Original Investigation
Intracranial Atherosclerotic Plaque as a Potential Cause of Embolic Stroke of Undetermined Source

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Abstract

Background

Previous studies investigated the potential mechanism of embolic stroke of undetermined source (ESUS) from extracranial artery plaque, but there has been no study other than a case report on high-risk intracranial plaque in ESUS.

Objectives

The aim of this study was to investigate the issue by evaluating the morphology and composition of intracranial plaque in patients with ESUS and small-vessel disease (SVD) using 3.0-T high-resolution magnetic resonance imaging.

Methods

Two hundred forty-three consecutive patients with ESUS and 160 patients with SVD-associated stroke between January 2015 and December 2019 were retrospectively enrolled. Multidimensional parameters involving the presence of plaque on both sides, including remodeling index (RI), plaque burden, presence of discontinuity of plaque surface, thick fibrous cap, intraplaque hemorrhage, and complicated American Heart Association type VI plaque at the maximal luminal narrowing site, were evaluated using intracranial high-resolution magnetic resonance imaging.

Results

Among 243 patients with ESUS, the prevalence of intracranial plaque was much higher in the ipsilateral than the contralateral side (63.8% vs. 42.8%; odds ratio [OR]: 5.25; 95% confidence interval [CI]: 2.83 to 9.73), a finding that was not evident in patients with SVD (35.6% vs. 30.6%; OR: 2.14; 95% CI: 0.87 to 5.26; p = 0.134). Logistic analysis showed that RI was independently associated with ESUS in model 1 (OR: 2.329; 95% CI: 1.686 to 3.217; p < 0.001) and model 2 (OR: 2.295; 95% CI: 1.661 to 3.172; p < 0.001). RI alone with an optimal cutoff of 1.162, corresponding to an area under the curve of 0.740, had good diagnostic efficiency for ESUS.

Conclusions

The present study supports an etiologic role of high-risk nonstenotic intracranial plaque in ESUS.

Key Words

embolic stroke of undetermined source
high-resolution magnetic resonance imaging
nonstenotic intracranial plaque
plaque burden
plaque composition
remodeling index

Abbreviations and Acronyms

CI
confidence interval
DPS
discontinuity of plaque surface
ESUS
embolic stroke of undetermined source
FC
fibrous cap
IPH
intraplaque hemorrhage
MLN
maximal luminal narrowing
MRI
magnetic resonance imaging
OR
odds ratio
PB
plaque burden
RI
remodeling index
ROC
receiver-operating characteristic
SVD
small-vessel disease

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