Correlation between plaque instability and presence of preoperative ischemic brain lesions in patients undergoing carotid endarterectomy M.L. Rots, D.P.V. de Kleijn, G. Pasterkamp, M.M. Brown, L.H. Bonati, G.J. de Borst I do not have any potential conflict of interest
Background Intraplaque hemorrhage (IPH) Carotid Artery Disease • Associated with higher risk of ipsilateral Vulnerable Plaques stroke 1-2 • IPH more common in symptomatic patients 3 • Symptomatic patients with IPH increased Thrombo-embolisms Stroke / TIA chance of recurrent events 4 1 Turc et al, Relationships between recent intraplaque hemorrhage and stroke risk factors in patients with carotid stenosis: The HIRISC study, Aterioscler. Throm. Vasc. Biol. 2012 2 Takaya et al, Association between Carotid Plaque Characteristics and Subsequent Ischemic Cerebrovascular Events, Stroke, 2006 3 Gao et al, Correlation between carotid intraplaque hemorrhage and clincal symptoms: sytematic review of observational studies. Stroke , 2007 4 Altaf et al, Carotid intraplaque hemorrhage predicts recurrent symptoms in patients with high-grade carotid stenosis, Stroke, 2007 Munich Vascular Conference (MAC) 2018 2
Background INDEX EVENT Patients with instable plaques: High risk interval period Aim: To investigate the correlation between intraplaque REVASCULARIZATION hemorrhage and presence of fresh pre-operative ischemic brain Development of asymptomatic ischemic brain lesions in waiting period? lesions in carotid stenosis patients Magnetic Resonance Diffusion Weighted Imaging (MR-DWI) lesions • Surrogate marker for cerebral ischemia • Clinically relevant: associated with increased chance of future cerebrovascular events 5 5 Gensicke, Ischemic brain lesions after carotid artery stenting increase future cerebrovascular risk. J Am Coll Cardiol . 2015
METHODS Retrospective study on prospectively collected data Plaque Characteristics (histology) MRI 1-7 days prior to surgery ICSS – MRI substudy - Intraplaque hemorrhage Ipsilateral DWI lesions (appearing hypo-/isointense on ADC) - Large lipid core (81% of CEA patients >14 days between last symptom and surgery) Lesion 0-10 days old 6 - Calcifications - Collagen - Microvessels - Macrophage staining - Smooth muscle cell staining 82% of patients Athero-Express biobank (UMC Utrecht) > 14 days waiting time Recurrent thrombo-embolism 1-10 days 1-7 days Atherosclerotic plaques of CEA patients t Index event MRI revascularization 6 Allen et al, Sequence-specific MR Imaging Findings That Are Useful in dating Ischemic Stroke . RadioGraphics 2012 Munich Vascular Conference (MAC) 2018 4
RESULTS No ipsilateral DWI lesions n=40 Multivariate analysis corrected for age and type of index event Inclusion of 53 patients ≥1 ipsilateral DWI lesion n=13 Ipsilateral DWI – (n=40) DWI + (n=13) OR (adjusted) p-value multivariate DWI – (n=40) DWI + (n=13) p-value Intraplaque hemorrhage 60% 92% 10 (1.2-100) 0.036 Age 68.2 (8.6) 69.3 (8.4) 0.673 Male gender 70% 85% 0.299 Lipid core ≥40% 58% 23% 0.18 (0.04-0.836) 0.028 Hypertension 65% 83% 0.227 Moderate/heavy calcifications 43% 39% 0.82 (0.22-3.04) 0.770 Diabetes Mellitus 23% 23% 0.966 Moderate/heavy collagen 78% 54% 0.34 (0.09-1.267) 0.107 Hypercholersterolemia 64% 63% 0.977 DWI – (n=40) DWI + (n=13) Β (adjusted) p-value Smoking 38% 25% 0.425 multivariate BMI 25.8 (3.7) 25.0 (2.9) 0.520 % Microvessels 9.15 (5.22) 9.00 (8.00) 1.07 (0.420-2.639) 0.890 History of CAD 30% 41% 0.450 % Macrophage staining 0.63 (1.40) 0.74 (1.68) 1.10 (0.286-4.264) 0.886 Stenosis > 70% 93% 100% 0.218 Index event stroke 33% 39% 0.693 % Smooth muscle cell staining 1.16 (2.40) 0.91 (1.58) 0.74 (0.217-2.520) 0.630 Waiting time in days (IQR) 45 (24-66) 34 (18-50) 0.179 Munich Vascular Conference (MAC) 2018 5
DISCUSSION Patients with intraplaque hemorrhage have an increased risk for recurrent ischemic lesions after the index event Detection of intraplaque hemorrhage can be helpful in prioritizing patients for timing of revascularization Low number of patients ↔ first study relating histological plaque features to preprocedual risk of (recurrent) ischemic lesions Reliable methods for in vivo detection needed Thank You For Your Attention! Munich Vascular Conference (MAC) 2018 6
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