Plaque Surface Irregularity Research Articles

Prevalence of ipsilateral “vulnerable carotid plaques with

BackgroundCarotid plaques may be an important etiology in ischemic stroke. We aimed to assess carotid plaque characteristics ipsilateral and contralateral to the ischemic stroke and assessed the prevalence of “vulnerable carotid plaques with <50% stenosis” based on different imaging-based definitions in patients with large vessel occlusion and source of embolic stroke of undetermined source (ESUS) on CT Angiography (CTA). MethodsData are from the ESCAPE-NA1 trial (Efficacy and safety of nerinetide for the treatment of acute ischemic stroke), a multicenter, randomized study that included anterior circulation large vessel occlusion patients undergoing thrombectomy. Various CTA features of plaque vulnerability were combined to define “vulnerable carotid plaques” in different ways. Within ESUS patients, prevalence of vulnerable plaques ipsilateral vs. contralateral to the intracranial occlusion was compared. ResultsWe analyzed 132 patients whose ischemic stroke mechanism was determined to be ESUS. Plaques causing 30–50 % stenosis (as compared to no stenosis) and plaque surface irregularity were significantly more common in ipsilateral carotid arteries (37[28.0 %] vs. 18[13.6 %]; p < 0.001 and 102[77.3 %] vs. 78[59.1 %]; p = 0.002). The prevalence of ipsilateral “vulnerable carotid plaques” varied depending on imaging definition used for such plaques between 55 and 74 %, but irrespective of the definition used, the prevalence of “vulnerable carotid plaques” was consistently higher in ipsilateral carotid arteries compared to contralateral carotid arteries. ConclusionsIn ESUS patients undergoing thrombectomy for anterior circulation large vessel occlusion, vulnerable carotid plaques are more prevalent ipsilateral to the intracranial occlusion. Irregular plaque surface, and a higher degree of stenosis were the most common vulnerable plaque features.

Comparison of computer-aided quantitative measurement and physician visual assessment in the evaluation of intracranial atherosclerotic stenosis: a vessel wall magnetic resonance imaging study.

Intracranial atherosclerotic stenosis is a leading cause of ischemic stroke in China. Accurate assessment of intracranial atherosclerotic stenosis through imaging techniques is crucial for guiding therapeutic interventions and prognostic stratification. Vessel wall magnetic resonance imaging (VWMRI) has emerged as a reliable method for evaluating intracranial arterial vessels. With the advancement of technology, computer-aided quantitative measurement (CAQM) is increasingly used in imaging assessment. This study aimed to compare physician visual assessment (PVA) with CAQM in the VWMRI evaluation of intracranial atherosclerotic stenosis. This retrospective cross-sectional study consecutively enrolled patients diagnosed with intracranial atherosclerotic stenosis through imaging examinations at the Fourth Affiliated Hospital of China Medical University from December 2018 to December 2023. Clinical data were collected for analysis. Two radiologists independently and separately conducted CAQM and PVA on the VWMRI images of intracranial atherosclerotic stenosis patients. The imaging features evaluated encompassed stenosis severity, vessel wall remodeling, vessel wall thickening patterns, fibrous cap characteristics, lipid core ratio, and plaque enhancement degree. The study further assessed the discrepancies and concordance between the assessment results obtained from the two methods using paired sample t-tests, Wilcoxon signed-rank tests, and Cohen's kappa coefficient analysis. This study enrolled a total of 589 patients. The PVA time was shorter than CAQM (12.02±3.63 vs. 20.48±6.50 min). However, compared with digital subtraction angiography, the CAQM had a better area under the curve (0.88) than the PVA (0.80) in assessing luminal stenosis degree. The proportions of vessel wall remodeling (227/38.5%) and plaque surface irregularity (127/21.6%) evaluated by PVA were both lower than those by CAQM (438/74.4%, 171/29.0%). Meanwhile, no statistically significant differences were found in the patterns of wall thickening (P=0.12/0.39) and the proportion of plaque lipid core (P=0.65 and P=0.27), with good agreement between the two methods (K=0.67/0.85, K=0.97/0.94). While there were no statistical differences in the assessment of plaque enhancement degree in specific arteries (middle cerebral artery and basilar artery) (n=77/36, P=0.08/0.21), an overall statistical difference was observed (n=113, P=0.03). Additionally, there was poor agreement in assessing plaque enhancement degree, with Cohen's kappa values of 0.13 (-0.05 to 0.32) and 0.16 (-0.06 to 0.39). This study revealed disparities between PVA and CAQM in the evaluation of intracranial atherosclerotic stenosis of VWMRI. CAQM is recommended for assessing stenosis degree, vessel wall remodeling, and fibrous cap characteristics. However, PVA is suggested to assess wall thickening patterns and lipid core ratio to expedite diagnosis. Further research is needed to validate CAQM's superiority in evaluating plaque enhancement degrees.

