Lack of association between carotid plaque hematoma and ischemic cerebral symptoms.

Abstract

Tb investigate the association between carotid plaque hematoma and symptoms of cerebral ischemia a retrospective review of 200 consecutive carotid endarterectomies at the Neurological Institute of New York was carried out. Data analyzed included cerebral ischemic symptoms, angiographic findings, preoperative use of antithrombotic agents, and microscopic pathology of endarterectomy specimens. No association was found between ischemic symptoms ipsilateral to the endarterectomy and presence, size, or age of plaque hematomas. Plaque hematomas were less common among patients who took antithrombotic agents preoperatively than among those who did not. The presence of plaque hematoma was associated with angiographic carotid cross-sectional area stenosis of >75%. Patients with stenosis of <75% were more likely than those with stenosis of >75% to have ischemic symptoms ipsilateral to the endarterectomy, suggesting that criteria for surgical treatment of carotid atherosclerosis differ for those who are symptomatic vs. those who are asymptomatic. These results demonstrate the limitation of using a surgical series to extend causal inferences about the relation between plaque hematoma and cerebral ischemic symptoms to the general population of people with carotid atherosclerosis. (Stroke 1987;18:879-881) H emorrhage into atheromatous plaque is a common feature of large artery atherosclerosis. 1 " 3 Some investigators have reported that carotid plaque hematomas occur significantly more often in symptomatic patients undergoing endarterectomy compared with those who are asymptomatic and that there is a correlation between age of the hematoma and timing of the symptoms.4 "* They postulate that plaque hematoma is an important precipitator of transient ischemic attack (TIA) and stroke, either by causing acute severe stenosis or by producing intimal disruption leading to overlying thrombus formation and consequent embolism. This argument provides a rationale for the role of endarterectomy in the prevention of stroke in people with atherosclerotic plaques or stenosis, both symptomatic and asymptomatic. Furthermore, it is suggested that the use of antithrombotic agents may obscure warning symptoms and may increase the risk of plaque hematoma. 6 We conducted a study of all persons undergoing endarterectomy at the Neurological Institute of New York from October 1982 to May 1984 to further investigate the relation of carotid plaque hematoma to the occurrence of TIA and stroke in surgically treated patients and to determine if preoperative use of antithrombotic agents was associated with the presence of plaque hematoma. Subjects and MethodsDuring the period under study, 200 carotid endarterectomies were performed. The study included those 198 endarterectomies about which clinical information could be found. Ninety-three men and 84 women with a mean age of 66 years comprised the study population; 156 had unilateral and 21 had bilateral endarterectomies. Clinical information was obtained by chart review to determine whether symptoms of foc...

Correlation Between Carotid Intraplaque Hemorrhage and Clinical Symptoms

“…However, when remote hemorrhage was also taken into consideration, the differences between the 2 groups lost significance. To estimate the age of IPH, considerable work 1,[3][4][5][6][7][8][9][10][11][12][13][14][15][16]20 was done, and a modified elastochrome stain that could clearly delineate hemorrhages was introduced for the first time. 7 Three pathologic categories were defined: acute (Ͻ1week), recent (1 to 6 weeks), and remote (Ͼ6 weeks) hemorrhage.…”

“…7 Three pathologic categories were defined: acute (Ͻ1week), recent (1 to 6 weeks), and remote (Ͼ6 weeks) hemorrhage. 3,7,15,16 An age of 4 weeks was used as the threshold for recent and old hemorrhage in the report of Lenninhan et al, 4 wherein there was no association between acute hemorrhage and the onset of ipsilateral symptoms. Recent (or "significant") hemorrhage was otherwise graded when it involved Ͼ50% of the plaque thickness.…”

“…2 However, it was reported that a correlation could not be corroborated, and the mere presence of IPH at the carotid bifurcation did not necessarily produce symptoms. [3][4][5] Most recently, Milei et al 6 found that IPH was not potentially associated with symptoms, and it appeared that IPH might occur at any time, irrespective of symptoms. Moreover, the age of IPH (acute, recent, or old) and its role have been the subject of disagreement.…”

“…Moreover, the age of IPH (acute, recent, or old) and its role have been the subject of disagreement. 1,[3][4][5][6][7][8][9][10][11][12][13][14][15][16] Quite a few studies have indicated that the presence of IPH appears to increase with the severity of carotid artery stenosis. 2,4,5,13,16 -23 Some attention has focused on the quantification of hemorrhage volume.…”

Relationships of Cerebral MRI Findings to Ultrasonographic Carotid Atherosclerosis in Older Adults

“…Some of these associations have been disputed, however, with other investigators failing to demonstrate more frequent symptoms associated with ulcerations 14,21 and plaque hemorrhage. 23,24 The documented ability of B-mode ultrasonographic scanning to detect plaque ulceration, 25 heterogeneity, 26,27 and hemorrhage, 28 though disputed by some, 24,29,30 has led to the demonstration that these ultrasound-defined characteristics are also associated with ipsilateral neurologic symptoms, 31 clinical events, 26 and MRI-defined infarcts. 18,32 The mechanisms by which carotid artery disease may be associated with neurological symptoms and stroke include (1) thrombotic occlusion of large vessels such as the carotid and middle cerebral arteries with hypoperfusion in the vascular distribution supplied by these vessels; (2) cerebral embolism of either atheromatous material from a ruptured or ulcerated carotid plaque or of fibrin-platelet material from a thrombotic plaque to distal vessels; or (3) manifestation or general marker of systemic atherosclerosis occurring at the large and small vessel level.…”