Mona Al Banna, MB BCh, Msc(Res)

van Dam-Nolen DHK, van Egmond NCM, Dilba K, Nies K, van der Kolk AG, Liem MI, Kooi ME, Hendrikse J, Nederkoorn PJ, Koodstaal PJ, et al. Sex Differences in Plaque Composition and Morphology Among Symptomatic Patients With Mild-to-Moderate Carotid Artery Stenosis. Stroke. 2022.

Data regarding outcome differences in carotid revascularization between males and females has been mixed. The authors of this study set out to explore whether carotid plaque composition and morphology differed between male and female stroke patients using an imaging-based approach whilst taking into account degree of plaque burden. The plaque characteristics that were evaluated included intra-plaque hemorrhage, lipid rich necrotic core, calcifications, thin or ruptured fibrous cap, plaque ulcerations and total plaque volume. The authors also explored combinations of plaque characteristics to evaluate the relationship between multiple vulnerable plaque phenotypes. Plaque characteristics were assessed with CTA and dedicated vessel wall MRI.

156 men and 68 women were included in the study. The patients were enrolled from the Plaque At RISK (PARISK) study, which is a prospective multicenter cohort study aiming to better identify those with high recurrent stroke risk in the setting of mild‐to‐moderate carotid artery stenosis. All patients had a diagnosis of a TIA or ischemic infarct within the last 3 months and <70% ipsilateral carotid stenosis. The authors found significant difference in plaque volume between men and women, with men having a larger volume on average. Additionally, men were more likely to have intra-plaque hemorrhage and a lipid rich necrotic core, both known to be high risk carotid atherosclerotic features, even after adjustment of total plaque volume. Men were also more likely to have a thin or ruptured fibrous cap and ulcerations though these values were not statistically significant when adjusted for total plaque volume. No sex difference was found with regards to the prevalence of plaque calcifications. In terms of combinations of plaque characteristics, the presence of thin or ruptured fibrous cap, lipid rich necrotic core and intraplaque hemorrhage had strong correlations with each other in both men and women.

Though the study’s sample size is small and the male:female distribution is unequal, the authors have shown that in symptomatic carotid stenosis with mild-moderate stenosis, men are more likely to have a high-risk carotid plaque than women, regardless of the overall plaque burden. This indicates that sex specific management could potentially be helpful in determining who would benefit most from carotid revascularization. This could also help with determining which patient population group would benefit from asymptomatic carotid revascularization. In general, plaque morphology, beyond only degree of stenosis, needs to be taken into account in the management of this stroke population group.