Prevalence and Characteristics of Carotid Artery High-Risk Atherosclerotic Plaques in Chinese Patients With Cerebrovascular Symptoms: A Chinese Atherosclerosis Risk Evaluation II Study

Xihai Zhao, Daniel S Hippe, Rui Li, Gador M Canton, Binbin Sui, Yan Song, Feiyu Li, Yunjing Xue, Jie Sun, Kiyofumi Yamada, Thomas S Hatsukami, Dongxiang Xu, Maoxue Wang, Chun Yuan, CARE‐II Study Collaborators, Xihai Zhao, Daniel S Hippe, Rui Li, Gador M Canton, Binbin Sui, Yan Song, Feiyu Li, Yunjing Xue, Jie Sun, Kiyofumi Yamada, Thomas S Hatsukami, Dongxiang Xu, Maoxue Wang, Chun Yuan, CARE‐II Study Collaborators

Abstract

Background: Carotid atherosclerotic plaque rupture is an important source of ischemic stroke. However, the prevalence of high-risk plaque (HRP) defined as plaques with luminal surface disruption, a lipid-rich necrotic core occupying >40% of the wall, or intraplaque hemorrhage in Chinese population remains unclear. This study uses carotid magnetic resonance imaging (CMRI) to investigate HRP prevalence in carotid arteries of Chinese patients with cerebrovascular symptoms.

Methods and results: Patients with cerebral ischemic symptoms in the anterior circulation within 2 weeks and carotid plaque determined by ultrasound were recruited and underwent CMRI. The HRP features were identified and compared between symptomatic and asymptomatic arteries. Receiver-operating-characteristic analysis was used to calculate area-under-the-curve (AUC) of stenosis and maximum wall thickness for discriminating presence of HRP. In 1047 recruited subjects, HRP detected by CMRI was nearly 1.5 times more prevalent than severe stenosis (≥50%) in this cohort (28% versus 19%, P<0.0001). Approximately two thirds of HRPs were found in arteries with <50% stenosis. The prevalence of HRP in symptomatic carotid arteries was significantly higher than that of the contralateral asymptomatic carotid arteries (23.0% versus 16.4%, P=0.001). Maximum wall thickness was found to be a stronger discriminator than stenosis for HRP (AUC: 0.93 versus 0.81, P<0.0001).

Conclusions: There are significantly more high-risk carotid plaques than carotid arteries with ≥50% stenosis in symptomatic Chinese patients. A substantial number of HRPs were found in arteries with lower grade stenosis and maximum wall thickness was a stronger indicator for HRP than luminal stenosis.

Clinical trial registration: URL: https://www.clinicaltrials.gov/. Unique identifier: NCT02017756.

Keywords: MRI; atherosclerosis; carotid artery; high‐risk plaque; prevalence.

© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Figures

Figure 1
Figure 1
Diagram of measuring carotid morphology on MRI. Lumen area represents the area of vessel lumen (red region). Wall area represents the area of wall (gray region). Maximum wall thickness is the maximum distance between lumen and wall.
Figure 2
Figure 2
Flow chart of patients with confirmed side of symptoms.
Figure 3
Figure 3
Prevalence of high‐risk features by degree of luminal stenosis in known symptomatic arteries. High‐risk plaque is a composite of disrupted luminal surface, intraplaque hemorrhage or %lipid‐rich necrotic core >40%.
Figure 4
Figure 4
A high‐risk plaque with %lipid‐rich necrotic core >40% can be found in the right common carotid artery without luminal stenosis (arrow). *Marks common carotid artery. JV indicates jugular vein. The atherosclerotic plaque had large lipid‐rich necrotic core (arrowheads), which is hypointense on T2W image.
Figure 5
Figure 5
A high‐risk plaque with intraplaque hemorrhage can be found in the right internal carotid artery without luminal stenosis (arrow). *Marks internal carotid artery. The atherosclerotic plaque had intraplaque hemorrhage, which is hyperintense on MP‐RAGE image (arrow).
Figure 6
Figure 6
ROC curves for discriminating between known symptomatic arteries with and without high‐risk plaque. Maximum wall thickness had a significant greater area under the curve (AUC) than luminal stenosis (0.93 vs 0.81, P<0.0001).
Figure 7
Figure 7
Prevalence of high‐risk plaque features by maximum wall thickness in known symptomatic arteries. High‐risk plaque is a composite of disrupted luminal surface, intraplaque hemorrhage or %lipid‐rich necrotic core >40%.

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