BACKGROUND AND OBJECTIVES:Identification of the symptomatic aneurysm in patients with multiple intracranial aneurysms (MIAs) represents a challenge. Aneurysm wall enhancement is a potential imaging biomarker to assess symptomatic status among intracranial aneurysms. We aimed to use aneurysm wall enhancement in the identification of symptomatic aneurysms in patients with MIAs. METHODS:Patients who underwent high-resolution 3 Tesla magnetic resonance imaging between 2018 and 2024 at 3 institutions-one in the United States and 2 in China-were included in the analysis. Eligible patients had MIAs, with at least 1 aneurysm classified as symptomatic. Morphological measurements were obtained from angiography studies. Three-dimensional circumferential aneurysm wall enhancement (3D-CAWE) was assessed for all aneurysms. Multivariate logistic regression was used to identify variables independently associated with symptomatic status. RESULTS:Thirty patients with 82 MIAs were included, 30/82 (36.6%) were symptomatic and 52/82 (63.3%) were asymptomatic. Aneurysmal size (adjusted odds ratio [aOR]: 1.5, 95% CI: 0.95-2.8, P = .1) and size ratio (aOR: 2.2, 95% CI: 0.8-3.2, P = .2) were not associated with symptomatic presentation. Symptomatic aneurysms were more likely to have a higher 3D-CAWE (aOR: 1.15, 95% CI: 1.05-1.24, P = .01) when compared with asymptomatic aneurysms. Receiver operating characteristic analysis revealed that a 3D-CAWE cutoff point of 1.02 has a specificity of 88% and negative predictive value of 79% in detecting symptomatic aneurysms among patients with MIAs. CONCLUSION:3D-CAWE can be used in the identification of symptomatic aneurysms in patients with MIAs.

PURPOSE:Malignant cerebral edema (MCE) is a life-threatening complication following reperfusion therapy for anterior circulation large vessel occlusion stroke. This study evaluate the association between individual Alberta Stroke Program Early CT Score (ASPECTS) territories and MCE development and to quantify the synergistic risk amplification when a key territory co-occurs with ASPECTS, the National Institutes of Health Stroke Scale (NIHSS) score, and onset-to-CT time. METHODS:This multicenter retrospective study of 523 patients used multivariable logistic regression to identify independent MCE predictors. Generalized linear models and stratified analyses evaluated synergistic effects. RESULTS:MCE occurred in 22.2 % of the cohort. Insular infarction (odds ratio [OR] = 2.93; 95 % confidence interval [CI], 1.51-5.70), higher NIHSS (per point OR = 1.11; 95 % CI, 1.07-1.16), and elevated blood glucose (per mmol/L OR = 1.13; 95 % CI, 1.05-1.22) were factors independently associated with MCE. A critical synergistic effect was observed: coexisting insular infarction and ASPECTS < 6 yielded the highest risk, with 46 % of patients developing MCE (risk ratio [RR] = 4.41; 95 % CI, 2.94-7.42). Insular infarction also amplified MCE risk in patients presenting within 4.5 hours of stroke onset (RR = 5.43; 95 % CI, 3.21-12.43; interaction P = 0.006) and in those with NIHSS scores > 14 (RR = 12.89; 95 % CI, 5.85-58.86). Trend tests confirmed a dose-dependent risk escalation (P < 0.01). CONCLUSION:Insular infarction is a potent risk multiplier, synergistically amplifying MCE risk when combined with extensive early ischemia (ASPECTS < 6) or severe deficits (NIHSS score > 14), particularly during the hyperacute phase.

To determine whether three-dimensional quantitative assessment of aneurysm wall enhancement (AWE) improves the identification of high-risk intracranial aneurysms (IAs) compared to existing risk scoring systems. This cross-sectional, multicenter observational study included patients with saccular IAs who prospectively underwent 3T high-resolution MRI between 2018 and 2023 at the University of Iowa, Changhai Hospital, and Ren Ji Hospital. IAs were classified as symptomatic if associated with rupture, sentinel headache, cranial nerve palsy, or neurological symptoms due to mass effect. AWE was quantified using three-dimensional aneurysm wall mapping. The diagnostic performance of the PHASES score was compared to a multivariate logistic regression model developed using all-subsets regression, incorporating PHASES components along with sex, smoking status, aneurysm morphology, and AWE data. A total of 334 patients with 387 saccular IAs were analyzed; 73 aneurysms (19

