Diagnostic and therapeutic approaches in stroke patients with atherosclerosis

Stroke is a heterogenous condition with many possible causes. In up to 20% of ischemic stroke patients, atherosclerotic disease is found as the underlying cause (i.e. a large vessel disease). Patients with large artery atherosclerosis are at high risk of early recurrence of stroke.

In acute iscemic stroke due to intracranial large vessel occlusions (LVOs), tandem occlusions are seen in approximately 20% of patients undergoing endovascular treatment (EVT) for stroke. A tandem lesion is defined as the combination of an intracranial LVO and a high-grade stenosis of the ipsilateral cervical carotid artery. Up to 60-70% of these lesions are due to atherosclerosis. Variation in clinical practice exists regarding the timing of the management of these lesions. Immediate carotid artery stenting (CAS) during EVT could improve cerebral blood flow, reduce the risk of early stroke recurrence and avoid a second procedure (carotid endarterectomy [CEA] or CAS). The CASES trial (Carotid Artery Stenting during EVT of acute ischemic Stroke) aims to evaluate the efficacy and safety of immedaite CAS during EVT. As trial coordinator, I am responsible for the overall management of the CASES trial. 

One of the main focuses in chronic atherosclerotic carotid artery disease is a better risk stratification of patients with so-called vulnerable plaques in order to enable more patient-specific treatment recommendations. In addition to the degree of stenosis, other plaque characteristics have been associated with increased risk of ischemic events such as intraplaque hemorrhage, intraplaque neovascularization, presence of a lipid-rich necrotic core or a thin fibrous cap, plaque thickness and presence of plaque ulceration and inflammation. Different imaging modalities can be used to visualize these features such as computed tomography angiography (CTA), magnetic resonance imaging angiography (MRA) and molecular imaging (e.g. 18F-FDG Positron Emission Tomography [PET])

I want to further investigate the potential of several CTA-derived markers of plaque vulnerability in future risk stratification of patients with mild-to-moderate carotid artery stenosis and recent TIA/stroke. I will also evaluate whether molecular imaging with 18F-AlF-OC PET/MRI has the potential to characterize and quantify carotid atherosclerotic disease manifestations in patients with moderate carotid artery stenosis and recent TIA/stroke.