Carotid plaque volume measurement in ischemic stroke: A pilot study

Objectives: Carotid atherosclerosis is a significant risk factor for acute ischemic stroke. Three-dimensional (3D) sonography is a new technique that can be used to analyze carotid plaque both quantitatively and qualitatively. The aim was to study carotid atherosclerosis in stroke patients and healthy controls in terms of plaque volume quantification by 3D ultrasound (US). Materials and Methods: An observational descriptive study was conducted in the stroke unit of a university referral hospital in South India. Patients with ischemic stroke between the ages of 20 and 70 years were studied, along with age- and sex-matched controls. Carotid sonography (2D and 3D) along with Doppler studies was done in all patients, using Philips Affiniti 50 US system. Vascular plaque quantification software was used to assess plaque volume. Results: Twenty-four subjects were recruited, and two were excluded from the study. Twelve were cases, and ten were controls. The mean carotid intima-media thickness (CIMT) (average CIMT in six sites in common carotid artery, three on each side) studied in patients was 0.65 ± 0.10 mm, while that for healthy subjects was 0.62 ± 0.06 mm. The mean plaque volume in patients with stroke or transient ischemic attack was 179.82 ± 310.3 mm3, and that in healthy subjects was 56.75 ± 69.6 mm3. Plaque heterogeneity, surface irregularity, and ulceration were found to be common in symptomatic carotid plaques. Conclusion: The 3D sonography is a non-invasive and simple feasible tool for the analysis of carotid plaque.

Association of systemic inflammatory response index and plaque characteristics with the severity and recurrence of cerebral ischemic events

AimWe aimed to investigate the relationship between systemic inflammatory response index (SIRI) and intracranial plaque features, as well as the risk factors related to the severity and recurrence of cerebral ischemic events. MethodsWe enrolled 170 patients with cerebral ischemic events. Baseline demographic characteristics and laboratory indicators were collected from all participants. All patients were assessed by high-resolution magnetic resonance vessel wall imaging for culprit plaque characteristics and intracranial atherosclerotic burden. Outpatient or telephone follow-up were conducted at 1, 3, and 6 months after discharge. ResultsSIRI levels were significantly associated with the enhanced plaque number (r = 0.205, p = 0.007), total plaque stenosis score (r = 0.178, p = 0.020), total plaque enhancement score (r = 0.222, p = 0.004), intraplaque hemorrhage (F = 5.630, p = 0.004), and plaque surface irregularity (F = 3.986, p = 0.021). Higher SIRI levels (OR = 1.892), total plaque enhancement score (OR = 1.392), intraplaque hemorrhage (OR = 3.370) and plaque surface irregularity (OR = 2.846) were independent risk factors for moderate-severe stroke, and these variables were significantly positively correlated with NIHSS (P < 0.05 for all). In addition, higher age (HR = 1.063, P = 0.015), higher SIRI levels (HR = 2.003, P < 0.001), and intraplaque hemorrhage (HR = 4.482, P = 0.008) were independently associated with recurrent stroke. ConclusionsHigher SIRI levels may have adverse effects on the vulnerability and burden of intracranial plaques, and links to the severity and recurrence of ischemic events. Therefore, SIRI may provide important supplementary information for evaluating intracranial plaque stability and risk stratification of patients.

Peak systolic velocity ratio for evaluation of internal carotid artery stenosis correlated with plaque morphology: substudy results of the ANTIQUE study.

Accurate assessment of carotid stenosis severity is important for proper patient management. The present study aimed to compare the evaluation of carotid stenosis severity using four duplex sonography (DUS) measurements, including peak systolic velocity (PSV), PSV ratio in stenosis and distal to stenosis (PSVICA/ICA ratio), end-diastolic velocity (EDV), and B-mode, with computed tomography angiography (CTA), and to evaluate the impact of plaque morphology on correlation between DUS and CTA. Consecutive patients with carotid stenosis of ≥40% examined using DUS and CTA were included. Plaque morphology was also determined using magnetic resonance imaging. Spearman's correlation and Kendall's rank correlation were used to evaluate the results. A total of 143 cases of internal carotid artery stenosis of ≥40% based on DUS were analyzed. The PSVICA/ICA ratio showed the highest correlation [Spearman's correlation r = 0.576) with CTA, followed by PSV (r = 0.526), B-mode measurement (r = 0.482), and EDV (r = 0.441; p < 0.001 in all cases]. The worst correlation was found for PSV when the plaque was calcified (r = 0.238), whereas EDV showed a higher correlation (r = 0.523). Correlations of B-mode measurement were superior for plaques with smooth surface (r = 0.677), while the PSVICA/ICA ratio showed the highest correlation in stenoses with irregular (r = 0.373) or ulcerated (r = 0.382) surfaces, as well as lipid (r = 0.406), fibrous (r = 0.461), and mixed (r = 0.403; p < 0.01 in all cases) plaques. Nevertheless, differences between the mentioned correlations were not statistically significant (p > 0.05 in all cases). PSV, PSVICA/ICA ratio, EDV, and B-mode measurements showed comparable correlations with CTA in evaluation of carotid artery stenosis based on their correlation with CTA results. Heavy calcifications and plaque surface irregularity or ulceration negatively influenced the measurement accuracy.

