High-Resolution MRI-Based Clinical-Radiological Phenotypes of Carotid Vulnerability and Long-Term Outcomes After
Sunan Xu1, Yunhao Lei1, Tingting Li1
1Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, Beijing 100029, China.
Abstract:
Background/Objectives: Patients undergoing carotid revascularization may show distinct patterns of bilateral carotid vulnerability and clinical risk. This study used latent class analysis (LCA) to identify high-resolution magnetic resonance imaging (HR-MRI)-based clinical-radiological phenotypes and evaluate their association with long-term major adverse cardiovascular events (MACE). Methods: This retrospective cohort included 289 patients who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) between April 2017 and April 2024 and had preoperative carotid HR-MRI within 90 days. Ipsilateral and contralateral plaque features were assessed on multi-contrast vessel-wall HR-MRI. LCA included five indicators: ipsilateral intraplaque hemorrhage, ipsilateral lipid-rich necrotic core, contralateral intraplaque hemorrhage, cardiovascular disease history, and symptomatic status. MACE comprised cardiovascular death, nonfatal myocardial infarction, coronary revascularization, or stroke. Outcomes were assessed using Kaplan-Meier analysis and multivariable Cox regression. Results: Among 289 patients undergoing carotid revascularization, the mean age was 65.12 ± 9.46 years, and 237 (82.0%) patients were men. LCA identified three phenotypes: Systemic High-Risk (n = 128), Silent High-Risk (n = 37), and Stable/Moderate (n = 124). The Systemic High-Risk phenotype showed high probabilities of symptomatic presentation, cardiovascular disease history, and bilateral carotid vulnerability, whereas the Silent High-Risk phenotype showed marked ipsilateral plaque vulnerability despite lower clinical risk. During a median follow-up of 4.4 years, MACE-free survival differed significantly across phenotypes (log-rank p = 0.043). Compared with the Stable/Moderate phenotype, the Systemic High-Risk and Silent High-Risk phenotypes were both associated with increased MACE risk (HR 1.65, 95% CI 1.15-2.37, p = 0.039; HR 1.43, 95% CI 1.12-2.15, p = 0.034). Conclusions: HR-MRI-based LCA identified clinically meaningful carotid vulnerability phenotypes associated with long-term MACE after carotid revascularization. These findings support integrated assessment of bilateral plaque vulnerability and clinical risk for postoperative cardiovascular risk stratification.