Objective To determine the vascular ultrasound and contrast-enhanced ultrasound characteristics of ischaemic stroke in patients with Takayasu's arteritis (TAK) and explore the diagnostic value of ultrasound characteristics for diagnosing ischaemic stroke in such patients. Methods We retrospectively analysed 80 patients with TAK who underwent vascular ultrasound and contrast-enhanced ultrasound on admission. We analysed the ultrasound characteristics of ischaemic stroke in these patients and performed multiple logistic regression analyses to determine the independent risk factors for ischaemic stroke in the patient cohort. The value of ultrasound characteristics in patients with TAK and ischaemic stroke was evaluated using the net reclassification and integrated discrimination improvement indices. Results Among 80 patients, 22 (27.5%) had ischaemic stroke. Fourteen patients had anterior circulation infarction, two had posterior circulation infarction, and six had both. Multivariate analysis showed that the number of occluded arteries (odds ratio (OR), 2.01; p=0.005), high-grade enhancement (grade >= 2, OR, 6.52; p=0.016), and revascularisation (OR, 0.05; p=0.002) were independent influencing factors for ischaemic stroke in patients with TAK. The area under the curve indicated that the number of occluded arteries (>= 3) and high-grade enhancement (grade >= 2) can be used to identify patients with TAK at high risk for ischaemic stroke. Conclusion A higher number of cervical artery occlusions and high-grade enhancement (grade >= 2) are independent risk factors for ischaemic stroke in patients with TAK. The combination of these factors can facilitate the diagnosis of ischaemic stroke in these patients.

BACKGROUND AND PURPOSE:Aneurysm wall enhancement on MRI after administration of gadolinium is associated with aneurysm growth or rupture. Aneurysm wall enhancement has mostly been studied at baseline. The change in the presence or absence of aneurysm wall enhancement with time is largely unknown but can provide a better understanding of the pathophysiological processes occurring within the aneurysm wall. Therefore, we aimed to determine the proportion of aneurysm wall enhancement appearance or disappearance. MATERIALS AND METHODS:In this multicenter cohort study, we analyzed individual patient data from 11 international cohorts. Patients 18 years of age or older with at least 1 untreated saccular unruptured intracranial aneurysm were included if they had 2 consecutive MRIs with aneurysm wall imaging. A Wilson score interval was used to calculate confidence intervals for the proportion of aneurysms with aneurysm wall enhancement changes, defined as appearance or disappearance between the 2 MRIs. RESULTS:We included 305 patients with 387 unruptured intracranial aneurysms. Aneurysm wall enhancement was present at baseline in 142 (37%) aneurysms in 122 patients. Aneurysm wall enhancement appeared or disappeared in 20/387 aneurysms (5.2% [95% CI, 3.4-7.8]) after a median follow-up of 12 months (interquartile range, 5-13). Of the 245 aneurysms without enhancement at baseline, 13 (5.3% [95% CI, 3.1-8.9]) had the appearance of wall enhancement at the second MR aneurysm wall imaging. Of the 142 aneurysms with aneurysm wall enhancement at baseline, 7 aneurysms (4.9% [95% CI, 2.4-9.8]) had the disappearance of aneurysm wall enhancement. CONCLUSIONS:Most unruptured intracranial aneurysms have persistent presence or absence of aneurysm wall enhancement during a median 1-year follow-up period. This finding suggests that underlying pathophysiological processes in the aneurysm wall are long-lasting.

Background: Managing unruptured intracranial aneurysms (IAs) involves balancing procedural risks with the long-term risk of rupture. Aneurysm wall enhancement (AWE) has been associated with aneurysm instability and symptomatic presentation. However, assessing AWE typically relies on subjective two-dimensional visual inspection, which lack objectivity. This study aims to evaluate a predictive model for symptomatic status by integrating clinical, morphological, and three dimensional-AWE (3D-AWE) metrics from a large dataset of IAs. Methods: Patients from three large academic center from the US and China, with saccular unruptured IAs underwent 3T high-resolution magnetic resonance imaging. Morphological assessment was conducted through angiographic studies. The determination of AWE was performed using a 3D-mapping pipeline that quantifies the average signal intensity of the aneurysm wall after contrast administration producing an objective metric: 3D-AWE (figure). Symptomatic status was defined by rupture, sentinel headaches, cranial nerve palsy, and focal neurological symptoms due to mass effect by the aneurysm. The optimal multivariate model for predicting symptomatic presentation of IAs was determined using an all-subsets regression approach. Results: A total of 389 IAs were included, with 73 (19%) being symptomatic at presentation. The model using clinical and morphological aneurysm variables achieved an AUC of 0.78, with 60% sensitivity and 86% specificity in identifying symptomatic aneurysms. Adding 3D-AWE metrics improved the model's performance, increasing the AUC to 0.82, with 73% sensitivity and 78% specificity. High-risk locations (anterior communicating, posterior communicating, and basilar arteries; OR 1.87, p 0.04), size ratio (OR 1.52, p<0.001), smoking (OR 1.91, p 0.07), and positive 3D-AWE (OR 7.09, p<0.001) were identified as independent predictors of symptomatic presentation. Conclusions: Incorporating objective 3D-AWE data enhanced the predictive performance of clinical and morphological information for detecting symptomatic IAs.

