significant uncertainties are noted in patient selection for surgical treatment of asymptomatic carotid stenosis and in optimal treatment targets for pharmacological therapies. Advanced imaging has been used to predict future risk of ipsilateral stroke and clarify mechanisms of actions of pharmacological therapies, primarily in observational studies.

Summary

Pharmacological and surgical treatments for extracranial carotid artery stenosis continue to evolve with many relevant clinical trials completed and clinical guidelines updated in recent years. Future clinical trials to tackle the areas of uncertainties are warranted.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. de Weerd M, Greving JP, Hedblad B, Lorenz MW, Mathiesen EB, O’Leary DH, Rosvall M, Sitzer M, Buskens E, Bots ML. Prevalence of asymptomatic carotid artery stenosis in the general population: an individual participant data meta-analysis. Stroke. 2010;41:1294–7.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Wilson PW, Hoeg JM, D’Agostino RB, Silbershatz H, Belanger AM, Poehlmann H, O’Leary D, Wolf PA. Cumulative effects of high cholesterol levels, high blood pressure, and cigarette smoking on carotid stenosis. N Engl J Med. 1997;337:516–22.

    Article  CAS  PubMed  Google Scholar 

  3. Sun J, Underhill HR, Hippe DS, Xue Y, Yuan C, Hatsukami TS. Sustained acceleration in carotid atherosclerotic plaque progression with intraplaque hemorrhage: a long-term time course study. J Am Coll Cardiol Img. 2012;5:798–804.

    Article  Google Scholar 

  4. Domanski MJ, Tian X, Wu CO, Reis JP, Dey AK, Gu Y, Zhao L, Bae S, Liu K, Hasan AA, Zimrin D, Farkouh ME, Hong CC, Lloyd-Jones DM, Fuster V. Time course of LDL cholesterol exposure and cardiovascular disease event risk. J Am Coll Cardiol. 2020;76:1507.

    Article  CAS  PubMed  Google Scholar 

  5. Naylor AR, Ricco JB, Borst de GJ, Debus S, Haro de J, Halliday A, Hamilton G, Kakisis J, Kakkos S, Lepidi S, Markus HS, McCabe DJ, Roy J, Sillesen H, Berg van den JC, Vermassen F, ESVS, Kolh GC, Chakfe P, Hinchliffe N, Koncar RJ, Lindholt I, Vega De Ceniga JS, Verzini M, ESVS F, Archie GR, Bellmunt J, Chaudhuri S, Koelemay A, Lindahl M, Padberg AK, Venermo FM. Editor's Choice - Management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the european society for vascular surgery (ESVS). Eur J Vasc Endovasc Surg. 2018;55:3–81.

  6. Flaherty ML, Kissela B, Khoury JC, Alwell K, Moomaw CJ, Woo D, Khatri P, Ferioli S, Adeoye O, Broderick JP, Kleindorfer D. Carotid artery stenosis as a cause of stroke. Neuroepidemiology. 2013;40:36–41.

    Article  PubMed  Google Scholar 

  7. Turc G, Oppenheim C, Naggara O, Eker OF, Calvet D, Lacour JC, Crozier S, Guegan-Massardier E, Henon H, Neau JP, Toussaint JF, Mas JL, Meder JF, Touze E. Relationships between recent intraplaque hemorrhage and stroke risk factors in patients with carotid stenosis: the HIRISC study. Arterioscler Thromb Vasc Biol. 2012;32:492–9.

    Article  CAS  PubMed  Google Scholar 

  8. Gupta A, Baradaran H, Schweitzer AD, Kamel H, Pandya A, Delgado D, Dunning A, Mushlin AI, Sanelli PC. Carotid plaque MRI and stroke risk: a systematic review and meta-analysis. Stroke. 2013;44:3071–7.

    Article  PubMed  Google Scholar 

  9. von Reutern G, Goertler M, Bornstein NM, Sette MD, Evans DH, Hetzel A, Kaps M, Perren F, Razumovky A, von Reutern M, Shiogai T, Titianova E, Traubner P, Venketasubramanian N, Wong LKS, Yasaka M. Grading carotid stenosis using ultrasonic methods. Stroke. 2012;43:916–21.

    Article  Google Scholar 

  10. Wardlaw JM, Chappell FM, Best JJ, Wartolowska K, Berry E. Non-invasive imaging compared with intra-arterial angiography in the diagnosis of symptomatic carotid stenosis: a meta-analysis. Lancet. 2006;367:1503–12.

