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Updated: Jan 28, 2026

Permanent Cerebral Vessel Occlusion via Double Ligature and Transection
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External Validation of Atherosclerotic Neuroimaging Biomarkers in Emergent Large-Vessel Occlusion

Fazeel M Siddiqui1, Jeffrey J Fletcher2, Andrew V Barnes1

  • 1Department of Neuroscience University of Michigan Health-West Wyoming MI.

Stroke (Hoboken, N.J.)
|January 26, 2026
PubMed

Insights

Intracranial atherosclerosis related large vessel occlusion (ICAS-LVO) is a key cause of mechanical thrombectomy failure. Imaging biomarkers like Delta Hu <6 show high predictive power for diagnosing ICAS-LVO, improving patient outcomes.

Area of Science:

  • Neuroimaging
  • Vascular Neurology
  • Interventional Neuroradiology

Background:

  • Intracranial atherosclerosis related large vessel occlusion (ICAS-LVO) frequently leads to mechanical thrombectomy failure.
  • ICAS-LVO can cause reocclusion or stenosis, resulting in suboptimal revascularization and poor functional outcomes.
  • Accurate identification of ICAS-LVO is crucial for effective treatment strategies.

Purpose of the Study:

  • To externally validate four pre-identified imaging biomarkers for ICAS-LVO.
  • To assess the diagnostic performance of these biomarkers in patients with emergent large-vessel occlusion (ELVO).
  • To determine the most effective imaging biomarker for predicting ICAS-LVO.

Main Methods:

  • Retrospective cohort study of 161 patients undergoing mechanical thrombectomy for acute M1/terminal internal carotid artery occlusions.
  • Evaluation of four imaging biomarkers: absent hyperdense sign, Hu ratio ≤1.1, Delta Hu <6, and truncal-type occlusion on noncontrast CT and CT angiography.
  • Statistical analysis included C statistics, ROC curve analysis, and multivariate logistic regression.

Main Results:

  • 30 patients (18.6%) had suspected ICAS-LVO.
  • Delta Hu <6 demonstrated the highest predictive power (AUC, 0.96), significantly outperforming other biomarkers.
  • Absent hyperdense sign (AUC, 0.88), Hu ratio ≤1.1 (AUC, 0.89), and truncal-type occlusion (AUC, 0.87) also showed significant predictive value.

Conclusions:

  • A combination of neuroimaging biomarkers on CT and CT angiography can effectively identify ICAS-LVO.
  • Delta Hu <6 is a highly accurate imaging biomarker for diagnosing ICAS-LVO.
  • Prospective, multicenter studies are needed to further confirm the effectiveness of these biomarkers.
Abstract

Keywords:
atherosclerosisimagingstrokethrombectomy

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