BACKGROUND AND PURPOSE:Early identification of malignant cerebral edema (MCE) in patients with acute ischemic stroke is crucial for timely interventions. We aimed to identify regions critically associated with MCE using the ASPECTS to evaluate the association between location-specific net water uptake (NWU) and MCE. MATERIALS AND METHODS:This multicenter, retrospective cohort study included patients with acute ischemic stroke following large anterior circulation occlusion. The ASPECTS was determined by RAPID ASPECTS software. ASPECTS-NWU and Region-NWU were calculated automatically by comparing the Hounsfield unit values in the ischemic and contralateral regions. Critical ASPECTS MCE regions and Region-NWU were evaluated by multivariate logistic regression and the areas under the receiver operating characteristic curves (AUCs). RESULTS:The study included 513 patients. Multivariate analysis showed that the ASPECTS insula (OR = 2.49; 95% CI, 1.44-4.31) and M5 (OR = 1.59; 95% CI, 1.11-3.41) regions were significantly associated with MCE. After adjustment, only the insula (OR = 2.34; 95% CI, 1.23-4.45) was independently associated with MCE. Univariable receiver operating characteristic curve analysis found AUCs for Insula-NWU (AUC, 0.70; 95% CI, 0.65-0.76) and ASPECTS-NWU (AUC, 0.64; 95% CI, 0.58-0.70). The Insula-NWU had better diagnostic power than ASPECTS-NWU (DeLong test; P = .01). A multivariate regression model that combined the NIHSS, ASPECTS, insula involvement, and Insula-NWU had good discriminatory power (AUC = 0.80; 95% CI, 0.74-0.86) and better diagnostic power than Insula-NWU (DeLong test; P < .01). CONCLUSIONS:The insula region is critical for MCE, and Insula-NWU has better prediction efficacy than ASPECTS-NWU. This method does not rely on advanced imaging, facilitating rapid assessment in emergencies.

PURPOSE:Accurate delineation of the infarct region on acute-phase Computed Tomography (CT) remains challenging, and radiomics applications in stroke are limited. We aimed to develop and validate a multimodal prediction model for malignant cerebral edema (MCE) using clinical and radiomic features extracted based on the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) framework, eliminating the need for manual infarct segmentation. METHOD:This multicenter retrospective study included patients with acute ischemic stroke (AIS) from five stroke centers who underwent Non-Contrast Computed Tomography (NCCT) and computed tomography angiography (CTA). Radiomic features were extracted from ASPECTS regions. Clinical, imaging-alone, and fused models were developed using machine learning. Model performance was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC) analysis, accuracy, calibration curves, and decision curve analysis (DCA). Shapley Additive exPlanations (SHAP) was used to interpret feature contributions. RESULTS:A total of 708 patients were included (median age: 67 years; interquartile range (IQR): 60-76; 448 men, 63.3 %). In the training cohort, the fused model (AUC = 0.91, 95 %CI: 0.88-0.95) outperformed the clinical (AUC = 0.72, 95 %CI: 0.66-0.78, p < 0.001) and CTA_Features (AUC = 0.83, 95 %CI: 0.79-0.88, p < 0.001) models. In the internal validation cohort, the fused model (AUC = 0.78, 95 %CI: 0.70-0.87) outperformed the clinical model (AUC = 0.68, 95 %CI: 0.59-0.77, p = 0.030). In the external validation, the fused model (AUC = 0.88, 95 %CI: 0.82-0.94) outperformed the clinical (AUC = 0.71, 95 %CI: 0.59-0.83, p = 0.010) and CT_Features (AUC = 0.70, 95 %CI: 0.56-0.85, p = 0.012) models. SHAP analysis identified ASPECTS, National Institutes of Health Stroke Scale (NIHSS) score, and collateral score (CS) as top predictors. The fused model demonstrated the highest specificity (82.5 %) and accuracy (78.3 %). CONCLUSIONS:The fused model integrating clinical, radiological, and radiomic features extracted using the ASPECTS framework, demonstrated superior and generalizable predictive performance for early MCE prediction. As it uses routinely acquired baseline NCCT and CTA with readily available admission variables and avoids manual segmentation through an ASPECTS-based framework, it can be integrated into clinical workflows to enable rapid and consistent MCE risk estimation.

