CAN RADIOLOGICAL ASSESSMENT OF THE DEGREE OF CAROTID ARTERY STENOSIS BE USED AS AN INDEPENDENT PREDICTOR FOR THE RISK OF RECURRENT ISCHEMIC STROKE IN PATIENTS WITH PRIOR ISCHEMIC STROKE? A SYSTEMATIC REVIEW
Keywords:
Carotid stenosis, recurrent ischemic stroke, independent predictor, intraplaque hemorrhage, cerebrovascular reserve, systematic reviewAbstract
Introduction: Recurrent ischemic stroke poses a significant clinical challenge, with carotid artery stenosis traditionally considered a major risk factor. However, whether the degree of stenosis alone independently predicts recurrence remains debated. This systematic review evaluates whether radiological assessment of carotid stenosis degree can serve as an independent predictor for recurrent ischemic stroke in patients with prior stroke.
Methods: A systematic review was conducted following standardized screening criteria. Studies were included if they enrolled patients with confirmed prior ischemic stroke, assessed carotid stenosis using radiological methods (CT angiography, MR angiography, duplex ultrasound, or conventional angiography), quantified stenosis degree, and reported recurrent stroke outcomes. Data extraction encompassed study populations, stenosis assessment methods, recurrent stroke outcomes, multivariable analyses, and alternative predictors.
Results: Fifty-nine studies were included, comprising 15 randomized controlled trials, 18 systematic reviews, and 26 cohort studies. The association between stenosis degree and recurrent stroke was heterogeneous. Large trials demonstrated significant independent prediction (POINT trial: OR 2.77, 95% CI 1.78-4.31; ENOS trial: OR 1.88, 95% CI 1.44-2.44 for ≥70% stenosis). However, other studies found no significant association (Mingyong Liu et al., 2014: annual risk 3.3% vs 4.7%, P=0.691; NAVIGATE-ESUS: HR 1.11, 95% CI 0.73-1.69). Plaque characteristics, particularly intraplaque hemorrhage, demonstrated stronger predictive value (HR 4.59-11.7) than stenosis degree alone. Cerebrovascular reserve also outperformed stenosis measurement (P=0.003 vs P=0.691). Recurrent events concentrated within the first 7-14 days post-index stroke (58% within 14 days), emphasizing the need for rapid risk stratification.
Discussion: The predictive value of stenosis degree varies by clinical context, being most reliable in recently symptomatic severe (≥70%) stenosis but diminishing in moderate stenosis or when plaque vulnerability markers are considered. The pathophysiological basis for these findings relates to stenosis reflecting luminal narrowing without capturing plaque instability or hemodynamic compromise.
Conclusion: Radiological assessment of carotid stenosis degree can serve as an independent predictor of recurrent ischemic stroke, but with moderate predictive accuracy (approximately 70%). Its clinical utility is enhanced when combined with plaque vulnerability markers, hemodynamic assessment, and consideration of timing from index event. Future risk stratification should integrate these multidimensional factors.
References
A. AbuRahma. “Part Two: Against the Motion. Carotid Endarterectomy Is Not Safer Than Stenting in the Hyperacute Period After Onset of Symptoms.” European Journal of Vascular and Endovascular Surgery, 2015.
A. Lahlouh, R. Kiwan, J. Mandzia, and S. Pandey. “P.055 Efficacy and Safety of Using Standardized Size of Stents in Patients with Carotid Artery Stenosis.” Canadian Journal of Neurological Sciences / Journal Canadien Des Sciences Neurologiques, 2022.
A. Podlasek, and R. Simpson. “Another Step Toward the Understanding of Carotid Artery Pathology.” American Journal of Neuroradiology, 2021.
A. Ross Naylor. “Translating Evidence into Practice: Surveillance After Carotid Interventions.” European Journal of Vascular and Endovascular Surgery, 2018.
———. “You May Delay, but Time Will Not!” Stroke, 2014.