Association of plaque characteristics with long-term stroke recurrence in patients with intracranial atherosclerotic disease: a 3D high-resolution MRI-based cohort study

ObjectivesTo evaluate the predictive ability of plaque characteristics for long-term stroke recurrence among patients with symptomatic intracranial atherosclerotic disease (ICAD).MethodsThis cohort study included 132 patients with acute ischemic stroke (AIS) attributed to ICAD who were recruited between July 2017 and December 2020 and followed until stroke recurrence or December 2021. Plaque surface irregularity, degree of stenosis, plaque burden, remodeling ratio, enhancement ratio, and intraplaque hemorrhage were assessed with 3-dimensional high-resolution magnetic resonance vessel wall imaging (3D HR-MRI). Data were analyzed using Cox models, receiver operating characteristic (ROC) curves, and Kaplan–Meier survival analysis.ResultsOf the 132 patients, during a median follow-up of 2.8 years, stroke recurrence occurred in 35 patients. The multivariable-adjusted hazard ratio (95% confidence interval) of stroke recurrence was 3.15 (1.34–7.42) per 10% increase in plaque burden and 2.17 (1.27–3.70) for enhancement ratio. The area under the curve (AUC) to predict stroke recurrence was 0.725 (95% CI 0.629–0.822) for plaque burden, 0.692 (95% CI 0.593–0.792) for enhancement ratio, and only 0.595 (95% CI 0.492–0.699) for the Essen stroke risk score. The Kaplan–Meier survival analysis further demonstrated significant differences in survival of free recurrent stroke between patients with plaque burden or enhancement ratio below and above the optimum cut-offs (both p < 0.001).ConclusionHigher plaque burden and enhancement ratio are independent risk factors for long-term stroke recurrence among patients with symptomatic ICAD, and valuable imaging markers for predicting and stratifying risk of stroke recurrence.Clinical relevance statementIn patients with symptomatic ICAD, the results of this high-resolution magnetic resonance vessel wall imaging study have potential implications for optimal management of intracranial plaques and secondary prevention of stroke recurrence based on plaque burden and enhancement ratio.Key Points• Identification of intracranial plaque characteristics responsible for stroke recurrence is essential to preventing stroke recurrence in patients with symptomatic intracranial atherosclerotic disease.• Higher plaque burden and enhancement ratio are independent risk factors for stroke recurrence.• Plaque burden and enhancement ratio are valuable imaging markers in the prediction and stratification of the risk of stroke recurrence.

Contrast-Enhanced Ultrasound Feasibility in Assessing Carotid Plaque Vulnerability-Narrative Review.

The risk assessment for carotid atherosclerotic lesions involves not only determining the degree of stenosis but also plaque morphology and its composition. Recently, carotid contrast-enhanced ultrasound (CEUS) has gained importance for evaluating vulnerable plaques. This review explores CEUS's utility in detecting carotid plaque surface irregularities and ulcerations as well as intraplaque neovascularization and its alignment with histology. Initial indications suggest that CEUS might have the potential to anticipate cerebrovascular incidents. Nevertheless, there is a need for extensive, multicenter prospective studies that explore the relationships between CEUS observations and patient clinical outcomes in cases of carotid atherosclerotic disease.

Peripheral atherosclerosis in acute coronary syndrome patients with plaque rupture vs plaque erosion: A prospective coronary optical coherence tomography and peripheral ultrasound study

Plaque rupture (PR) and plaque erosion (PE) are two distinct, different, and most common culprit lesion morphologies responsible for acute coronary syndrome (ACS). However, the prevalence, distribution, and characteristics of peripheral atherosclerosis in ACS patients with PR vs PE has never been studied. The aim of this study was to assess peripheral atherosclerosis burden and vulnerability evaluated by vascular ultrasound in ACS patients with coronary PR versus PE identified by optical coherence tomography (OCT). Between October 2018 and December 2019, 297 ACS patients who underwent preintervention OCT examination of the culprit coronary artery were enrolled. Peripheral ultrasound examinations of carotid, femoral, and popliteal arteries were performed before discharge. Overall, 265/297 (89.2%) patients had at least one atherosclerotic plaque in a peripheral arterial bed. Compared with coronary PE, patients with coronary PR had a higher prevalence of peripheral atherosclerotic plaques (93.4% vs 79.1%, P<0.001), regardless of location: carotid, femoral, or popliteal arteries. The number of peripheral plaques per patient was significantly larger in the coronary PR group than coronary PE (4 [2-7] vs 2 [1-5], P<0.001). Additionally, there was a greater prevalence of peripheral vulnerable characteristics including plaque surface irregularity, heterogeneous plaque, and calcification in patients with coronary PR versus PE. Peripheral atherosclerosis exists commonly in patients presenting with ACS. Patients with coronary PR had greater peripheral atherosclerosis burden and more peripheral vulnerability compared to those with coronary PE, suggesting that comprehensive evaluation of peripheral atherosclerosis and multidisciplinary cooperative management maybe necessary, especially in patients with PR. clinicaltrials.gov (NCT03971864).

