Intraplaque hemorrhage assessed by high-resolution magnetic resonance imaging and C-reative protein in carotid atherosclerosis

Background: Carotid intraplaque hemorrhage is a marker of atheroma instability. Noninvasive assessment of bleeding can be performed by high-resolution magnetic resonance imaging (MRI), but its association with inflammatory markers has
not been clearly demonstrated.
Methods: We evaluated consecutive carotid endarterectomy patients that underwent high-resolution MRI, independent evaluation of neurologic symptoms, C-reactive protein measurement, and histologic analysis. Intraplaque hemorrhage
was determined by the presence of a hyperintense MRI signal (T1-weighted sequence).
Results: The study included 70 predominantly male (66%) and hypertensive (89%) patients (89%) aged 66 9 years old.
MR angiography identified 15 patients (21.5%) with stenosis between 50% and 69%, 15 (21.5%) with stenosis between 70% and 90%, and 40 (57%) with stenosis >90%. High-resolution MRI depicted a hyperintense signal suggestive of intraplaque bleeding in 45 subjects (64%). All patients who had had transient ischemic attacks >90 days before the surgery showed a hyperintense signal on MRI (P.007). Age, gender, traditional cardiovascular risk factors, and history of myocardial infarction or peripheral arterial disease were similar in patients with or without signs of intraplaque bleeding on MRI. There was excellent agreement between acute or recent hemorrhage on histologic and MRI findings (coefficient, 0.91; 95% confidence interval, 0.81 to 1.00). Only one of 45 patients (2%) with a hyperintense signal on MRI did not have acute or recent hemorrhage in the histologic analysis (P < .001). High-sensitivity C-reactive protein levels were similar for different degrees of carotid stenosis as assessed by MR angiography, but they were significantly higher in
clinically unstable patients (P .006) and in those with a positive hyperintense MRI signal (P .01). In an aggregatedanalysis of neurologic symptoms and MRI findings, we found a progressive increase of high-sensitivity C-reactive protein
levels (P .02).
Conclusions: Intraplaque hemorrhage evaluated by MRI identified neurologically unstable patients with increased levels
of high-sensitivity C-reactive protein regardless of the degree of carotid stenosis. ( J Vasc Surg 2007;46:1130-7.)
Cerebral vascular disease is a major cause of morbidity and mortality in the adult population.1,2 Atherothrombosis of the carotid bifurcation is responsible for approximately
30% of cerebral ischemic episodes, and carotid endarterectomy is considered the treatment of choice for selected patients.3 Although current indications for carotid endarterectomy
are based on luminal stenosis, some clinical and histopathologic evidence indicates that acute vascular events occur mostly due to the instability of vulnerable plaques.4,5 Indeed, atheroma vulnerability is not directly related to the occlusive nature of the atheroma, depending
instead on other factors, such as local and systemic immunoinflammatory responses, structural

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