Correlation of the characteristics of symptomatic intracranial atherosclerotic plaques with stroke types and risk of stroke recurrence: a cohort study

Abstract

Background: Symptomatic intracranial atherosclerotic stenosis (sICAS) patients had a higher risk of stroke recurrence, and the risk of acute ischemic stroke (AIS) was higher than transient ischemic attack (TIA). Therefore, it is important to explore the risk factors associated with sICAS clinical subtypes and the risk of stroke recurrence. The purpose of this study was to investigate the association between intracranial arterial culprit plaque characteristics with sICAS clinical subtypes and the risk of stroke recurrence.

Methods: A total of 206 patients with sICAS were included. Baseline demographic data and relevant serologic indices were collected from all participants. All participants were assessed by high-resolution vessel wall imaging (HR-VWI) for culprit vessel and culprit plaque characteristics. The follow-up method was outpatient or telephone follow-up. Associated factors for sICAS clinical subtypes were analyzed by binary logistic regression. Cox proportional hazard regression analysis were used to analysis the independent risk factors for recurrent stroke.

Results: In this group, there were 154 patients with AIS, 52 patients with TIA, 124 patients with anterior circulation ischemic symptom (ACiS), and 82 patients with posterior circulation ischemic symptom (PCiS). Male gender [odds ratio (OR) =5.575, 95% confidence interval (CI): 2.120 to 14.658], history of previous statin use (OR =0.309, 95% CI: 0.113 to 0.843) and serum apolipoprotein A/B values (OR =0.363, 95% CI: 0.139 to 0.948) were associated factors for AIS. A total of 24 patients (11.7%) experienced stroke recurrence during the 1-year follow-up period. Hyperintensity on T1 weighted imaging (T1WI) in the culprit plaque [hazard ratio (HR) =3.798, 95% CI: 1.433 to 10.062] was an independent risk factor for stroke recurrence. The incidence of significant enhancement (62.2% vs. 39.5%, χ²=9.681, P=0.002), positive remodeling (69.5% vs. 52.4%, χ²=5.661, P=0.020), and hyperintensity on T1WI (42.7% vs. 22.6%, χ²=16.472, P=0.003) was higher in the posterior circulation than in the anterior circulation.

Conclusions: The characteristics of intracranial arterial culprit plaques were independent risk factors for recurrent stroke, and there were differences in the plaque characteristics of anterior and posterior circulation. Early HR-VWI examination for sICAS patients is of great significance for patient risk stratification and personalized management.

Keywords: Intracranial atherosclerotic plaques (ICAP); acute ischemic stroke (AIS); high-resolution magnetic resonance vessel wall imaging; stroke recurrence; transient ischemic attack (TIA).

Figure 1

Flow diagram of study identification. ACiS, anterior circulation ischemic symptom; PCiS, posterior circulation ischemic symptom; PACNS, primary angiitis of the central nervous system; HR-VWI, high-resolution vessel wall imaging; sICAS, symptomatic intracranial atherosclerotic stenosis; AIS, acute ischemic stroke; TIA, transient ischemic attack.

Figure 2

Example case of a patient with 3 days of weakness in the right limb. (A) DWI. The green arrow indicated hyperintense in the left basal ganglia. (B) TOF-MRA. The green arrow indicated lumen stenosis in the M1 segment of the left middle cerebral artery. (C-F) 3D-T1-SPACE. The green arrow indicated an eccentric plaque, which showed hyperintensity on T1WI and significantly enhanced. T1WI, T1 weighted imaging; DWI, diffusion weighted imaging; TOF-MRA, time-of-flight MR angiography; 3D-T1-SPACE, 3-dimensional T1 sampling perfection with application optimized contrasts using different flip angle evolution.