Ajay Gupta, H. Baradaran, A. Schweitzer, H. Kamel, A. Pandya, Diana Delgado, A. Dunning, A. Mushlin, and P. Sanelli. “Carotid Plaque MRI and Stroke Risk: A Systematic Review and Meta-Analysis.” Stroke, 2013.
Albeir Y. Mousa, A. AbuRahma, J. Bozzay, M. Broce, M. Kali, M. Yacoub, P. Stone, and M. Bates. “Long-Term Comparative Outcomes of Carotid Artery Stenting Following Previous Carotid Endarterectomy Vs De Novo Lesions.” Journal of Endovascular Therapy, 2015.
Aletta T. R. Tholen, C. de Monyé, T. Genders, E. Buskens, D. Dippel, A. van der Lugt, and M. Hunink. “Suspected Carotid Artery Stenosis: Cost-Effectiveness of CT Angiography in Work-up of Patients with Recent TIA or Minor Ischemic Stroke.” Radiology, 2010.
B. Kragsterman, A. Nordanstig, D. Lindström, S. Strömberg, M. Thuresson, and J. Nordanstig. “Editor's Choice - Effect of More Expedited Carotid Intervention on Recurrent Ischaemic Event Rate: A National Audit.” European Journal of Vascular and Endovascular Surgery, 2018.
D. Doig. “The Safety of Carotid Artery Surgery and Stenting,” 2015.
D. Kashiwazaki, K. Chida, Kazumichi Yoshida, Kiyofumi Yamada, Motohiro Morioka, Katsuhiko Maruichi, E. Hori, et al. “Clinical Features, Radiological Findings, and Outcome in Patients with Symptomatic Mild Carotid Stenosis: A MUSIC Study.” Journal of Neurosurgery, 2025.
Erben Y, C. Franco-Mesa, M. D, Lanzino G, Bendok Br, L. Y., Sandhu Sjs, et al. “Higher Risk for Reintervention In Patients After Stenting For Radiation Induced Internal Carotid Artery Stenosis: A Single Center Analysis And Systematic Review.” Annals of Vascular Surgery, 2020.
Fengbin Deng, X. Hao, Zhuoran Tang, Changping Mu, Kang Li, and Huaqiang Li. “Carotid Plaque Magnetic Resonance Imaging and Recurrent Stroke Risk.” Medicine, 2019.
G. Ntaios, Balakumar Swaminathan, S. Berkowitz, R. Gagliardi, W. Lang, J. Siegler, P. Lavados, et al. “Efficacy and Safety of Rivaroxaban Versus Aspirin in Embolic Stroke of Undetermined Source and Carotid Atherosclerosis.” Stroke, 2019.
H. Maqsood, S. Younus, M. Saim, S. Qazi, A. Basit, and H. Shakeel. “Identification, Risk Stratification and Prognostication of Stroke by Detection of Intra-Carotid Plaque Hemorrhage,” 2021.
Hossein Hemmati, Amirhossein Larijani, Amirabbas Mollaei, Mohammad Amin Ashoobi, Abolfazl Nikkhoy, Parnia Vajdi Mozzayan, M. A. Hajari, et al. “Prognostic Role of Carotid Plaque MRI Features in Cerebrovascular Accidents: A Systematic Review and Meta-Analysis.” Journal of Clinical Neuroscience, 2025.
J. Appleton, L. Woodhouse, Andrew Belcher, D. Bereczki, E. Berge, V. Caso, Hui-Meng Chang, et al. “It Is Safe to Use Transdermal Glyceryl Trinitrate to Lower Blood Pressure in Patients with Acute Ischaemic Stroke with Carotid Stenosis.” Stroke and Vascular Neurology, 2019.
J. Appleton, L. Woodhouse, Z. Law, N. Sprigg, and P. Bath. “The Effect of Transdermal Glyceryl Trinitrate in Acute Stroke Patients with Carotid Stenosis: Data from the Efficacy of Nitric Oxide in Stroke Trial,” 2018.
J. Streifler, A. D. den Hartog, Samuel Pan, Hongchao Pan, R. Bulbulia, Dafydd J. Thomas, Martin M. Brown, and A. Halliday. “Ten-Year Risk of Stroke in Patients with Previous Cerebral Infarction and the Impact of Carotid Surgery in the Asymptomatic Carotid Surgery Trial.” International Journal of Stroke, 2016.
