By Dr Francesco Arba

ESOC 2023 Session Report -Recent Insights in Carotid Arteriopathies

This clinical session “Recent Insights in Carotid Arteriopathies” chaired by Maarten Uytten-Boogaart and Petra Ijas covered the topic of carotid pathology.

The first talk challenged the concept of a rigid cut-off to determine whether a carotid may be considered pathogenetic. Anna Kopczak tackled the topic starting with the concept that an atheromatous plaque may be complicated without causing a stenosis of the vessel. The main causes of complicated plaque are ruptured cap, thrombus formation and intraplaque hemorrhage. The latter is the most frequent cause of complicated plaque, accounting for about 75% of total cases. All this features, which could coexist, may increase by more than twofold the risk of stroke in the ipsilateral hemisphere, as also confirmed by large data from the Rotterdam study. When assessing cause of stroke, looking more closely to characteristics of non-stenotic plaque may reclassify around 15% of ischemic stroke from all causes, mainly adding another cause to cardioembolic stroke and reclassifying ischemic stroke of undetermined source. Accordingly, the new guidelines of the European Society of Vascular Surgery have been modified, and carotid stenting or endarterectomy may be considered in case of recurrence of symptoms and failure of best medical treatment.

The second talk, delivered by Frank Erik de Leeuw was about causes and identification of arteriopathy in young adults with stroke. Arteriopathy may be defined as any disorder affecting the vessel wall, and may result in stenosis, occlusion and dilation of the vessel. Causes range from classical vascular risk factors such as hypertension, to neck or head trauma, radiation therapy, vasoactive medications (illicit drugs), but also infective processes (e.g. meningitis), fever of unknown origin and viral infections. Congenital disorders and family history should also carefully evaluated. Arteriopathy may account for around 40-50% of ischemic stroke in the young, with roughly 35% extracranial and 15% intracranial localization. One-third of arteriopathy is non-atherosclerotic (e.g. dissection). Anatomic location (unilateral, bilateral, systemic) may help to identify the underlying cause. Examples of carotid arteriopathy in the young such as fibromuscular dysplasia and carotid web are increasingly diagnosed in clinical practice, other causes (e.g.) genetics and rare diseases may require a more comprehensive assessment.

The third talk (Nabila Bouatia Naji) was dedicated to fibromuscular dysplasia (FMD), defined as succession of stenoses and aneurysms of medium-sized arteries. The pathology is mostly asymptomatic, and the exact prevalence is unknown, however, a study showed that 4% of renal kidney donors showed had FMD. It seems to be a gender-oriented pathology, with around 80% of cases in women and is usually diagnosed around 45-55 years of age. There is a direct link between FMD and arterial dissection, and often FMD presents with multiple arterial dissections. Research in FMD received attention in last years. A collaborative study identified genetic loci and shared genetics between FMD and cardiovascular diseases, particularly with arterial dissection, migraine, hypertension, and aneurysms.

The fourth talk covered the topic of the carotid web. Bart Emmer gave to the audience an overview of diagnosis a pitfalls in diagnosis of carotid web, risk of stroke and potential treatments. Carotid web is defined as a shelf like protrusion of the posterior wall of internal carotid and is a rare cause of stroke. It can be seen on CT angiography as a thin intraluminal defect along the posterior wall of carotid bulb, beyond carotid bifurcation. Differential diagnosis of carotid web include atherosclerosis, arterial dissection, intraluminal thrombus. As highlighted in a study from Mac Grory et al,, JNNP 2020, there are criteria based on morphology, location, composition, course that may help clinicians in diagnosis of carotid web. A computational flow analysis showed that carotid web is associated with increased recirculation of blood close to the web zones and regional increase of wall shear stress, which are the two main reasons of the increased risk of thrombus formation and consequent ischemic stroke. The risk of recurrent stroke in carotid web is around eight times higher than the absence of carotid web. There are no randomized data, however, observational studies showed that medical management is associated with increased risk of stroke recurrency within one year compared with endovascular or surgical approach. More data are of course needed to guide clinical decisions on management of carotid web.

The last talk covered the management of cervical artery dissections. Stephan Engelter showed the epidemiological relevance of dissection as a cause of stroke, particulary in the young. Despite this, there are no randomized controlled data on management of this specific population in the acute stroke phase. Intravenous thrombolysis is safe but the presence of arterial dissection is associated with around a half reduced probability of getting a good clinical outcome. Although endovascular treatment seems to be associated with higher recanalization, this does not reflect a consequent good clinical outcome. However, acute stroke therapy should be administered in patients with arterial dissection. Stroke recurrency has been the second part of the talk. The risk of stroke lower with time, being higher in the first two weeks. In the long term (>6 months) the risk of stroke is low, although not null, and available data showed  there seems to be no difference between management with antiplatelets, anticoagulants, or no therapy. The duration of antithrombotic treatment should be balanced together with benefits and considering that the proportion of complete recanalization of the vessel peaks at 6 months. Therefore, antithrombotic treatment is recommended for 6-12 months: in patients with complete recanalization and no recurrent symptoms clinicians may consider to stop antithrombotics.