Background:The second Enhanced Control of Hypertension and Thrombectomy Stroke Study (ENCHANTED2/MT) was terminated early when the intensive blood pressure lowering to a systolic level of 120 mm Hg or lower, compared to 140-180 mm Hg, was harmful in patients who received successful endovascular therapy for acute ischaemic stroke due to large-vessel occlusion. We aimed to determine the interaction of key brain imaging features and the effect of treatment on clinical outcomes. Methods:ENCHANTED2/MT was a prospective, randomised, open-label, blinded-endpoint, controlled trial that aimed to assess the effectiveness of different intensities of blood pressure control on the functional independence in patients who had received successful endovascular therapy for acute ischaemic stroke from large-vessel occlusion at 44 hospitals in China between July 20, 2020 and March 7, 2022. In these pre-specified secondary analyses, neuroradiologists reviewed the baseline brain images of participants (computerised tomography [CT], CT with angiography [CTA] and digital subtraction angiography [DSA]) blind to treatment allocation, to determine the degree of cerebral infarction on the Alberta Stroke Program Early CT Score (ASPECTS), collateral status according to modified TAN score, and degree of reperfusion on the expanded Treatment In Cerebral Infarction (eTICI) scale. The primary outcome was functional independence, according to the distribution of scores on the modified Rankin scale (range 0 [no symptoms] to 6 [death]) at 90 days. Multivariable logistic regression analysis was done according to the modified intention-to-treat principle in all participants with available outcome data. ENCHANTED2/MT is registered with ClinicalTrials.gov, NCT04140110. Findings:Of 816 participants in the trial, in whom 407 were assigned to more intensive blood pressure lowering and 409 were assigned to less intensive blood pressure lowering treatment, there were 533, 372, and 757 participants with available data for ASPECTS, collateral flow, and eTICI analyses, respectively. Intensive blood pressure lowering was associated with worse functional independence in participants with complete reperfusion (eTICI 3: adjusted odds ratio [aOR] 1.51, 95% CI 1.14-2.02) but not in those with incomplete reperfusion (eTICI 2b/c: aOR 1.29, 95% CI 0.73-2.28), without significant interaction (pinteraction = 0.82). There was no significant interaction between blood pressure treatment and ASPECTS (0-5 vs. 6-10: aOR 1.27, 95% CI 0.77-2.11 vs. aOR 1.37, 95% CI 0.91-2.07; pinteraction = 0.14) on functional independence. However, more intensive blood pressure lowering treatment was associated with worse functional independence in participants with poor collateral status (aOR 1.99, 95% CI 1.11-3.57) compared to those with good collateral status (aOR 0.87, 95% CI 0.53-1.45), with a moderate level of interaction (pinteraction = 0.037). Interpretation:Our study indicates that collateral status may help identify patients at risk from intensive blood pressure lowering treatment to a systolic target of 120 mm Hg or lower, in patients undergoing endovascular therapy for acute ischaemic stroke from large-vessel occlusion. Funding:The Shanghai Hospital Development Center; National Health and Medical Research Council of Australia; Medical Research Foundation (MRF) of the UK; AstraZeneca; China Stroke Prevention; Shanghai Changhai Hospital, Science and Technology Commission of Shanghai Municipality; Takeda China; Hasten Biopharmaceutic; Genesis Medtech; Penumbra.

Background Cerebral small vessel disease (CSVD) can lead to stroke and cognitive impairment. Small vessels cannot be visualized by neuroimaging directly, and CSVD can only be evaluated by cerebral parenchymal changes in MRI. Therefore, a convenient screening method for identifying high-risk and susceptible patients is needed. Recently, some studies found that CSVD was related to large atherosclerosis, and atherosclerosis was an essential pathological feature of CSVD. Therefore, we aimed to investigate the association between carotid plaque size characteristics and white matter hyperintensities (WMHs) in patients with CSVD. Methods We continuously enrolled patients with CSVD. Carotid plaque features were evaluated using carotid ultrasound, and WMHs were evaluated using brain magnetic resonance imaging. Plaque characteristics were compared between patients with no/mild WMHs and those with severe WMHs. Associations between the plaque characteristics and WMH severity were analyzed using logistic regression. Results In total, 180 patients were recruited, of whom 92 had severe WMHs. The severe WMHs group had a higher sum of the bilateral maximum intima-media thickness (4.15 mm vs. 3.30 mm), longer maximum plaque length (17.20 mm vs. 13.90 mm), thicker plaques (2.70 mm vs. 2.30 mm), and more plaques (3 vs. 2) than the no/mild WMHs group. Adjusted logistic regression analyses revealed that maximum plaque length and thickness were associated with WMHs. Conclusions Carotid atherosclerotic plaque features, such as plaque length and thickness, were associated with the severity of WMHs, which suggested that carotid atherosclerotic plaque characteristics measured using ultrasound might be helpful indicators for identifying high-risk patients with CSVD.