J. Streifler, Anne G denHartog, Samuel Pan, Dafydd J. Thomas, and A. Halliday. “Abstract 67: Importance Of Previous Brain Infarcts In Patients With Asymptomatic Carotid Stenosis And The Impact Of Surgery From The Asymptomatic Carotid Surgery Trial-1.” Stroke, 2013.
Jianping Liu, Yun Zhu, Yuh-Tsuen Wu, Yan Liu, Z. Teng, and Yinglu Hao. “Association of Carotid Atherosclerosis and Recurrent Cerebral Infarction in the Chinese Population: A Meta-Analysis.” Neuropsychiatric Disease and Treatment, 2017.
Juan Carlos Martín Gutiérrez, Alexis T. Roy, Salvatore A. D’Amato, Jillian M. Berkman, D. Montes, J. Romero, and Scott B. Silverman. “Abstract 1122‐000038: Anticoagulation Versus Antiplatelet Alone in Acutely Symptomatic Carotid Artery Stenosis.” Stroke: Vascular and Interventional Neurology, 2021.
K. Kim, and K. Jang. “E-097 Emergent Carotid Artery Stenting Improves Neurological Outcome in Patients with Acute Ischemic Stroke.” Electronic Poster Abstracts, 2019.
K. Paraskevas, and P. Gloviczki. “The Jury Is Still Out on Optimal Management of Restenosis After Carotid Interventions.” Journal of Vascular Surgery, 2019.
Kara A. Rothenberg, Lue-Yen Tucker, Rebecca C. Gologorsky, A. Avins, Hui C. Kuang, R. Faruqi, A. Flint, M. Nguyen-Huynh, and R. Chang. “Long-Term Stroke Risk with Carotid Endarterectomy in Patients with Severe Carotid Stenosis.” Journal of Vascular Surgery, 2019.
Kyu Sun Lee, S. E. Lee, J. Hong, and J. S. Lee. “Abstract TMP14: Baseline Characteristics and Clinical Outcomes of Acute Symptomatic Internal Carotid Artery Stump.” Stroke, 2016.
L. Bonati, J. Ederle, J. Dobson, S. Engelter, R. Featherstone, P. Gaines, J. Beard, et al. “Length of Carotid Stenosis Predicts Peri-Procedural Stroke or Death and Restenosis in Patients Randomized to Endovascular Treatment or Endarterectomy.” International Journal of Stroke, 2013.
L. Bonati, J. Gregson, J. Dobson, D. McCabe, P. Nederkoorn, H. B. van der Worp, G. D. de Borst, et al. “Restenosis and Risk of Stroke After Stenting or Endarterectomy for Symptomatic Carotid Stenosis in the International Carotid Stenting Study (ICSS): Secondary Analysis of a Randomised Trial.” Lancet Neurology, 2018.
Luke C Smith, J. Funnell, T. Richards, and L. Best. “Carotid Plaque Ulceration: Unquantified Predictor of Stroke.” BJS Open, 2023.
M. Homssi, Atin Saha, Diana Delgado, A. Roychoudhury, Charlene Thomas, Matthew Lin, H. Baradaran, H. Kamel, and Ajay Gupta. “Extracranial Carotid Plaque Calcification and Cerebrovascular Ischemia: A Systematic Review and Meta-Analysis.” Stroke, 2023.
M. Jusufovic, E. Sandset, P. Bath, B. Karlson, and E. Berge. “Effects of Blood Pressure Lowering in Patients with Acute Ischemic Stroke and Carotid Artery Stenosis.” International Journal of Stroke, 2015.
M. Lashin, Aktham Ismaeel Alemam, Khaled Afifi, and Ahmed Nabil Moneer. “Comparative Outcomes of Elective Carotid Artery Stenting Versus Optimal Medical Treatment in Egyptian Patients with Symptomatic Moderate Carotid Artery Stenosis: A Case–Control Study.” The Egyptian Journal of Neurology Psychiatry and Neurosurgery, 2025.
