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Singh N, Marko M, Ospel JM, Goyal M, Almekhlafi M. The Risk of Stroke and TIA in Nonstenotic Carotid Plaques: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2020; 41:1453-1459. [PMID: 32646945 DOI: 10.3174/ajnr.a6613] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 04/29/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Severe carotid stenosis carries a high risk of stroke. However, the risk of stroke with nonstenotic carotid plaques (<50%) is increasingly recognized. PURPOSE We aimed to summarize the risk of TIA or stroke in patients with nonstenotic carotid plaques. DATA SOURCES We performed a comprehensive systematic review and meta-analysis in patients with acute ischemic stroke in whom carotid imaging was performed using MEDLINE and the Cochrane Database, including studies published up to December 2019. STUDY SELECTION Included studies had >10 patients with <50% carotid plaques on any imaging technique and reported the incidence or recurrence of ischemic stroke/TIA. High-risk plaque features and the risk of progression to stenosis >50% were extracted if reported. DATA SYNTHESIS We identified 31 studies reporting on the risk of ipsilateral stroke/TIA in patients with nonstenotic carotid plaques. Twenty-five studies (n = 13,428 participants) reported on first-ever stroke/TIA and 6 studies (n = 122 participants) reported on the recurrence of stroke/TIA. DATA ANALYSIS The incidence of first-ever ipsilateral stroke/TIA was 0.5/100 person-years. The risk of recurrent stroke/TIA was 2.6/100 person-years and increased to 4.9/100 person-years if intraplaque hemorrhage was present. The risk of progression to severe stenosis (>50%) was 2.9/100 person-years (8 studies, n = 448 participants). LIMITATIONS Included studies showed heterogeneity in reporting stroke etiology, the extent of stroke work-up, imaging modalities, and classification systems used for characterizing carotid stenosis. CONCLUSIONS The risk of recurrent stroke/TIA in nonstenotic carotid plaques is not negligible, especially in the presence of high-risk plaque features. Further research is needed to better define the significance of nonstenotic carotid plaques for stroke etiology.
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Affiliation(s)
- N Singh
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - M Marko
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada.,Department of Neurology (M.M.), Medical University of Vienna, Vienna, Austria
| | - J M Ospel
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology (J.M.O.), University Hospital of Basel, Basel, Switzerland
| | - M Goyal
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - M Almekhlafi
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
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Gujral D, Shah B, Chahal N, Senior R, Harrington K, Nutting C. Clinical Features of Radiation-induced Carotid Atherosclerosis. Clin Oncol (R Coll Radiol) 2014; 26:94-102. [DOI: 10.1016/j.clon.2013.10.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Revised: 09/23/2013] [Accepted: 09/24/2013] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Uncertainty exists over whether listening for carotid bruits as part of the clinical examination is informative in terms of predicting the presence or severity of carotid stenosis. AIM We sought to undertake a comprehensive meta-analysis and meta-regression of all studies to date that have assessed the relationship between a carotid bruit and severity of degree of stenosis. METHODS Electronic databases were used to identify all published studies in humans evaluating the association between bruit and stenosis published until and including October 2011. Pooled sensitivity, specificity and diagnostic odds ratio (DOR) were calculated for each stenosis group. Summary receiver operating characteristic (SROC) curve analysis was performed in studies assessing clinically relevant (i.e. >70%) stenosis. Meta-regression was performed in all studies, using random effects. RESULTS We identified 26 studies evaluating the association between carotid bruit and stenosis, in 15 117 arteries. For clinically relevant stenosis (i.e. >70%), we found pooled sensitivity 0.53 [95% confidence interval (CI): 0.5-0.55], specificity 0.83 (95% CI: 0.82-0.84) and DOR 4.32 (95% CI: 2.78-6.66). SROC curve analysis gave an area under the curve of 0.73. Meta-regression analysis showed a (non-significant) (P = 0.067) inverse relationship between carotid bruit and stenosis. CONCLUSION The carotid bruit is of moderate value for detecting clinically relevant carotid stenosis. It gives high specificity but low sensitivity. The likelihood of a carotid bruit does not increase at increasing degrees of stenosis.
