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Increased incidence of napkin-ring sign plaques on cervicocerebral computed tomography angiography associated with the risk of acute ischemic stroke occurrence

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Abstract

Objectives

Carotid atherosclerosis plays an essential role in the occurrence of ischemic stroke. This study aimed to investigate whether a larger burden of napkin-ring sign (NRS) plaques on cervicocerebral computed tomography angiography (CTA) increased the risk of acute ischemic stroke (AIS).

Methods

This retrospective, single-center, cross-sectional study enrolled patients with NRS plaques identified in the subclavian arteries, brachiocephalic trunk, carotid arterial system, and vertebrobasilar circulation on contrast-enhanced cervicocerebral CTA. Patients were divided into AIS and non-AIS groups based on imaging within 12 h of symptom onset. Univariate and multivariate logistic regression analyses were performed to determine the risk factor of AIS occurrence.

Results

A total of 202 patients (66.72 years ± 8.97, 157 men) were evaluated. Plaques with NRS in each subject of the AIS group (N = 98) were significantly more prevalent than that in the control group (N = 104) (1.96 ± 1.17 vs 1.41 ± 0.62). In the AIS group, there were substantially more NRS plaques on the ipsilateral side than contralateral side (1.55 ± 0.90 vs. 0.41 ± 0.66). NRS located on the ipsilateral side of the AIS showed an area under the receiver curve (AUC) of 0.86 to identify ischemic stroke. NRS plaque amounts were an independent risk factor for AIS occurrence (odds ratio, 1.86) after adjusting for other factors.

Conclusions

Increased incidence of napkin-ring sign plaques on cervicocerebral CTA was positively associated with AIS occurrence, which could aid in detecting asymptomatic atherosclerotic patients at high risk of AIS in routine screening or emergency settings.

Clinical relevance statement

Napkin-ring sign plaque provides an important imaging target for estimating acute ischemic stroke risk and identifying high-risk patients in routine screening or emergency settings, so that timely anti-atherosclerotic therapy can be used for prevention.

Key Points

• This cross-sectional study investigated the association between high-risk carotid artery plaques and acute ischemic stroke.

• Increased incidence of napkin-ring sign plaques on cervicocerebral computed tomography angiography is positively associated with acute ischemic stroke occurrence.

• Napkin-ring signs help identify risky patients prone to acute ischemic stroke to facilitate prevention.

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Abbreviations

ACS:

Acute coronary syndrome

AIS:

Acute ischemic stroke

CTA:

Computed tomography angiography

CVD:

Cerebrovascular disease

HRP :

High-risk plaques

LAP:

Low attenuation plaque

MACE:

Major adverse cardiovascular events

NRS:

Napkin-ring sign

PR:

Positive remodeling

TCFA:

Thin-cap fibroatheroma

TIA :

Transient ischemic attack

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Acknowledgements

We would like to thank all the patients who agreed to participate in this study.

Funding

This work is supported by the Key R&D program of Hainan Province (ZDYF2019169), Natural Science Foundation of Hainan Province (822RC738), and Sanya University Talent Introduction Project (USYRC22-05).

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Authors and Affiliations

  1. The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China

    **g** Wu & Fan Zhang

  2. Department of Radiology, Hainan Hospital of PLA General Hospital, Sanya, China

    **g** Wu, Ying Zou & Fan Zhang

  3. Department of Nutrition, School of Public Health, Sun Yat-Sen University, Guangzhou, China

    **-Wu-Aff1-Aff2">**g** Wu

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  4. Ying Zou
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  5. **ao Meng
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  6. Zhaoyang Fan
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Corresponding author

Correspondence to Fan Zhang.

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Guarantor

The scientific guarantor of this publication is Fan Zhang.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

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

Ethical approval

Institutional Review Board approval was obtained. This study has been approved by our institutional Medical Ethical Committee of Hainan Hospital of PLA General Hospital.

Study subjects or cohorts overlap

Study subjects or cohorts have not been previously reported.

Methodology

• retrospective

• cross-sectional study

• performed at one institution

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**g** Wu and Ying Zou contributed to the work equally and could be regarded as co-first authors.

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Wu, J., Zou, Y., Meng, X. et al. Increased incidence of napkin-ring sign plaques on cervicocerebral computed tomography angiography associated with the risk of acute ischemic stroke occurrence. Eur Radiol 34, 4438–4447 (2024). https://doi.org/10.1007/s00330-023-10404-w

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