Risk for transient ischemic attacks is mainly determined by intima-media thickness and carotid plaque echogenicity



      Stenosis severity, plaque morphology, and intima-media thickness (IMT), all have been found to provide prognostic information in patients with asymptomatic carotid artery disease. However, limited data exist on the association between these parameters and the risk for transient ischemic attack (TIA).


      We compared the ultrasonographic characteristics of 88 consecutive patients with first TIA without known cardioembolic source with those of 176 propensity-matched asymptomatic control subjects.


      IMT was higher in TIA patients compared to control subjects (0.74 ± 0.14 mm versus 0.68 ± 0.13 mm, p = 0.001). Plaques were found in 70.5% of patients and 64.8% of controls (p = 0.407). Compared with controls, TIA patients demonstrated more frequently predominantly echolucent lesions (77.4% versus 56.1%, p = 0.005) and high-grade carotid stenoses (21.0% versus 9.6%, p = 0.042). TIA patients with low-to-moderate grade (<70%) lesions exhibited higher IMT and more prevalent echolucent morphology in comparison with their control counterparts. No significant differences were observed between groups regarding high-grade lesions. In multivariate models, IMT and plaque echogenicity, but not stenosis severity, emerged as independent determinants of risk.


      Risk for TIA is primarily associated with IMT and plaque echogenicity, especially in the absence of high-grade lesions. Stenosis severity appears to be of limited prognostic value.


