Plaque Inflammation and Unstable Morphology Are Associated With Early Stroke Recurrence in Symptomatic Carotid Stenosis

Abstract

Background and Purpose-Although symptomatic carotid stenosis is associated with 3-fold increased risk of early stroke recurrence, the pathophysiologic mechanisms of high early stroke risk have not been established. We aimed to investigate the relationship between early stroke recurrence after initial symptoms and histological features of plaque inflammation and instability in resected carotid plaque. Methods-Carotid

You May Delay, but Time Will Not!

“…A 27% stroke risk at 28 days contrasts markedly with the 21% risk of ipsilateral stroke at 5 years reported in a meta-analysis of medically treated patients with 50% to 99% stenoses in the European Carotid Surgery Trial (ECST), the North American Symptomatic Carotid Endarterectomy Trial (NASCET), and the Veteran's Affairs (VA) Study. 2 In the study of Marnane et al, 1 recurrent stroke was associated with histological features of plaque instability. After multivariate analysis; the only independent predictor was heavy macrophage inflammation, and this is consistent with evidence that inflammation diminishes after symptom onset after plaque stabilization, 3 and that heavy macrophage infiltration is associated with higher rates of spontaneous embolization.…”

“…I n this issue of Stroke, Marnane et al 1 reports that 12/44 patients (27%) with 50% to 99% stenoses had recurrent, ipsilateral strokes within 28 days of symptom onset, with 17% occurring <48 hours, 33% <7 days, and 58% <14 days of the index event. A 27% stroke risk at 28 days contrasts markedly with the 21% risk of ipsilateral stroke at 5 years reported in a meta-analysis of medically treated patients with 50% to 99% stenoses in the European Carotid Surgery Trial (ECST), the North American Symptomatic Carotid Endarterectomy Trial (NASCET), and the Veteran's Affairs (VA) Study.…”

“…It is salutary to observe that, in the study of Marnane, all 12 recurrent strokes occurred after the index event, but before seeking medical advice, 1 that is, no amount of imaging investment would have prevented them. The pragmatist will also observe that, however, attractive it might be to invest in technologies for imaging macrophage inflammation using positron emission tomographycomputed tomography, 8 this genre of imaging modality will never become accessible for everyday clinical use.…”

“…In the study of Marnane, intraplaque hemorrhage was not predictive of an increased risk of early recurrent stroke. 1 Duplex ultrasound remains the most accessible imaging modality, but it must deliver reproducible and objective data. In studies similar to Marnane, Salem et al 10 showed that a Gray Scale Median <25 was associated with a significantly increased risk of recurrent events in the hyperacute period between admission and CEA, whereas 2 ultrasound features were associated with histological plaque instability.…”

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“…Thus, a certain number of features of plaque morphology may play an important role in the occurrence of cerebrovascular events. [5][6][7] An unstable plaque, on the one hand, has a thin fibrous cap that contains large numbers of macrophages and T lymphocytes and a small number of smooth muscle cells. A stable plaque, on the other hand, has a thicker cap with larger numbers of smooth muscle cells and less inflammation.…”