Research Article| Volume 446, 120578, March 15, 2023

Simple CaroTID-VasC score to predict one-year risk of stroke in symptomatic carotid stenosis patients

Published:January 30, 2023DOI:


      • Degree of stenosis was not associated with the event recurrence in ESCS patients.
      • OMT was beneficial for most ESCS patients during one year follow-up.
      • CaroTID-VasC score was effective in stratifying patients for risk of event recurrence.
      • CaroTID-VasC score is a pragmatic, easy-to-use tool for predicting the annual risk of event recurrence in ESCS patients.



      A subset of extracranial symptomatic carotid stenosis (ESCS) patients may fare well on current optimal medical therapy (OMT), and surgery may be avoided in these patients. Therefore, we aimed to develop and validate a stroke risk prediction model to stratify the risk among ESCS patients.


      Adult ESCS patients who denied revascularization procedures were enrolled prospectively and prescribed OMT. Patients were followed-up for twelve months after assessing the clinical, imaging, and hemodynamics-based risk predictors at baseline. Cox regression analysis was performed on predictors which were significant in univariate analysis. Beta coefficients of significant predictors in Cox regression were used to generate a numeric score. The model was internally validated using bootstrapping.


      A total of 20 (20.2%) out of 99 patients had event recurrence during the follow-up. Transient ischemic attack index event (P = 0.014), diabetes mellitus (P = 0.018), contralateral significant stenosis (P = 0.007), echolucent plaque (P = 0.011), and impaired vasomotor reactivity (P = 0.006) were significant predictors in Cox regression analysis. A points score (0–6) was derived from regression coefficients of the significant predictors. The area under ROC was 0.884 for the developed model and 0.832 for the bootstrapped model. Youden's index divided the score into low-risk (2.2%) and high-risk (35.8%) groups, and the difference in risk was significant (P < 0.001).


