Carotid revascularization in patients with crescendo TIA (cTIA) and stroke in evolution (SIE)
EANS Academy. Hosoda K. Sep 27, 2019; 275960; EP01141
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Background: In patients with cTIA or SIE, the risk of stroke or death after carotid endarterectomy (CEA) or carotid artery stenting (CAS) is significantly higher than in neurologically stable patients.
Methods: Between August 2006 and September 2017, 320 consecutive carotid revascularizations (CEA/CAS) were performed in our institute. The patients were divided into 3 groups: cTIA/SIE group (n=12), stable symptomatic group (n=122) or asymptomatic group (n=186). Clinical characteristics, magnetic resonance (MR) plaque imaging, plaque pathology, and long-term outcomes with survival analysis were investigated.
Results: 8 CEA and 4 CAS were performed in cTIA/SIE group, 80 CEA and 42 CAS in stable symptomatic group, and 106 CEA and 80 CAS in asymptomatic group. The periprocedural stroke/death/MI rate was higher in cTIA/SIE group (1/12 [8.3%]; CEA 0/8, CAS 1/4 [25%]) than in stable symptomatic group (6/122 [4.9%]; CEA 3/80 [3.8%], CAS 3/42 [7.1%]) and asypmptomatic group (5/186 [2.7%]; CEA 2/106 [1.9%], CAS 3/80 [3.8%]) but no significant difference was observed. Signal intensity ratio of plaque relative to sternocleidomastoid muscle was significantly higher in cTIA/SIE group than in stable symptomatic and asymptomatic group (2.0 vs 1.57 vs 1.43, p< 0.05) in MR plaque imaging study, which was consistent with intraplaque hemorrhage in pathological findings of cTIA/SIE group. Estimates of the 4-year event rate of primary end point (stroke/death/MI within 30 days, and any ipsilateral stroke thereafter) using competing risk analysis were 30% for cTIA/SIE group, 4.6% for stable symptomatic group and 4.2% for asymptomatic group (P=0.01; Figure).
Conclusion: The instability of carotid plaque was likely to be due to severe intraplaque hemorrhage, which might explain relatively poor outcome of CAS in cTIA/SIE group. Poorer long-term outcome of cTIA/SIE after revascularization suggests presence of some unkonwn factor.

[Competing risk analysis]

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