M. Reinhard, G. Schwarzer, M. Briel, C. Altamura, P. Palazzo, A. King, N. Bornstein, et al. “Cerebrovascular Reactivity Predicts Stroke in High-Grade Carotid Artery Disease.” Neurology, 2014.
Mandy D Müller, F. Ahlhelm, A. Hessling, D. Doig, P. Nederkoorn, S. Macdonald, P. Lyrer, et al. “Vascular Anatomy Predicts the Risk of Cerebral Ischemia in Patients Randomized to Carotid Stenting Versus Endarterectomy.” Stroke, 2017.
Marc P. Bonaca, S. Ameriso, M. Alberts, J. Mohr, G. Hankey, S. Murphy, B. Scirica, E. Braunwald, and D. Morrow. “Abstract TP121: Predictors of Ischemic Stroke in Patients with Atherosclerotic Vascular Disease: Observations from the TRA 2°P-TIMI 50 Trial.” Stroke, 2013.
Michael E. Porambo, and J. DeMarco. “MR Imaging of Vulnerable Carotid Plaque.” Cardiovascular Diagnosis and Therapy, 2020.
Mingsheng Yu, X. Miao, Ying Huang, Lin Ma, L. Yin, H. Ren, and Zengguang Wang. “A Clinical Application Study of a Stent Placement Assessment.” Medicine, 2022.
Mingyong Liu, and Lichun Zhou. “Cerebrovascular Reserve May Be a More Accurate Predictor of Stroke Than Degree of ICA or MCA Stenosis.” Medical Science Monitor, 2014.
N. Ohara, M. Nakajima, L. Pearce, E. Feldmann, C. Bazan, R. Hart, D. Liebeskind, and O. Benavente. “Abstract 209: Intracranial Wall Irregularity and Recurrent Stroke: The SPS3 Trial.” Stroke, 2015.
Natalie Bourand, and J. Brorson. “Predictors of Very Early Stroke Recurrence in the POINT Trial Population.” BMC Neurology, 2022.
Nishita Singh, M. Marko, M. Marko, J. Ospel, J. Ospel, M. Goyal, and M. Almekhlafi. “The Risk of Stroke and TIA in Nonstenotic Carotid Plaques: A Systematic Review and Meta-Analysis.” American Journal of Neuroradiology, 2020.
O. Naggara, E. Touzé, B. Beyssen, L. Trinquart, G. Chatellier, J. Meder, and J. Mas. “Anatomical and Technical Factors Associated With Stroke or Death During Carotid Angioplasty and Stenting: Results From the Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis (EVA-3S) Trial and Systematic Review.” Stroke, 2011.
Olga Rukovets. “For Your Patients-Stenosis and Stroke.” Neurology Today, 2018.
OlivierNaggara, EmmanuelTouzé, BernardBeyssen, LudovicTrinquart, GillesChatellier, Jean-FrançoisMeder, and Jean-LouisMas. “Anatomical and Technical Factors Associated With Stroke or Death During Carotid Angioplasty and Stenting,” 2011.
P. Clavel, S. Hébert, S. Saleme, C. Mounayer, A. Rouchaud, and B. Marin. “Cumulative Incidence of Restenosis in the Endovascular Treatment of Extracranial Carotid Artery Stenosis: A Meta-Analysis.” Journal of NeuroInterventional Surgery, 2019.
P. Kelly, P. Camps-Renom, N. Giannotti, J. Martí-Fábregas, S. Murphy, J. McNulty, M. Barry, et al. “Carotid Plaque Inflammation Imaged by 18F-Fluorodeoxyglucose Positron Emission Tomography and Risk of Early Recurrent Stroke.” Stroke, 2019.
P. Paty, Gary L. Bernardini, M. Mehta, Paul J. Feustel, Khusboo Desai, S. Roddy, and R. Darling. “Standardized Protocols Enable Stroke Recognition and Early Treatment of Carotid Stenosis.” Journal of Vascular Surgery, 2014.
