Large Culprit Plaque and More Intracranial Plaques Are Associated with Recurrent Stroke: A Case-Control Study Using Vessel Wall Imaging

Abstract

BACKGROUND AND PURPOSE:Intracranial atherosclerotic plaque features are potential factors associated with recurrent stroke, but previous studies only focused on a single lesion, and few studies investigated them with perfusion impairment. This study aimed to investigate the association among whole-brain plaque features, perfusion deficit, and stroke recurrence. MATERIALS AND METHODS:Patients with ischemic stroke due to intracranial atherosclerosis were retrospectively collected and categorized into first-time and recurrent-stroke groups. Patients underwent high-resolution vessel wall imaging and DSC-PWI. Intracranial plaque number, culprit plaque features (such as plaque volume/burden, degree of stenosis, enhancement ratio), and perfusion deficit variables were recorded. Logistic regression analyses were performed to determine the independent factors associated with recurrent stroke. RESULTS:One hundred seventy-five patients (mean age, 59 [SD,12] years; 115 men) were included. Compared with the first-time stroke group (n ¼ 100), the recurrent-stroke group (n ¼ 75) had a larger culprit volume (P ¼ .006) and showed more intracranial plaques (P , .001) and more enhanced plaques (P ¼ .003). After we adjusted for other factors, culprit plaque volume (OR, 1.16 per 10mm 3 increase; 95% CI, 1.03-1.30; P ¼ .015) and total plaque number (OR, 1.31; 95% CI, 1.13-1.52; P , .001) were independently associated with recurrent stroke. Combining these factors increased the area under the curve to 0.71. CONCLUSIONS:Large culprit plaque and more intracranial plaques were independently associated with recurrent stroke. Performing whole-brain vessel wall imaging may help identify patients with a higher risk of recurrent stroke.ABBREVIATIONS: HR-VWI ¼ high-resolution vessel wall imaging; IQR ¼ interquartile range I ntracranial atherosclerosis is the primary etiology of stroke in Asia, 1 and the risk of recurrent stroke in these patients is high even under aggressive medication. 2 Identification of the risk factors associated with recurrent stroke is essential for secondary stroke prevention.The degree of stenosis is a well-recognized predictor of recurrent stroke, and patients with .50% stenosis are recommended for more aggressive treatment. 3,4 However, vulnerable atherosclerotic plaques with ,50% stenosis can also lead to stroke events. 5,6 The development of high-resolution vessel wall imaging (HR-VWI) has enabled the visualization of vulnerable features (intraplaque hemorrhage, outward remodeling, neurovascularture) in vivo and has provided important insight into plaque vulnerability rather than the degree of stenosis alone. 7,8 The use of whole-brain HR-VWI also allows the evaluation of multiple lesions simultaneously. 9Previous HR-VWI studies of intracranial plaques focused on comparing patients with stroke and asymptomatic patients. 10,11 However, investigations of intracranial plaque features associated with recurrent stroke are still rare. A few studies found that plaque enhancement 12 and plaque burden 13 were associated with...

Characteristics of culprit intracranial plaque without substantial stenosis in ischemic stroke using three-dimensional high-resolution vessel wall magnetic resonance imaging

“…It was probably because that those studies involved vessels with different degrees of stenosis and in different areas (including anterior and posterior circulation), which might cause various confounding factors. Nevertheless, one study also found that culprit plaque volume were independently associated with recurrent stroke ( Wu et al, 2022 ). Thus, it should be noted that “plaque volume” is distinct from “plaque burden”: plaque volume is the accumulation of the area in each layer of the whole plaque; plaque burden is the percentage of plaque area in the vessel area in the narrowest layer (single layer) ( Lu M. et al, 2018 ; Wu et al, 2022 ).…”

“…Nevertheless, one study also found that culprit plaque volume were independently associated with recurrent stroke ( Wu et al, 2022 ). Thus, it should be noted that “plaque volume” is distinct from “plaque burden”: plaque volume is the accumulation of the area in each layer of the whole plaque; plaque burden is the percentage of plaque area in the vessel area in the narrowest layer (single layer) ( Lu M. et al, 2018 ; Wu et al, 2022 ). Resulted of the positive remodeling effect, the plaque burden on the narrowest layer may not be the largest among the whole plaque layers.…”

The incomplete circle of Willis is associated with vulnerable intracranial plaque features and acute ischemic stroke

“…Furthermore, intracranial atherosclerosis often involves multiple vessel beds. Wu et al found an increased number of intracranial plaques was one of the independent risk factors for recurrent stroke [ 16 ]. In our study, we evaluated all the large intracranial vessels and measured all the plaque features downstream (bilateral MCA, ACA and PCA) of CoW.…”

Intracranial atherosclerotic plaque enhancement and long‐term risk of future strokes: A prospective, longitudinal study

“…14,15,16 Moreover, the association between intracranial plaque enhancement as a predictor of future strokes in ICAD patients was not consistently found in all the studies, which may also justify new studies in the field. [17][18][19][20] In addition, most of the studies performed so far were single-center, so whether the parameter enhancement is ready to be applied in multicenter real clinical practice remains to be clarified. 21,22 Finally, the follow-up period in most studies is limited, and therefore the prognostic significance of enhancement as a predictor of long-term clinical recurrence in ICAD patients is largely unknown.…”

“…However, the majority of the studies found in the literature addressing this topic were performed in Asian populations, and some of them have a retrospective design 14,15,16 . Moreover, the association between intracranial plaque enhancement as a predictor of future strokes in ICAD patients was not consistently found in all the studies, which may also justify new studies in the field 17–20 . In addition, most of the studies performed so far were single‐center, so whether the parameter enhancement is ready to be applied in multicenter real clinical practice remains to be clarified 21,22 .…”