OBJECTIVE:This study was performed to clarify the clinical and radiological features of patients with moyamoya disease under 4 years of age in Japan. METHODS:For this retrospective multicenter cohort study, the MACINTOSH Study (Moyamoya Disease with Aggressive Clinical Course in Infants for Safety and Healthy Growth Study), patients were included if they were younger than 4 years of age, were hospitalized due to transient ischemic attack (TIA) or stroke between January 2008 and December 2018, and had a diagnosis of moyamoya disease or moyamoya syndrome. Patient clinical and radiological data were collected between January 1, 2021, and December 31, 2021. A Central Judgement Committee performed blind evaluations of imaging studies. RESULTS:Seventy-one patients were included in the study, 31 males and 40 females, whose mean age was 29.7 ± 12.7 months (0-47 months). Patients under 1 year of age had a strong male predominance (p = 0.0344) and no family history of moyamoya disease. Clinical diagnosis at disease onset included TIA (n = 31) and ischemic stroke (n = 40). All patients under 1 year of age presented with ischemic stroke. Among all the patients with ischemic stroke, seizure occurred at a mean age of 11.8 ± 9.9 months compared with 29.5 ± 11.7 months in those without ischemic stroke (p < 0.001). Most patients (69/71) had a diagnosis of bilateral moyamoya disease. Suzuki disease stage 2 was the most frequent (53/142 hemispheres). Among the 140 diseased hemispheres, 79 had cerebral infarcts, which were categorized as watershed zone infarcts (n = 64) and branch territory infarcts (n = 15). The branch territory infarcts were most frequently observed in Suzuki stage 2 hemispheres. CONCLUSIONS:This study demonstrated that demographic, clinical, and radiological characteristics are very specific in patients with moyamoya disease under 4 years of age, especially those under 1 year. Even a very early disease stage (Suzuki stage 2) could provoke TIA and/or ischemic stroke through the mechanism of artery-to-artery embolism as well as hemodynamic ischemia. Clinical trial registration no.: UMIN000040169 (www.umin.ac.jp).

INTRODUCTION:The aim of this study was to establish the score for predicting the 5-year risk of hemorrhagic stroke in patients with asymptomatic moyamoya disease (MMD) using the Asymptomatic Moyamoya Registry (AMORE) data and to evaluate its reproducibility. METHODS:The AMORE study was a prospective cohort study that recruited participants from 18 centers in Japan. A total of 103 patients completed the 5-year follow-up and of these, 6 patients experienced hemorrhagic stroke. According to the results of multivariate analysis, we selected age ≥46 years, grade-2 choroidal anastomosis, and microbleeds as variables in the prediction model. The cumulative rates of hemorrhagic stroke were estimated per hemisphere using the Kaplan-Meier method. Nonparametric bias-corrected confidence intervals (CIs) based on the Bootstrap sample were calculated to assess the reproducibility of the 5-year risk of hemorrhagic stroke. RESULTS:We created the AMORE score (0-3 points) to estimate the 5-year risk of hemorrhage with 1 point for each of age ≥46 years, grade-2 choroidal anastomosis, and microbleeds. The AMORE score was applied to a total of 135 MMD hemispheres. The 5-year risk of hemorrhagic stroke per hemisphere was 1.8%, 1.6%, 15.4%, and 50.0% for AMORE scores of 0, 1, 2, and 3, respectively. The cumulative rate of hemorrhagic stroke for AMORE score 3 was significantly higher than for AMORE score 0 (hazard ratio [HR], 38.7; 95% CI, 3.45-433; p = 0.003) and score 1 (HR, 41.8; 95% CI, 3.74-468; p = 0.002). The corresponding 90% CIs were 0%-5.6%, 0%-5.2%, 0%-38.5%, and 0%-100%, and the corresponding 80% CIs were 0%-4.7%, 0%-4.5%, 5.9%-33.3%, and 23%-100% for AMORE scores 0, 1, 2, and 3, respectively. CONCLUSION:The 5-year risk of hemorrhagic stroke in patients with asymptomatic MMD can be adequately estimated using the AMORE score.

