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Symptomatic Nonstenotic Carotids: A Topical Review. | LitMetric

Symptomatic Nonstenotic Carotids: A Topical Review.

Stroke

Department of Neurology and Stroke Program, University of Maryland, Baltimore (S.C.).

Published: December 2024

AI Article Synopsis

  • The management of carotid artery disease has predominantly relied on the degree of stenosis, but new research indicates that features like intraplaque hemorrhage can provide better diagnostic and treatment insights.
  • Current guidelines often overlook less than 50% stenosis cases, which can lead to misdiagnosis and inadequate treatments for potential stroke causes, leaving many patients untreated.
  • There is a push to reclassify certain strokes as symptomatic nonstenotic carotid disease when high-risk plaque features are present, and this review discusses historical practices, modern biomarkers of plaque vulnerability, imaging tools, and recent studies on this emerging classification.

Article Abstract

Historically, the management of carotid artery disease has primarily focused on the degree of stenosis as the main indicator for assessing stroke etiology, risk, and need for intervention. However, accumulating evidence suggests that structural and biological features within the arterial wall, such as intraplaque hemorrhage, may have superior diagnostic, prognostic, and therapeutic values. Under current guidelines, unless an atheroma results in ≥50% stenosis, it is not considered the cause of a cerebrovascular event. This results in extensive and often unproductive diagnostic workup, prescription of ineffective medical therapy, and preclusion of patients from receiving revascularization procedures that have been shown to prevent recurrent cerebrovascular events in cases of ≥50% stenosis. A subset of embolic strokes of undetermined source, which account for up to 25% of all ischemic cerebrovascular events, are thought to be due to thromboembolic phenomena from undiagnosed plaque disruptions in nonstenotic arteries (<50% stenosis). Recently, it has been proposed to reclassify this subgroup of patients as symptomatic nonstenotic carotid if the carotid plaque ipsilateral to the cerebrovascular event presents with high-risk features including intraplaque hemorrhage, lipid-rich necrotic core, thinning/rupture of the fibrous cap, and ulceration. In this review, we first provide a historical overview of the chain of events and circumstances that resulted in the present management of carotid artery disease. Second, we embed the contemporary biomarkers of plaque vulnerability in a modern mechanistic paradigm of carotid plaque disruption and thromboembolization. Third, we review the clinically available imaging tools to detect these biomarkers, and how their use has started to shed light on the prevalence and natural history of this underdiagnosed condition. Fourth, we review recent clinical studies employing a contemporary definition of symptomatic nonstenotic carotid and discuss targeted treatments for this condition. Finally, we make a case to generate the much-needed high-level evidence to align the clinical management of patients with symptomatic nonstenotic carotid with a contemporary understanding of plaque disruption and thromboembolization.

Download full-text PDF

Source
http://dx.doi.org/10.1161/STROKEAHA.123.035675DOI Listing

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