Atherosclerotic plaque evolution predicts cerebral ischemic events in patients with intracranial atherosclerosis: a multicentre longitudinal study using high-resolution MRI

Category	Detail
Condition	Intracranial atherosclerosis stenosis (ICAS) primarily affecting the middle cerebral artery (MCA)
Key Mechanisms	Dynamic progression or regression of intracranial atherosclerotic plaques assessed by high-resolution MRI, including plaque morphology and composition
Target Population	Adults (≥18 years) with 50–99% MCA stenosis and at least one cardiovascular risk factor
Care Setting	Multicenter hospital settings with access to high-resolution MRI and neurological follow-up

ICAS is a leading cause of ischemic stroke, especially in East Asian populations, with ~15% recurrent ischemic events within the first year despite optimal medical treatment.
High-resolution MRI vessel wall imaging (hrMRI) provides detailed morphological and compositional plaque features beyond luminal stenosis, improving risk stratification.
Longitudinal hrMRI studies of intracranial plaque evolution can better predict subsequent cerebral ischemic events compared to cross-sectional assessments.

Use high-resolution MRI vessel wall imaging (hrMRI) to assess plaque morphology, composition, and enhancement in patients with MCA stenosis.
Evaluate luminal stenosis degree using 3D TOF MRA following WASID criteria.
Exclude non-atherosclerotic causes of MCA stenosis and coexisting ipsilateral carotid stenosis >50%.

Implement optimal medical treatment targeting cardiovascular risk factors including hypertension, diabetes, hyperlipidemia, obesity, smoking, and coronary artery disease.
Consider personalized medical therapy guided by hrMRI plaque features such as enhancement and intraplaque hemorrhage.

Perform repeated hrMRI exams within 1 year to monitor plaque progression or regression.
Conduct clinical follow-up at 3, 6, and 12 months post-baseline hrMRI to assess for ipsilateral ischemic events (stroke or TIA).

Patients with progressive plaque features on hrMRI have a higher risk of recurrent cerebral ischemic events despite medical therapy.
Intraplaque hemorrhage and plaque enhancement are high-risk features associated with ischemic stroke recurrence.

Patients with symptomatic MCA stenosis and cardiovascular risk factors undergoing repeated hrMRI follow-up

Plaque progression detected by hrMRI may identify patients at higher risk who might benefit from intensified or personalized medical therapy.

Use hrMRI to complement luminal stenosis assessment for comprehensive risk stratification in ICAS patients.
Exclude patients with non-atherosclerotic stenosis or significant carotid disease to ensure accurate intracranial plaque evaluation.
Ensure high-quality imaging (quality score ≥3) and blinded image analysis by experienced neuroradiologists.
Incorporate serial imaging and clinical follow-up to detect dynamic plaque changes and correlate with ischemic event risk.

Clinical Scorecard: Progression of Atherosclerotic Plaque as a Predictor of Cerebral Ischemic Events in Patients with Intracranial Atherosclerosis: A Multicenter Longitudinal Study Utilizing High-Resolution MRI