Clinical Implications of Basilar Artery Plaques in the Pontine Infarction with Normal Basilar Angiogram: A High-Resolution Magnetic Resonance Imaging Study
Introduction
It has been traditionally accepted that the pathological findings of small subcortical infarctions are lipohyalinosis or fibrinoid necrosis of the perforating arteries.1, 2 However, this concept is debatable because previous researchers have described that atheromatous plaque in the intracranial arteries can obstruct the orifice of the perforators, the so-called branch atheromatous disease (BAD), and subsequently cause a subcortical infarction.3, 4 Although advances in imaging methods such as magnetic resonance angiography (MRA) made it possible to detect atheromatous plaques occluding the perforating arteries, the incidence of BAD may be underestimated since atheromatous plaques that do not cause luminal narrowing cannot be identified by MRA. Therefore, the application of imaging technologies that are able to show the arterial wall is necessary to improve our understanding of the pathogenesis of subcortical infarction.
High-resolution magnetic resonance imaging (HR-MRI), a promising noninvasive tool for depicting the arterial wall characteristics,5 can be more useful than MRA for identifying and localizing the atheromatous plaque in the intracranial arteries.6, 7, 8, 9 A previous study based on HR-MRI suggested that the atheromatous plaque close to the orifice of perforating arteries could increase the risk of an unfavorable functional outcome in cases of lenticulostriate artery territory infarction.10 However, there have been limited data regarding how the presence and location of atheromatous plaque relate to functional outcomes in patients with acute pontine infarction, especially those with a normal basilar artery on MRA. Thus, using HR-MRI, we sought to detect the basilar artery plaques that were not recognized by MRA and investigated its impact on functional outcomes in patients with acute pontine infarction.
Section snippets
Patient Selection
From January 2014 to June 2016, we prospectively screened 70 patients with unilateral isolated pontine infarction, as demonstrated by diffusion-weighted image (DWI) that was performed within 48 hours of symptom onset. Of these, we enrolled the patients with a normal basilar artery on MRA. Patients were excluded if they had greater than 50% stenosis in the vertebral arteries, potential cardiac sources of embolism according to the Trial of Organization 10172 in Acute Stroke Treatment
Patient Characteristics
Among the 70 screened patients, 40 were eligible for this study. The median age was 67.5 (59.0-75.0) years, and 27 (67.5%) patients were male. The median NIHSS score was 2.0 (1.0-4.0) on admission, and neurological deterioration occurred in 9 (22.5%) patients. An unfavorable functional outcome at 3 months was observed in 15 (37.5%) patients. Basilar artery plaques were observed in 24 (60.0%) patients. Of them, 14 (58.3%) patients had relevant basilar artery plaques. Interobserver reliability
Discussion
This study demonstrated that the presence of a relevant basilar artery plaque was associated with neurological deterioration within 7 days and unfavorable functional outcome at 3 months in patients with an acute pontine infarction. On the contrary, there was no significant difference in functional outcomes between the patients with irrelevant plaques and those without basilar artery plaques. Therefore, we suggest that functional outcome may be critically affected by basilar artery plaque
Conclusions
This study suggests that basilar artery plaques, if they were located close to the orifice of perforating arteries, could be responsible for severe initial clinical symptoms, neurological deterioration accompanied by a significant increase in subacute lesion volume, and subsequent unfavorable functional outcomes. Therefore, basilar artery plaque location should be carefully assessed, even in patients with normal basilar findings on MRA.
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Grant Support: This work was supported by Clinical Research Grant from Pusan National University Hospital 2018.