Stroke, Vol 25, 304-308, Copyright © 1994 by American Heart Association
M Eliasziw, JY Streifler, AJ Fox, VC Hachinski, GG Ferguson and HJ Barnett
BACKGROUND AND PURPOSE: The importance of carotid plaque ulceration as a
cause of cerebral ischemic symptoms remains uncertain. Moreover, its
prominence in symptomatic patients with severe carotid stenosis is unknown.
METHODS: The association between angiographically defined plaque ulceration
and risk of subsequent stroke was assessed using Cox proportional hazards
regression in 659 patients with severe (70% to 99%) carotid stenosis from
the North American Symptomatic Carotid Endarterectomy Trial. RESULTS:
Treatment assignment (medical versus surgical) and degree of ipsilateral
stenosis were identified as having a significant influence on the results.
The risk of ipsilateral stroke at 24 months for medically treated patients
with ulcerated plaques increased incrementally from 26.3% to 73.2% as the
degree of stenosis increased from 75% to 95%. For patients with no ulcer,
the risk of stroke remained constant at 21.3% for all degrees of stenosis.
The net result yielded relative risks of stroke (ulcer versus no ulcer)
ranging from 1.24 (95% confidence interval, 0.61 to 2.52) to 3.43 (95%
confidence interval, 1.49 to 7.88). Conversely, for surgically treated
patients with antecedent presence of an ulcerated plaque, the risk of
stroke increased slightly at the highest degrees of stenosis. Overall,
carotid endarterectomy reduced the risk of ipsilateral stroke at 24 months
by at least 50%. Similar results were obtained for risk of major
ipsilateral stroke and risk of all strokes and death. CONCLUSIONS: The
presence of angiographically defined ulceration for medically treated
symptomatic patients is associated with an increased risk of stroke. The
risk of stroke more than doubles at higher degrees of stenosis. Carotid
endarterectomy is beneficial in substantially reducing the risk of stroke,
regardless of plaque ulceration and degree of severe carotid stenosis.
ARTICLES
Significance of plaque ulceration in symptomatic patients with high- grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial
Clinical Trials Resources Group, John P. Robarts Research Institute, London, Ontario, Canada.
This article has been cited by other articles:
 |
|
 |
|
  B. Chu, M. S. Ferguson, H. Chen, D. S. Hippe, W. S. Kerwin, G. Canton, C. Yuan, and T. S. Hatsukami Cardiac Magnetic Resonance Features of the Disruption-Prone and the Disrupted Carotid Plaque J. Am. Coll. Cardiol. Img., July 1, 2009; 2(7): 883 - 896. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Anzidei, A. Napoli, B. C. Marincola, I. Nofroni, D. Geiger, F. Zaccagna, C. Catalano, and R. Passariello Gadofosveset-enhanced MR Angiography of Carotid Arteries: Does Steady-State Imaging Improve Accuracy of First-Pass Imaging? Comparison with Selective Digital Subtraction Angiography Radiology, May 1, 2009; 251(2): 457 - 466. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. T. de Weert, S. Cretier, H. C. Groen, P. Homburg, H. Cakir, J. J. Wentzel, D. W.J. Dippel, and A. van der Lugt Atherosclerotic Plaque Surface Morphology in the Carotid Bifurcation Assessed With Multidetector Computed Tomography Angiography Stroke, April 1, 2009; 40(4): 1334 - 1340. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 F. Sallustio, S. Di Legge, G. Koch, A. Ippoliti, A. Mauriello, and P. Stanzione Urgent Carotid Endarterectomy: The Role of Serial Ultrasound Studies in Early Detection of Plaque Rupture J. Ultrasound Med., February 1, 2009; 28(2): 239 - 243. [Full Text] [PDF]
|
|
|
|
 |
|
