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The MRI enhancement ratio and plaque steepness may be more accurate for predicting recurrent ischemic cerebrovascular events in patients with intracranial atherosclerosis



To assess the complementary value of high-resolution multi-contrast MRI (hrMRI) in identifying symptomatic patients with intracranial atherosclerosis (ICAS) who are likely to experience recurrent ischemic cerebrovascular events.


In this retrospective cohort study, eighty patients with acute ischemic events attributed to ICAS who underwent hrMRI examination between January 2015 and January 2019 were included. Median follow-up for all patients was 30 months (range: 1 to 52 months) and recurrent ischemic cerebrovascular events were recorded. Cox regression analysis and time-dependent ROC were performed to quantify the association between the plaque characteristics and recurrent events.


During the follow-up, 14 patients experienced recurrent ischemic cerebrovascular events. Young males and those with diabetes and poor medication persistence were more likely to experience recurrent events. ICAS in patients with recurrence had significantly higher enhancement ratio and steepness which is defined as the ratio between the plaque height and length than those without (p < 0.001 and p = 0.015, respectively). After adjustment of clinical factors, enhancement ratio (HR, 13.13 [95% CI, 3.58–48.20], p < 0.001) and plaque steepness (HR, 110.27 [95% CI, 4.75–2560.91], p = 0.003) were independent imaging biomarkers associated with recurrent events. Time-dependent ROC indicated that integrated high enhancement ratio and steepness into clinical risk factors improved discrimination power with the ROC increased from 0.79 to 0.94 (p = 0.008).


The enhancement ratio and plaque steepness improved the accuracy over traditional clinical risk factors in predicting recurrent ischemic cerebrovascular events for patients with ICAS.

Key Points

• High-resolution magnetic resonance imaging helps clinicians to evaluate high-risk Intracranial plaque.

• The higher enhancement ratio and plaque steepness (= height/length) were the primary biomarkers associated with future ischemic cerebrovascular events.

• High-resolution magnetic resonance imaging combined with clinical characteristics showed a higher accuracy for the prediction of recurrent events in patients with intracranial atherosclerosis.

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Diffusion-weighted imaging


Hazard ratio


High-resolution multi-contrast magnetic resonance imaging


Intracranial atherosclerosis


Intraplaque hemorrhage


Interquartile range




Vessel structural stress


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This study is supported in part by DRAGON, the European Research Council and Innovative Medicines Initiative, and the National Institute of Health Research Cambridge Biomedical Research Centre.


This study has received funding from the Fundamental Research Funds for the Central Universities (WK9110000056) and the National Natural Science Foundation of China (U20A20357, 81870946).

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Correspondence to Juan Du or Xinfeng Liu.

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The scientific guarantor of this publication is Xinfeng Liu, MD, PhD, Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Email:

Conflict of interest

Dr. Zhongzhao Teng is the chief scientist of Tenoke Ltd., Cambridge, UK, and Nanjing Jingsan Medical Science and Technology, Ltd., Nanjing, China. Other authors declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.


• Retrospective cohort

• observational

• performed at one institution

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Yang, D., Liu, J., Yao, W. et al. The MRI enhancement ratio and plaque steepness may be more accurate for predicting recurrent ischemic cerebrovascular events in patients with intracranial atherosclerosis. Eur Radiol 32, 7004–7013 (2022).

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  • Intracranial atherosclerosis
  • Stroke
  • Magnetic resonance imaging
  • Recurrence
  • Biomarkers