Pulmonary arterial hypertension (PAH) harboring the heterozygous ring finger protein 213 (RNF213) p.Arg4810Lys variant responds poorly to PAH treatment and has a poor prognosis. Here, we present a case of severe PAH and moyamoya disease (MMD) harboring a heterozygous RNF213 p.Arg4810Lys variant that responded well to PAH monotherapy. A 23-year-old woman with cerebral infarction due to MMD was referred to our center for MMD bypass surgery and treatment of severe PAH. Genetic analysis revealed a heterozygous RNF213 p.Arg4810Lys variant. We initiated PAH-targeted therapy before MMD bypass surgery, as bypass surgery was considered high-risk in the presence of severe PAH. Despite a positive response to acute vasoreactivity testing with nitric oxide (NO) inhalation, calcium channel blockers were avoided due to the risk of hypotension-induced cerebral ischemia. We initiated endothelin receptor antagonist (macitentan, 10 mg/day) monotherapy because upfront combination therapy may also cause hypotension. Endothelin receptor antagonist monotherapy improved symptoms and pulmonary hemodynamics, reducing vascular resistance from 11.4 to 7.1 Wood Units after 1 month. Bilateral cerebral bypass surgery was performed after hemodynamic improvement. The clinical spectrum of RNF213-associated PAH may be broader than previously reported. This case highlights the importance of personalized medicine that considers patient conditions and comorbidities when selecting treatment options for patients with PAH harboring the RNF213 p.Arg4810Lys variant.

PurposeThe efficacy of mechanical thrombectomy (MT) for M2 occlusion remains uncertain, partly due to recanalization challenges owing to anatomical factors and hemorrhagic complications. This study investigated the best method for M2 occlusion based on the M1-M2 bifurcation angle.MethodsWe retrospectively evaluated the clinical data of 134 consecutive patients with M2 occlusion who underwent MT. The M1-M2 angle was measured between the conterminous (M2) and immediately proximal (M1) vessel segments with respect to the occlusion site. Patients were divided into the acute- and obtuse-angle groups. For each angle, we investigated the stent retriever (SR), contact aspiration (CA), and combined technique (CT) of MT.ResultsThere were 64 and 70 obtuse- and acute-angle cases, respectively. Univariate analysis showed no significant difference in the M1-M2 angle between the groups, but there was a trend toward increased intracranial hemorrhage in the obtuse-angle group (56% vs. 41%, p = 0.09). CA was significantly associated with lower postoperative subarachnoid hemorrhage incidence in the obtuse-angle group (CA vs. SR vs. CT: 9% vs. 39% vs. 50%, p = 0.02). In the acute-angle group, CT was significantly superior in number of passes (CT vs. SR vs. CA: 1.4 vs. 1.8 vs. 2.4, p = 0.03), puncture-recanalization time (48.5 vs. 59.1 vs. 69.4, p = 0.04), and modified first-pass effect (mFPE; 67% vs. 48% vs. 21%, p = 0.01). No association was observed between the first-line technique and clinical outcomes for any angle.ConclusionProcedure results varied according to the M1-M2 bifurcation angle. For treating M2 occlusion, the bifurcation angle should be considered in the choice of technique.

The mechanisms underlying neurological symptoms, including epilepsy, in unruptured brain arteriovenous malformations (bAVM) remain to be elucidated. The dual-tracer basis function method (DBFM) with single-scan dual-tracer (15O2 and C15O2) approach is a novel PET imaging technique that can evaluate the hemodynamics and metabolism of brain tissue adjacent to the nidus without the influence of abundant vascular radioactivity. We aimed to clarify the relationship between neurological symptoms and hemodynamic and metabolic abnormalities using the DBFM. Cerebral blood volume (CBV), cerebral blood flow (CBF), cerebral metabolic rate of oxygen (CMRO2), and oxygen extraction fraction (OEF) were compared between symptomatic and asymptomatic bAVMs and before and after treatment. Among 46 patients with unruptured bAVMs who underwent DBFM, 26 cases were included. While CBV and OEF increased in the perinidus (p < 0.01), CBF and CMRO2 decreased (p < 0.01). Symptoms were significantly associated with higher OEF (symptomatic vs. asymptomatic, ratio of perinidal to contralateral, n = 13 vs. n = 13, 1.07 ± 0.030 vs. 1.01 ± 0.080, p = 0.017). All elevated OEFs in symptomatic bAVMs with therapeutic symptom resolved in post-therapeutic PET imaging. DBFM revealed a higher OEF was associated with symptomatic bAVM. The DBFM potentially aids in predicting post-therapeutic symptom improvement.

