White Matter Lesion Asymmetry and Carotid Intraplaque Hemorrhage: A Novel Imaging Phenotype for Stroke Risk in Older Men

Background: While identifying high-risk carotid disease remains a significant clinical challenge, the specific role of carotid intraplaque hemorrhage (IPH) is poorly understood. Although IPH has been linked to white matter lesion (WML) burden, current assessments overlook the directional impact of plaque instability on the brain. This study sought to determine whether IPH is an independent driver of asymmetric WML pathology and evaluate if this phenotype can identify a high-risk demographic for TIA and stroke. Methods: This multi-center retrospective study analyzed 264 participants (mean age 71.8 years) from the Canadian Atherosclerosis Imaging Network (2010-2015). Participants underwent 3T MRI to assess carotid IPH and WMLs. We quantified WMLs using a deep-learning pipeline to extract three biomarkers: volume (WML-ICV), intensity (WML-Intensity), and intensity ratio (WML-IR). The Asymmetry Index Measure (AIM) defined the inter-hemispheric log-ratio, while the association between IPH and AIM was examined using multivariable linear regression adjusted for age, sex, stenosis, and scanner manufacturer. A secondary composite outcome of TIA/stroke was analyzed via logistic regression to evaluate the interaction between IPH, age, and sex. Results: While whole-brain WML burden did not significantly differ by IPH status (p > 0.60), IPH status was a robust independent predictor of hemispheric asymmetry (WML-ICV: p = 0.01; WML-Intensity, p = 0.01). Post-hoc analysis confirmed WML burden was significantly higher in IPH+ older males (=> 70 years) compared to younger cohorts (p < 0.04). This older male subgroup also demonstrated 4.57-fold higher adjusted odds of TIA/stroke (p = 0.02) compared to other demographic subgroups (all p > 0.87). Conclusions: Carotid IPH is independently associated with a rightward asymmetric WML phenotype not captured by global metrics. This imaging marker identifies a high-risk demographic of older males with a nearly five-fold increase in clinical events, suggesting that hemispheric-level analysis provides critical prognostic value for stroke risk stratification. ### Competing Interest Statement The authors have declared no competing interest.