AbstractObjectiveCarotid intraplaque neovascularization (IPN) detected by contrast‐enhanced ultrasound (CEUS) is a risk factor for recurrent ischemic stroke. However, it is still unclear whether IPN can be used to accurately identify patients with recurrent ischemic stroke in clinical practice. Herein, we investigated the clinical predictive value of IPN for recurrent ischemic stroke in a real‐world setting.MethodsWe enrolled 200 patients with ischemic stroke and atherosclerotic carotid stenosis who were followed up for 2 years. The endpoint was recurrent ischemic stroke. Cox regression and subgroup analyses were employed to assess whether treatment affected the relationship between IPN and recurrent ischemic stroke. The net classification index (NRI) and integrated discriminant improvement index (IDI) were used to validate the additional clinical value of IPN in identifying recurrent ischemic stroke.ResultsDuring the 2‐year follow‐up, 36 patients experienced recurrent ischemic stroke. Cox regression analyses showed that IPN (grade 2), hypoechoic plaque, high homocysteine levels, and smoking were independent risk factors for recurrent ischemic stroke. Additional IPN evaluation may increase the NRI (0.512; 95% confidence interval [CI]: 0.083–0.624) and IDI (0.151; 95% CI: 0.010–0.213) for identifying high‐risk patients with recurrent ischemic stroke. In addition, in the subgroup undergoing revascularization, the proportion of IPN (grade 2) was significantly higher in patients with recurrent ischemic stroke than in patients with nonrecurrent ischemic stroke (p = 0.001).InterpretationIn clinical settings, IPN, assessed by CEUS, may provide additional clinical value for predicting recurrent ischemic stroke, helping to identify patients with ischemic stroke who require close follow‐up.

Background The effectiveness of using a balloon guide catheter during endovascular thrombectomy in patients with acute ischaemic stroke due to large vessel occlusion of the anterior circulation remains uncertain. We aimed to assess the effectiveness and safety of using a balloon guide catheter during endovascular thrombectomy, compared with using a conventional guide catheter, in this patient population. Methods We conducted a multicentre, open-label, blinded-endpoint, randomised controlled trial at 28 hospitals in China. Adults aged 18 years or older with acute ischaemic stroke who were able to receive endovascular thrombectomy within 24 h after symptom onset, according to local guidelines, were eligible. Patients were randomly assigned (1:1) to the balloon guide catheter group or the conventional guide catheter group using a central internet-based system with a minimisation algorithm. The treating physicians and patients were aware of treatment allocation, but clinical outcomes were collected by local trained physicians who were masked. Neurological assessments were performed at baseline, 24 h after randomisation, and at 7 days or hospital discharge (whichever occurred first). The primary outcome was functional recovery, assessed by change in modified Rankin Scale (mRS) scores (ranging from 0 [no symptoms] to 6 [death]) at 90 days in the intention-to-treat population and obtained from structured interviews. Treatment effect was estimated using ordinal logistic regression with adjustment for site and baseline prognostic factors (time from symptom onset to randomisation, the preferred thrombectomy strategy, baseline National Institutes of Health Stroke Scale score, prestroke function [estimated mRS score], and age). This trial is registered with ClinicalTrials.gov, NCT05592054 (terminated). Findings Between Feb 7 and Nov 13, 2023, 1698 patients were assessed for eligibility and 329 were randomly assigned to the balloon guide catheter group (n=164) or conventional guide catheter group (n=165) when the trial was paused and subsequently terminated on April 18, 2024, due to safety concerns. The median age was 69 years (IQR 59-76). Of 329 patients, 201 (61%) were male and 128 (39%) were female. Participants in the balloon guide catheter group had significantly worse scores on the mRS at 90 days than those in the conventional guide catheter group (adjusted common odds ratio 066 [95% CI 045-098]; p=0037). All-cause mortality at 90 days was numerically higher in the balloon guide catheter group than in the conventional guide catheter group (39 [24%] vs 26 [16%]). There were no statistically significant differences between groups in intracranial haemorrhage, symptomatic intracranial haemorrhage, or other serious adverse events. Interpretation Compared with conventional guide catheters, the use of balloon guide catheters led to worse functional recovery in patients receiving endovascular thrombectomy for intracranial large vessel occlusion. Future studies are needed to confirm these results.