      Most ESCS patients benefited from OMT, and the CaroTID-VasC score was effective in stratifying patients for risk of endpoint occurrence. The developed model may help identify high-risk subgroups of ESCS patients and assist the decision-making of carotid interventions.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the Neurological Sciences
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Feigin V.L.
        • Stark B.A.
        • Johnson C.O.
        • Roth G.A.
        • Bisignano C.
        • Abady G.G.
        • et al.
        Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the global burden of disease study 2019.
        Lancet Neurol. 2021; 20: 795-820
        • Feigin V.L.
        • Norrving B.
        • Mensah G.A.
        Global burden of stroke.
        Circ. Res. 2017; 120: 439-448
        • Collaborators* NASCET
        Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.
        N. Engl. J. Med. 1991; 325: 445-453
        • Barnett H.J.
        • Taylor D.W.
        • Eliasziw M.
        • Fox A.J.
        • Ferguson G.G.
        • Haynes R.B.
        • et al.
        Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis.
        N. Engl. J. Med. 1998; 339: 1415-1425
        • Group ECSTC
        Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European carotid surgery trial (ECST).
        Lancet. 1998; 351: 1379-1387
        • Fairhead J.
        • Mehta Z.
        • Rothwell P.
        Population-based study of delays in carotid imaging and surgery and the risk of recurrent stroke.
        Neurology. 2005; 65: 371-375
        • Ois A.
        • Cuadrado-Godia E.
        • Rodríguez-Campello A.
        • Jimenez-Conde J.
        • Roquer J.
        High risk of early neurological recurrence in symptomatic carotid stenosis.
        Stroke. 2009; 40: 2727-2731
        • Chaturvedi S.
        Aggressive medical therapy alone is adequate in certain patients with severe symptomatic carotid stenosis.
        Stroke. 2013; 44: 2957-2958
        • Sillesen H.
        • Amarenco P.
        • Hennerici M.G.
        • Callahan A.
        • Goldstein L.B.
        • Zivin J.
        • et al.
        Atorvastatin reduces the risk of cardiovascular events in patients with carotid atherosclerosis: a secondary analysis of the stroke prevention by aggressive reduction in cholesterol levels (SPARCL) trial.
        Stroke. 2008; 39: 3297-3302
        • Wang Y.
        • Wang Y.
        • Zhao X.
        • Liu L.
        • Wang D.
        • Wang C.
        • et al.
        Clopidogrel with aspirin in acute minor stroke or transient ischemic attack.
        N. Engl. J. Med. 2013; 369: 11-19
        • Chaturvedi S.
        Treatment of a Hot Carotid: More Fuel Is Needed to Clarify the Best Treatments.
        AAN Enterprises, 2018
        • Johnston S.C.
        • Easton J.D.
        • Farrant M.
        • Barsan W.
        • Conwit R.A.
        • Elm J.J.
        • et al.
        Clopidogrel and aspirin in acute ischemic stroke and high-risk TIA.
        N. Engl. J. Med. 2018; 379: 215-225
        • Chimowitz M.I.
        • Lynn M.J.
        • Derdeyn C.P.
        • Turan T.N.
        • Fiorella D.
        • Lane B.F.
        • et al.
        Stenting versus aggressive medical therapy for intracranial arterial stenosis.
        N. Engl. J. Med. 2011; 365: 993-1003
        • Shahidi S.
        • Owen-Falkenberg A.
        • Hjerpsted U.
        • Rai A.
        • Ellemann K.
        Urgent best medical therapy may obviate the need for urgent surgery in patients with symptomatic carotid stenosis.
        Stroke. 2013; 44: 2220-2225
        • Joakimsen O.
        • Bønaa K.H.
        • Stensland-Bugge E.
        Reproducibility of ultrasound assessment of carotid plaque occurrence, thickness, and morphology: the Tromsø study.
        Stroke. 1997; 28: 2201-2207
        • Silvestrini M.
        • Vernieri F.
        • Pasqualetti P.
        • Matteis M.
        • Passarelli F.
        • Troisi E.
        • et al.
        Impaired cerebral vasoreactivity and risk of stroke in patients with asymptomatic carotid artery stenosis.
        Jama. 2000; 283: 2122-2127
        • Altaf N.
        • Kandiyil N.
        • Hosseini A.
        • Mehta R.
        • MacSweeney S.
        • Auer D.
        Risk factors associated with cerebrovascular recurrence in symptomatic carotid disease: a comparative study of carotid plaque morphology, microemboli assessment and the European carotid surgery trial risk model.
        J. Am. Heart Assoc. 2014; 3e000173
        • Johnston S.C.
        • Gress D.R.
        • Browner W.S.
        • Sidney S.
        Short-term prognosis after emergency department diagnosis of TIA.
        Jama. 2000; 284: 2901-2906
        • Mancia G.
        • Fagard R.
        • Narkiewicz K.
        • Redon J.
        • Zanchetti A.
        • Boehm M.
        • et al.
        2013 ESH/ESC guidelines for the management of arterial hypertension: the task force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).
        Blood Press. 2013; 22: 193-278
        • Handelsman Y.
        • Mechanick J.
        • Blonde L.
        • Grunberger G.
        • Bloomgarden Z.
        • Bray G.
        • et al.
        American Association of Clinical Endocrinologists Medical Guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan: executive summary.
        Endocr. Pract. 2011; 17: 287-302
        • Stone N.J.
        • Robinson J.G.
        • Lichtenstein A.H.
        • Merz C.N.B.
        • Blum C.B.
        • Eckel R.H.
        • et al.
