Abstract
Background: Risk stratification of asymptomatic carotid artery stenosis (ACAS) is still an issue for carotid revascularization. We sought to identify factors associated with symptomatic carotid artery stenosis (SCAS) using multimodal imaging techniques.Methods: We retrospectively collected data on patients who underwent carotid artery revascularization. Results from duplex sonography, computerized tomography angiography, brain magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), perfusion-weighted imaging, and demographic profiles were compared between ACAS and SCAS patients. Differences in baseline characteristics between the two groups were balanced by the propensity matching score method. Multivariable regression analysis was performed to identify factors associated with symptomaticity of carotid artery stenosis. We compared the strength of associations between significant imaging factors and symptomatic carotid stenosis using C statistics.Results: A total of 259 patients (asymptomatic 57.1%, symptomatic 42.9%) with carotid stenosis were included. After 1:1 propensity score matching, the multivariable regression analysis revealed that the absence of plaque calcification [Odds ratio 0.41, 95% confidence interval (CI) 0.182–0.870, p = 0.023], deep white matter hyperintensity (DWMH; Odds ratio 3.46, 95% CI 1.842–6.682, p < 0.001), susceptibility vessel sign seen on gradient-echo MRI (Odds ratio 2.35, 95% CI 1.113–5.107, p = 0.027), and increased cerebral blood volume (CBV) seen on perfusion-weighted MRI (CBV; Odds ratio 2.17, 95% CI 1.075–4.454, p = 0.032) were associated with SCAS. The combination of these variables had a fair accuracy to classify SCAS (Area under the curve 0.733, 95% CI 0.662–0.803).Conclusions: We identified several multimodal imaging markers independently associated with SCAS. These markers may provide information to identify ACAS patients with high risk of ischemic stroke. Future studies are needed to predict SCAS using our findings in other independent cohorts.
Highlights
Risk stratification of asymptomatic carotid artery stenosis (ACAS) is still an issue for carotid revascularization
In the population over 65 years old, 5–10% of people have over a 50%degree of stenosis in the proximal carotid artery and 0.3–2.0% of patients with asymptomatic carotid artery stenosis (ACAS) have an ischemic stroke event each year [1]
We aimed to identify independent imaging markers of symptomatic carotid artery stenosis (SCAS), which may suggest the risk of impending stroke when present in ACAS, and test if the multimodal approach would be superior to each method
Summary
Risk stratification of asymptomatic carotid artery stenosis (ACAS) is still an issue for carotid revascularization. We sought to identify factors associated with symptomatic carotid artery stenosis (SCAS) using multimodal imaging techniques. In the population over 65 years old, 5–10% of people have over a 50%degree of stenosis in the proximal carotid artery and 0.3–2.0% of patients with asymptomatic carotid artery stenosis (ACAS) have an ischemic stroke event each year [1]. The mechanisms of stroke or transient ischemic attack in proximal carotid stenosis are artery-to-artery embolism from an unstable plaque or hypo-perfusion due to severe stenosis with poor collaterals. Imaging predictors of ischemic stroke should be identified to identify high-risk patients with ACAS and make a clinical decision on the necessity of preventive revascularization. Previous studies suggested high-degree stenosis is more associated with symptomatic carotid artery stenosis (SCAS) [4, 5]. We questioned how to better predict symptomatic carotid stenosis using a combination of already known factors
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