Objectives In patients with an unruptured intracranial aneurysm, gadolinium enhancement of the aneurysm wall is associated with growth and rupture. However, most previous studies did not have a longitudinal design and did not adjust for aneurysm size, which is the main predictor of aneurysm instability and the most important determinant of wall enhancement. We investigated whether aneurysm wall enhancement predicts aneurysm growth and rupture during follow-up and whether the predictive value was independent of aneurysm size. Materials and methods In this multicentre longitudinal cohort study, individual patient data were obtained from twelve international cohorts. Inclusion criteria were as follows: 18 years or older with ≥ 1 untreated unruptured intracranial aneurysm < 15 mm; gadolinium-enhanced aneurysm wall imaging and MRA at baseline; and MRA or rupture during follow-up. Patients were included between November 2012 and November 2019. We calculated crude hazard ratios with 95%CI of aneurysm wall enhancement for growth (≥ 1 mm increase) or rupture and adjusted for aneurysm size. Results In 455 patients (mean age (SD), 60 (13) years; 323 (71%) women) with 559 aneurysms, growth or rupture occurred in 13/194 (6.7%) aneurysms with wall enhancement and in 9/365 (2.5%) aneurysms without enhancement (crude hazard ratio 3.1 [95%CI: 1.3–7.4], adjusted hazard ratio 1.4 [95%CI: 0.5–3.7]) with a median follow-up duration of 1.2 years. Conclusions Gadolinium enhancement of the aneurysm wall predicts aneurysm growth or rupture during short-term follow-up, but not independent of aneurysm size. Clinical relevance statement Gadolinium-enhanced aneurysm wall imaging is not recommended for short-term prediction of growth and rupture, since it appears to have no additional value to conventional predictors. Graphical abstract Key Points • Although aneurysm wall enhancement is associated with aneurysm instability in cross-sectional studies, it remains unknown whether it predicts risk of aneurysm growth or rupture in longitudinal studies. • Gadolinium enhancement of the aneurysm wall predicts aneurysm growth or rupture during short-term follow-up, but not when adjusting for aneurysm size. • While gadolinium-enhanced aneurysm wall imaging is not recommended for short-term prediction of growth and rupture, it may hold potential for aneurysms smaller than 7 mm.

Purpose:Intraplaque neovascularization, assessed using contrast-enhanced ultrasound (CEUS), is associated with ischemic stroke. It remains unclear whether detection of intraplaque neovascularization combined with color Doppler ultrasound (CDUS) provides additional value compared with CDUS alone in assessing ischemic stroke risk. Therefore, we investigated the clinical value of combined CEUS, CDUS, and clinical features for ischemic stroke risk stratification. Patients and Methods:We recruited 360 patients with ≥50% carotid stenosis between January 2019 and September 2022. Patients were examined using CDUS and CEUS. Covariates associated with ischemic stroke were identified using multivariate logistic regression analysis. The discrimination and calibration were verified using the C-statistic and Hosmer-Lemeshow test. The incremental value of intraplaque neovascularization in the assessment of ischemic stroke was analyzed using the Delong test. Results:We analyzed the data of 162 symptomatic and 159 asymptomatic patients who satisfied the inclusion and exclusion criteria, respectively. Based on multivariate logistic regression analysis, we constructed a nomogram using intraplaque neovascularization, degree of carotid stenosis, plaque hypoechoicity, and smoking status, with a C-statistic of 0.719 (95% confidence interval [CI]: 0.666-0.768) and a Hosmer-Lemeshow test p value of 0.261. The net reclassification index of the nomogram was 0.249 (95% CI: 0.138-0.359), and the integrated discrimination improvement was 0.053 (95% CI: 0.029-0.079). Adding intraplaque neovascularization to the combination of CDUS and clinical features (0.672; 95% CI: 0.617-0.723) increased the C-statistics (p=0.028). Conclusion:Further assessment of intraplaque neovascularization after CDUS may help more accurately identify patients at risk of ischemic stroke. Combining multiparametric carotid ultrasound and clinical features may help improve the risk stratification of patients with ischemic stroke with ≥50% carotid stenosis.

