The Added Prognostic Value of Intracranial Artery Morphology to Predict Non-Cardioembolic Ischemic Stroke

Na Hye Han; Jinhee Jang; Hokyun Byun; Kijeong Lee; Jaseong Koo; Hyun Seok Choi; So-Lyung Jung; Kook-Jin Ahn; Bum-soo Kim

doi:10.3348/jksr.2018.78.4.249

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Han, Jang, Byun, Lee, Koo, Choi, Jung, Ahn, and Kim: The Added Prognostic Value of Intracranial Artery Morphology to Predict Non-Cardioembolic Ischemic Stroke

Original Article

J Korean Soc Radiol 2018;78(4):249-258.

Published online: 20 January 2018

DOI: https://doi.org/10.3348/jksr.2018.78.4.249

The Added Prognostic Value of Intracranial Artery Morphology to Predict Non-Cardioembolic Ischemic Stroke

Na Hye Han, MD¹, Jinhee Jang, MD^1,^∗, Hokyun Byun, MD¹, Kijeong Lee, MD², Jaseong Koo, MD², Hyun Seok Choi, MD¹, So-Lyung Jung, MD¹, Kook-Jin Ahn, MD¹, Bum-soo Kim, MD¹

¹Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

²Department of Neurology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

^∗Corresponding author: Jinhee Jang, MD Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea. Tel. 82-2-2258-5799 Fax. 82-2-599-6771 E-mail: znee@catholic.ac.kr

Received 24 May 2017 Revised 8 August 2017 Accepted 21 October 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To assess the added prognostic value of the morphologic characteristics of intracranial arteries in the risk modeling of a future non-cardioembolic stroke.

Materials and Methods

This retrospective study included 86 patients without acute ischemic stroke who first underwent magnetic resonance imaging (MRI) including the time-of-flight magnetic resonance angiography (TOF-MRA) at 3T. Diffusion-weighted imaging (DWI) was performed for the follow-up imaging of these patients > 120 days after the initial MRI. The TOF-MRA result was used to analyze three morphological characteristics: dilatation, stenosis, and tortuosity. The presence of acute ischemic stroke was assessed using the follow-up DWI data. We built two prognostic models: model 1 includes the conventional stroke-risk factors, while model 2 includes the conventional risk factors and the morphologic characteristics of the intracranial arteries. We used the likelihood-ratio test to compare these two models. The models' performances were evaluated using Harrell's concordance index.

Results

Fourteen patients suffered non-cardioembolic strokes. The performances of the two models differed significantly regarding the future-risk modeling of the non-cardioembolic stroke (p = 0.031). The Harrell's concordance index of model 2 (0.78 ± 0.05) exceeded that of model 1 (0.72 ± 0.07).

Conclusion

In addition to the conventional stroke-risk factors, the morphologic characteristics of the intracranial arteries were useful in the modeling of the future risk of the non-cardioembolic ischemic stroke.

Keywords: Index terms Cerebral Arteries Morphology MRI Angiography Brain Infarction Intracranial Arteriosclerosis

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Fig. 1.

Patient selection flow chart. After systematic evaluation of the radiology database, 86 patients were included in this study. Among them, 14 patients had acute non-cardioembolic ischemic strokes. DWI = diffusion-weighted imaging, FU = follow-up, MR = magnetic resonance, TOF-MRA = time-of-flight magnetic resonance angiography

Fig. 2.

Survival curves of non-cardioembolic strokes according to three morphological characteristics. Three survival curves for non-cardioembolic stroke according to the intracranial arterial diameter (A), stenosis score (B) and tortuosity score (C). A mean intracranial arterial diameter > 3.1 was associated with significant risk for future non-cardioembolic stroke (p < 0.001). Tortuous intracranial arteries were also associated with a tendency toward a high probability of future non-cardioembolic stroke (p = 0.158).

Table 1.

Multivariate Analysis Result for HRs for Ischemic Stroke (n = 86)

Table 2.

Patient Characteristics (n = 86)

