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Indication for carotid endarterectomy
1Department of Neurosurgery, Yokohama City University School of Medicine.
Insights
Intraplaque hemorrhage and plaque disruption are key indicators of stroke risk in carotid artery disease. Detecting these features via less invasive methods may guide prophylactic carotid endarterectomy decisions.
Area of Science:
- Vascular Surgery
- Neurology
- Pathology
Background:
- Carotid endarterectomy (CEA) benefits symptomatic high-grade carotid stenosis.
- Surgical indications for asymptomatic carotid artery disease remain unclear.
- Plaque characteristics influence stroke risk.
Purpose of the Study:
- To investigate the presence of intraplaque hemorrhage and plaque disruption in symptomatic versus asymptomatic carotid artery plaques.
- To determine if these features can predict stroke risk in asymptomatic patients.
Main Methods:
- Analysis of 63 atheromatous plaques from 57 patients undergoing CEA.
- Histopathological examination for intraplaque hemorrhage and plaque disruption.
- Correlation of findings with clinical presentation (symptomatic vs. asymptomatic) and angiographic features.
Main Results:
- Intraplaque hemorrhage present in 75% of symptomatic vs. 33% of asymptomatic plaques.
- Plaque disruption observed in 76% of symptomatic vs. 42% of asymptomatic plaques.
- Asymptomatic plaques with carotid ulcer (types B and C) showed high rates of hemorrhage and disruption.
- Three patients with asymptomatic contralateral disease suffered strokes post-revascularization; specimens showed hemorrhage and disruption.
Conclusions:
- Intraplaque hemorrhage and plaque disruption are more prevalent in symptomatic carotid plaques.
- These features are also present in asymptomatic plaques, particularly those with angiographic ulceration.
- Detection of intraplaque hemorrhage and/or disruption via non-invasive methods like ultrasonography is recommended before considering prophylactic CEA.
Abstract:
From recent randomized studies, carotid endarterectomy (CEA) is highly beneficial to the patients with a symptomatic high-grade carotid artery stenosis (70-99%), but the surgical indication for an asymptomatic carotid artery disease remains unsolved. Sixty-three atheromatous plaques (symptomatic 51, asymptomatic 12) were obtained from 57 patients who underwent CEA. The presence of an intraplaque hemorrhage was noted in 75% from symptomatic plaques, compared with 33% from asymptomatic ones. A plaque disruption occurred over protruding mounds of intraplaque hemorrhage and was noted in 76% and 42% from symptomatic and asymptomatic ones, respectively. However, asymptomatic plaques, which were angiographically demonstrated as carotid ulcer of types B and C, had a high incidence of intraplaque hemorrhage as well as plaque disruption. Three patients followed with asymptomatic contralateral carotid artery disease developed a stroke following ipsilateral revascularization and all three specimens showed the presence of plaque hemorrhage and disruption. It is concluded that before prophylactic CEA is considered, an intraplaque hemorrhage and/or plaque disruption should be detected by less invasive procedures such as ultrasonography.