BACKGROUND:The effect of embolization of the middle meningeal artery in patients with subacute or chronic subdural hematoma is uncertain. METHODS:We performed a multicenter, open-label, randomized trial in China, involving patients with symptomatic nonacute subdural hematoma with mass effect. Patients were assigned to undergo burr-hole drainage or receive nonsurgical treatment at the surgeon's discretion, and patients in each group were then randomly assigned, in a 1:1 ratio, to undergo middle meningeal artery embolization with liquid embolic material or to receive usual care. Patients whose condition warranted craniotomy were excluded. The primary outcome was symptomatic recurrence or progression of subdural hematoma within 90 days after randomization. Secondary outcomes included clinical and imaging outcomes. The main safety outcome was any serious adverse event (including death). RESULTS:The analysis included 722 patients, of whom 360 were assigned to the embolization group and 362 to the usual-care group. Burr-hole drainage was performed in 78.3% of the enrolled patients; among the patients who underwent burr-hole drainage, the procedure occurred after embolization in 99.6%. Symptomatic recurrence or progression of subdural hematoma within 90 days occurred in 24 patients (6.7%) in the embolization group and in 36 (9.9%) in the usual-care group (between-group difference, -3.3 percentage points; 95% confidence interval, -7.4 to 0.8; P = 0.10). The incidence of serious adverse events was lower in the embolization group than in the usual-care group (6.7% vs. 11.6%, P = 0.02). CONCLUSIONS:Among patients with symptomatic nonacute subdural hematoma (of whom 78% underwent burr-hole drainage), middle meningeal artery embolization resulted in a 90-day incidence of symptomatic recurrence or progression similar to that with usual care but was associated with a lower incidence of serious adverse events. (Funded by Shanghai Shenkang Hospital Development Center and others; MAGIC-MT ClinicalTrials.gov number, NCT04700345.).

Purpose: The differences between the Alberta Stroke Program Early CT Score (ASPECTS) obtained by experts and artificial intelligence (AI) software require elucidation. We aimed to characterize the discrepancies between the ASPECTS obtained by AI and experts and determine the associated factors and prognostic implications. Methods: This multicenter, retrospective, observational cohort study included patients showing acute ischemic stroke caused by large-vessel occlusion in the anterior circulation. ASPECTS was determined by AI software (RAPID ASPECTS) and experts from the core laboratory. Interclass correlation coefficients (ICCs) and Bland-Altman plots were used to illustrate the consistency and discrepancies; logistic regression analyses were used to assess the correlates of inconsistency; and receiver operating characteristic analyses were performed to assess the diagnostic performance for predicting unfavorable clinical outcomes. Results: The study population included 491 patients. The ICC for the expert and AI ASPECTS was 0.63 (95 % confidence interval [CI]: 0.25-0.79).The mean difference between expert and AI ASPECTS was 2.24. Chronic infarcts (odds ratio [OR], 1.9; 95 % CI, 1.1-3.4; P=0.021) and expert scores in the internal capsule (OR, 2.9; 95 % CI, 1.1-7.7; P=0.034) and lentiform (OR, 2.4; 95 % CI, 1.3-4.7; P=0.008) were significant correlates of inconsistency. The ASPECTS obtained by AI showed a significantly higher area under the curve for unfavorable outcomes (0.68 vs. 0.63, P=0.04). Conclusions: In comparison with expert ASPECTS, AI ASPECTS overestimated the infarct extent. Future studies should aim to determine whether AI ASPECTS assessments should use a lower threshold to screen patients for endovascular therapy.

Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke worldwide, especially in China and Asia. The prevalence of ICAD in stroke-free individuals ranges from 3.5% to 45% across different studies, depending on the definition, characteristics of the study population, and diagnostic methods [1]. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) are popular diagnostic imaging methods for ICAD by identifying luminal stenosis. However, plaques can present without causing significant stenosis due to outward remodeling, and angiographic imaging may miss plaques with low or zero degree of stenosis [2]. High-resolution magnetic resonance imaging (HR-MRI) provides a unique chance to directly assess the intracranial artery wall, which has been increasingly used to study atherosclerotic plaques [2]. A few studies have investigated the prognosis value of HR-MRI to predict recurrent stroke in acute stroke patients [3] [4], but the value of HR-MRI in predicting first-ever stroke is still unknown. In this Journal issue, the article by Li et al. describes a community-based prospective cohort study that included 1060 stroke-free participants evaluated by HR-MRI that found ICAD detected using HR-MRI increases the long-term risk of a first-ever ischemic stroke by 2.5 times in a stroke-free Chinese population, after adjusting for other risk factors [5]. This is the largest sample size study using HR-MRI on ICAD with a long follow-up duration of more than 4 years on average. The first-ever stroke rate was 5.2% during about 4.5 years' follow-up in patients with ICAD, and the stroke rate increased significantly to 12.5% if the area of stenosis of the intracranial artery was more than 70%, considered very high in such stroke-free individuals. How can we prevent these first-ever strokes in this subcohort of patients? Nearly all the included individuals received medication for risk factor control, but such a high rate of stroke indicates that the current medical management awaits further optimization. In patients with ICAD, especially those with a high degree of stenosis, more aggressive medication may be beneficial to these patients, including high-dose statin treatment, more strict blood pressure control, and so on. The screening of such high-risk patients using HR-MRI may be beneficial, pending future cost-effectiveness studies. With the aid of HR-MRI, this study is the first to identify the features of high-risk intracranial plaques (plaque burden, length, high signal, etc.) in stroke-free participants, which provides baseline data for future stroke-prevention strategies. However, in order to interpret the prevalence and prognosis of asymptomatic ICAD detected in this study, a few critical aspects need to be considered carefully. First, only the middle cerebral artery (MCA) and basilar artery (BA) were assessed in this study using HR-MRI, and other intracranial arteries were only assessed using luminal imaging, which might decrease the rate of ICAD. Future studies are needed to evaluate the major intracranial arteries in the whole brain using HR-MRI. Second, the stenosis was defined as luminal area stenosis, and not the traditionally used diameter stenosis, which should be interpreted with caution. Assuming a circular lumen, a 50% diameter stenosis (the narrowest lumen is half the diameter of the normal artery) is equal to 75% area stenosis. Previous studies have shown that three-dimensional HR-MRI can quantify the diameter stenosis of the intracranial artery accurately and reproducibly [6]. Diameter stenosis is still the most widely used parameter in clinical practice and it is used in the current clinical guidelines. Third, the resolution of HR-MRI used in this study was low compared to the state-of-the-art technique, and only pre-contrast HR-MRI sequences were acquired, which might lead to a missed diagnosis of small plaques, especially non-stenotic ICAD. Also the plaque enhancement feature was not evaluated. The use of higher-resolution HR-MRI sequences, or a higher field strength, can potentially further improve the accuracy of detecting asymptomatic ICAD [7]. Chengcheng Zhu: Conceptualization; writing – review and editing; writing – original draft. Bing Tian: Conceptualization; writing – original draft; writing – review and editing. The authors declare there is no conflict of interest. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

