Clinical features, radiological findings, and outcome in patients with symptomatic mild carotid stenosis: a MUSIC study
Authors: Kashiwazaki Daina , Chida Kohei , Yoshida Kazumichi , Yamada Kiyofumi , Morioka Motohiro , Maruichi Katsuhiko , Hori Emiko , Akioka Naoki , Takagi Yasushi , Moroi Junta , Miyamoto Susumu , Iwama Toru , Chin Masaki , Kamiyama Kenji , Wada Kojiro , Sakai Nobuyuki , Izumo Tsuyoshi , Nishikawa Yusuke , Mase Mitsuhito , Hosoda Kohkichi , Takizawa Katsumi , Kobayashi Eiichi , Kubo Michiya , Fujita Atsushi , Sugiyama Taku , Fujimura Miki , Yoshioka Hideyuki , Kinouchi Hiroyuki , Kunieda Takeharu , Nishimura Ataru , Yoshimura Shinichi , Shiokawa Yoshiaki , Abe Hiroshi , Kataoka Hiroharu , Ogasawara Kuniaki , Uno Masaaki , Sasaki Makoto , Kuroda Satoshi , Egashira Yusuke , Imamura Hirotoshi , Goto Masanori , Fukumitsu Ryu , Omura Yoshihiro , Ohara Nobuyuki , Kimura Hidehito , Hiroki Takai , Morofuji Yoichi , Kurosaki Yoshitaka , Korai Masaaki , Kobayashi Hiromasa , Yoshida Yasuyuki , Okawa Masakazu , Matsumoto Shirabe , Yamamoto Shusuke 
Published: February 2025

OBJECTIVE
Plaque composition, but not degree of stenosis, may play a key role in the development of recurrent ischemic events in patients with symptomatic mild (< 50%) carotid artery stenosis. This multicenter prospective cohort study was aimed to determine their clinical and radiological features and to evaluate the benefits of carotid endarterectomy (CEA) for them.

METHODS
This study included 124 patients with cerebrovascular or retinal ischemic events ipsilateral to mild carotid stenosis. Best medical therapy (BMT) was administered to all participants. CEA or carotid artery stenting was implemented at each institution’s discretion. Baseline and 6-, 12-, and 24-month follow-up data were collected. The primary endpoint was ipsilateral ischemic stroke. Secondary endpoints included any stroke, ipsilateral transient ischemic attack, ipsilateral ocular symptoms, any death, and plaque progression requiring CEA/carotid artery stenting. The multivariate Cox proportional hazards model was used to evaluate the predictors for each endpoint.

RESULTS
Of 124 patients, 70 (56.5%) had a history of ipsilateral ischemic stroke and 51 (43.5%) had been treated with antiplatelet agents. The mean (± SD) degree of stenosis was 22.4% ± 13.7%. Plaque composition was categorized as fibrous plaque in 22 patients, lipid-rich or necrotic core in 25, and intraplaque hemorrhage (IPH) in 69. BMT was indicated for 59 patients, and CEA was performed in 63. The incidence of primary endpoint was significantly higher in the BMT group than in the CEA group (15.1% vs 1.7%; HR 0.18; 95% CI 0.05–0.84; p = 0.03). The predictors for primary endpoint were CEA (HR 0.18; 95% CI 0.05–0.84; p = 0.03) and IPH (HR 1.92; 95% CI 1.26–4.28; p = 0.04). The incidence of secondary endpoint was significantly higher in the BMT group than in the CEA group (31.4% vs 7.3%; HR 0.32; 95% CI 0.13–0.79; p = 0.01). The predictors for secondary endpoints were also CEA (HR 0.32; 95% CI 0.13–0.79; p = 0.01) and IPH (HR 1.52; 95% CI 1.06–4.39; p = 0.03).

CONCLUSIONS
IPH may highly predict subsequent cerebrovascular events, whereas CEA may reduce these risks during a 2-year follow-up in patients with symptomatic mild carotid stenosis.