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        • Golledge J.
        • Cuming R.
        • Ellis M.
        • Davies A.H.
        • Greenhalgh R.M.
        Carotid plaque characteristics and presenting symptom.
        Br J Surg. 1997; 84: 1697-1701
        • Sabetai M.M.
        • Tegos T.J.
        • Nicolaides A.N.
        • et al.
        Hemispheric symptoms and carotid plaque echomorphology.
        J Vasc Surg. 2000; 31: 39-49
        • Polak J.F.
        • Shemanski L.
        • O’Leary D.H.
        • et al.
        Hypoechoic plaque at US of the carotid artery: an independent risk factor for incident stroke in adults aged 65 years or older. Cardiovascular Health Study.
        Radiol. 1998; 208: 649-654
        • Mathiesen E.B.
        • Bonaa K.H.
        • Joakimsen O.
        Echolucent plaques are associated with high risk of ischemic cerebrovascular events in carotid stenosis: the Tromso study.
        Circulation. 2001; 103: 2171-2175
        • Aburahma A.F.
        • Thiele S.P.
        • Wulu Jr., J.T.
        Prospective controlled study of the natural history of asymptomatic 60% to 69% carotid stenosis according to ultrasonic plaque morphology.
        J Vasc Surg. 2002; 36: 437-442
        • Kitamura A.
        • Iso H.
        • Imano H.
        • et al.
        Carotid intima-media thickness and plaque characteristics as a risk factor for stroke in Japanese elderly men.
        Stroke. 2004; 35: 2788-2794
        • Bots M.L.
        • Hoes A.W.
        • Koudstaal P.J.
        • Hofman A.
        • Grobbee D.E.
        Common carotid intima-media thickness and risk of stroke and myocardial infarction: the Rotterdam Study.
        Circulation. 1997; 96: 1432-1437
        • Chambless L.E.
        • Heiss G.
        • Folsom A.R.
        • et al.
        Association of coronary heart disease incidence with carotid arterial wall thickness and major risk factors: the Atherosclerosis Risk in Communities (ARIC) Study.
        Am J Epidemiol. 1997; 146: 483-494
        • O’Leary D.H.
        • Polak J.F.
        • Kronmal R.A.
        • Manolio T.A.
        • Burke G.L.
        • Wolfson Jr., S.K.
        Carotid-artery intima and media thickness as a risk factor for myocardial infarction and stroke in older adults. Cardiovascular Health Study Collaborative Research Group.
        N Engl J Med. 1999; 340: 14-22
        • Chambless L.E.
        • Folsom A.R.
        • Clegg L.X.
        • et al.
        Carotid wall thickness is predictive of incident clinical stroke: the Atherosclerosis Risk in Communities (ARIC) study.
        Am J Epidemiol. 2000; 151: 478-487
        • Rosvall M.
        • Janzon L.
        • Berglund G.
        • Engstrom G.
        • Hedblad B.
        Incidence of stroke is related to carotid IMT even in the absence of plaque.
        Atherosclerosis. 2005; 179: 325-331
        • Johnston S.C.
        • Gress D.R.
        • Browner W.S.
        • Sidney S.
        Short-term prognosis after emergency department diagnosis of TIA.
        JAMA. 2000; 284: 2901-2906
        • Albers G.W.
        • Caplan L.R.
        • Easton J.D.
        • et al.
        Transient ischemic attack – proposal for a new definition.
        N Engl J Med. 2002; 347: 1713-1716
        • Hennerici M.G.
        The unstable plaque.
        Cerebrovasc Dis. 2004; 17: 17-22
        • Daffertshofer M.
        • Mielke O.
        • Pullwitt A.
        • Felsenstein M.
        • Hennerici M.
        Transient ischemic attacks are more than “ministrokes”.
        Stroke. 2004; 35: 2453-2458
        • Baldassarre D.
        • Amato M.
        • Bondioli A.
        • Sirtori C.R.
        • Tremoli E.
        Carotid artery intima-media thickness measured by ultrasonography in normal clinical practice correlates well with atherosclerosis risk factors.
        Stroke. 2000; 31: 2426-2430
        • AbuRahma A.F.
        • Wulu Jr., J.T.
        • Crotty B.
        Carotid plaque ultrasonic heterogeneity and severity of stenosis.
        Stroke. 2002; 33: 1772-1775
        • Honda O.
        • Sugiyama S.
        • Kugiyama K.
        • et al.
        Echolucent carotid plaques predict future coronary events in patients with coronary artery disease.
        J Am Coll Cardiol. 2004; 43: 1177-1184
        • Touboul P.J.
        • Labreuche J.
        • Vicaut E.
        • Amarenco P.
        Carotid intima-media thickness, plaques, and Framingham risk score as independent determinants of stroke risk.
        Stroke. 2005; 36: 1741-1745
        • Goldstein L.B.
        • Bian J.
        • Samsa G.P.
        • Bonito A.J.
        • Lux L.J.
        • Matchar D.B.
        New transient ischemic attack and stroke: outpatient management by primary care physicians.
        Arch Intern Med. 2000; 160: 2941-2946
        • D’Agostino Jr., R.B.
        Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group.
        Stat Med. 1998; 17: 2265-2281
        • Newgard C.D.
        • Hedges J.R.
        • Arthur M.
        • Mullins R.J.
        Advanced statistics: the propensity score–a method for estimating treatment effect in observational research.
        Acad Emerg Med. 2004; 11: 953-961
        • Simons P.C.
        • Algra A.
        • Bots M.L.
        • Grobbee D.E.
        • van der Graaf Y.
        Common carotid intima-media thickness and arterial stiffness: indicators of cardiovascular risk in high-risk patients. The SMART Study.
        Circulation. 1999; 100: 951-957
        • Joakimsen O.
        • Bonaa K.H.
        • Stensland-Bugge E.
        Reproducibility of ultrasound assessment of carotid plaque occurrence, thickness, and morphology.
        Tromso Study Stroke. 1997; 28: 2201-2207
        • Rosenbaum P.R.
        • Rubin D.B.
        Constructing a control group using multivariate matched sampling methods that incorporate the propensity score.
        Am. Statistician. 1985; 39: 33-38
        • Fateh-Moghadam S.
        • Li Z.
        • Ersel S.
        • et al.
        Platelet degranulation is associated with progression of intima-media thickness of the common carotid artery in patients with diabetes mellitus type 2.
        Arterioscler Thromb Vasc Biol. 2005; 25: 1299-1303
        • Shimizu M.
        • Kohara S.
        • Yamamoto M.
        • Ando Y.
        • Haida M.
        • Shinohara Y.
        Significant relationship between platelet activation and intra-media thickness of the carotid artery in patients with ischemic cerebrovascular disease.
        Thromb Res. 2005;
        • Nomura E.
        • Kohriyama T.
        • Yamaguchi S.
        • Kajikawa H.
        • Nakamura S.
        Association between carotid atherosclerosis and hemostatic markers in patients with cerebral small artery disease.
        Blood Coagul Fibrinolysis. 1998; 9: 55-62
        • Goldstein J.A.
        Multifocal coronary plaque instability.
        Prog Cardiovasc Dis. 2002; 44: 449-454
        • Johnston S.C.
        Clinical practice. Transient ischemic attack.
        N Engl J Med. 2002; 347: 1687-1692
        • Norris J.W.
        • Zhu C.Z.
        Silent stroke and carotid stenosis.
        Stroke. 1992; 23: 483-485
        • Kang S.
        • Wu Y.
        • Li X.
        Effects of statin therapy on the progression of carotid atherosclerosis: a systematic review and meta-analysis.
        Atherosclerosis. 2004; 177: 433-442
        • Reid J.A.
        • Wolsley C.
        • Lau L.L.
        • et al.
        The effect of pravastatin on intima media thickness of the carotid artery in patients with normal cholesterol.
        Eur J Vasc Endovasc Surg. 2005; 30: 464-468
        • Nighoghossian N.
        • Derex L.
        • Douek P.
        The vulnerable carotid artery plaque: current imaging methods and new perspectives.
        Stroke. 2005; 36: 2764-2772