Diagnostic utility of high-resolution magnetic resonance vessel wall imaging for identifying culprit plaques in intracranial atherosclerotic disease

Background Gadolinium enhancement and T1-weighted hyperintensity in intracranial atherosclerotic plaques are recognized markers of plaque instability. This study aimed to evaluate the utility of plaque enhancement grading and T1-weighted imaging (T1WI) hyperintensity in identifying culprit plaques in patients with intracranial atherosclerosis. Methods A retrospective analysis was conducted on high-resolution magnetic resonance vessel wall imaging (HRMR-VWI) data from patients with symptomatic intracranial atherosclerosis. Detected plaques were categorized as culprit, possible culprit, or non-culprit plaques based on clinical and imaging criteria. Plaque enhancement and T1WI hyperintensity were qualitatively assessed. Associations between these imaging features and culprit plaques were examined using logistic regression analysis. Results The study included 69 patients, comprising 60 with acute ischemic stroke (≤ 1 month after the ischemic event), 7 with chronic ischemic stroke (> 1 month), and 2 with transient ischemic attack. A total of 474 intracranial atherosclerotic plaques were identified: 72 (15.19%) were categorized as culprit, 132 (27.85%) as possible culprit, and 270 (56.96%) as non-culprit plaques. Multivariate logistic regression analysis demonstrated that grade II enhancement ( p < 0.001) and T1WI hyperintensity ( p = 0.018) were independently associated with culprit plaques. Conclusion Grade II enhancement and T1WI hyperintensity are independently associated with culprit intracranial plaques and may serve as imaging biomarkers of plaque instability, offering valuable insights into stroke risk.