The Role of Large Artery Atherosclerosis and Predictive Risk Factors in Symptomatic and Asymptomatic Ischemic Stroke

Large-artery atherosclerosis (LAA) is common in acute ischemic stroke, before determinants of whether LAA presents symptomatically or remains silent are unclear. We aimed to identify risk factors distinguishing symptomatic from asymptomatic LAA.

We retrospectively analyzed 411 consecutive patients (January 2020-January 2025) with acute ischemic stroke and imaging-confirmed ≥ 50% stenosis/occlusion. Demographics, comorbidities; Hypertension (HT), Diabetes mellitus (DM), Hyperlipidemia (HL), Atrial fibrillation (AF), and fasting laboratories were recorded; triglyceride-to-high-density lipoprotein (TG/HDL) and triglyceride-to-glucose (TG/Gl) indices were calculated. Vascular territory was classified (carotid, vertebrobasilar (VBS), carotid-vertebrobasilar system) via Doppler, brain computerised tomography (CT), and/or magnetic resonance imaging (MRI) angiography. Patients with ≥ 50% stenosis or occlusion in extra or intracranial arteries were classified as having LAA. Those with neurological deficits attributable to LAA were considered symptomatic, while patients with unrelated stroke etiologies were classified as asymptomatic. Group comparisons used chi-square, Mann-Whitney U, and Kruskal-Wallis tests.

The mean age was 70.4 ± 10.6 years; 38.2% were women. Territory involvement was 49.6% carotid, 21.2% vertebrobasilar, and 29.2% carotid-vertebrobasilar system. In younger patients (40-60 years), AF was associated with VBS involvement (p = 0.035). In the oldest group (81-99 years), HL was associated with VBS/carotid-VBS atherosclerosis (p = 0.003). Overall, 285 patients were symptomatic and 126 were asymptomatic. Hyperlipidemia was associated with symptomatic LAA (OR = 1.64; p = 0.023), remaining significant in men. AF was more frequent among asymptomatic LAA in those aged 61-99, suggesting cardioembolism predominated the index event while LAA remained silent. TG/HDL was higher in symptomatic women and elevated across symptomatic patients aged 40-80 (p = 0.010; borderline at 61-80 ages, p = 0.050). TG/Gl did not discriminate symptom status in any subgroup.

In elderly patients, hypertension; in men, hyperlipidemia; and in women and middle-to-older age groups, elevated TG/HDL are linked to symptomatic conversion of LAA. In the presence of AF, concomitant LAA often remains clinically silent. Tight control of modifiable risks, may delay or prevent symptomatic transition of LAA and is an alternative for patients ineligible for intervention.