P. Tsantilas, A. Kühnl, M. Kallmayer, C. Knappich, Sofie Schmid, A. Kuetchou, Alexander Zimmermann, and Hans-Henning Eckstein. “Stroke Risk in the Early Period After Carotid Related Symptoms: A Systematic Review.” Journal of Cardiovascular Surgery, 2015.
Ravi Kumar, A. Batchelder, A. Saratzis, A. AbuRahma, P. Ringleb, B. Lal, J. Mas, M. Steinbauer, and A. Naylor. “Restenosis After Carotid Interventions and Its Relationship with Recurrent Ipsilateral Stroke: A Systematic Review and Meta-Analysis.” European Journal of Vascular and Endovascular Surgery, 2017.
S. Coutts, J. Modi, Shiel K. Patel, A. Demchuk, M. Goyal, and M. Hill. “Abstract 70: Predicting Recurrent Stroke After TIA And Minor Stroke: Results Of The Prospective CT And MRI In The Triage Of TIA And Minor Cerebrovascular Events To Identify High Risk Patients (CATCH) Study.” Stroke, 2012.
S. F. Cheng, Twan J. van Velzen, J. Gregson, T. Richards, H. Jäger, R. Simister, M. Kooi, et al. “The 2nd European Carotid Surgery Trial (ECST-2): Rationale and Protocol for a Randomised Clinical Trial Comparing Immediate Revascularisation Versus Optimised Medical Therapy Alone in Patients with Symptomatic and Asymptomatic Carotid Stenosis at Low to Intermediate Risk of Stroke.” Trials, 2022.
“Stroke,” 2011.
T. Uphaus, T. Richards, C. Weimar, H. Neugebauer, S. Poli, K. Weissenborn, C. Imray, et al. “Revacept, an Inhibitor of Platelet Adhesion in Symptomatic Carotid Stenosis: A Multicenter Randomized Phase II Trial.” Stroke, 2022.
U. Fisch, S. Felten, G. Roubin, W. Mali, O. Jansen, G. Howard, G. Fraederich, et al. “Low Risk of Stroke or Death Among Patients with Recently Symptomatic Carotid Stenosis Awaiting Revascularization—A Pooled Analysis of Recent Randomized Trials,” 2015.
W. Brinjikji, A. Rabinstein, G. Lanzino, M. Murad, E. Williamson, J. DeMarco, and John Huston III. “Ultrasound Characteristics of Symptomatic Carotid Plaques: A Systematic Review and Meta-Analysis.” Cerebrovascular Diseases, 2015.
Y. Liu, Y. Y. Yin, Q. L. Lu, C. Li, and C. Y. Zhang. “[Clinical Analysis of Dual Enhanced Antiplatelet Therapy After Cerebrovascular Intervention for Reducing the Risk of Cerebral Infarction Recurrence].” Zhonghua Yu Fang Yi Xue Za Zhi [Chinese Journal of Preventive Medicine], 2024.
Yingying Yang, Jianbo Yang, Ying Gao, Weiqi Chen, Xuan Wang, Hongyi Yan, Tingting Wang, Yongjun Wang, Yuesong Pan, and Yilong Wang. “Dual Antiplatelet Therapy After Ischemic Stroke Stratified by Intracranial or Extracranial Atherosclerotic Stenosis.” Annals of Neurology, 2025.
Z. Teng, Adam J. Brown, and J. Gillard. “Carotid Intraplaque Hemorrhage: A Biomarker for Subsequent Ischemic Cerebrovascular Event?” Cerebrovascular Diseases, 2017.
Ларьков Роман Николаевич, Колесников Юрий Юрьевич, Сотников Павел Геннадьевич, Лазарев Руслан Александрович, Загаров Сергей Сергеевич, Котов Алексей Сергеевич, Литвиненко Марина Александровна, and Казакова Елена Константиновна. “Оценка Эффективности Хирургической Реваскуляризации Головного Мозга у Больных с Крупными Постинсультными Кистами,” 2016.
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Haekal Mahargias, Febrina Mayasari Gunawan, Mutiara Amalia (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