    Article  CAS  PubMed  Google Scholar 

  11. Romero JM, Pizzolato R, Atkinson W, Meader A, Jaimes C, Lamuraglia G, Jaff MR, Buonanno F, Delgado Almandoz J, Gonzalez RG. Vasa vasorum enhancement on computerized tomographic angiography correlates with symptomatic patients with 50% to 70% carotid artery stenosis. Stroke. 2013;44:3344–9.

    Article  PubMed  Google Scholar 

  12. Zhou T, Jia S, Wang X, Wang B, Wang Z, Wu T, Li Y, Chen Y, Yang C, Li Q, Yang Z, Li M, Sun G. Diagnostic performance of MRI for detecting intraplaque hemorrhage in the carotid arteries: a meta-analysis. Eur Radiol. 2019;29:5129-38.

  13. Pickett CA, Jackson JL, Hemann BA, Atwood JE. Carotid bruits as a prognostic indicator of cardiovascular death and myocardial infarction: a meta-analysis. The Lancet. 2008;371:1587–94.

    Article  Google Scholar 

  14. Münzel T, Hahad O, Kuntic M, Keaney JFJ, Deanfield JE, Daiber A. Effects of tobacco cigarettes, e-cigarettes and waterpipe smoking on endothelial function and clinical outcomes. Eur Heart J. 2020;41:4057–70.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  15. Tong TYN, Appleby PN, Key TJ, Dahm CC, Overvad K, Olsen A, Tjønneland A, Katzke V, Kühn T, Boeing H, Karakatsani A, Peppa E, Trichopoulou A, Weiderpass E, Masala G, Grioni S, Panico S, Tumino R, Boer JMA, Verschuren WMM, Quirós JR, Agudo A, Rodríguez-Barranco M, Imaz L, Chirlaque M, Moreno-Iribas C, Engström G, Sonestedt E, Lind M, Otten J, Khaw K, Aune D, Riboli E, Wareham NJ, Imamura F, Forouhi NG, di Angelantonio E, Wood AM, Butterworth AS, Perez-Cornago A. The associations of major foods and fibre with risks of ischaemic and haemorrhagic stroke: a prospective study of 418 329 participants in the EPIC cohort across nine European countries. Eur Heart J. 2020;41:2632–40.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC, Virani SS, Williams KA, Yeboah J, Ziaeian B. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease. Journal of the American College of Cardiology 2019;74: e177.

  17. Lovett JK, Howard SC, Rothwell PM. Pulse pressure is independently associated with carotid plaque ulceration. J Hypertens. 2003;21:1669–76.

    Article  CAS  PubMed  Google Scholar 

  18. Sun J, Canton G, Balu N, Hippe DS, Xu D, Liu J, Hatsukami TS, Yuan C. Blood pressure is a major modifiable risk factor implicated in pathogenesis of intraplaque hemorrhage: an in vivo magnetic resonance imaging study. Arterioscler Thromb Vasc Biol. 2016;36:743–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ 2009;338:b1665.

  20. Xie X, Atkins E, Lv J, Bennett A, Neal B, Ninomiya T, Woodward M, MacMahon S, Turnbull F, Hillis GS, Chalmers J, Mant J, Salam A, Rahimi K, Perkovic V, Rodgers A. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. The Lancet. 2016;387:435–43.

    Article  Google Scholar 

  21. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, Clement DL, Coca A, Simone de G, Dominiczak A, Kahan T, Mahfoud F, Redon J, Ruilope L, Zanchetti A, Kerins M, Kjeldsen SE, Kreutz R, Laurent S, Lip GYH, McManus R, Narkiewicz K, Ruschitzka F, Schmieder RE, Shlyakhto E, Tsioufis C, Aboyans V, Desormais I. ESC SDG 2018 ESC/ESH guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). Eur Heart J. 2018;39:3021–3104.

  22. Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, Faiella-Tommasino J, Forman DE, Goldberg R, Heidenreich PA, Hlatky MA, Jones DW, Lloyd-Jones D, Lopez-Pajares N, Ndumele CE, Orringer CE, Peralta CA, Saseen JJ, Smith SJ, Sperling L, Virani SS, Yeboah J. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. Circulation. 2019;139:e1082–143.

    PubMed  Google Scholar 

  23. Cholesterol Treatment Trialists’ (CTT) Collaboration. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. Lancet. 2010;376:1670–1681.

