Intracranial atherosclerotic plaque features on vessel wall imaging predict first ever and recurrence of stroke: a meta-analysis

Abstract

Objectives: Intracranial atherosclerotic disease (ICAD) features on vessel wall magnetic resonance imaging (VW-MRI) are associated with first-ever or recurrent ischemic stroke (IS) or transient ischemic attack (TIA). There are multiple longitudinal ICAD VW-MRI studies, but they are limited by small sample size, non-standardized imaging acquisition and analysis, and some controversial results. Hence, we conducted the current meta-analysis of intracranial plaque features predicting recurrence of IS. Materials and methods: PubMed, Web of Science, and EMBASE databases were searched through March 2024. Two independent reviewers extracted data on study design, VW-MRI techniques, and patient outcome. Quality assessment was used by the NOS tool. Subgroup analyses, sensitivity analysis, and evaluation of publication bias were also performed. Results: For recurrent IS, eighteen studies were included for meta-analysis, comprising 2240 participants, and 472 participants had recurrent IS during an average of 16-month follow-up. All studies were of high quality with an NOS score ≥ 7. Plaque enhancement (OR 2.18, [95% CI 1.70-4.65]), plaque enhancement ratio (SMD 0.46, [95% CI 0.15-0.77]), plaque thickness, (SMD 0.271, [95% CI 0.047-0.496]), T1-weighted (T1W) hyperintensity, (OR 2.58, [95% CI 1.56-4.26]), and degree of stenosis (SMD 0.41, [95% CI 0.03-0.79]) significantly predicted IS recurrence. Subgroup analyses found plaque enhancement was significantly higher in the IS and TIA recurrence group as compared to the non-recurrence group (OR 3.39, 95% CI 1.84-6.22). Conclusion: Plaque enhancement, plaque enhancement ratio, plaque thickness, T1W hyperintensity and degree of stenosis emerged as strong imaging biomarkers of recurrence of stroke. Clinical trial registration: Clinical trial registration no: CRD42023479678. Key points: Questions Several studies suggest that vessel wall MRI (VWMRI) features of intracranial atherosclerotic disease (ICAD) may be associated with first-time or recurrent ischemic strokes, though this remains a debated topic. Findings Our study demonstrates that plaque enhancement, plaque enhancement ratio, plaque thickness, T1W hyperintensity, and degree of stenosis are strong imaging biomarkers for predicting stroke recurrence. Clinical relevance Incorporating these features into post-stroke evaluations using VWMRI could help guide patient management more effectively, enabling more targeted treatments for secondary stroke prevention.