The primitive lateral basilovertebral anastomosis (PLBA) is a transient embryonic vessel in the vertebrobasilar system that typically regresses during cerebellar artery development. Persistent PLBA (PPLBA), which forms a vertebrobasilar duplication, is a rare vascular anomaly. This is the first reported case of multiple fusiform aneurysms associated with a PPLBA. A 14-year-old girl was diagnosed with intracranial aneurysms before undergoing coronary artery bypass grafting surgery for myocardial infarction. Digital subtraction angiography showed two fusiform aneurysms on a PPLBA, connecting the left vertebral artery (VA) and the left anterior inferior cerebellar artery (AICA). After 3 years of follow-up, a new aneurysm developed at the origin of the PPLBA, proximal to the existing two aneurysms. Due to the AICA blood flow originating mainly from the basilar artery (BA) rather than the PPLBA, endovascular parent artery occlusion of the PPLBA was planned to prevent aneurysmal rupture and subarachnoid hemorrhage. Complete occlusion of all three aneurysms was achieved without complications. Understanding the embryological anatomy of this rare vertebrobasilar duplication involving the PPLBA, AICA, BA, and VA facilitated the successful development of a therapeutic strategy. Aneurysms associated with PPLBA exhibit various vascular structures and can be treated effectively with tailored endovascular approaches.

Moyamoya disease(MMD) is a progressive cerebrovascular disorder characterized by stenosis or occlusion of the terminal portion of the internal carotid arteries and development of abnormal collateral vessels. Recent studies have suggested a clinical association between MMD and autoimmune thyroid disorders or antithyroid antibodies. In patients with concurrent Graves'disease, thyrotoxicosis may precipitate ischemic cerebrovascular events, and normalization of thyroid function is crucial before revascularization surgery. Notably, elevated levels of antithyroid autoantibodies, such as antithyroid peroxidase and anti-thyroglobulin, are frequently observed in patients with MMD, despite the absence of clinically overt thyroid dysfunction. Genetic susceptibility, including RNF213 variants and immunological factors, might contribute to the pathophysiology of MMD and autoimmune thyroid disorders. The presence of thyroid autoantibodies may be associated with the pathological extension and cerebrovascular events in MMD. However, the underlying mechanisms linking thyroid autoimmunity and moyamoya angiopathy remain unclear. Further investigation is warranted to elucidate these associations and establish appropriate diagnostic and therapeutic approaches.

Objective:Moyamoya disease and dural arteriovenous fistulas (dAVFs) are both rare conditions, and their coexistence is extremely uncommon. The causal relationship between moyamoya disease and cavernous sinus dAVFs (CS-dAVFs) remains unclear. We report a successfully treated case of CS-dAVF in a patient with moyamoya disease, focusing on vascular structural changes and potential pathophysiological associations. Case Presentation:A 69-year-old man with a history of moyamoya disease presented with progressive left ocular symptoms. Imaging studies, including 3D-DSA, revealed a CS-dAVF supplied by multiple feeders and draining into the superior ophthalmic and angular veins. Compared to previous imaging, the progression of moyamoya disease was evident, with worsening middle cerebral artery stenosis and increased collateral vessels. Superselective transvenous embolization was performed under general anesthesia. Microcatheters were navigated into the affected venous structures, and coil embolization successfully obliterated the shunt. Postoperatively, the patient had significant symptomatic improvement, with no moyamoya-related complications, and was discharged on postoperative day 4. Conclusion:To our knowledge, this is the first report of a successfully treated CS-dAVF in a patient with moyamoya disease. Superselective transvenous embolization was successfully performed, which led to a favorable outcome despite the presence of moyamoya disease.

