A Risk Score Including Carotid Plaque Inflammation and Stenosis Severity Improves Identification of Recurrent Stroke

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Title: A Risk Score Including Carotid Plaque Inflammation and Stenosis Severity Improves Identification of Recurrent Stroke
Authors: Kelly, PeterCamps-Renom, PolGiannotti, NicolaMcNulty, Jonathan P.Barry, MaryFoley, Shane J.Horgan, GillianKavanagh, EoinMarnane, MichaelMcCabe, JohnMcDonnell, CiaranO'Connell, MartinMurphy, S. (Sean)et al.
Permanent link: http://hdl.handle.net/10197/11564
Date: 17-Jan-2020
Online since: 2020-09-15T11:30:03Z
Abstract: Background and Purpose— In randomized trials of symptomatic carotid endarterectomy, only modest benefit occurred in patients with moderate stenosis and important subgroups experienced no benefit. Carotid plaque 18F-fluorodeoxyglucose uptake on positron emission tomography, reflecting inflammation, independently predicts recurrent stroke. We investigated if a risk score combining stenosis and plaque 18F-fluorodeoxyglucose would improve the identification of early recurrent stroke. Methods— We derived the score in a prospective cohort study of recent (<30 days) non-severe (modified Rankin Scale score ≤3) stroke/transient ischemic attack. We derived the SCAIL (symptomatic carotid atheroma inflammation lumen-stenosis) score (range, 0–5) including 18F-fluorodeoxyglucose standardized uptake values (SUVmax <2 g/mL, 0 points; SUVmax 2–2.99 g/mL, 1 point; SUVmax 3–3.99 g/mL, 2 points; SUVmax ≥4 g/mL, 3 points) and stenosis (<50%, 0 points; 50%–69%, 1 point; ≥70%, 2 points). We validated the score in an independent pooled cohort of 2 studies. In the pooled cohorts, we investigated the SCAIL score to discriminate recurrent stroke after the index stroke/transient ischemic attack, after positron emission tomography-imaging, and in mild or moderate stenosis. Results— In the derivation cohort (109 patients), recurrent stroke risk increased with increasing SCAIL score (P=0.002, C statistic 0.71 [95% CI, 0.56–0.86]). The adjusted (age, sex, smoking, hypertension, diabetes mellitus, antiplatelets, and statins) hazard ratio per 1-point SCAIL increase was 2.4 (95% CI, 1.2–4.5, P=0.01). Findings were confirmed in the validation cohort (87 patients, adjusted hazard ratio, 2.9 [95% CI, 1.9–5], P<0.001; C statistic 0.77 [95% CI, 0.67–0.87]). The SCAIL score independently predicted recurrent stroke after positron emission tomography-imaging (adjusted hazard ratio, 4.52 [95% CI, 1.58–12.93], P=0.005). Compared with stenosis severity (C statistic, 0.63 [95% CI, 0.46–0.80]), prediction of post-positron emission tomography stroke recurrence was improved with the SCAIL score (C statistic, 0.82 [95% CI, 0.66–0.97], P=0.04). Findings were confirmed in mild or moderate stenosis (adjusted hazard ratio, 2.74 [95% CI, 1.39–5.39], P=0.004). Conclusions— The SCAIL score improved the identification of early recurrent stroke. Randomized trials are needed to test if a combined stenosis-inflammation strategy improves selection for carotid revascularization where benefit is currently uncertain.
Funding Details: Health Research Board
metadata.dc.description.othersponsorship: Clinical Trials Networks Awards
Irish Heart Foundation
Fondo de Investigaciones Sanitarias Instituto de Salud Carlos III
Clinical Scientist Award
National Medical Research Council, Signapore
Irish Institute of Radiography and Radiation Therapy
Type of material: Journal Article
Publisher: Wolters Kluwer
Journal: Stroke
Volume: 51
Issue: 3
Start page: 838
End page: 845
Copyright (published version): 2020 American Heart Association
Keywords: Diabetes mellitusEndarterectomyHypertensionInflammationPositron emission tomography
DOI: 10.1161/strokeaha.119.027268
Language: en
Status of Item: Peer reviewed
Appears in Collections:Medicine Research Collection

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