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

BackgroundThe circle of Willis (CoW) plays a significant role in intracranial atherosclerosis (ICAS). This study investigated the relationship between different types of CoW, atherosclerosis plaque features, and acute ischemic stroke (AIS). MethodsWe investigated 97 participants with AIS or transient ischemic attacks (TIA) underwent pre- and post-contrast 3T vessel wall cardiovascular magnetic resonance within 7 days of the onset of symptoms. The culprit plaque characteristics (including enhancement grade, enhancement ratio, high signal in T1, irregularity of plaque surface, and normalized wall index), and vessel remodeling (including arterial remodeling ratio and positive remodeling) for lesions were evaluated. The anatomic structures of the anterior and the posterior sections of the CoW (A-CoW and P-CoW) were also evaluated. The plaque features were compared among them. The plaque features were also compared between AIS and TIA patients. Finally, univariate and multivariate regression analysis was performed to evaluate the independent risk factors for AIS. ResultPatients with incomplete A-CoW showed a higher plaque enhancement ratio (P = 0.002), enhancement grade (P = 0.01), and normalized wall index (NWI) (P = 0.018) compared with the patients with complete A-CoW. A higher proportion of patients with incomplete symptomatic P-CoW demonstrated more culprit plaques with high T1 signals (HT1S) compared with those with complete P-CoW (P = 0.013). Incomplete A-CoW was associated with a higher enhancement grade of the culprit plaques [odds ratio (OR):3.84; 95% CI: 1.36–10.88, P = 0.011], after adjusting for clinical risk factors such as age, sex, smoking, hypertension, hyperlipemia, and diabetes mellitus. Incomplete symptomatic P-CoW was associated with a higher probability of HT1S (OR:3.88; 95% CI: 1.12–13.47, P = 0.033), after adjusting for clinical risk factors such as age, sex, smoking, hypertension, hyperlipemia, and diabetes mellitus. Furthermore, an irregularity of the plaque surface (OR: 6.24; 95% CI: 2.25–17.37, P < 0.001), and incomplete symptomatic P-CoW (OR: 8.03, 95% CI: 2.43–26.55, P = 0.001) were independently associated with AIS. ConclusionsThis study demonstrated that incomplete A-CoW was associated with enhancement grade of the culprit plaque, and incomplete symptomatic side P-CoW was associated with the presence of HT1S of culprit plaque. Furthermore, an irregularity of plaque surface and incomplete symptomatic side P-CoW were associated with AIS.

Association of Plaque Morphology With Stroke Mechanism in Patients With Symptomatic Posterior Circulation ICAD.

Although the main mechanisms of stroke in patients with intracranial atherosclerotic disease (ICAD)-perforating artery occlusion (PAO) and artery-to-artery embolism (AAE)-have been identified and described, relatively little is known about the morphology of the symptomatic plaques and how they differ between these 2 mechanisms. We prospectively recruited patients with acute ischemic stroke in the posterior circulation that was attributable to ICAD. Fifty-one eligible patients were enrolled and underwent magnetic resonance imaging before being assigned to the PAO or AAE group according to probable stroke mechanism. Plaque morphological properties including plaque length, lumen area, outer wall area, plaque burden, plaque surface irregularity, vessel wall remodeling, and plaque enhancement were assessed using high-resolution MRI. Plaque morphological parameters of both PAO and AAE groups were compared using nonparametric tests. A binary logistic regression model was used to identify independent predictors while a receiver operating characteristic curve tested the sensitivity and specificity of the model. Among patients who met the imaging eligibility criteria, 38 (74.5%) had PAO and 13 (25.5%) had AAE. Plaque length was shorter (6.39 interquartile range [IQR, 5.18-7.7]1 mm vs 10.90 [IQR, 8.18-11.85] mm, p < 0.01) in patients with PAO. Plaque burden was lower in PAO group (78.00 [IQR, 71.94-86.35] % vs 86.37 [IQR, 82.24-93.04] %, p = 0.04). The proportion of patients with plaque surface irregularity was higher in patients with AAE than in patients with PAO (19/38, 50.00% vs 12/13, 92.30%, p = 0.008). Plaque length was significantly associated with the PAO mechanism (adjusted OR 0.57, 95% CI, 0.41-0.79). Intracranial atherosclerotic plaque morphology differs between patients with PAO and those with AAE. Plaque with shorter length, lower plaque burden, and regular surface is more likely to cause PAO.

