Three-dimensional Rotational Angiography Assessment of Symptomatic Intracranial Atherosclerotic Disease Plaque
Xinyi Leng1, Jia Liu2, Yu Liu2
1Department of Medicine and Therapeutics, The Chinese University of Hong Kong, 9/F, Clinical Sciences Building, Prince of Wales Hospital, Ngan Shing St. 30-32, Shatin, Hong Kong SAR.
Insights
Thicker plaque, smaller shoulder angulation, and distal stenosis in symptomatic intracranial atherosclerotic disease (sICAD) predict stroke recurrence and plaque progression. These high-risk lesion characteristics guide improved risk stratification for sICAD patients.
Area of Science:
- Neurology
- Radiology
- Biomedical Engineering
Background:
- Symptomatic intracranial atherosclerotic disease (sICAD) requires understanding of plaque evolution and high-risk lesion identification for better risk stratification.
- Current understanding of plaque morphology and hemodynamic changes in sICAD over time is limited.
Purpose of the Study:
- To delineate plaque morphologic and hemodynamic evolution patterns in sICAD.
- To identify specific morphologic and hemodynamic features associated with plaque progression and recurrent cerebrovascular events (stroke/TIA).
Main Methods:
- Prospective, longitudinal study of 97 patients with high-grade sICAD (60%-99% stenosis) treated medically.
- Follow-up evaluations included serial three-dimensional rotational angiography (3DRA) and 3DRA-based computational fluid dynamics (CFD) at 1 year.
- Primary outcome: composite of ischemic stroke/TIA recurrence or plaque progression at 1 year.
Main Results:
- The primary outcome occurred in 27% of participants (18% stroke/TIA recurrence, 9% plaque progression).
- Greater plaque thickness, smaller upstream shoulder angulation, and distal maximum stenosis at baseline independently predicted the primary outcome.
- Focal pressure and wall shear stress also evolved; specific patterns were associated with adverse outcomes.
Conclusions:
- Plaque morphology and hemodynamics evolve in sICAD patients under medical treatment.
- Thicker plaque, smaller upstream shoulder angulation, and distal stenosis are independently associated with lesion progression and recurrent stroke/TIA.
- These findings aid in identifying high-risk sICAD lesions for improved patient management and risk stratification.
Abstract:
Background Understanding how symptomatic intracranial atherosclerotic disease (sICAD) evolves and identifying high-risk lesion characteristics could improve risk stratification. Purpose To delineate the evolution patterns of plaque morphologic features and focal hemodynamics in sICAD and identify morphologic features and hemodynamics associated with plaque progression and recurrence of stroke and/or transient ischemic attack (TIA). Materials and Methods In this prospective, longitudinal study, participants with high-grade (60%-99% stenosis) sICAD confirmed at three-dimensional rotational angiography (3DRA) between August 2007 and December 2021 received guideline-based medical treatment, with follow-up evaluations at 1, 3, 6, and 12 months and every 6 months afterward. All participants underwent follow-up 3DRA at 1 year or upon stroke recurrence if earlier. The sICAD plaque morphologic features and focal hemodynamics were assessed and compared at baseline and follow-up 3DRA and using 3DRA-based computational fluid dynamics models. The primary outcome was a composite of relevant ischemic stroke or hard TIA recurrence and/or plaque progression in 3DRA at 1 year. Results Among 97 participants (median age, 62 years [IQR, 56-68 years]; 68 male), the primary outcome occurred in 26 (27%): 17 (18%) with relevant ischemic stroke and/or TIA recurrence and nine (9%) with plaque progression. Focal pressure and wall shear stress measures also changed over 1 year. Greater plaque thickness (adjusted odds ratio, 10.49 [95% CI: 2.67, 41.20]), smaller upstream plaque shoulder angulation (adjusted odds ratio, 0.97 [95% CI: 0.95, 1.00]), and maximum stenosis located distally (adjusted odds ratio, 3.81 [95% CI: 1.19, 12.18]) at baseline were independently associated with primary outcome. Higher and lower wall shear stress measures across the upstream and downstream plaque segments, respectively, at baseline were also associated with primary outcome. Conclusion Plaque morphologic features and focal hemodynamics evolved over time in participants with sICAD under medical treatment; thicker plaque, smaller upstream shoulder angulation, and skewed distal load were associated with lesion progression and recurrence of stroke and/or TIA. © The Author(s) 2026. Published by the Radiological Society of North America under a CC BY 4.0 license. Supplemental material is available for this article.
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