  24. Sun J, Lepor NE, Cantón G, Contreras L, Hippe DS, Isquith DA, Balu N, Kedan I, Simonini AA, Yuan C, Zhao X, Hatsukami TS. Serial magnetic resonance imaging detects a rapid reduction in plaque lipid content under PCSK9 inhibition with alirocumab. Int J Cardiovasc Imaging. 2021;37:1415–22.

    Article  PubMed  Google Scholar 

  25. Sarwar N, Gao P, Seshasai SR, Gobin R, Kaptoge S, Di Angelantonio E, Ingelsson E, Lawlor DA, Selvin E, Stampfer M, Stehouwer CD, Lewington S, Pennells L, Thompson A, Sattar N, White IR, Ray KK, Danesh J. Diabetes mellitus, fasting blood glucose concentration and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet. 2010;375:2215–22.

    Article  CAS  PubMed  Google Scholar 

  26. The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358:2545–59.

    Article  PubMed Central  Google Scholar 

  27. Cosentino F, Grant PJ, Aboyans V, Bailey CJ, Ceriello A, Delgado V, Federici M, Filippatos G, Grobbee DE, Hansen TB, Huikuri HV, Johansson I, Jüni P, Lettino M, Marx N, Mellbin LG, Östgren CJ, Rocca B, Roffi M, Sattar N, Seferović PM, Sousa-Uva M, Valensi P, Wheeler DC. ESC SDG 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: the task force for diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and the European Association for the Study of Diabetes (EASD). Eur Heart J. 2019;41:255–323.

  28. Das SR, Everett BM, Birtcher KK, Brown JM, Januzzi JL, Kalyani RR, Kosiborod M, Magwire M, Morris PB, Neumiller JJ, Sperling LS. 2020 Expert consensus decision pathway on novel therapies for cardiovascular risk reduction in patients with type 2 diabetes. J Am Coll Cardiol. 2020;76:1117.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Antithrombotic Trialists' (ATT) Collaboration. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009;373:1849–60.

    Article  CAS  Google Scholar 

  30. Park J, Kang K, Cho Y, Hong K, Lee KB, Park TH, Lee SJ, Ko Y, Han M, Lee J, Cha J, Kim D, Kim D, Kim J, Choi JC, Yu K, Lee B, Lee JS, Lee J, Gorelick PB, Bae H, On TBOC. Comparative effectiveness of prestroke aspirin on stroke severity and outcome. Ann Neurol. 2016;79:560–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Mujaj B, Bos D, Muka T, Lugt AV, Ikram MA, Vernooij MW, Stricker BH, Franco OH. Antithrombotic treatment is associated with intraplaque haemorrhage in the atherosclerotic carotid artery: a cross-sectional analysis of the Rotterdam study. Eur Heart J. 2018;39:3369-76.

  32. Liem MI, Schreuder FHBM, van Dijk AC, de Rotte AAJ, Truijman MTB, Daemen MJAP, van der Steen AFW, Hendrikse J, Nederveen AJ, van der Lugt A, Kooi ME, Nederkoorn PJ. Use of antiplatelet agents is associated with intraplaque hemorrhage on carotid magnetic resonance imaging: the plaque at risk study. Stroke. 2015;46:3411–5.

    Article  CAS  PubMed  Google Scholar 

  33. PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet. 2001;358:1033–41.

  34. Kitagawa K, Yamamoto Y, Arima H, Maeda T, Sunami N, Kanzawa T, Eguchi K, Kamiyama K, Minematsu K, Ueda S, Rakugi H, Ohya Y, Kohro T, Yonemoto K, Okada Y, Higaki J, Tanahashi N, Kimura G, Umemura S, Matsumoto M, Shimamoto K, Ito S, Saruta T, Shimada K, For TRSP. Effect of standard vs intensive blood pressure control on the risk of recurrent stroke: a randomized clinical trial and meta-analysis. JAMA Neurol. 2019;76:1309–18.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Crisby M, Nordin-Fredriksson G, Shah PK, Yano J, Zhu J, Nilsson J. Pravastatin treatment increases collagen content and decreases lipid content, inflammation, metalloproteinases, and cell death in human carotid plaques - Implications for plaque stabilization. Circulation. 2001;103:926–33.

    Article  CAS  PubMed  Google Scholar 

  36. The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med. 2006;355:549–59.

  37. Lau LH, Lew J, Borschmann K, Thijs V, Ekinci EI. Prevalence of diabetes and its effects on stroke outcomes: a meta-analysis and literature review. J Diabetes Investig. 2019;10:780–92.