MRI Outcomes Achieved by Simple Flow Blockage Technique in Symptomatic Carotid Artery Stenosis Stenting.

In this study, we aimed to determine the frequency and clinical impact of new ischemic lesions detected with diffusion-weighted-imaging-MRI (DWI-MRI) as well as the clinical outcomes after carotid artery stenting (CAS) using the simple flow blockage technique (SFB). This is a retrospective study with data extraction from a monocentric prospective clinical registry (from 2017 to 2019) of consecutive patients admitted for symptomatic cervical ICA stenosis or web. Herein, patients benefited from DWI-MRI before and within 48 h of CAS for symptomatic ICA stenosis or web. The primary endpoint was the frequency of new DWI-MRI ischemic lesions and the secondary (composite) endpoint was the rate of mortality, symptomatic stroke or acute coronary syndrome within 30 days of the procedure. All of the 82 CAS procedures were successfully performed. Among the 33 patients (40.2%) with new DWI-MRI ischemic lesions, 30 patients were asymptomatic (90.9%). Irregular carotid plaque surface with (n = 13, 44.8%) or without ulceration (n = 12, 60.0%) was associated with higher rates of new DWI-MRI lesions by comparison to patients with a regular plaque (n = 7, 25%) (p = 0.048) using the univariate analysis. Less than half of this CAS cohort using the SFB technique had new ischemic lesions detected with DWI-MRI. Among these patients, more than 90% were asymptomatic. Irregularity of the plaque seems to increase the risk of peri-procedural DWI-MRI lesions.

Relationship between the stroke mechanism of symptomatic middle cerebral artery atherosclerotic diseases and culprit plaques based on high-resolution vessel wall imaging.

PurposeFor patients with symptomatic middle cerebral artery (MCA) atherosclerotic stenosis, identifying the potential stroke mechanisms may contribute to secondary prevention. The purpose of the study is to explore the relationship between stroke mechanisms and the characteristics of culprit plaques in patients with atherosclerotic ischemic stroke in the M1 segment of the middle cerebral artery (MCA) based on high-resolution vessel wall imaging (HR-VWI).MethodsWe recruited 61 patients with acute ischemic stroke due to MCA atherosclerotic stenosis from Shenzhen Bao'an District People's Hospital. According to prespecified criteria based on infarct topography and magnetic resonance angiography, possible stroke mechanisms were divided into parent artery atherosclerosis occluding penetrating artery (P), artery-to-artery embolism (A), hypoperfusion (H), and mixed mechanisms (M). The correlation between the characteristics of MCA M1 culprit plaque and different stroke mechanisms was analyzed using HR-VWI. The indicators included plaque surface irregularity, T1 hyperintensity, location, plaque burden (PB), remodeling index (RI), enhancement rate, and stenosis rate.ResultsParental artery atherosclerosis occluding penetrating artery was the most common mechanism (37.7%). The proposed criteria showed substantial to excellent interrater reproducibility (κ, 0.728; 0.593–0.863). Compared with the P group, the surface irregularity, T1 hyperintensity, and obvious enhancement of the culprit plaque in the A group were more common (p < 0.0125). Compared with the other stroke mechanisms, positive remodeling of culprit plaques was more common (p < 0.0125), the RI was greater (p < 0.05), and the PB was the smallest (p < 0.05) in the P group. The enhancement ratio (ER) was smaller in the P group (p < 0.05). Compared with the A group, T1 hyperintensity of the culprit plaque was more common in the H group (p < 0.0125), and the stenosis rate was greater (p < 0.05). After adjustment for clinical demographic factors in the binary logistic regression analysis, the enhancement level (odds ratio [OR] 0.213, 95% CI (0.05–0.91), p = 0.037) and PB of culprit plaque (OR 0, 95% CI (0–0.477), p = 0.034) were negatively associated with P groups.ConclusionThe culprit plaque characteristics of patients with symptomatic MCA atherosclerotic in different stroke mechanisms may be evaluated using HR-VWI. The plaque characteristics of different stroke mechanisms may have clinical value for the selection of treatment strategies and prevention of stroke recurrence.Clinical trial registrationIdentifier: ChiCTR1900028533.

