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A Risk Score Including Carotid Plaque Inflammation and Stenosis Severity Improves Identification of Recurrent Stroke.
Stroke ( IF 8.3 ) Pub Date : 2020-01-17 , DOI: 10.1161/strokeaha.119.027268
Peter J Kelly 1, 2 , Pol Camps-Renom 3 , Nicola Giannotti 1, 4 , Joan Martí-Fàbregas 3 , Jonathan P McNulty 4 , Jean-Claude Baron 5 , Mary Barry 6 , Shelagh B Coutts 7 , Simon Cronin 2, 8 , Raquel Delgado-Mederos 3 , Eamon Dolan 2, 9 , Alejandro Fernández-León 10 , Shane Foley 4 , Joseph Harbison 2, 11 , Gillian Horgan 1, 2 , Eoin Kavanagh 12 , Michael Marnane 1, 2 , John McCabe 1, 2 , Ciaran McDonnell 13 , Vijay K Sharma 14 , David J Williams 2, 15 , Martin O'Connell 12 , Sean Murphy 1, 2, 16
Affiliation  

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.

中文翻译:

包括颈动脉斑块发炎和狭窄严重程度在内的风险评分可改善复发性中风的识别率。

背景与目的-在有症状的颈动脉内膜切除术的随机试验中,中度狭窄的患者仅产生了适度的获益,而重要的亚组则没有获益。在正电子发射断层显像上摄取颈动脉斑块18 F-氟代脱氧葡萄糖可以反映炎症,独立预测复发性中风。我们调查了狭窄和斑块18 F-氟脱氧葡萄糖联合使用的风险评分是否可以改善早期复发性中风的识别。方法—我们在一项近期(<30天)非严重(修订的Rankin量表评分≤ 3)中风/短暂性脑缺血发作。我们得出SCAIL(有症状的颈动脉粥样硬化炎症管腔狭窄)评分(范围为0-5),包括18F-氟脱氧葡萄糖标准化摄取值(SUV最大值<2 g / mL,0分; SUV最大值2–2.99 g / mL,1分; SUV最大值3–3.99 g / mL,2分; SUV最大值≥4g / mL, 3分)和狭窄(<50%,0分; 50%–69%,1分;≥70%,2分)。我们在2个研究的独立汇总队列中验证了分数。在汇总的队列中,我们调查了SCAIL评分以区分指数性卒中/短暂性脑缺血发作后,正电子发射断层扫描成像后以及轻度或中度狭窄中的复发性卒中。结果—在衍生队列(109例)中,复发性卒中风险随着SCAIL分数的增加而增加(P= 0.002,C统计量为0.71 [95%CI,0.56-0.86]。每增加1点SCAIL,校正后的(年龄,性别,吸烟,高血压,糖尿病,抗血小板和他汀类药物)危险比为2.4(95%CI,1.2-4.5,P = 0.01)。在验证队列中证实了结果(87例患者,调整后的危险比,2.9 [95%CI,1.9-5],P <0.001; C统计量为0.77 [95%CI,0.67-0.87])。SCAIL评分可独立预测正电子发射断层显像后的复发性卒中(调整后的危险比为4.52 [95%CI,1.58-12.93],P = 0.005)。与狭窄严重程度(C统计量,0.63 [95%CI,0.46-0.80])相比,使用SCAIL评分可改善对正电子发射断层扫描中风复发的预测(C统计量,0.82 [95%CI,0.66-0.97],P= 0.04)。证实为轻度或中度狭窄(调整后的危险比,2.74 [95%CI,1.39–5.39],P = 0.004)。结论— SCAIL评分可改善对早期复发性中风的识别。需要一项随机试验来测试狭窄-炎症联合策略是否能改善目前尚不确定获益的颈动脉血运重建的选择。
更新日期:2020-02-24
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