Integrated imaging assessment of large arteries, intracranial plaque, and cerebral small vessel disease to distinguish acute ischemic stroke from transient ischemic attack.

PURPOSE: To explore the interrelationships among global large artery status, local plaque features and cerebral small vessel disease (CSVD) imaging markers in patients with symptomatic intracranial atherosclerotic disease (ICAD), and to identify independent risk factors associated with the occurrence of acute ischemic stroke (AIS). METHODS: Patients were stratified into AIS and transient ischemic attack (TIA) groups based on clinical and diffusion-weighted imaging characteristics. Spearman's correlation analysis was employed to examine the associations between large artery status, plaque features, and CSVD imaging markers in each group. Multivariate logistic regression was performed to assess discriminative performance, with discriminatory ability quantified by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve, and internal validation was conducted via 1,000 bootstrap resamples. RESULTS: A total of 108 patients were included. The correlation patterns among large artery status, plaque features, and CSVD markers revealed significant differences between AIS and TIA patients. Notably, vessel wall enhancement demonstrated positive correlations with T1 hyperintensity, surface irregularity, stenosis severity, and plaque length (all p < 0.05) in AIS patients. Multivariate logistic regression identified the degree of plaque enhancement, vessel wall enhancement score, number of enlarged perivascular spaces, and white matter hyperintensity Fazekas score as independent risk factors associated with AIS. The model achieved an AUC of 0.962 (95% confidence interval: 0.932-0.991; p < 0.001) for identifying AIS, with a sensitivity of 84.40% and a specificity of 95.50%. The optimism -corrected AUC was 0.918. CONCLUSION: Our findings demonstrate distinct interrelationships among large artery, plaque, and CSVD features in AIS versus TIA patients. Integrating these imaging markers significantly improves the ability to identify AIS in patients with ICAD.