High-Resolution Vessel Wall Imaging Can Differentiate Between Branch Atheromatous Disease From Small Vessel Ischemic...

Ischemic stroke in deep brain regions is commonly attributed to small vessel ischemic disease (SVID) or branch atheromatous disease (BAD). Differentiating these mechanisms is clinically important, as BAD is associated with progressive symptoms, early neurological deterioration, and poorer outcomes, whereas SVID typically follows a more stable course. Conventional imaging is limited in distinguishing these entities. High-resolution vessel wall imaging enables direct visualization of intracranial vessel wall pathology and may refine risk stratification.

We conducted a prospective, single-center study of patients with acute subcortical infarcts admitted between 2023 and 2025. Eligible patients underwent magnetic resonance imaging with high-resolution vessel wall imaging within 1 week of admission. SVID was defined as lacunar infarction without evidence of parent artery plaque or vessel wall enhancement. BAD was defined as infarction in the territory of a penetrating artery with associated parent artery enhancement. The primary outcome was differentiation of BAD from SVID based on vessel wall enhancement. Secondary outcomes included 90-day functional outcomes.

Of 23 patients enrolled, 10 underwent magnetic resonance imaging with high-resolution vessel wall imaging. Vessel wall enhancement was observed in 5 patients (50%). Patients with enhancement were more often male (100% versus 40%) and had a higher prevalence of hyperlipidemia (100% versus 20%) compared with those without enhancement. Functional outcomes at 90 days were similar between the 2 groups.

High-resolution vessel wall imaging can identify parent artery pathology not evident on conventional imaging, helping to distinguish BAD from SVID. This differentiation is clinically meaningful, as BAD may require more intensive secondary prevention. Larger studies are needed to validate these findings.