 L. Saba, R. Sanfilippo, L. Pascalis, R. Montisci, and G. Mallarini Carotid Artery Abnormalities and Leukoaraiosis in Elderly Patients: Evaluation with MDCT Am. J. Roentgenol., February 1, 2009; 192(2): W63 - W70. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. Mumoli, M. Cei, and C. Invernizzi Symptomatic Ulcerative Carotid Plaque Circulation, December 9, 2008; 118(24): 2594 - 2595. [Full Text] [PDF]
|
|
|
|
 |
|
 C. W. Akins and R. P. Cambria Myocardial Revascularization with Carotid Artery Disease Card. Surg. Adult, January 1, 2008; 3(2008): 655 - 668. [Full Text]
|
|
|
|
|
|
L. Saba and G. Mallarini MDCTA of Carotid Plaque Degree of Stenosis: Evaluation of Interobserver Agreement Am. J. Roentgenol., January 1, 2008; 190(1): W41 - W46. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Kinlay, G. G. Schwartz, A. G. Olsson, N. Rifai, M. Szarek, D. D. Waters, P. Libby, P. Ganz, and for the Myocardial Ischemia Reduction with Aggress Inflammation, Statin Therapy, and Risk of Stroke After an Acute Coronary Syndrome in the MIRACL Study Arterioscler Thromb Vasc Biol, January 1, 2008; 28(1): 142 - 147. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. Saba, G. Caddeo, R. Sanfilippo, R. Montisci, and G. Mallarini CT and Ultrasound in the Study of Ulcerated Carotid Plaque Compared with Surgical Results: Potentialities and Advantages of Multidetector Row CT Angiography AJNR Am. J. Neuroradiol., June 1, 2007; 28(6): 1061 - 1066. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. H. Tonnessen and S. R. Money Redgrave JNE, Lovett JK, Gallagher PJ, et al. Histological assessment of 526 symptomatic carotid plaques in relation to the nature and timing of ischemic symptoms: the Oxford Plaque Study. Circulation. 2006; 113:2320-2328 Perspectives in Vascular Surgery and Endovascular Therapy, June 1, 2007; 19(2): 194 - 195. [Abstract] [PDF]
|
|
|
|
|
|
N. Yamada, M. Higashi, R. Otsubo, T. Sakuma, N. Oyama, R. Tanaka, K. Iihara, H. Naritomi, K. Minematsu, and H. Naito Association between Signal Hyperintensity on T1-Weighted MR Imaging of Carotid Plaques and Ipsilateral Ischemic Events AJNR Am. J. Neuroradiol., February 1, 2007; 28(2): 287 - 292. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Saloner, G. Acevedo-Bolton, M. Wintermark, and J. H. Rapp MRI of Geometric and Compositional Features of Vulnerable Carotid Plaque Stroke, February 1, 2007; 38(2): 637 - 641. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Fayad Endarterectomy and Stenting for Asymptomatic Carotid Stenosis: A Race at Breakneck Speed Stroke, February 1, 2007; 38(2): 707 - 714. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Prabhakaran, T. Rundek, R. Ramas, M. S.V. Elkind, M. C. Paik, B. Boden-Albala, and R. L. Sacco Carotid Plaque Surface Irregularity Predicts Ischemic Stroke: The Northern Manhattan Study Stroke, November 1, 2006; 37(11): 2696 - 2701. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J.N.E. Redgrave, J.K. Lovett, P.J. Gallagher, and P.M. Rothwell Histological Assessment of 526 Symptomatic Carotid Plaques in Relation to the Nature and Timing of Ischemic Symptoms: The Oxford Plaque Study Circulation, May 16, 2006; 113(19): 2320 - 2328. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. L. Faries, R. A. Chaer, S. Patel, S. C. Lin, B. DeRubertis, and K. C. Kent Current Management of Extracranial Carotid Artery Disease Vascular and Endovascular Surgery, May 1, 2006; 40(3): 165 - 175. [Abstract] [PDF]
|
|
|
|
|
|
G. Aidinian, J. M. Weiswasser, S. Arora, C. J. Abularrage, N. Singh, and A. N. Sidawy Carotid Plaque Morphologic Characteristics Perspectives in Vascular Surgery and Endovascular Therapy, March 1, 2006; 18(1): 63 - 70. [Abstract] [PDF]
|
|
|
|
|
|