Comparative assessment of the signs of instability of atherosclerotic plaques in the carotid arteries in elderly patients with acute coronary syndrome with duplex scanning and computed tomography angiography

Aim . To study the signs of instability of atherosclerotic plaques (ASP) in the carotid arteries in elderly patients with acute coronary syndrome (ACS) in the comparative aspect of duplex ultrasound scanning (DUS) and computed tomography angiography (CT). M aterial and methods. 27 patients with ACS (75 years and over) were included in the study. The signs of instability of ASP were assessed according to DUS and CT. Results . The signs of instability of ASP according to DUS were detected in 85,7%, according to CT — in 84,6%. The following signs were detected with DUS and CT: the presence of irregular plaque surface including signs of ulceration — 6,4 and 11,6% (p=0,021), positive remodeling — 3,8 and 3,8% (p=0,998), signs of local calcification — 23 and 25,9% (p=0,536), heterogenous structure — 55,1 and 46,8% (p=0,045), hypoechogenic component and low-density areas — 11,5 and 11,6% (p= 0,998). The correlation analysis showed high comparability of DUS and CT: irregular plaque surface with ulceration (K=0,624, p=0,02), positive remodeling (K=1, p&lt;0,001), calcification (K=0,858, p&lt;0,001), heterogenous structure (K=0,754, p&lt;0,001), the presence of hypoechogenic component and low-density areas (K=1, p&lt;0,001). Conclusion . The study of elderly patients with ACS found high comparability of DUS and CT in the definition of the signs of instability of ASP in the carotid arteries. It is possible to use DUS as a routine method for assessing carotid atherosclerosis in patients of this group, which can reduce the risk of complications during CT, shorten the examination time, and minimize economic costs.

Symptomatic plaque enhancement is associated with early-onset post-stroke depression

BackgroundThe association between imaging features closely associated with symptomatic intracranial atherosclerotic plaques and early-onset post-stroke depression (PSD) is currently unclear. Materials and methods76 ischemic stroke patients who underwent high-resolution vessel wall magnetic resonance imaging (HR-VWI) were divided into PSD and non-PSD groups according to their DSM-V diagnoses and HAMD-17 scores at 14 days after onset. Clinical data and the imaging features associated with symptomatic plaques (including the enhancement index (EI), remodeling index, and plaque surface irregularity) were compared between groups. Multifactorial logistic regression analysis was used to find independent predictors of early-onset PSD. Spearman rank correlation analysis explores the association between clinical data, symptomatic plaque imaging features, and HAMD-17 in patients. ResultsThe sample comprised 36 patients with early-onset PSD. The symptomatic plaque EI and infarct volume were significantly higher in depressed patients than in patients without depression (P < 0.05). Multivariate logistic regression showed that symptomatic plaque EI could be used as an independent predictor of early-onset PSD after correcting for the confounding factor of infarct volume (OR = 1.034, 95% CI:1.014–1.055, P = 0.001). In the total sample, symptomatic plaque EI, infarct volume, and HAMD-17 had a significant positive correlation with each other (P < 0.05). LimitationsThis study focused only on the patients' symptomatic plaques and did not monitor patients' systemic inflammation levels at the time of HR-VWI. ConclusionsThe degree of symptomatic plaque enhancement is an independent predictive imaging marker of early-onset PSD and can be used the early diagnosis of early-onset PSD.

Vulnerable Carotid Artery Plaques in Asymptomatic Patients—A Narrative Review

AbstractOver the last two decades, medical management of carotid artery patients has improved significantly. Most patients remain stable on best medical therapy (BMT), making interventions unnecessary in all patients. “Selective” intervention is advocated for only those few patients who are having vulnerable or unstable carotid artery plaques. Literature search was done to explore current concept and role of available investigations to identify vulnerable carotid plaques. Vulnerable plaque is defined as those plaques having active inflammation, high large necrotic lipid content, neovascularity, thin capsule, surface irregularity, or intraplaque hemorrhage. Ultrasound (US) is the simple, noninvasive, cost-effective investigation to differentiate soft (echolucent) from fibrocalcified (echogenic) plaques. It can also comment on other high-risk plaque features such as plaque volume and area. Contrast-enhanced US can visualize neovascularization and plaque surface irregularities better than conventional US. Computed tomography is limited in identifying most high-risk plaque features and is not useful. High-resolution magnetic resonance imaging is the most accurate and externally validated investigation to characterize most high-risk plaque components. Positron emission tomography has emerged as the most promising dynamic investigation to identify and quantify inflammatory plaques and will be clinically very useful in decision making.