To determine if three-dimensional (3D) radiomic features of contrast-enhanced CT (CECT) images improve prediction of rapid abdominal aortic aneurysm (AAA) growth. This longitudinal cohort study retrospectively analyzed 195 consecutive patients (mean age, 72.4 years ± 9.1) with a baseline CECT and a subsequent CT or MR at least 6 months later. 3D radiomic features were measured for 3 regions of the AAA, viz. the vessel lumen only; the intraluminal thrombus (ILT) and aortic wall only; and the entire AAA sac (lumen, ILT, and wall). Multiple machine learning (ML) models to predict rapid growth, defined as the upper tercile of observed growth (> 0.25 cm/year), were developed using data from 60 • Radiomic analysis of 195 abdominal CECT revealed that an ML-based model that included textural features of intraluminal thrombus (if present) and aortic wall improved prediction of rapid AAA progression compared to maximum diameter. • Predictive accuracy was higher when radiomic features were obtained from the thrombus and wall as opposed to the entire AAA sac (including lumen), or the lumen alone. • Logistic regression of selected radiomic features yielded similar accuracy to predict rapid AAA progression as random forests or support vector machines.

目的 分析自发性未破裂头颈动脉夹层(CCAD)患者药物治疗前后高分辨率磁共振成像(HR-MRI)特征变化.方法 回顾性连续收集2015年8月至2022年12月于海军军医大学(第二军医大学)第一附属医院确诊并在药物治疗前后行HR-MRI检查的 30 例CCAD患者资料.根据随访时磁共振血管成像(MRA)图像上夹层血管管腔狭窄的改善情况,将患者分为改善组(随访时管腔狭窄程度较基线减轻1个级别及以上的患者)与未改善组(随访时管腔狭窄程度较基线加重 1 个级别及以上或无变化的患者).分析改善组与未改善组患者的临床资料及治疗前后HR-MRI管腔及管壁特征差异.结果 30 例CCAD患者共计30 处夹层,其中改善组14 例(11 例完全恢复正常,3例管腔狭窄程度改善)、未改善组16例.改善组患者的年龄小于未改善组[(37.86±9.83)岁vs(56.94±9.86)岁,P=0.001],其余临床特征差异均无统计学意义(P均＞0.05).改善组患者中基线壁内血肿比例高、管腔狭窄程度相对较轻,而未改善组患者的基线管腔狭窄程度较严重,内膜瓣与双腔征、假腔内血栓形成更常见(P均＜0.05).治疗后随访时,改善组患者壁内血肿、管腔狭窄程度均改善,未改善组患者壁内血肿、内膜瓣与双腔征、假腔内血栓形成仍有较多残留(P均＜0.05).两组基线夹层血管壁强化程度差异无统计学意义(P＞0.05),治疗后随访时改善组患者血管壁强化程度较未改善组降低(P＜0.001).结论 HR-MRI可对CCAD药物治疗前后管腔及管壁形态学特征变化进行评估,年龄小、基线管腔狭窄程度相对较轻的患者经药物治疗后夹层恢复好.