BACKGROUND Although bypass surgery can reduce rebleeding risk in hemorrhagic moyamoya disease, the risk remaining after surgery is not negligible. We hypothesized that the postoperative persistence of periventricular anastomosis (PA), a fragile periventricular collateral manifestation, is associated with rebleeding. METHODS This retrospective cohort study included patients with moyamoya disease who underwent direct bypass at 2 institutions after hemorrhagic presentation. Either presence or absence of PA after surgery was radiologically determined by grading of each subtype, lenticulostriate, thalamic, or choroidal anastomosis, 3–6 months after surgery. The time interval between the surgery and the rebleeding event or last visit was calculated. RESULTS Of 116 eligible patients comprising 232 hemispheres, 172 hemispheres underwent surgery. Rebleeding occurred in 16 hemispheres of 15 patients (2.0% per person‐year) during the median follow‐up period of 6.3 years. The hemisphere‐based annual rebleeding rate was 2.0% in the PA‐positive hemispheres as compared with 0.46% in the PA‐negative hemispheres. The adjusted hazard ratio of rebleeding for positive PA relative to negative PA was 4.11 (95% CI, 1.07–15.82). Among subtypes of PA, lenticulostriate anastomosis was the most likely to persist after surgery (34 of 62 anastomoses) and to cause rebleeding (8 of 16 hemispheres). CONCLUSION The persistence of PA, especially that of lenticulostriate anastomosis, might be associated with rebleeding after surgery. This suggests the importance of assessing and optimally managing PA for improving long‐term outcomes.

PURPOSE:Periventricular anastomosis (PA) is a potential cause of intracranial hemorrhage in moyamoya disease. While bypass surgery can reduce PA, an effective target vessel to prevent hemorrhagic stroke remains unidentified. We investigated postoperative PA regression at different anastomosis sites. METHODS:Overall, 126 hemispheres of 100 patients with moyamoya disease, who underwent superficial temporal artery-middle cerebral artery single-barrel bypass between 2019 and 2022 at our institution were evaluated. Hemispheres with anastomosis anterior or posterior to the central sulcus were categorized into the anterior and posterior groups. Among the PA subtypes, lenticulostriate anastomosis (LSA) and choroidal anastomosis (ChA) were analyzed. Revascularization areas resulting from bypass surgery and PA regression were evaluated by postoperative angiography. The correlation of the anastomosis site and revascularization area with PA regression was investigated. RESULTS:In total, 126 hemispheres were analyzed individually, with 33 and 93 in the anterior and posterior groups, respectively. LSA regression was more commonly observed in the anterior group than in the posterior group. ChA regression occurred more frequently in the posterior group than in the anterior group. PA grade decreased in many large revascularization area cases in the LSA group but not in the ChA group. Multivariate analysis showed that LSA regression was associated with the anastomosis site and revascularization area. However, the anastomosis site was the only independent factor for ChA. CONCLUSION:Postoperative PA regression correlated with anastomosis site and revascularization area. The anastomosis site may be important for ChA, and considering the target vessel based on the PA development is necessary.

OBJECTIVE: Surgical indications for low-grade carotid stenosis have not yet been established. This study aimed to clarify the characteristics of low-grade carotid stenosis refractory to medical treatment. METHODS: We retrospectively analyzed 48 patients with symptomatic low-grade carotid stenosis ( <50%). Recurrence was defined as an ipsilateral ischemic event in the symptomatic lesions during the follow-up period. Patient demographics and imaging findings were compared between the recurrence and nonrecurrence groups to investigate risk factors associated with medical treatment. RESULTS: The mean age was 74.1 (58 - 90 years), and the mean follow-up period was 35.4 months (2.0 - 97 months). Recurrence occurred in 15 of the symptomatic patients. Ulceration was significantly associated with recurrence - nder medical treatment ( P = 0.001). The median time to recurrence was 26.1 months in patients with ulcers and 54.3 months in those without ulcers ( P = 0.04). Pathological study with recurrence showed plaque rupture with multilayered lesions, indicating lesions refractory to medical treatment. - CONCLUSIONS: In cases of low-grade carotid stenosis, lesions with ulcerations are likely refractory to medical therapy. Consideration of the indications for surgical treatment may be warranted for lesions with ulceration, even if the degree of stenosis is low.

Flow diverter (FD) devices are new-generation stents placed in the parent artery at the aneurysmal neck to obstruct intra-aneurysmal blood flow, thus favoring intra-aneurysmal thrombosis. In Japan, about eight years have passed since health insurance approval was granted for FD devices, and FD placement to treat aneurysms has become widespread. Treatment indications have also been expanded with the introduction of novel devices. At present, three types of FD (Pipeline, FRED, and Surpass Streamline) are available in Japan. This report represents a compilation of available FD technologies and describes the current consensus on this treatment.

