Nonstenotic Carotid Plaques in Ischemic Stroke: Analysis of the STRATIS Registry

N. Singh; J. Ospel; A. Mayank; M. Marko; O.O. Zaidat; N.H. Mueller-Kronast; D.S. Liebeskind; M. Goyal; on behalf of the STRATIS Investigators

doi:10.3174/ajnr.A7218

Article Figures & Data

Figures

Tables

Download figure
Open in new tab
Download powerpoint
FIG 1.
Sagittal oblique reformatted and axial CT angiographic images of exemplary cases of nonstenotic carotid plaques with varying morphology in patients with ipsilateral ischemic stroke. All plaques were classified as predominantly calcified. A, Predominantly calcified plaque. B, C, and D, Predominantly calcified plaque with hypodense plaque features.
Download figure
Open in new tab
Download powerpoint
FIG 2.
Sagittal oblique reformatted and axial CT angiographic images of exemplary cases of nonstenotic carotid plaques with varying morphology in patients with ipsilateral ischemic stroke. All plaques were classified as predominantly noncalcified. A, Predominantly noncalcified and hypodense plaque. B, Predominantly noncalcified, hypodense, and irregular plaque. C, Predominantly noncalcified, hypodense, and ulcerated plaque.
Download figure
Open in new tab
Download powerpoint
FIG 3.
Sagittal oblique reformatted and axial CT angiographic images of exemplary cases of nonstenotic carotid disease with varying morphology in patients with ipsilateral ischemic stroke. A, Predominantly noncalcified plaque with an irregular surface. B, Carotid web. C, Predominantly noncalcified plaque with ulceration. D, Predominantly noncalcified plaque with hypodense plaque features.

Tables

Figures

View popup

Table 1:

Patient baseline characteristics for the entire patient sample (n = 367), patients with cardioembolic stroke (n = 226), and patients with cryptogenic stroke (n = 141)

Variable	Entire Patient Sample (n = 367)	Cardioembolic Stroke (n = 226)	Cryptogenic Stroke (n = 141)	P Value^{^a}
Age (median) (IQR) (yr)	71 (60–81)	72 (62–82)	69 (59–78)	.23
Female sex (No.) (%)	189/367 (51.5)	116/226 (51.3)	73/141 (51.8)	.51
Baseline NIHSS (median) (IQR)	16 (12–20)	16 (12–20)	17 (13–22)	.09
Comorbidities (No.) (%)
CAD	107 (29.2)	68 (30.1)	39 (27.7)	.63
Previous stroke	46 (12.5)	32 (14.2)	14 (9.9)	.26
Previous ICH	7 (1.9)	3 (1.3)	4 (2.8)	.43
Previous TIA	24 (6.5)	14 (6.2)	10 (7.1)	.82
Diabetes	94 (25.6)	54 (23.9)	40 (28.4)	.39
Hypertension	267 (72.8)	169 (74.8)	98 (69.5)	.28
Smoking (No.) (%)
Current smoker	69/333 (20.7)	35/204 (17.2)	34/129 (26.4)	.001
Former smoker	106/333 (31.8)	80/204 (39.2)	26/129 (24.5)	.001
ASPECTS (median) (IQR)	9 (8–9)	9 (8–9)	9 (8–9)	.88
Occlusion site (No.) (%)	(n = 330)	(n = 210)	(n = 120)	.43
ICA (intracranial)	47 (12.8)	28 (12.4)	19 (13.5)
M1	235 (64.0)	147 (65.0)	88 (62.4)
M2	65 (17.7)	42 (18.6)	23 (16.3)
Other	20 (5.5)	9 (4.0)	11 (7.8)

Note:—CAD indicates coronary artery disease; ICH, intracerebral hemorrhage
↵a Derived from the Wilcoxon rank sum test (continuous variables) or Fisher exact test (categoric variables).

View popup

Table 2:

Ipsilateral and contralateral nonstenotic carotid plaque in patients with cryptogenic and cardioembolic stroke

Overall Ischemic Strokes (n = 367 Patients/734 Carotid Arteries)
Cardioembolic stroke^{^b} (n = 226 patients/452 carotid arteries)
Ipsilateral stroke	Yes	No (contralateral/unaffected side)
Nonstenotic carotid plaque (No.) (%)	35 (16.7)	23 (9.5)
No nonstenotic carotid plaque (No.) (%)	175 (83.3)	219 (90.5)
Total (No.) (%)^{^a}	210 (100)	242 (100)
Cryptogenic stroke^{^b} (n = 141 patients/282 carotid arteries)
Ipsilateral stroke	Yes	No (contralateral/unaffected side)
Nonstenotic carotid plaque (No.) (%)	31 (23.9)	24 (15.8)
No nonstenotic carotid plaque (No.) (%)	99 (76.2)	128 (84.2)
Total (No.) (%)^{^a}	130 (100)	152 (100)

↵a Note that 16 patients in the cardioembolic group and 11 patients in the cryptogenic group had bilateral and/or posterior circulation strokes that were not confined to the ipsilateral ICA vascular territory. These strokes were, therefore, classified neither as right-sided nor left-sided strokes.
↵b Two-sided P value (derived from the Fisher exact test) = .025 for cardioembolic strokes and .099 for cryptogenic stroke.

View popup

Table 3:

Plaque features with significant association with ipsilateral strokes in patients with cryptogenic and cardioembolic strokes

Plaque Feature	uOR (95%CI)	aOR (95%CI)^{^a}
Cardioembolic stroke (n = 226 patients/452 carotid arteries)
Predominantly calcified plaque	0.75 (0.52–1.09)
Irregularity	1.50 (0.81–2.79)
Ulceration	1.94 (0.46–8.23)
Hypodense plaque	1.17 (0.77–1.76)
Maximum plaque thickness	1.11 (0.95–1.30)
Donut sign	–^{^b}
Stenosis degree (31%–50% vs 0%–30%)	1.05 (0.77–1.43)
Web^{^c}	3.49 (0.36–33.83)
Unremarkable carotid artery (absence of any of the above–mentioned features)	0.96 (0.66–1.40)
Cryptogenic stroke (n = 141 patients/282 carotid arteries)
Predominantly calcified plaque	0.94 (0.58–1.51)
Irregularity	2.32 (1.15–4.70)	2.50 (1.22–5.14)
Ulceration	1.47 (0.39–5.59)
Hypodense plaque	1.78 (1.09–2.92)	1.89 (1.14–3.14)
Maximum plaque thickness	1.24 (1.03–1.50)	1.29 (1.05–1.57)
Donut sign^{^c}	1.17 (0.07–18.90)
Stenosis degree (31%–50% vs. 0%–30%)	1.31 (0.89–1.96)
Web^{^c}	1.77 (0.29–10.77)
Unremarkable carotid artery (absence of any of the above-mentioned features)	0.75 (0.46–1.21)

Note:—uOR indicates unadjusted OR.
↵a With adjustment for age and sex and patient as a cluster variable. Multivariable analysis was performed for variables only when a significant association was found in univariable analysis.
↵b Omitted because of collinearity (all patients with a donut sign had ipsilateral strokes).
↵c Not a plaque feature but included in the definition of nonstenotic carotid disease.