    Article  PubMed  Google Scholar 

  38. Johnston KC, Bruno A, Pauls Q, Hall CE, Barrett KM, Barsan W, Fansler A, Van de Bruinhorst K, Janis S, Durkalski-Mauldin VL. For TNET. Intensive vs standard treatment of hyperglycemia and functional outcome in patients with acute ischemic stroke: the SHINE randomized clinical trial. JAMA. 2019;322:326–35.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Lovett JK, Coull AJ, Rothwell PM. Early risk of recurrence by subtype of ischemic stroke in population-based incidence studies. Neurology. 2004;62:569–73.

    Article  CAS  PubMed  Google Scholar 

  40. Ois A, Cuadrado-Godia E, Rodríguez-Campello A, Jimenez-Conde J, Roquer J. High risk of early neurological recurrence in symptomatic carotid stenosis. Stroke. 2009;40:2727–31.

    Article  PubMed  Google Scholar 

  41. Rothwell PM, Algra A, Chen Z, Diener H, Norrving B, Mehta Z. Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of randomised trials. Lancet. 2016;388:365–75.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Markus HS, Droste DW, Kaps M, Larrue V, Lees KR, Siebler M, Ringelstein EB. Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using doppler embolic signal detection. Circulation. 2005;111:2233–40.

    Article  CAS  PubMed  Google Scholar 

  43. Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C, Wang C, Li H, Meng X, Cui L, Jia J, Dong Q, Xu A, Zeng J, Li Y, Wang Z, Xia H, Johnston SC. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med. 2013;369:11–9.

    Article  CAS  PubMed  Google Scholar 

  44. Johnston SC, Easton JD, Farrant M, Barsan W, Conwit RA, Elm JJ, Kim AS, Lindblad AS, Palesch YY. Clopidogrel and aspirin in acute ischemic stroke and high-risk TIA. N Engl J Med. 2018;379:215–25.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50:e344–418.

    Article  PubMed  Google Scholar 

  46. Antithrombotic Trialists’ Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002;324:71–86.

    Article  Google Scholar 

  47. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee Lancet. 1996;348:1329–39.

    Google Scholar 

  48. Trifan G, Gorelick PB, Testai FD. Efficacy and safety of using dual versus monotherapy antiplatelet agents in secondary stroke prevention: systematic review and meta-analysis of randomized controlled clinical trials. Circulation. 2021;143:2441-53.

  49. Sardar P, Chatterjee S, Aronow HD, Kundu A, Ramchand P, Mukherjee D, Nairooz R, Gray WA, White CJ, Jaff MR, Rosenfield K, Giri J. Carotid artery stenting versus endarterectomy for stroke prevention: a meta-analysis of clinical trials. J Am Coll Cardiol. 2017;69:2266–75.

    Article  PubMed  Google Scholar 

  50. Brott TG, Howard G, Roubin GS, Meschia JF, Mackey A, Brooks W, Moore WS, Hill MD, Mantese VA, Clark WM, Timaran CH, Heck D, Leimgruber PP, Sheffet AJ, Howard VJ, Chaturvedi S, Lal BK, Voeks JH, Hobson RW. Long-term results of stenting versus endarterectomy for carotid-artery stenosis. N Engl J Med. 2016;374:1021–31.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Walker MD, Marler JR, Goldstein M, Grady PA, Toole JF, Baker WH, Castaldo JE, Chambless LE, Moore WS, Robertson JT, Young B, Howard VJ, Purvis S, Vernon DD, Needham K, Beck P, Celani VJ, Sauerbeck L, von Rajcs JA, Atkins D. Endarterectomy for asymptomatic carotid artery stenosis. JAMA. 1995;273:1421–8.

    Article  Google Scholar 

  52. Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, Thomas D. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet. 2004;363:1491–502.

    Article  CAS  PubMed  Google Scholar 

  53. den Hartog AG, Achterberg S, Moll FL, Kappelle LJ, Visseren FLJ, van der Graaf Y, Algra A, de Borst GJ. Asymptomatic carotid artery stenosis and the risk of ischemic stroke according to subtype in patients with clinical manifest arterial disease. Stroke. 2013;44:1002–7.

    Article  Google Scholar 

  54. Keyhani S, Cheng EM, Hoggatt KJ, Austin PC, Madden E, Hebert PL, Halm EA, Naseri A, Johanning JM, Mowery D, Chapman WW, Bravata DM. Comparative effectiveness of carotid endarterectomy vs initial medical therapy in patients with asymptomatic carotid stenosis. JAMA Neurol. 2020;77:1110–21. By analyzing data from real-world practice (2005-2009), this comparative effectiveness study demonstrated that the absolute risk reduction of fatal and nonfatal strokes by CEA was only 2.3% (95% CI: -4.0% to -0.3%) in 5 years and was no longer statistically significant (-0.8%, 95% CI: -2.1% to 0.5%) after accounting for the competing risk of non-stroke death.

