Major carotid plaque surface irregularities correlate with neurologic symptoms

Many studies have linked carotid plaque surface irregularities with stroke risk, but this relationship has been obscured by the limited ability of available imaging modalities to resolve plaque surface morphology. To address this issue, we performed a prospective study correlating the presenting neurologic symptoms of patients with high-resolution magnetic resonance imaging (MRI; 200 microm) studies of ipsilateral plaque surface invaginations and ledges, lumen shape, and the location of the plaque bulk creating the stenosis.

One hundred patients, 17 women and 83 men, 45 to 81 years old (mean, 68 years) underwent surgery. Forty-five patients had a transient ischemic attack (TIA) or stroke as the indication for surgery, and 55 patients had no symptoms. Angiograms were obtained in 50 patients. Carotid plaques were removed "en bloc" and placed in gadolinium doped saline for imaging in a Siemens Symphony, 1.5T scanner with a custom-built transmit-receive radiofrequency coil. The resulting slice thickness was 200 microm, with 200 microm by 200 microm in plane resolution. The MRI data and angiograms were reviewed by using National Institutes of Health Image software and read by consensus. A surface irregularity was categorized as a ledge or ulcer and measured by using electronic calipers. Luminal shape was determined at the point of maximal stenosis with a "slice" set at 90 degrees to the lumen axis. The location of the maximal stenosis was recorded. In the internal carotid artery, plaque bulk was designated to be on the flow divider wall or non-flow divider wall.

The mean maximal stenosis was 81.5% +/- 12.0%. Surface contour irregularities were found in 80 plaques. Thirty-five plaques were graded as having major surface contour irregularities, and 45 plaques were graded as having minor irregularities. There was a significant correlation between major surface irregularity and TIA or stroke (P <.01). Irregular plaques were identified with angiography, but the irregularity in size was underestimated (P <.01). Only 28% of plaques had circular lumens; 50% had elliptical lumens, and 22% had either crescentic or multi-lobular lumens. The maximal stenosis was located in the internal carotid artery in 82 plaques, the bifurcation in 17 plaques, and the common carotid artery in one plaque.

Surface irregularities were revealed by means of submillimeter resolution of the carotid plaques with MRI to be common, but only the presence of major irregularities correlated with the patient having TIA or stroke. Lumen shape and plaque location did not appear to predict stroke risk, but may effect imaging accuracy in determining the degree of stenosis. These data further define the relationship of plaque irregularity and cerebrovascular symptoms caused by atheroemboli.