Incorporating intracranial vessel wall MRI findings changed etiologic classification in about 13-14% of young ischemic stroke patients, mostly toward large artery atherosclerosis, with baseline cryptogenic stroke associated with reclassification, suggesting incremental diagnostic value.
Key Findings
Results
Adding VWI findings changed stroke etiologic classification in a minority of young stroke patients under both classification systems.
Sixty-nine patients aged 18-59 years with acute ischemic stroke in the middle cerebral or anterior choroidal artery territory were prospectively included in a two-centre study.
Reclassification occurred in 9/69 (13%) patients by TOAST and 10/69 (14%) by CCS.
Contrast-enhanced VWI was performed within 2 weeks of stroke onset, and etiology was assessed before and after incorporating VWI findings.
Results
Under TOAST, VWI shifted the distribution of etiologies toward large artery atherosclerosis and away from cryptogenic stroke.
Large artery atherosclerosis increased from 17% to 28%.
Cryptogenic stroke decreased from 22% to 14%.
Reclassification was predominantly toward large artery atherosclerosis.
Results
VWI frequently identified intracranial atherosclerotic plaques not evident on luminal imaging.
These plaques drove the etiologic reclassification toward large artery atherosclerosis.
Luminal imaging alone did not reveal the arterial wall pathology detected by VWI.
Results
Baseline cryptogenic stroke classification was associated with etiologic reclassification after VWI.
Adjusted for age and sex, OR 7.8 (95% CI: 1.2-49.7; p = 0.029).
The wide confidence interval reflects the small number of reclassified patients.
Results
The study population was predominantly male and middle-aged.
Median age was 53 years.
72% of the 69 patients were male.
Conclusions
The authors conclude VWI has incremental diagnostic value in young stroke, especially cryptogenic cases, but larger prospective studies are needed.
Prior evidence on VWI was largely retrospective; this study was prospective.
Larger studies are warranted to determine its role in routine diagnostic algorithms.
What This Means
This study looked at whether a special type of MRI that images the walls of brain arteries (vessel wall MRI) could help doctors work out why young adults had a stroke. Sixty-nine people aged 18-59 who had a stroke in specific brain artery territories were scanned within two weeks. Doctors assigned a cause of stroke using two standard systems, first without and then with the vessel wall MRI results.
Adding the MRI findings changed the assigned cause in about 1 in 7 patients (13-14%). Most changes moved patients toward a diagnosis of large artery atherosclerosis (fatty plaque buildup in the arteries), because the scan found plaques in brain arteries that standard imaging of the vessel's channel had not shown. The share of strokes labeled 'cryptogenic' (unknown cause) fell from 22% to 14% under one system. Patients who were initially labeled cryptogenic were more likely to be reclassified, though the estimate was imprecise because the study was small.
This research suggests vessel wall MRI may add useful information on the cause of stroke in young people, especially when the cause is otherwise unclear. However, the study was small, and the authors note that larger prospective studies are needed before it can be considered part of routine diagnostic workups.
Reimand J, Schneider S, Vibo R, Kõrv L, Loorits D, Jõgi K, et al.. (2026). Diagnostic Impact of Intracranial Vessel Wall MRI on Ischemic Stroke Etiology in Young Adults.. European journal of neurology. https://doi.org/10.1111/ene.70795