Variable	No Stroke (n = 62)	Non-Cardioembolic Stroke (n = 14)	Cardioembolic Stroke (n = 10)	p-Value
Age (year)	69.5 (64, 77)	67.5 (63, 73)	80 (67, 82)	0.114
Sex (%)				0.939
Female	33 (53.2)	8 (57.1)	5 (50.0)
Male	29 (46.8)	6 (42.9)	5 (50.0)
Hypertension (%)	36 (58.1)	13 (92.9)	9 (90.0)	0.012
Diabetes (%)	20 (32.3)	3 (21.4)	4 (40.0)	0.603
Dyslipidemia (%)	15 (24.2)	5 (35.7)	5 (50.0)	0.208
Coronary artery disease (%)	9 (14.5)	3 (21.4)	4 (40.0)	0.151
Previous territorial infarction (%)	10 (16.1)	5 (35.7)	3 (30.0)	0.201
White matter hyperintensity (%)				0.919
None	31 (50.0)	8 (57.1)	4 (40.0)
Mild	19 (30.6)	3 (21.4)	3 (30.0)
Moderate	7 (11.3)	1 (7.1)	2 (20.0)
Severe	5 (8.1)	2 (14.3)	1 (10.0)
Lacune (%)	24 (38.7)	7 (50.0)	6 (60.0)	0.382
ICA stenosis (NASCET method, %)	0 (0, 0)	0 (0, 0)	0 (0, 32)	0.117
Mean diameter (cm)	2.8 (2.5, 2.9)	3.1 (3, 3.3)	2.8 (2.6, 3.4)	0.005
Tortuosity score	3 (2, 4)	3 (2, 4)	2 (2, 4)	0.35
Stenosis score (%)				0.726
0	54 (85.5)	11 (78.6)	9 (90)
1	7 (11.3)	2 (14.3)	0 (0)
2	2 (3.2)	0 (0)	1 (10)
3	0 (0)	1 (7.1)	0 (0)
Observation duration (days)	611.05 ± 376.75	683.14 ± 360.54	660.80 ± 391.06	0.778

p-values were calculated using the chi-square or Mann-Whitney U test. Values are median with interquartile range in parentheses or number of patients with percentages in parentheses. ICA = internal carotid artery, NASCET = North American Symptomatic Carotid Endarterectomy Trial

Table 3.

Univariate Analysis Result for HRs for Ischemic Strokes (n = 86)

Variable	HR (95% CI) for Non-Cardioembolic Ischemic Stroke (n = 14)	p-Value	HR (95% CI) for Acute Ischemic Stroke (n = 24)	p-Value
ICA stenosis	1.04 (1.01–1.07)	0.01^∗	1.04 (1.01–1.06)	< 0.001^∗
Hypertension	4.12 (0.54–31.8)	0.14^†	3.57 (0.83–15.3)	0.07^†
Diabetes mellitus	0.66 (0.18–2.40)	0.52	1.02 (0.42–2.47)	0.97
Dyslipidemia	1.35 (0.44–4.15)	0.59	1.89 (0.81–4.38)	0.13^†
Coronary artery disease	1.67 (0.45–6.17)	0.44	2.76 (1.10–6.92)	0.02^∗
Previous territorial infarction	2.84 (0.92–8.74)	0.06^†	2.53 (1.06–6.06)	0.03^∗
Lacune	1.27 (0.44–3.62)	0.66	1.54 (0.69–3.45)	0.29
White matter hyperintensity		0.75		0.69
Mild	1.10 (0.28–4.40)		1.52 (0.54–4.29)
Moderate	0.37 (0.05–2.97)		0.79 (0.22–2.83)
Severe	0.60 (0.08–4.84)		0.60 (0.12–2.91)
Mean diameter	3.27 (1.10–9.74)	0.04^∗	2.31 (0.89–6.02)	0.11^†
Tortuosity score	1.35 (0.88–2.07)	0.17^†	1.25 (0.89–1.73)	0.20^†
Stenosis score	1.99 (0.91–4.34)	0.07^†	1.70 (0.88–3.24)	0.15^†

^∗ p < 0.05.

^† p < 0.2. CI = confidence interval, HR = hazard ratio, ICA = internal carotid artery

Table 4.

Multivariate Analysis Result for HRs for Ischemic Stroke (n = 86)

Variable	Non-Cardioembolic Stroke				All Ischemic Stroke
Variable	Model 1 HR (95% CI)	p-Value	Model 2 HR (95% CI)	p-Value	Model 1 HR (95% CI)	p-Value	Model 2 HR (95% CI)	p-Value
Hypertension	3.64 (0.46–28.59)	0.22	3.95 (0.44–35.28)	0.22	2.71 (0.60–12.29)	0.20	2.41 (0.51–11.34)	0.27
Previous territorial infarction	3.49 (1.03–11.87)	0.04	3.55 (1.03–12.20)	0.04	4.14 (1.39–12.31)	0.01	4.04 (1.28–12.77)	0.02
ICA stenosis	1.04 (1.01–1.08)	0.009	1.04 (1.00–1.08)	0.061	1.04 (1.02–1.07)	0.002	1.04 (1.02–1.07)	0.002
Coronary artery disease	NA		NA		2.54 (0.87–7.43)	0.09	2.24 (0.77–6.48)	0.14
Dyslipidemia	NA		NA		0.98 (0.33–2.91)	0.97	1.02 (0.33–3.13)	0.98
Mean diameter	NA		9.45 (1.41–63.55)	0.02	NA		2.01 (0.66–6.10)	0.22
Tortuosity score	NA		0.97 (0.57–1.63)	0.90	NA		0.95 (0.66–1.39)	0.80
Stenosis score	NA		2.26 (0.84–6.07)	0.11	NA		1.65 (0.74–3.66)	0.22

Model 1: Analysis with conventional risk factors, Model 2: Analysis with conventional risk factors and morphological characteristics of the intracranial arteries. CI = confidence interval, HR = hazard ratio, ICA = internal carotid artery, NA = not available

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