Carotid near-occlusion with full collapse carries a markedly elevated risk of stroke recurrence within 48 hours, supporting dedicated trials of urgent revascularisation strategies.
Key Findings
Results
The 90-day recurrent stroke risk in symptomatic carotid near-occlusion was 16.4%, with 5.9% occurring within the first 2 days.
360 patients with symptomatic carotid near-occlusion were pooled from 3 prospective cohort studies (TACNOS, UCC, CAOS).
Primary outcome was ipsilateral ischaemic stroke or retinal infarction within 90 days, censored at revascularisation.
Full collapse defined by visual appearance was not significantly associated with higher 90-day stroke risk, but full collapse defined by measurement was associated with a doubling of risk.
Visual appearance classification was available in 333 patients; measurement-based classification in 219 patients.
By visual appearance: adjHR 1.5 (95% CI, 0.8–2.9) for full collapse vs. without full collapse — not statistically significant.
By measurement (distal ICA ≤ 2.0 mm and/or ICA ratio ≤ 0.42): adjHR 2.0 (95% CI, 1.0–3.9) for full collapse.
Cox regression with pre-specified sensitivity analyses addressed ascertainment bias and informative censoring.
Results
Full collapse strongly predicted ultra-early (0–2 day) stroke recurrence regardless of the definition used.
By visual appearance: adjHR 4.0 (95% CI, 1.5–10.5) for 0–2 day recurrence in full collapse.
By measurement: adjHR 4.8 (95% CI, 1.8–12.8) for 0–2 day recurrence in full collapse.
Both definitions showed consistent and statistically significant associations for ultra-early risk.
Sensitivity analyses confirmed the robustness of these estimates.
Results
Full collapse combined with TIA presentation identified a particularly high-risk subgroup with 90-day stroke risks of 37.8% (by appearance) and 50.4% (by measurement).
This was described as an exploratory analysis.
90-day stroke risk was 37.8% when full collapse defined by visual appearance was combined with TIA presentation.
90-day stroke risk was 50.4% when full collapse defined by measurement was combined with TIA presentation.
The authors noted this is a hypothesis-generating observation that requires independent validation.
Results
There was substantial between-study heterogeneity in 90-day recurrent stroke rates across the three pooled cohorts.
I² = 77%, P = .012 for heterogeneity in 90-day stroke rates across cohorts.
Per-cohort rates ranged from 8.1% (CAOS) to 23.9% (TACNOS).
The authors interpreted findings in the context of this substantial heterogeneity and informative censoring.
Sensitivity analyses were pre-specified to address ascertainment bias and informative censoring.
Conclusions
The authors concluded that carotid near-occlusion with full collapse supports dedicated trials of urgent revascularisation strategies given the markedly elevated 48-hour recurrence risk.
The study is described as a pooled individual patient data analysis of three prospective cohort studies.
Revascularisation was used as a censoring event for the primary outcome.
The authors call for dedicated trials of urgent revascularisation strategies specifically for full collapse patients.
The TIA subgroup finding is explicitly labeled hypothesis-generating and requiring independent validation.
What This Means
This research suggests that people who have a near-complete blockage of the carotid artery (the major artery supplying blood to the brain) face a significant risk of having another stroke very quickly after their first stroke or TIA (transient ischemic attack, or 'mini-stroke'). By combining data from three studies including 360 patients, the researchers found that about 1 in 6 patients (16.4%) had another stroke within 90 days, and nearly 6% had a recurrent stroke within just the first 48 hours.
A key finding was that patients whose carotid artery had 'full collapse' — meaning the artery was so narrowed it appeared to shrink in diameter — were at especially high risk in those critical first two days. Depending on how full collapse was measured (by visual assessment or by specific size measurements), patients with full collapse were 4 to nearly 5 times more likely to have a stroke within 48 hours compared to those without full collapse. When full collapse was combined with an initial presentation as a TIA rather than a full stroke, the 90-day stroke risk was extremely high — between 38% and 50%.
This research suggests that patients with carotid near-occlusion, especially those with full collapse of the artery, may need very urgent treatment to restore blood flow and prevent rapid recurrent stroke. However, the findings should be interpreted with caution because the three studies showed considerable variation in their results, and the way patients were censored (removed from analysis when they received treatment) may have influenced the estimates. The authors call for dedicated clinical trials to test whether emergency revascularisation procedures can reduce this very high early stroke risk.
García-Pastor A, Johansson E. (2026). Short-term risk of recurrent stroke in symptomatic carotid near-occlusion: pooled analysis of three cohort studies.. European stroke journal. https://doi.org/10.1093/esj/aakag100