Combined Assessment of Elevated Plasma Lipoprotein-Associated Phospholipase A2 and Plaque Enhancement Improved Accuracy in the Risk of Acute Ischemic Stroke in Patients with Intracranial Artery Stenosis

PurposeWe evaluated the relationship between plasma lipoprotein-associated phospholipase A2 (Lp-PLA2) concentration and plaque characteristics in patients with intracranial artery stenosis and their clinical relevance in acute ischemic stroke. MethodsEighty-seven patients with intracranial atherosclerotic stenosis (66 males, 21 females) were retrospectively enrolled. Plasma Lp-PLA2 concentration was measured, and vessel wall magnetic resonance imaging (VW-MRI) was used to determine intracranial vascular stenosis and plaque characteristics, including plaque enhancement, surface morphology, and T1 hyperintensity. Binary logistic regression was used to evaluate the relationship between Lp-PLA2 concentration and plaque characteristics of intracranial artery after adjusting for demographic and confounding factors and to assess their diagnostic efficacy for the risk of acute ischemic stroke. ResultsAfter adjustment for demographic, medication and related lipid factors, Lp-PLA2 elevation was associated with plaque enhancement (odds ratio [OR]=12.7, 95% confidence interval [CI] 2.51–64.82, P=0.002) and surface irregularity (OR=2.9, 95% CI 1.06–7.98, P=0.038). Both Lp-PLA2 elevation (OR=8.8, 95% CI 1.64–47.72, P=0.011) and plaque enhancement (OR=34.3, 95% CI 5.88–200.4, P=0.001) were associated with acute ischemic stroke. Receiver operating characteristic curve analysis showed that the area under the curve for Lp-PLA2 concentration and plaque enhancement combined in the diagnosis of acute ischemic stroke was 0.884, significantly higher than that for Lp-PLA2 concentration (0.724) and plaque enhancement (0.794) alone. ConclusionElevated Lp-PLA2 is associated with plaque enhancement and plaque surface irregularity. Combined assessment of Lp-PLA2 concentration and plaque enhancement is of greater diagnostic value for the risk of acute ischemic stroke in patients with intracranial artery stenosis.

Association of Plaque Features with Infarct Patterns in Patients with Acutely Symptomatic Middle Cerebral Artery Atherosclerotic Disease

Background and PurposeUnderstanding the stroke mechanism of middle cerebral artery (MCA) atherosclerosis is important for stroke triage and future trial design. The aim of this study was to characterize intrinsic MCA plaque and acute cerebral infarct in vivo by using high-resolution black-blood (BB) and diffusion-weighted magnetic resonance (MR) imaging and to investigate the relationship between plaque features and infarct patterns. MethodsA single-center retrospective study was conducted at a tertiary referral center between March 2017 and August 2019. Patients consecutively admitted for acute ischemic stroke with MCA stenosis underwent diffusion-weighted and BB MR imaging. Plaque features and infarct patterns were assessed. The association between plaque features and infarct patterns (binary variable: single/multiple) was evaluated using a multivariate logistic regression model. ResultsOf 49 patients with MCA atherosclerotic stenosis, diffusion-weighted MR imaging showed that 28 patients (57%) had multiple acute cerebral infarcts and 21 patients had single acute cerebral infarcts. In contrast to single infarct, multiple infarcts were associated with greater plaque burden (81.9±7.24 versus 71.3±13.7; P=0.012). A multivariate logistic regression model adjusted for 7 potential confounders confirmed a statistically significant positive association between plaque burden and multiple acute infarcts (adjusted R2 =0.432, P< 0.001). The rate of plaque surface irregularity was significantly greater in patients with multiple infarcts than those with single infarct (71% versus 43%, P=0.044). For single acute penetrating artery infarct, patients with infarct size > 2cm had greater plaque burden compared with patients with infarct size < 2cm (75.3±13.4 versus 63.4±10.9; P = 0.016). ConclusionsIncreased plaque burden, plaque surface irregularity in patients with MCA stenosis is associated with its likelihood to have caused an artery-to-artery embolism that produces multiple cerebral infarcts, especially along the border zone region, and increased plaque burden may promote subcortical single infarct size by occluding penetrating arteries. Our results provide important insight into stroke mechanism of MCA atherosclerosis.

Abstract 35: Vessel Wall Magnetic Resonance Imaging Biomarkers of Symptomatic Intracranial Atherosclerosis: A Meta-Analysis

Background: Intracranial vessel wall MR imaging (VWI) may be able to identify imaging biomarkers of symptomatic plaque. A meta-analysis was performed to evaluate the strength of association of imaging features of symptomatic plaque on VWI and downstream ischemia. Methods: PubMed, Scopus, Web of Science, EMBASE and Cochrane databases were searched up to October 2019. Studies evaluating acute/subacute cerebrovascular ischemia using VWI on 1.5 or 3 Tesla MR were included. Studies with insufficient exclusion of other stroke etiologies, insufficient or duplicated data and conference abstracts were excluded. Two independent reviewers extracted data on study design, VWI techniques, imaging endpoints, and conducted a study design risk bias assessment using the QUADAS-2 tool. Per-lesion odds ratios (OR) were calculated and pooled using a bivariate random-effects model. Subgroup analyses and evaluation of publication bias were performed. Results: Twenty-one articles met inclusion criteria (1,750 lesions; 1,542 subjects). Plaque enhancement (OR 7.4, 95% CI 3.4-16.4; Figure), positive remodeling (OR 5.6, 95% CI 2.2-14.0), surface irregularity (OR 4.5, 95% CI 1.4-8.6), and T1 hyperintensity (OR 2.1, 95% CI 1.3-3.3) were significantly associated with downstream ischemia. T2 signal intensity was not significant (p=0.59). Plaque enhancement showed stronger associations when measured in retrospectively designed studies (OR 35.3, 95% CI 7.4-141, p=0.02), by a radiologist as a rater (OR 12.6, 95% CI 5.3-29.7, p&lt;0.001), and on VWI pulse sequences with lower spatial resolution (OR 30.4, 95% CI 7.0-132.4, p=0.02). There was no publication bias (Egger’s test p=0.48). Conclusions: Plaque enhancement, positive remodeling, T1 hyperintensity and surface irregularity emerged as imaging biomarkers of symptomatic plaque. Plaque enhancement had the strongest association and remained significant accounting for sources of bias and variability in both study design and instrument.

