Intracranial Plaque Characteristics of Recurrent Ischemic Stroke After Intensive Medical Therapy for a 6-month Follow-up

BACKGROUND Intensive medical management has been recommended to ischemic stroke of intracranial atherosclerosis (ICAS), but 9.4-15% probability of recurrent stroke remains an inevitable reality. The characteristics of high-risk intracranial plaque that contribute to stroke recurrence after intensive therapy is unclear. METHODS All the patients for acute ischemic stroke due to ICAS underwent the 3D head&neck high-resolution vessel wall magnetic resonance imaging (hr-VW-MRI) at baseline and received intensive medical management within 90 days in this two-center and prospective study. The clinical risk factors and blood biomarkers were recorded. The morphological features, such as minimal lumen area (MLA), and histogram parameters including entropy were assessed based on MR images. The primary endpoint event after 6 months is recurrence of ischemic events (hyperintense signals on diffusion-weighted images or TIA in the ipsilateral vascular territory). Cox regression analysis was used to calculate the hazard ratio (HR) and 95% confidence interval (CI) for recurrent events. RESULTS 222 patients (age, 59.5±12.1; males, 153) were included in the subsequent analysis. After an average of six months of follow-up (average days, 177.4±23.1), 38 patients have reached the primary endpoint. After adjusting the age, BMI and gender, the multivariate Cox regression demonstrated that three clinical factors including smoking (HR=4.321; 95%CI, 1.838-10.161; P =0.001), taking exercise (HR=0.409; 95%CI, 0.198-0.843; P =0.015) and blood pressure management (HR=0.180; 95%CI, 0.073-0.443; P =0.001), and two MR-related parameters (MLA [HR=0.771; 95%CI, 0.625-0.951; P =0.015] and entropy [HR=0.274; 95%CI, 0.130-0.576; P =0.001]) were significant predictors of recurrent ischemic stroke. The Kaplan– Meier curve depicted that the cumulative incidences of patients with all high-risk features were significantly higher than those without(P < 0.001). CONCLUSIONS The plaque characteristics based on 3D head&neck hr-VW-MRI may provide complementary values over traditional clinical features in predicting ischemic recurrence for ICAS and help risk stratification of patients at risk of recurrent stroke. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial This prospective study was not a clinical trial but an observational study for ICAS patients undergoing intensive medical management. And it was not an interventional study for medical treatment comparison. Additionally, the study was approved by the Institutional Review Board of Changhai Hospital of Shanghai (No.CHEC2018-092) and Zhongshan Hospital, Fudan University (No.B2022-112R), and written informed consent was obtained from all patients. ### Funding Statement This study was supported in part by the National Natural Science Foundation of China (No. 82202145) and the Pujiang Project of Shanghai Magnolia talent plan (23PJD012) ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was approved by the Institutional Review Board of Changhai Hospital of Shanghai (No.CHEC2018-092) and Zhongshan Hospital, Fudan University (No.B2022-112R), and written informed consent was obtained from all patients. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Anonymized data not published within this article can be provided upon request by the corresponding author.