R. Sztajzel, I. Momjian-Mayor, M. Comelli, and S. Momjian Correlation of Cerebrovascular Symptoms and Microembolic Signals With the Stratified Gray-Scale Median Analysis and Color Mapping of the Carotid Plaque Stroke, March 1, 2006; 37(3): 824 - 829. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J.K. Lovett, J.N.E. Redgrave, and P.M. Rothwell A Critical Appraisal of the Performance, Reporting, and Interpretation of Studies Comparing Carotid Plaque Imaging With Histology Stroke, May 1, 2005; 36(5): 1085 - 1091. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. G. Spagnoli, A. Mauriello, G. Sangiorgi, S. Fratoni, E. Bonanno, R. S. Schwartz, D. G. Piepgras, R. Pistolese, A. Ippoliti, and D. R. Holmes Jr Extracranial Thrombotically Active Carotid Plaque as a Risk Factor for Ischemic Stroke JAMA, October 20, 2004; 292(15): 1845 - 1852. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J.K. Lovett, P.J. Gallagher, L.J. Hands, J. Walton, and P.M. Rothwell Histological Correlates of Carotid Plaque Surface Morphology on Lumen Contrast Imaging Circulation, October 12, 2004; 110(15): 2190 - 2197. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. C. Wang, D. Saloner, and J. H. Rapp Characteristics of Carotid Plaque as Risk Factors for Stroke Perspectives in Vascular Surgery and Endovascular Therapy, September 1, 2004; 16(3): 193 - 199. [Abstract] [PDF]
|
|
|
|
 |
|
 J. M. U-King-Im, R. A. Trivedi, M. J. Graves, N. J. Higgins, J. J. Cross, B. D. Tom, W. Hollingworth, H. Eales, E. A. Warburton, P. J. Kirkpatrick, et al. Contrast-enhanced MR angiography for carotid disease: Diagnostic and potential clinical impact Neurology, April 27, 2004; 62(8): 1282 - 1290. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. B. Goldstein Extracranial Carotid Artery Stenosis Stroke, November 1, 2003; 34(11): 2767 - 2773. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Denzel, K. Balzer, K.-M. Muller, F. Fellner, C. Fellner, and W. Lang Relative Value of Normalized Sonographic In Vitro Analysis of Arteriosclerotic Plaques of Internal Carotid Artery Stroke, August 1, 2003; 34(8): 1901 - 1906. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. W. Akins and A. C. Moncure Myocardial Revascularization with Carotid Artery Disease Card. Surg. Adult, January 1, 2003; 2(2003): 627 - 637. [Full Text]
|
|
|
|
|
|
A. Barth, C. Bassetti, J. Berkefeld, and M. Sitzer Patient Selection for Carotid Angioplasty and Stenting Stroke, October 1, 2002; 33(10): 2347 - 2348. [Full Text] [PDF]
|
|
|
|
 |
|
 J. Kelly, B.J. Hunt, A. Rudd, and R.R. Lewis Should patients with lacunar stroke and severe carotid artery stenosis undergo endarterectomy? QJM, May 1, 2002; 95(5): 313 - 319. [Full Text] [PDF]
|
|
|
|
|
|
L. J. Walker, A. Ismail, W. McMeekin, D. Lambert, A. D. Mendelow, and D. Birchall Computed Tomography Angiography for the Evaluation of Carotid Atherosclerotic Plaque: Correlation With Histopathology of Endarterectomy Specimens Stroke, April 1, 2002; 33(4): 977 - 981. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K-T Khaw and P D Griffiths Non-invasive imaging of the cervical carotid and vertebral arteries Imaging, December 15, 2001; 13(5): 376 - 390. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. D. Coombs, J. H. Rapp, P. C. Ursell, L. M. Reilly, and D. Saloner Structure of Plaque at Carotid Bifurcation: High-Resolution MRI With Histological Correlation Stroke, November 1, 2001; 32(11): 2516 - 2521. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. J. Tegos, K. J. Kalomiris, M. M. Sabetai, E. Kalodiki, and A. N. Nicolaides Significance of Sonographic Tissue and Surface Characteristics of Carotid Plaques AJNR Am. J. Neuroradiol., September 1, 2001; 22(8): 1605 - 1612. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. Randoux, B. Marro, F. Koskas, M. Duyme, M. Sahel, A. Zouaoui, and C. Marsault Carotid Artery Stenosis: Prospective Comparison of CT, Three-dimensional Gadolinium-enhanced MR, and Conventional Angiography Radiology, July 1, 2001; 220(1): 179 - 185. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. J. Hunt, G. W. Evans, A. R. Folsom, A. R. Sharrett, L. E. Chambless, C. H. Tegeler, and G. Heiss Acoustic Shadowing on B-Mode Ultrasound of the Carotid Artery Predicts Ischemic Stroke : The Atherosclerosis Risk in Communities (ARIC) Study Stroke, May 1, 2001; 32(5): 1120 - 1126. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P.M. Rothwell The Interrelation between carotid, femoral and coronary artery disease Eur. Heart J., January 1, 2001; 22(1): 11 - 14. [PDF]
|
|
|
|
|
|
J. H. III, S. B. Fain, J. T. Wald, P. H. Luetmer, C. H. Rydberg, D. J. Covarrubias, S. J. Riederer, M. A. Bernstein, R. D. Brown, F. B. Meyer, et al. Carotid Artery: Elliptic Centric Contrast-enhanced MR Angiography Compared with Conventional Angiography Radiology, January 1, 2001; 218(1): 138 - 143. [Abstract] [Full Text]
|
|
|
|
|
|
G. B. Anderson, R. Ashforth, D. E. Steinke, R. Ferdinandy, and J. M. Findlay CT Angiography for the Detection and Characterization of Carotid Artery Bifurcation Disease Stroke, September 1, 2000; 31(9): 2168 - 2174. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
U. Schminke, L. Motsch, L. Hilker, and C. Kessler Three-Dimensional Ultrasound Observation of Carotid Artery Plaque Ulceration Stroke, July 1, 2000; 31(7): 1651 - 1655. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. A. McAlister, S. E. Straus, G. H. Guyatt, R. B. Haynes, and for the Evidence-Based Medicine Working Group Users' Guides to the Medical Literature: XX. Integrating Research Evidence With the Care of the Individual Patient JAMA, June 7, 2000; 283(21): 2829 - 2836. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. J. Connors III, D. Seidenwurm, J. C. Wojak, R. W. Hurst, M. E. Jensen, R. Wallace, T. Tomsick, J. Barr, C. Kerber, E. Russell, et al. Treatment of Atherosclerotic Disease at the Cervical Carotid Bifurcation: Current Status and Review of the Literature AJNR Am. J. Neuroradiol., March 1, 2000; 21(3): 444 - 450. [Full Text]
|
|
|
|
|
|
P. M. Rothwell, R. Gibson, and C. P. Warlow Interrelation Between Plaque Surface Morphology and Degree of Stenosis on Carotid Angiograms and the Risk of Ischemic Stroke in Patients With Symptomatic Carotid Stenosis Stroke, March 1, 2000; 31(3): 615 - 621. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. M. Rothwell and C. P. Warlow Low Risk of Ischemic Stroke in Patients With Reduced Internal Carotid Artery Lumen Diameter Distal to Severe Symptomatic Carotid Stenosis : Cerebral Protection Due to Low Poststenotic Flow? Stroke, March 1, 2000; 31(3): 622 - 630. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Golledge, R. M. Greenhalgh, and A. H. Davies The Symptomatic Carotid Plaque Stroke, March 1, 2000; 31(3): 774 - 781. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Mauriello, G. Sangiorgi, G. Palmieri, R. Virmani, D. R. Holmes Jr, R. S. Schwartz, R. Pistolese, A. Ippoliti, and L. G. Spagnoli Hyperfibrinogenemia Is Associated With Specific Histocytological Composition and Complications of Atherosclerotic Carotid Plaques in Patients Affected by Transient Ischemic Attacks Circulation, February 22, 2000; 101(7): 744 - 750. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Aoki, H. Nakajima, H. Kumagai, and T. Araki Dynamic Contrast-Enhanced MR Angiography and MR Imaging of the Carotid Artery: High-Resolution Sequences in Different Acquisition Planes AJNR Am. J. Neuroradiol., February 1, 2000; 21(2): 381 - 385. [Abstract] [Full Text]
|
|
|
|
|
|
