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High-intensity vessel sign on fluid-attenuated inversion recovery imaging: a novel imaging marker of high-risk carotid stenosis—a MRI and SPECT study

  • Original Article - Vascular Neurosurgery - Ischemia
  • Published:
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Abstract

Background

Measurement of luminal stenosis and determination of plaque instability using MR plaque imaging are effective strategies for evaluating high-risk carotid stenosis. Nevertheless, new methods are required to identify patients with carotid stenosis at risk of future stroke. We aimed to clarify the mechanisms and clinical implications of the hyperintense vessel sign (HVS) as a marker of high-risk carotid stenosis.

Methods

We included 148 patients who underwent carotid stent (CAS) or carotid endarterectomy (CEA). MRI FLAIR was performed to detect HVS prior to and within 7 days after CAS/CEA. MR plaque imaging and 123I-iodoamphetamine SPECT was performed prior to CEA/CAS. Detailed characteristics of HVS were categorized in terms of symptomatic status, hemodynamic state, plaque composition, and HVS on time series.

Results

Forty-six of 80 symptomatic hemispheres (57.5%) and 5 of 68 asymptomatic hemispheres (7.4%) presented HVS (P < 0.01). Of the 46 symptomatic hemispheres with HVS, 19 (41.3%) presented with hemodynamic impairment and 27 (58.7%) presented without hemodynamic impairment. Of 19 hemispheres with hemodynamic impairment, 12 subjects (63.2%) showed high intensity and 7 (36.8%) showed iso-intensity plaques on T1WI. All 27 hemispheres without hemodynamic impairment showed high-intensity plaques. Of the five asymptomatic and HVS-positive hemispheres, one showed hemodynamic impairment; MR plaque imaging revealed T1 iso-intensity. The other four hemispheres that did not show hemodynamic impairment showed T1WI high-intensity plaques.

Conclusion

There are two possible mechanisms of HVS, hemodynamic impairment due to severe carotid stenosis and micro-embolism from unstable plaques. HVS could be a radiological marker for high-risk carotid stenosis.

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Author information

Authors and Affiliations

  1. Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan

    Daina Kashiwazaki, Shusuke Yamamoto, Naoki Akioka, Emiko Hori, Takashi Shibata, Naoya Kuwayama & Satoshi Kuroda

  2. Department of Radiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan

    Kyo Noguchi

Authors
  1. Daina Kashiwazaki
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  2. Shusuke Yamamoto
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Corresponding author

Correspondence to Daina Kashiwazaki.

Ethics declarations

The institutional review board at the Toyama University Hospital approved this study using human carotid plaque samples.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of our institutional research committee and with the 1964 Helsinki declaration.

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Comments

In this manuscript from the experienced Toyama carotid group, the authors focus on the “hyperintense vessel sign” (HVS) on MRI FLAIR imaging as a potential novel diagnostic marker to identify high-risk carotid plaques and to explore possible mechanisms and clinical implications of HVS.

In consideration of the method, they studied 148 patients who underwent either CAS or CEA. MRI FLAIR was performed to detect HVS (defined as a linear or serpentine-appearing hyperintensity on FLAIR imaging corresponding to a typical arterial course in the ipsilateral hemisphere to carotid stenosis) prior to and within 7 days after CAS/CEA.

MR plaque imaging and 123I-iodoamphetamine SPECT cerebral perfusion (to detect hemodynamic impairment) were performed prior to CEA/CAS.

Results - 80 patients (54.1%) were symptomatic and the remaining 68 (45.9%) were asymptomatic. The mean degree of stenosis was 76.2 ± 17.5%.

Forty-six of 80 symptomatic hemispheres (57.5%) and 5 of 68 asymptomatic hemispheres (7.4%) showed HVS (P <0.01). Of the 46 symptomatic hemispheres with HVS, 19 (41.3%) had hemodynamic impairment and 27 (58.7%) were without hemodynamic impairment. Of 19 hemispheres with hemodynamic impairment, 12 subjects (63.2%) showed high intensity and 7 (36.8%) showed iso-intensity plaques on T1WI. All 27 hemispheres without hemodynamic impairment showed high-intensity plaques. Of the five asymptomatic and HVS-positive hemispheres, one showed hemodynamic impairment; MR plaque imaging revealed T1 iso-intensity. The other four hemispheres that did not show hemodynamic impairment showed T1WI high-intensity plaques.

I took away several important findings from this study:

1)HVS was a predictor of hemodynamic impairment. HVS was detected in 20 of 22 hemispheres (91.1%) with hemodynamic impairment. In contrast, HVS was detected in 31 of 126 hemispheres (24.6%) without hemodynamic impairment.

2)Revascularization resolved the HVS finding. Postoperative 99mTc-HMPAO SPECT revealed improvement of the hemodynamic state in all hemispheres. Ultimately, HVS disappeared or diminished after CAS/CEA in all hemispheres.

3)HVS may predict at-risk patients. In the present study, HSV was detected in 36.3% patients with TIA and in 44.4% of those with retinal artery occlusion. Of note, HSV was detected in 7.4% of asymptomatic patients. These patients should be thought of as high-risk patients even in the absence of cerebral infarction.

In conclusion, this is an early but important investigation suggesting that HVS could be a radiological marker for high-risk carotid stenosis, and the technique could help us identify at-risk patients for intervention, and likewise to screen out low-risk patients where simple medical management might be best.

Christopher M. Loftus

Philadelphia, PA, USA

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Kashiwazaki, D., Yamamoto, S., Akioka, N. et al. High-intensity vessel sign on fluid-attenuated inversion recovery imaging: a novel imaging marker of high-risk carotid stenosis—a MRI and SPECT study. Acta Neurochir 162, 2573–2581 (2020). https://doi.org/10.1007/s00701-020-04408-4

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