        2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association task force on practice guidelines.
        J. Am. Coll. Cardiol. 2014; 63: 2889-2934
        • Albers G.W.
        • Caplan L.R.
        • Easton J.D.
        • Fayad P.B.
        • Mohr J.
        • Saver J.L.
        • et al.
        Transient ischemic attack—proposal for a new definition.
        N. Engl. J. Med. 2002; 347: 1713-1716
        • Markus H.
        • Harrison M.
        Estimation of cerebrovascular reactivity using transcranial Doppler, including the use of breath-holding as the vasodilatory stimulus.
        Stroke. 1992; 23: 668-673
        • Tan I.
        • Demchuk A.
        • Hopyan J.
        • Zhang L.
        • Gladstone D.
        • Wong K.
        • et al.
        CT angiography clot burden score and collateral score: correlation with clinical and radiologic outcomes in acute middle cerebral artery infarct.
        Am. J. Neuroradiol. 2009; 30: 525-531
        • Muluk S.C.
        • Muluk V.S.
        • Sugimoto H.
        • Rhee R.Y.
        • Trachtenberg J.
        • Steed D.L.
        • et al.
        Progression of asymptomatic carotid stenosis: a natural history study in 1004 patients.
        J. Vasc. Surg. 1999; 29: 208-216
        • Hatano S.
        Experience from a multicentre stroke register: a preliminary report.
        Bull. World Health Organ. 1976; 54: 541
        • Hicks K.A.
        • Hung H.J.
        • Mahaffey K.W.
        • Mehran R.
        • Nissen S.E.
        • Stockbridge N.L.
        • et al.
        Standardized definitions for cardiovascular and stroke end point events in clinical trials.
        in: Clinical Data Interchange Standards Consortium. 2014
        • Rothwell P.
        • Eliasziw M.
        • Gutnikov S.
        • Warlow C.
        • Barnett H.
        • Collaboration CET
        Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery.
        Lancet. 2004; 363: 915-924
        • Wu C.M.
        • McLaughlin K.
        • Lorenzetti D.L.
        • Hill M.D.
        • Manns B.J.
        • Ghali W.A.
        Early risk of stroke after transient ischemic attack: a systematic review and meta-analysis.
        Arch. Intern. Med. 2007; 167: 2417-2422
        • Otite F.O.
        • Liaw N.
        • Khandelwal P.
        • Malik A.M.
        • Romano J.G.
        • Rundek T.
        • et al.
        Increasing prevalence of vascular risk factors in patients with stroke: a call to action.
        Neurology. 2017; 89: 1985-1994
        • Rothwell P.M.
        • Gibson R.
        • Warlow C.
        Interrelation between plaque surface morphology and degree of stenosis on carotid angiograms and the risk of ischemic stroke in patients with symptomatic carotid stenosis.
        Stroke. 2000; 31: 615-621
        • Johansson E.
        • Cuadrado-Godia E.
        • Hayden D.
        • Bjellerup J.
        • Ois A.
        • Roquer J.
        • et al.
        Recurrent stroke in symptomatic carotid stenosis awaiting revascularization: a pooled analysis.
        Neurology. 2016; 86: 498-504
        • Jashari F.
        • Ibrahimi P.
        • Bajraktari G.
        • Grönlund C.
        • Wester P.
        • Henein M.Y.
        Carotid plaque echogenicity predicts cerebrovascular symptoms: a systematic review and meta-analysis.
        Eur. J. Neurol. 2016; 23: 1241-1247
        • Reinhard M.
        • Schwarzer G.
        • Briel M.
        • Altamura C.
        • Palazzo P.
        • King A.
        • et al.
        Cerebrovascular reactivity predicts stroke in high-grade carotid artery disease.
        Neurology. 2014; 83: 1424-1431
        • Grubb Jr., R.L.
        • Derdeyn C.P.
        • Fritsch S.M.
        • Carpenter D.A.
        • Yundt K.D.
        • Videen TO
        • et al.
        Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion.
        Jama. 1998; 280: 1055-1060
        • Flaherty M.L.
        • Flemming K.D.
        • McClelland R.
        • Jorgensen N.W.
        • Brown Jr., R.D.
        Population-based study of symptomatic internal carotid artery occlusion: incidence and long-term follow-up.
        Stroke. 2004; 35 (e349-e52)
        • Baquis G.D.
        • Pessin M.S.
        • Scott R.M.
        Limb shaking--a carotid TIA.
        Stroke. 1985; 16: 444-448
        • Ali S.
        • Khan M.A.
        • Khealani B.
        Limb-shaking transient ischemic attacks: case report and review of literature.
        BMC Neurol. 2006; 6: 5
        • Das A.
        • Baheti N.N.
        Limb-shaking transient ischemic attack.
        J. Neurosci. Rural Pract. 2013; 4: 55-56
        • Shih Y.-T.
        • Chen W.-H.
        • Lee W.-L.
        • Lee H.-T.
        • Shen C.-C.
        • Tsuei Y.-S.
        Hybrid surgery for symptomatic chronic total occlusion of carotid artery a technical note.
        Oper. Neurosurg. 2013; 73 (onsE117-onsE23)
        • Li J.
        • Wang C.
        • Zou S.
        • Liu Y.
        • Qu L.
        Hybrid surgery for nontaper or nonstump lesions in symptomatic subacute or chronic internal carotid occlusion: a better solution.
        World Neurosurg. 2019; 122 (e1416-e25)
        • Zanaty M.
        • Samaniego E.A.
        • Teferi N.
        • Kung D.K.
        • Nakagawa D.
        • Hudson J.
        • et al.
        Hybrid surgery for internal carotid artery revascularization.
        World Neurosurg. 2019; 121: 137-144
        • Hayward R.A.
        • Kent D.M.
        • Vijan S.
        • Hofer T.P.
        Multivariable risk prediction can greatly enhance the statistical power of clinical trial subgroup analysis.
        BMC Med. Res. Methodol. 2006; 6: 18