R. D. Henderson, M. Eliasziw, A. J. Fox, P. M. Rothwell, and H. J. M. Barnett Angiographically Defined Collateral Circulation and Risk of Stroke in Patients With Severe Carotid Artery Stenosis Stroke, January 1, 2000; 31(1): 128 - 132. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Molloy and H. S. Markus Asymptomatic Embolization Predicts Stroke and TIA Risk in Patients With Carotid Artery Stenosis Stroke, July 1, 1999; 30(7): 1440 - 1443. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. C. van der Wal and A. E. Becker Atherosclerotic plaque rupture - pathologic basis of plaque stability and instability Cardiovasc Res, February 1, 1999; 41(2): 334 - 344. [Full Text] [PDF]
|
|
|
|
|
|
M.-L. M. Gronholdt Ultrasound and Lipoproteins as Predictors of Lipid-Rich, Rupture-Prone Plaques in the Carotid Artery Arterioscler Thromb Vasc Biol, January 1, 1999; 19(1): 2 - 13. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. W. Akins Combined carotid endarterectomy and coronary revascularization operation Ann. Thorac. Surg., October 1, 1998; 66(4): 1483 - 1484. [Full Text] [PDF]
|
|
|
|
|
|
A. Mathur, G. S. Roubin, S. S. Iyer, C. Piamsonboon, M. W. Liu, C. R. Gomez, J. S. Yadav, H. D. Chastain, L. M. Fox, L. S. Dean, et al. Predictors of Stroke Complicating Carotid Artery Stenting Circulation, April 7, 1998; 97(13): 1239 - 1245. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P M Rothwell, J Slattery, and C P Warlow Clinical and angiographic predictors of stroke and death from carotid endarterectomy: systematic review BMJ, December 13, 1997; 315(7122): 1571 - 1577. [Abstract] [Full Text]
|
|
|
|
|
|
M. Endres, U. Laufs, H. Merz, and M. Kaps Focal Expression of Intercellular Adhesion Molecule-1 in the Human Carotid Bifurcation Stroke, January 1, 1997; 28(1): 77 - 82. [Abstract] [Full Text]
|
|
|
|
|
|
T. S. Hatsukami, M. S. Ferguson, K. W. Beach, D. Gordon, P. Detmer, D. Burns, C. Alpers, and D. E. Strandness Carotid Plaque Morphology and Clinical Events Stroke, January 1, 1997; 28(1): 95 - 100. [Abstract] [Full Text]
|
|
|
|
 |
|
 G. G. Ferguson Angioplasty for Carotid Disease: No Arch Neurol, July 1, 1996; 53(7): 698 - 700. [Abstract] [PDF]
|
|
|
|
|
|
H. Moriwaki, M. Matsumoto, N. Handa, Y. Isaka, K. Hashikawa, N. Oku, M. Nakamura, T. Kamada, and T. Nishimura Functional and Anatomic Evaluation of Carotid Atherothrombosis : A Combined Study of Indium 111 Platelet Scintigraphy and B-Mode Ultrasonography Arterioscler Thromb Vasc Biol, December 1, 1995; 15(12): 2234 - 2240. [Abstract] [Full Text]
|
|
|
|
|
|
N. Handa, M. Matsumoto, H. Maeda, H. Hougaku, and T. Kamada Ischemic Stroke Events and Carotid Atherosclerosis : Results of the Osaka Follow-up Study for Ultrasonographic Assessment of Carotid Atherosclerosis (the OSACA Study) Stroke, October 1, 1995; 26(10): 1781 - 1786. [Abstract] [Full Text]
|
|
|
|
|
|
C. W. Akins, A. C. Moncure, W. M. Daggett, R. P. Cambria, A. D. Hilgenberg, D. F. Torchiana, and G. J. Vlahakes Safety and Efficacy of Concomitant Carotid and Coronary Artery Operations Ann. Thorac. Surg., August 1, 1995; 60(2): 311 - 317. [Abstract] [Full Text]
|
|
|
|
|
|
E. Falk, P. K. Shah, and V. Fuster Coronary Plaque Disruption Circulation, August 1, 1995; 92(3): 657 - 671. [Full Text]
|
|
|
|
|
|
L. Valton, V. Larrue, P. Arrue, G. Geraud, and A. Bes Asymptomatic Cerebral Embolic Signals in Patients With Carotid Stenosis : Correlation With Appearance of Plaque Ulceration on Angiography Stroke, May 1, 1995; 26(5): 813 - 815. [Abstract] [Full Text]
|
|
|
|
 |
|
 H. J.M. Barnett, M. Eliasziw, and H. E. Meldrum Drugs and Surgery in the Prevention of Ischemic Stroke N. Engl. J. Med., January 26, 1995; 332(4): 238 - 248. [Full Text] [PDF]
|
|