Postoperative cognitive dysfunction and recovery remain unclear in older patients undergoing interventional therapies for unruptured intracranial aneurysms (UIAs). This study aimed to compare changes in postoperative cognitive function between younger and older patients and to detect factors associated with non-recovery from postoperative cognitive dysfunction. This study reviewed 59 consecutive patients with UIAs who underwent interventional therapies, including microsurgical clipping or endovascular treatment, from 2021 to 2022. All patients were divided into the older (aged ≥ 70 years) and younger (aged < 70 years) groups. Mini-Mental State Examination (MMSE) and Frontal Assessment Battery (FAB) were performed within 2 months before interventions, at 1 week postoperatively (POW1), and 3–6 months postoperatively (POM3–6). MMSE and FAB scores decreased more frequently in the older group than in the younger group at POW1 (older vs. younger: MMSE: 48

Objective: Flow diverters (FDs), first introduced in Japan in 2015, were initially limited to wide-necked large cerebral aneurysms, which pose a high treatment risk. However, based on the results of the PREMIER study, the indications have expanded since 2020, and the number of treatment cases is increasing in Japan. At our hospital, FD placement with adjunctive coil embolization has been actively performed for medium-sized cerebral aneurysms, as indicated in the PREMIER study; herein, we report the outcomes of this treatment. Methods: Of the 25 patients with 28 aneurysms who underwent FD placement at our institution between April 2022 and June 2023, 15 with 17 wide-necked unruptured cerebral aneurysms with a maximum diameter of <12 mm in the internal carotid artery (ICA) or vertebral artery (VA) were included. Postoperative complications were investigated in each case, and the aneurysm occlusion status was assessed using ultrashort echo time (UTE)-MRA at 3 months postoperatively and angiography at 6 months postoperatively. Fifteen patients who underwent coiling or stent-assisted coiling (SAC) for the same criteria during the same period were compared. Baseline characteristics and treatment results were compared between FD and coiling/SAC cases. Results: Four males and 11 females with a mean age of 61.7 +/- 12.8 years were included, and the median follow-up period was 9 months (6-18 months). There were 14 aneurysms of the ICA and 3 of the VA, and the mean maximum aneurysm diameter was 7.9 +/- 1.7 mm. All patients were treated using the Pipeline Flex with Shield Technology (Medtronic, Minneapolis, MN, USA), and 14 aneurysms (82.4%) were treated with adjunctive coil embolization. There were no symptomatic strokes in the perioperative period; only one patient receiving corticosteroid therapy for thyroid eye disease had asymptomatic ICA occlusion at 3 months. Fifteen aneurysms (88.2%) were not visible on UTE-MRA at 3 months postoperatively, and angiography at 6 months showed complete occlusion in 16 (94.1%) aneurysms. The coiling/SAC group had a smaller neck size and higher volume embolization ratio than the FD group; however, complete occlusion was higher in the FD group. Conclusion: FD placement with adjunctive coil embolization for medium-sized cerebral aneurysms is expected to result in good occlusion rates in the early postoperative period.

This case report details the pathological findings of a vessel wall identified as the bleeding point for intracranial hemorrhage associated with Moyamoya disease. A 29-year-old woman experienced intracranial hemorrhage unrelated to hyperperfusion following superficial temporal artery-middle cerebral artery bypass surgery. A pseudoaneurysm on the lenticulostriate artery (LSA) was identified as the causative vessel and subsequently excised. Examination of the excised pseudoaneurysm revealed a fragment of the LSA, with a disrupted internal elastic lamina and media degeneration. These pathological findings in a perforating artery, akin to the circle of Willis, provide insights into the underlying mechanisms of hemorrhage in Moyamoya disease.

Objective: Clazosentan (CLA) reduces cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH). However, adverse events including pulmonary edema were reported. We examined whether the strict management of fluid balance reduces the adverse events and improves patient outcomes. Methods: Patients with aSAH between 2020 and 2023 were included. They were divided into pre-CLA (before CLA approval) and post-CLA (after approval) groups. The patients in the post-CLA group were further divided into the post-CLA1 (before the change in fluid management) and post-CLA2 (after the change) groups. To achieve fluid balance of 0–500 ml/day according to the modified protocol, the infusion volume was restricted. Results: The daily fluid balance increased from the pre-CLA to the post-CLA1 periods (p = 0.01). The protocol changes decreased the pulmonary edema (post-CLA1 vs. post-CLA2, 44 vs. 22 %, p = 0.09) and discontinuation of CLA (44 vs. 9 %, p < 0.01). The incidence of symptomatic spasm (SS) and delayed cerebral infarction (DCI) in the post-CLA2 were slightly reduced without significant differences (SS: 17 vs. 13 %, p = 0.69; DCI: 11 vs. 9 %, p = 1.00). Conclusion: Strict management of fluid balance during CLA treatment reduced the adverse events and discontinuation of CLA administration. Fluid restriction may positively affect the management of cerebral vasospasms.