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Affiliation(s)
- P McColgan
- Imperial College Cerebrovascular Research Unit (ICCRU), Imperial College & Hammersmith Hospitals, Fulham Palace Rd, London W6 8RF, UK
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Abbott AL. Medical (Nonsurgical) Intervention Alone Is Now Best for Prevention of Stroke Associated With Asymptomatic Severe Carotid Stenosis. Stroke 2009; 40:e573-83. [DOI: 10.1161/strokeaha.109.556068] [Citation(s) in RCA: 504] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Significant advances in vascular disease medical intervention since large randomized trials for asymptomatic severe carotid stenosis were conducted (1983–2003) have prompted doubt over current expectations of a surgical benefit. In this systematic review and analysis of published data it was found that rates of ipsilateral and any-territory stroke (+/−TIA), with medical intervention alone, have fallen significantly since the mid-1980s, with recent estimates overlapping those of operated patients in randomized trials. However, current medical intervention alone was estimated at least 3 to 8 times more cost-effective. In conclusion, current vascular disease medical intervention alone is now best for stroke prevention associated with asymptomatic severe carotid stenosis given this new evidence, other cardiovascular benefits, and because high-risk patients who benefit from additional carotid surgery or angioplasty/stenting cannot be identified.
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Affiliation(s)
- Anne L. Abbott
- From the Baker IDI Heart & Diabetes Institute, and the National Stroke Research Institute (at Austin Health), both in Melbourne, Victoria, Australia
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Rijbroek A, Wisselink W, Vriens EM, Barkhof F, Lammertsma AA, Rauwerda JA. Asymptomatic Carotid Artery Stenosis: Past, Present and Future. Eur Neurol 2006; 56:139-54. [PMID: 17035702 DOI: 10.1159/000096178] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2006] [Accepted: 07/17/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND The role of carotid endarterectomy (CEA) for asymptomatic carotid artery stenosis (aCAS) remains a matter of debate. It seems that not only the degree of stenosis, but also other factors have to be taken in account to improve patient selection and increase the benefit of CEA for aCAS. METHODS AND RESULTS The literature pertaining aCAS was reviewed in order to describe the natural history, risk of stroke and benefit of CEA for patients with aCAS in regard to several factors. CONCLUSION The benefit of CEA for aCAS is low. Current factors influencing the indication for CEA are severity of stenosis, age, contralateral disease, stenosis progression to >80%, gender, concomitant operations and life expectancy. To improve patient selection investigations will concentrate on plaque characteristics and instability and cerebral hemodynamics and metabolism.
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Affiliation(s)
- A Rijbroek
- Department of General Surgery, Kennemer Gasthuis, NK-2000 AK Haarlem, The Netherlands.
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Abayomi OK. Neck irradiation, carotid injury and its consequences. Oral Oncol 2004; 40:872-8. [PMID: 15380164 DOI: 10.1016/j.oraloncology.2003.12.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2003] [Accepted: 12/01/2003] [Indexed: 10/26/2022]
Abstract
Carotid stenosis is a major sequela of head and neck irradiation that has not received the attention it deserves. Its impact on the quality of life of patients can be substantial. This review discusses the incidence, pathogenesis and consequences of radiation-induced carotid stenosis following head and neck irradiation. This review is based on literature search (Medline and Pub Med) and cross-referencing. The incidence of significant carotid stenosis following head and neck irradiation range from 30% to 50%. Patients with carotid stenosis are at increased risk for stroke. Factors such as hypertension, diabetes, smoking and obesity increase the risk. Increased attention to the clinical signs of carotid stenosis and evaluation of these patients with appropriate imaging studies, together with strict implementation of management of hypertension and diabetes and, counseling on obesity and smoking have the potential to reduce the incidence of this sequela of head and neck irradiation. Those patients with severe carotid stenosis can be managed with endarterectomy or carotid artery stenting.
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Affiliation(s)
- Olubunmi K Abayomi
- Department of Radiation Oncology, Virginia Commonwealth University Medical Center, Massey Cancer Center, Basement Floor, 401 College Street, PO Box 980058, Richmond, VA 23298-0058, USA.
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Abstract
Multiple clinical trials have demonstrated the efficacy of endarterectomy in selected groups of patients based primarily on percent diameter stenosis. Although measurement of stenosis in the clinical trials was established by conventional angiography, there is considerable interest in noninvasive alternatives. Magnetic resonance angiography, performed using time-of-flight methods or with contrast enhancement, is one of several alternatives for noninvasive carotid evaluation. Screening examinations are routinely performed for carotid stenosis. Preoperative evaluations based on one or a combination of noninvasive tests have been proposed, although these proposals are the subject of ongoing controversy. Evaluation of the vertebral arteries is more difficult and less well studied: however, the increasing availability of therapies for posterior circulation atherosclerotic narrowing is resulting in increased interest in this problem.
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Affiliation(s)
- J E Heiserman
- Department of Radiology, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA.
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