Prospective clinicopathologic study of carotid intraplague hemorrhage

A prospective study was conducted of 82 carotid endarterectomy plaques from 73 patients to determine the incidence of intraplaque hemorrhage, its relation to the production of cerebral ischemic symptoms, and the role of the antiplatelets. These included 42 with hemispheric transient ischemic attacks (TIA), nine with hemispheric stroke (Group A), and 31 with nonhemispheric TIA's or asymptomatic carotid stenosis (Group B). The plaques were evaluated for the presence of hemorrhage. Intraplaque hemorrhage was present in 63 (76.8%) of 82; 46 (90.2%) of 51 in Group A had hemorrhage, in contrast to 17 (54.8%) of 31 in Group B (P less than .001). Twenty-nine (56.86%) plaques from patients in Group A had multiple hemorrhages and 22 (43.14%) had single or no hemorrhages; in contrast to two (6.45%) that had multiple hemorrhages and 29 (93.55%) that had single or no hemorrhages in patients in Group B (P less than .0005). Forty-seven plaques were removed from patients receiving antiplatelets; 43 (91.48%) of these showed hemorrhages. Of the 35 plaques that were removed from patients not receiving antiplatelets, 26 (74.2%) showed hemorrhages (P = .071). However, when the plaques were studied for multiple hemorrhages, 28 (59.5%) of 47 had multiple hemorrhages in patients receiving antiplatelet agents in contrast to 3 (8.57%) of 35 in patients receiving antiplatelet agents (P less than .00001). The authors conclude that 1) the intraplaque hemorrhage is an important and common feature in symptomatic carotid disease, 2) antiplatelets increase the incidence of plaque hemorrhages, particularly multiple hemorrhages that carry higher incidence of symptoms. Therefore the use of antiplatelet agents in certain patients with carotid artery disease is questioned.