Predictors for High-Risk Carotid Plaque in Asymptomatic Korean Population.

Aims High-risk carotid plaque remains an important risk factor for atherosclerotic cardiovascular disease (ASCVD). We sought to evaluate the characteristics of carotid plaque and to find out the predictors for high-risk carotid plaque in asymptomatic Koreans. Methods Subjects (n = 801) without a history of ASCVD from 12 university hospitals in Korea underwent carotid ultrasound. The images were standardized at core laboratory. Morphologic characteristics of plaque were analyzed with laboratory and clinical characteristics. High-risk carotid plaque features included the highest quartile of carotid plaque score (cPS), irregular plaque surface, and hypoechoic and ulcerated plaque. Results The carotid plaque prevalence was 22.1% (177/801 persons, 293 plaques). The plaque was increased with age (p < 0.001) and conventional ASCVD risk estimator (p < 0.001) and the most frequently found in bulb (n = 190, 64.8%). The number of the highest quartile of cPS was 44/177 (24.9%). Irregular plaque was seen in 20.8% out of total plaque (61/293) and was more frequent in the high-risk 10-year ASCVD risk group than in the low-risk group (36.1% vs. 15.8%, p = 0.023). Hypoechoic and ulcerated plaques were seen in 14.3% (42/293) and 2% (6/293), respectively. The independent predictors for high-risk plaque were age (β = 0.052, p < 0.001), HbA1c (β = 0.182, p = 0.004), male (β = 0.118, p = 0.006), hypertension (β = 0.090, p = 0.032), and multiple plaques (OR: 4.810 (two plaques) and 8.621 (three plaques), all p < 0.001). Conclusions This study suggests that high-risk carotid plaque was seen in 12.4% (99/801). The high-risk plaque was associated with diabetes control status reflected by the HbA1c level as well as traditional risk factors in asymptomatic Korean population.

Vessel Wall Magnetic Resonance Imaging Biomarkers of Symptomatic Intracranial Atherosclerosis: A Meta-Analysis.

Intracranial atherosclerotic disease is a common cause of stroke worldwide. Intracranial vessel wall magnetic resonance imaging may be able to identify imaging biomarkers of symptomatic plaque. We performed a meta-analysis to evaluate the strength of association of imaging features of symptomatic plaque leading to downstream ischemic events. Effects on the strength of association were also assessed accounting for possible sources of bias and variability related to study design and magnetic resonance parameters. PubMed, Scopus, Web of Science, EMBASE, and Cochrane databases were searched up to October 2019. Two independent reviewers extracted data on study design, vessel wall magnetic resonance imaging techniques, and imaging end points. Per-lesion odds ratios (OR) were calculated and pooled using a bivariate random-effects model. Subgroup analyses, sensitivity analysis, and evaluation of publication bias were also performed. Twenty-one articles met inclusion criteria (1750 lesions; 1542 subjects). Plaque enhancement (OR, 7.42 [95% CI, 3.35-16.43]), positive remodeling (OR, 5.60 [95% CI, 2.23-14.03]), T1 hyperintensity (OR, 2.05 [95% CI, 1.27-3.32]), and surface irregularity (OR, 4.50 [95% CI, 1.39-8.57]) were significantly associated with downstream ischemic events. T2 signal intensity was not significant (P=0.59). Plaque enhancement was significantly associated with downstream ischemic events in all subgroup analyses and showed stronger associations when measured in retrospectively designed studies (P=0.02), by a radiologist as a rater (P<0.001), and on lower vessel wall magnetic resonance imaging spatial resolution sequences (P=0.02). Plaque enhancement, positive remodeling, T1 hyperintensity, and surface irregularity emerged as strong imaging biomarkers of symptomatic plaque in patients with ischemic events. Plaque enhancement remained significant accounting for sources of bias and variability in both study design and instrument. Future studies evaluating plaque enhancement as a predictive marker for stroke recurrence with larger sample sizes would be valuable.