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. 2025 Mar 21;30(1):190.
doi: 10.1186/s40001-025-02371-3.

Napkin-ring sign plaques are associated with cerebral small vessel disease

Hui Zhou  1 , Qiao Lin  2 , Xinwei He  2 , Rui Huang  3 , Linkao Chen  4
Affiliations

Napkin-ring sign plaques are associated with cerebral small vessel disease

Hui Zhou et al. Eur J Med Res. .

Abstract

Background: Few studies have investigated the association between the carotid artery napkin-ring sign (NRS) and cerebral small vessel disease (CSVD). This study aimed to investigate whether carotid NRS plaque burden and CSVD are associated.

Methods: This retrospective, single-center, cross-sectional study following STROBE guidelines enrolled patients with symptoms or clinical suspicion of anterior circulation acute ischemic stroke (AIS). Plaques were evaluated using preoperative cervicocerebral computed tomography angiography (CTA). Imaging markers of CSVD, such as white matter hyperintensities (WMHs) and perivascular spaces (PVSs), were assessed.

Results: A total of 575 patients (64.9 ± 8.0 years, 378 men) were evaluated. Patients with AIS had a higher percentage of total NRS plaques than those in the control group (144 (37.1%) vs. 45 (24.1%), P = 0.002), and the total NRS amount increased the risk of AIS after adjusting for confounding factors (odds ratio 1.717; 95%CI 1.141-2.584; P = 0.009). A higher WMHs grade was associated with the presence of NRS plaques (P < 0.001) and a higher total NRS area (P < 0.001). A higher PVSs grade was associated with positive remodeling (PR) on the NRS (P = 0.006).

Conclusions: An increased incidence of NRS plaques on CTA was associated with the occurrence of AIS, and the area and PR of NRS plaques were associated with the risk stratification of CSVD.

Keywords: Acute ischemic stroke; Cerebral small vessel disease; Napkin-ring sign plaque.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: This study was approved by the ethical review committee of Taizhou Central Hospital waived of the requirement for informed consent and approved the study (ZFPH No: 2025L-01-06). All subject records and data were deidentified and anonymized prior to analysis. This study was conducted in accordance with the Declaration of Helsinki. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Napkin‑ring sign plaque analysis. A 67-year-old man had a plaque with NRS at the left common carotid artery identified on CTA. The yellow round demonstrates the low-attenuation area of the plaque surrounded by a high-attenuation rim (blue round), and the red area represents the lumen filled with contrast
Fig. 2
Fig. 2
Napkin‑ring sign plaque characteristics between symptomatic and contralateral sides of in acute ischemic stroke patients. A–C NRS plaques were higher in AIS patients; No difference was found between patients with AIS and the control group in the PR of the NRS and NRS areas; D–F NRS plaques, PR of NRS and NRS area were higher in the symptomatic sides. NRS napkin‑ring sign, AIS acute ischemic stroke
Fig. 3
Fig. 3
Association between napkin‑ring sign plaque and MRI markers of cerebral small vessel disease combined on both sides. A–C NRS plaques and NRS area were higher in higher WMHs grade patients. No association was found between the PR of the NRS and WMHs in the combined data on both sides. D–F PR of NRS was higher in higher PVSs grade patients. No association was found between NRS plaques, NRS areas, and PVSs in the combined data on both sides. NRS napkin‑ring sign, PR positive remodeling, WMHs white matter hyperintensities, PVSs perivascular spaces
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