BACKGROUND AND PURPOSE:Intracranial aneurysm growth is a significant risk factor for rupture; however, a few aneurysms remain unruptured for long periods, even after growth. Here, we identified hemodynamic features associated with aneurysmal rupture after growth. MATERIALS AND METHODS:We analyzed nine middle cerebral artery aneurysms that grew during the follow-up period using computational fluid dynamics analysis. Growth patterns of the middle cerebral artery aneurysms were divided into homothetic growth (Type 1), de novo bleb formation (Type 2), and bleb enlargement (Type 3). Hemodynamic parameters of the four ruptured aneurysms after growth were compared with those of the five unruptured aneurysms. RESULTS:Among nine aneurysms (78%), seven were Type 1, one was Type 2, and one was Type 3. Three (43%) Type 1 aneurysms ruptured after growth. Maximum oscillatory shear index after aneurysmal growth was significantly higher in ruptured Type 1 cases than in unruptured Type 1 cases (ruptured vs. unruptured: 0.455 ± 0.007 vs. 0.319 ± 0.042, p = 0.003). In Type 1 cases, a newly emerged high-oscillatory shear index area was frequently associated with rupture, indicating a rupture point. Aneurysm growth was observed in the direction of the high-pressure difference area before enlargement. In Types 2 and 3 aneurysms, the maximum oscillatory shear index decreased slightly, however, the pressure difference values remain unchanged. In Type 3 aneruysm, the maximum OSI and PD values remained unchanged. CONCLUSIONS:This study suggests that hemodynamic variations and growth pattern changes are crucial in rupture risk determination using computational fluid dynamics analysis. High-pressure difference areas may predict aneurysm enlargement direction. Additionally, high maximum oscillatory shear index values after enlargement in cases with homothetic growth patterns were potential rupture risk factors.

ObjectivePlaque ulceration in carotid artery stenosis is a risk factor for cerebral ischemic events; however, the characteristics that determine plaque vulnerability are not fully understood. We thus assessed the association between plaque ulceration sites and cerebrovascular ischemic attack.MethodsWe retrospectively collected the clinical data of 72 consecutive patients diagnosed with carotid artery stenosis with plaque ulcers. After excluding patients with pseudo-occlusion, a history of previous carotid endarterectomy (CEA) or carotid artery stenting (CAS) before the ulcer was first discovered, follow-up data of less than 1 month, or CEA or CAS performed within 1 month after the ulcer was first discovered, 60 patients were ultimately included. Patients were divided into proximal and distal groups based on the ulcer location relative to the most stenotic point. The primary endpoints were ipsilateral cerebrovascular ischemic events (“ischemic events”), such as amaurosis fugax, transient ischemic attack, or ischemic stroke due to carotid artery stenosis with plaque ulceration. The association between ulcer location and ischemic events was also assessed.ResultsIn the patients with plaque ulcer, more patients had proximal than distal plaque ulcers (39 vs. 21, p=0.028). The median follow-up duration was 3.8 (interquartile range: 1.5–6.2) years. Nineteen patients (32%) experienced ischemic event. Ischemic events occurred more frequently in the distal than in the proximal group (18% vs. 59%; p=0.005). Kaplan–Meier curves demonstrated a significantly shorter event-free time in the distal group (log-rank p=0.021). In univariate analysis, distal ulcer location was associated with ischemic events (odds ratio [OR]: 2.94, 95% confidence interval [CI]: 1.13–7.65, p=0.03). Multivariate analysis using two different models also showed that distal ulcer location was independently associated with ischemic events (Model 1, OR: 3.85, 95%CI: 1.26–11.78, p=0.03; Model 2, OR: 4.31, 95%CI: 1.49–12.49, p=0.009).ConclusionsPatients with carotid artery stenosis and plaque ulcers located distal to the most stenotic point are more likely to experience cerebrovascular ischemic attacks. Therefore, carotid plaques with ulcers located distal to the most stenotic point may be a potential indication for surgical treatment.