    Article  PubMed  Google Scholar 

  55. Müller MD, Lyrer PA, Brown MM, Bonati LH. Carotid artery stenting versus endarterectomy for treatment of carotid artery stenosis. Stroke. 2021;52:e3–5. This updated meta-analysis comparing CEA and CAS included 9,753 patients from 22 clinical trials and demonstrated that CAS was associated with a higher risk of periprocedural stroke or death in patients with symptomatic carotid stenosis, primarily attributed to an increased risk in those >=70 years.

    Article  PubMed  Google Scholar 

  56. https://clinicaltrials.gov/ct2/show/NCT02089217. Accessed 26 May 2021.

  57. European Carotid Surgery Trialists' Collaborative Group. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European carotid surgery trial (ECST). Lancet. 1998;351:1379–87.

  58. Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, Rankin RN, Clagett GP, Hachinski VC, Sackett DL, Thorpe KE, Meldrum HE, Spence JD. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1998;339:1415–25.

    Article  CAS  PubMed  Google Scholar 

  59. Rothwell PM, Eliasziw M, Gutnikov SA, Fox AJ, Taylor DW, Mayberg MR, Warlow CP, Barnett HJ. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet. 2003;361:107–16.

    Article  CAS  PubMed  Google Scholar 

  60. Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet. 2004;363:915–24.

    Article  CAS  PubMed  Google Scholar 

  61. Ricotta JJ, AbuRahma A, Ascher E, Eskandari M, Faries P, Lal BK. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011;54:e1–31.

    Article  PubMed  Google Scholar 

  62. Gupta A, Kesavabhotla K, Baradaran H, Kamel H, Pandya A, Giambrone AE, Wright D, Pain KJ, Mtui EE, Suri JS, Sanelli PC, Mushlin AI. Plaque echolucency and stroke risk in asymptomatic carotid stenosis. Stroke. 2015;46:91–7.

    Article  PubMed  Google Scholar 

  63. Jashari F, Ibrahimi P, Bajraktari G, Grönlund C, Wester P, Henein MY. Carotid plaque echogenicity predicts cerebrovascular symptoms: a systematic review and meta-analysis. Eur J Neurol. 2016;23:1241–7.

    Article  CAS  PubMed  Google Scholar 

  64. Schindler A, Schinner R, Altaf N, Hosseini AA, Simpson RJ, Esposito-Bauer L, Singh N, Kwee RM, Kurosaki Y, Yamagata S, Yoshida K, Miyamoto S, Maggisano R, Moody AR, Poppert H, Kooi ME, Auer DP, Bonati LH, Saam T. Prediction of stroke risk by detection of hemorrhage in carotid plaques: meta-analysis of individual patient data. JACC Cardiovasc Imaging. 2019;13:395–406. This meta-analysis of individual patient data included 560 patients from 7 cohort studies and demonstrated that intraplaque hemorrhage was a strong predictor of ipsilateral ischemic stroke independent of luminal stenosis whereas the risk of ipsilateral ischemic stroke was low in the absence of intraplaque hemorrhage irrespective of degree of stenosis.

    Article  PubMed  Google Scholar 

  65. O’Donnell MJ, Chin SL, Rangarajan S, Xavier D, Liu L, Zhang H, Rao-Melacini P, Zhang X, Pais P, Agapay S, Lopez-Jaramillo P, Damasceno A, Langhorne P, McQueen MJ, Rosengren A, Dehghan M, Hankey GJ, Dans AL, Elsayed A, Avezum A, Mondo C, Diener H, Ryglewicz D, Czlonkowska A, Pogosova N, Weimar C, Iqbal R, Diaz R, Yusoff K, Yusufali A, Oguz A, Wang X, Penaherrera E, Lanas F, Ogah OS, Ogunniyi A, Iversen HK, Malaga G, Rumboldt Z, Oveisgharan S, Al Hussain F, Magazi D, Nilanont Y, Ferguson J, Pare G, Yusuf S. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet. 2016;388:761–75.

    Article  PubMed  Google Scholar 

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Sun, J., Yuan, C. & Hatsukami, T.S. Stroke Prevention with Extracranial Carotid Artery Disease. Curr Cardiol Rep 23, 161 (2021). https://doi.org/10.1007/s11886-021-01593-1

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