Synopsis

Keywords: Atherosclerosis, Stroke

To evaluate the prognosis of ischemic stroke (IS) by plaque characteristics based on high-resolution MR vessel wall imaging combined with Mediterranean diet adherence screener (MEDAS). IS patients were divided into two groups according to their prognosis. Clinical data and plaque characteristics were obtained and compared between groups. The correlation between these characteristics and prognosis was investigated by multivariate analysis. The ROC curves were further performed to determine their predictive performance. NIHSS score, MEDAS score, and plaque enhancement ratio were independent predictors of IS prognosis. Noteworthy, the combined model of three parameters showed significant superiority in the prognosis evaluation of IS.

Background

Ischemic stroke (IS) is a common and frequently-occurring disease of the nervous system, which seriously endangers human health and quality of life. Intracranial atherosclerosis and unstable plaques are considered to be the important pathological basis and major causes of IS [1]. Mediterranean Diet (Me-Di), a standard healthy eating pattern, can influence plaque development and progression to further improve the prognosis of IS [2-3]. Thus, plaque characteristics and pre-stroke Me-Di appear to offer additional information for the IS outcome prognostication, but this combined prognostic value has not been evaluated before. Therefore, the purpose of this research was to explore the effects of plaque characteristics by high-resolution MR vessel wall imaging (HRMR-VWI) combined with the Me-Di pre-stroke on the prognosis of IS, and to also determine the valuable predictors related to clinical outcomes.

Methods

MCA plaque-induced subacute IS patients with a complete MRI and HRMR-VWI examination were included in the study.
Two independent radiologists in cardiovascular radiology and blinded to all clinical information manually contoured the lumen and outer wall boundaries. Then, outer area (OAMLN), lumen area (LAMLN), and wall area (WAMLN) at the site of maximal lumen narrowing (MLN) were automatically obtained. A similar segmentation was drawn in the contralateral normal lumen and the parameters, including OAref, LAref, and WAref at the reference lumen, were also calculated as described above. Finally, the plaque area, degree of stenosis, remodeling index, plaque burden and enhancement ratio were calculated based on the above parameters [4-5].
The adherence to the Me-Di prior to stroke was evaluated with 14-item Mediterranean Diet Adherence Screener (MEDAS). The MEDAS score (range 0 [low adherence] to 14 [high adherence]) was recorded in detail through a complete interview between neurologists and patients or their direct relatives [6]. The National Institute of Health Stroke Scale (NIHSS) score (range 0 [no symptom] to 42 [severe neurologic dysfunction]) of stroke patients within 24 hours after admission was recorded by the neurologist [7]. Furthermore, the clinical outcomes of patients at 3-month after discharge were evaluated using the Modified Rankin Scale (mRS; range, 0 [disease-free] to 6 [dead]) [8]. In addition, age, gender, hypertension, and other disease history were obtained by patient interview and medical records.
SPSS software was used for statistical analysis. All parameters were compared between the groups. To determine the factors related to the poor prognosis of stroke, these parameters (P ＜ 0.05 in comparisons between groups) were further conducted the multivariate logistic regression analysis. The receiver operating characteristics (ROC) curves, as well as the area under curves (AUCs) were further plotted and calculated to evaluate the predictive performance for each parameter. P < 0.05 was considered significant.

Results

A total of 49 patients (34 men and 15 women) with subacute IS were collected. According to mRS results, patients were assigned into two groups, including 25 patients with poor prognosis and 24 patients with good prognosis. The patients with poor prognosis were significantly older than those with favorable outcomes (P = 0.029). In poor prognosis group, the NIHSS score after admission was higher than good prognosis group (P < 0.001). Additionally, other general information did not differ significantly (Figures 1).
Among the imaging characteristics of MCA plaque based on HRMR-VWI, the degree of stenosis, plaque burden, and plaque enhancement ratio demonstrated a significant increase in poor prognosis group than in good prognosis group (all, P < 0.001). Statistical differences in other plaque indicators such as plaque area were not found (Figures 1-2).
The distribution of MEDAS scores between the two groups was demonstrated specifically in Figure 3. The median of MEDAS score in all patients was 6 (IQR 3). Among the 24 patients with good prognosis, 83.3% of the patients were highly adherent to the Me-Di (defined as MEDAS ≥ 6), whereas the proportion in the poor prognosis group was only 56% (14 / 25). The univariate analysis further demonstrated that the MEDAS score of poor prognosis patients was remarkably lower than good prognosis patients (P < 0.001) (Figures 1).
Multivariate logistic regression analysis demonstrated that admission NIHSS score (OR: 2.383; 95% CI: 1.095-5.186; P = 0.029), plaque enhancement ratio (OR: 1.379; 95% CI : 1.002-1.898; P = 0.048) and MEDAS score (OR: 0.444; 95% CI: 0.201-0.983; P = 0.045) were significant predictors for evaluating the prognosis of IS, whereas age, degree of stenosis, and plaque burden (all, P > 0.05) were not (Figure 4).
The AUCs of NIHSS score after admission, plaque enhancement ratio, and MEDAS score used to assess the prognosis were 0.818, 0.820, and 0.874, respectively. The combination of plaque enhancement ratio and MEDAS score improved it to 0.902, with sensitivity and specificity of 76.00 % and 91.67 %. Furthermore, the combined model of three parameters resulted in the highest AUC of 0.950, the sensitivity 84.00 %, and the specificity 95.83 % (Figure 4).

Conclusions

In conclusion, NIHSS score, MEDAS score, as well as the plaque enhancement ratio were independent predictors of subacute IS prognosis. Noteworthy, the combined model showed significant superiority in the prognosis evaluation of stroke.

Acknowledgements

This study has received funding by the National Natural Science Foundation of China (grant number 81971592), and the Beijing Medical Reward Fund (grant number YXJL-2021-0353-0604).

References

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