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Research ArticleExtracranial Vascular

Carotid Intraplaque Hemorrhage and Stenosis: At What Stage of Plaque Progression Does Intraplaque Hemorrhage Occur, and When is It Most Likely to Be Associated with Symptoms?

A.S. Larson, W. Brinjikji, L. Savastano, A.A. Rabinstein, L. Saba, J. Huston and J.C. Benson
American Journal of Neuroradiology July 2021, 42 (7) 1285-1290; DOI: https://doi.org/10.3174/ajnr.A7133
A.S. Larson
aFrom the Departments of Radiology (A.S.L., W.B., J.H., J.C.B.)
bNeurosurgery (A.S.L., W.B., L. Savastano)
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W. Brinjikji
aFrom the Departments of Radiology (A.S.L., W.B., J.H., J.C.B.)
bNeurosurgery (A.S.L., W.B., L. Savastano)
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L. Savastano
bNeurosurgery (A.S.L., W.B., L. Savastano)
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A.A. Rabinstein
cNeurology (A.A.R.), Mayo Clinic, Rochester, Minnesota
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L. Saba
dDepartment of Radiology (L. Saba), University of Cagliari, Cagliari, Italy
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J. Huston
aFrom the Departments of Radiology (A.S.L., W.B., J.H., J.C.B.)
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J.C. Benson
aFrom the Departments of Radiology (A.S.L., W.B., J.H., J.C.B.)
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    Patient- and artery-selection process.

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    Table 1:

    Patient characteristicsa

    OverallSymptomaticAsymptomaticP Value
    Total patients included449225224
    Total arteries included449225224
    Mean age (SD) (yr)66.4 (16.3)67.2 (13.1)65.6 (18.9).30
    Male (No.) (%)245 (54.6)150 (66.7)95 (42.4)<.0001
    Comorbidities
     Coronary artery disease (No.) (%)110 (24.5)69 (30.7)41 (18.3).003
     Hypertension (No.) (%)269 (59.9)154 (68.4)115 (51.3).0002
     Hyperlipidemia (No.) (%)287 (63.9)177 (78.7)110 (49.1)<.0001
     Diabetes mellitus (No.) (%)82 (18.3)56 (28.9)26 (11.6).0003
     Peripheral artery disease (No.) (%)29 (6.5)17 (7.6)12 (5.4).44
     Obstructive sleep apnea (No.) (%)85 (18.9)17 (7.6)12 (5.4).44
     Ever smoker (No.) (%)203 (45.2)125 (55.6)78 (34.8)<.0001
     Current smoker (No.) (%)45 (10.0)29 (12.9)16 (7.1).06
     Mean body mass index (SD)28.3 (5.3)28.5 (4.8)28.1 (5.7).39
    Imaging characteristics
     Arteries without presence of atherosclerotic plaqueb (No.) (%)202 (45.0)47 (20.9)155 (69.2)<.0001
     Mean degree of stenosisc (SD)23.8 (33.6)33.5 (35.2)14.0 (28.8)<.0001
     Presence of IPHd (No.) (%)71 (15.8)55 (24.4)16 (7.1)<.0001
    • ↵a P values pertain to the differences in values between asymptomatic and symptomatic groups.

    • ↵b As mentioned by radiology reports.

    • ↵c Degrees of stenosis were based on NASCET criteria.5

    • ↵d Intraplaque hemorrhage was defined as being hyperintense on MPRAGE with intralesional signal intensity of >150% of the ipsilateral sternocleidomastoid muscle.

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    Table 2:

    Multiple regression analysis to determine independent associations with the presence of carotid intraplaque hemorrhagea

    VariableOR (95% CI)
    Ipsilateral stenosis1.02 (1.01–1.03)
    Male sex2.70 (1.43–5.04)
    Coronary artery disease1.24 (0.68–2.25)
    Hypertension1.21 (0.61–2.42)
    Hyperlipidemia4.03 (1.58–10.32)
    Diabetes mellitus0.89 (0.47–1.70)
    Current smoker1.16 (0.47–2.83)
    Ever smoker1.06 (0.58–1.94)
    • ↵a All independent variables are listed in the table. The outcome variable was the presence or absence of carotid intraplaque hemorrhage.

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    Table 3:

    Stratified multiple regression analyses to determine independent associations with the presence of an anterior circulation ischemic eventa

    VariableOR (95% CI)
    <30% Stenosis30%–69% Stenosis>70% Stenosis
    Ipsilateral IPH5.68 (1.49–21.69)2.38 (0.67–8.43)0.95 (0.32–2.80)
    Age0.99 (0.97–1.0)0.99 (0.95–1.03)1.02 (0.98–1.06)
    Male sex1.92 (1.12–3.32)1.64 (0.46–5.90)2.04 (0.69–6.06)
    Coronary artery disease0.74 (0.33–1.66)0.75 (0.24–2.35)0.68 (0.21–2.19)
    Hypertension0.93 (0.50–1.70)0.93 (0.09–2.95)0.82 (0.20–3.35)
    Hyperlipidemia2.10 (1.17–3.79)0.57 (0.05–6.45)1.25 (0.26–6.02)
    Diabetes mellitus1.51 (0.66–3.49)1.56 (0.43–5.92)2.34 (0.59–9.24)
    Current smoker1.68 (0.66–4.28)1.82 (1.68–19.83)1.07 (0.25–4.53)
    Ever smoker1.59 (0.87–2.91)1.33 (0.41–4.41)0.65 (0.17–2.43)
    • ↵a All independent variables are listed in the table.

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    Table 4:

    Degree of carotid artery stenosis and prevalence of intraplaque hemorrhage in asymptomatic-versus-symptomatic arteriesa

    Degree of StenosiscPrevalence of Intraplaque Hemorrhageb (%)
    All (n = 449 Total)Asymptomatic (n = 224 Total)Symptomatic (n = 225 Total)P Value
    <30% (n = 295 total)13/295 (4.4)3/180 (1.7)10/115 (8.7).02
    30%–69% (n = 79 total)33/79 (41.8)5/19 (26.3)28/60 (46.7).18
    70%+ (n = 75 total)25/75 (33.3)8/25 (32.0)17/50 (34.0).99
    • ↵a P values pertain to the difference in the prevalence of IPH between asymptomatic and symptomatic groups and were calculated using the Fisher exact test. Data are number of arteries per group with intraplaque hemorrhage.

    • ↵b Intraplaque hemorrhage was defined as being hyperintense on MPRAGE with intralesional signal intensity of >150% of the ipsilateral sternocleidomastoid muscle.

    • ↵c Degrees of stenosis were based on the NASCET criteria.5

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A.S. Larson, W. Brinjikji, L. Savastano, A.A. Rabinstein, L. Saba, J. Huston, J.C. Benson
Carotid Intraplaque Hemorrhage and Stenosis: At What Stage of Plaque Progression Does Intraplaque Hemorrhage Occur, and When is It Most Likely to Be Associated with Symptoms?
American Journal of Neuroradiology Jul 2021, 42 (7) 1285-1290; DOI: 10.3174/ajnr.A7133

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Carotid Intraplaque Hemorrhage and Stenosis: At What Stage of Plaque Progression Does Intraplaque Hemorrhage Occur, and When is It Most Likely to Be Associated with Symptoms?
A.S. Larson, W. Brinjikji, L. Savastano, A.A. Rabinstein, L. Saba, J. Huston, J.C. Benson
American Journal of Neuroradiology Jul 2021, 42 (7) 1285-1290; DOI: 10.3174/ajnr.A7133
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