title: Carotid plaque hemorrhage on magnetic resonance imaging strongly predicts recurrent ischemia and stroke.
abstract: OBJECTIVE
  There is a recognized need to improve selection of patients with carotid artery stenosis for carotid endarterectomy (CEA). We assessed the value of magnetic resonance imaging (MRI)-defined carotid plaque hemorrhage (MRIPH) to predict recurrent ipsilateral cerebral ischemic events, and stroke in symptomatic carotid stenosis.
  
  
  METHODS
  One hundred seventy-nine symptomatic patients with ≥ 50% stenosis were prospectively recruited, underwent carotid MRI, and were clinically followed up until CEA, death, or ischemic event. MRIPH was diagnosed if the plaque signal intensity was >150% that of the adjacent muscle. Event-free survival analysis was done using Kaplan-Meier plots and Cox regression models controlling for known vascular risk factors. We also undertook a meta-analysis of reported data on MRIPH and recurrent events.
  
  
  RESULTS
  One hundred fourteen patients (63.7%) showed MRIPH, suffering 92% (57 of 62) of all recurrent ipsilateral events and all but 1 (25 of 26) future strokes. Patients without MRIPH had an estimated annual absolute stroke risk of only 0.6%. Cox multivariate regression analysis proved MRIPH as a strong predictor of recurrent ischemic events (hazard ratio [HR] = 12.0, 95% confidence interval [CI] = 4.8-30.1, p < 0.001) and stroke alone (HR = 35.0, 95% CI = 4.7-261.6, p = 0.001). Meta-analysis of published data confirmed this association between MRIPH and recurrent cerebral ischemic events in symptomatic carotid artery stenosis (odds ratio = 12.2, 95% CI = 5.5-27.1, p < 0.00001).
  
  
  CONCLUSIONS
  MRIPH independently and strongly predicts recurrent ipsilateral ischemic events, and stroke alone, in symptomatic ≥ 50% carotid artery stenosis. The very low stroke risk in patients without MRIPH puts into question current risk-benefit assessment for CEA in this subgroup.
authors: Division of Radiological and Imaging Sciences, University of Nottingham, Queen's Medical Campus, Nottingham, United Kingdom.
authors: Akram A
authors: AA
authors: Hosseini
authors: Neghal
authors: N
authors: Kandiyil
authors: Shane T S
authors: ST
authors: Macsweeney
authors: Nishath
authors: N
authors: Altaf
authors: Dorothee P
authors: DP
authors: Auer
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000175:diagnosis* / Q000453:epidemiology / Q000517:prevention & control; D016893:Carotid Stenosis / Q000175:diagnosis* / Q000453:epidemiology; D002543:Cerebral Hemorrhage / Q000175:diagnosis* / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods / Q000592:standards*; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012008:Recurrence; D020521:Stroke / Q000175:diagnosis* / Q000453:epidemiology / Q000517:prevention & control