Atherosclerotic Plaque Ulceration in the Symptomatic Internal Carotid Artery Is Associated With Nonlacunar Ischemic Stroke

Background and Purpose-Atherosclerotic carotid plaque ulceration is considered a marker of previous plaque rupture and subsequent thromboembolism. It can be accurately detected with multidetector CTA. We hypothesized that atherosclerotic plaque ulceration is associated with nonlacunar ischemic stroke rather than lacunar stroke. Methods-Prospectively, 750 consecutive patients with transient ischemic attack or ischemic stroke symptoms in the anterior cerebral circulation were evaluated for the presence of atherosclerotic plaque ulceration in the symptomatic carotid artery with multidetector CTA. Patients with stroke attributable to cardiac embolism or other specific etiologies and patients with amaurosis fugax were excluded. Ischemic strokes in the remaining 534 patients were classified as nonlacunar (n = 236) or lacunar (n = 298) based on clinical symptoms and multidetector CT of the brain. Ulceration was defined as extension of contrast material beyond the vascular lumen into the surrounding plaque. Results-Plaque ulceration in the symptomatic carotid artery was more common in nonlacunar strokes (n = 47; 20%) as compared to lacunar strokes (n = 20; 7%; P = 0.001). After adjustment for age, gender, cardiovascular risk factors, and degree of stenosis, ulcerations were independently associated with nonlacunar stroke compared to lacunar stroke (odds ratio, 2.70; 95% confidence interval, 1.43-5.09). Conclusions-Atherosclerotic carotid plaque ulceration is associated with nonlacunar ischemic stroke, independent of the degree of carotid stenosis. These results suggest that nonlacunar stroke and lacunar stroke are caused by different pathophysiological mechanisms. (Stroke. 2010; 41: 1151-1156.