Introduction: Anterior and posterior circulation atheroscleroses differ in vascular risk factors and stroke patterns. Posterior circulation stroke has worse clinical outcomes. However, few studies described the differentiation of plaque features between anterior and posterior circulation atheroscleroses via high-resolution vessel wall imaging (HR-VWI). We aimed to compare the plaque imaging features between anterior and posterior circulations to highlight the relevance of plaque imaging features to clinical events of ischemic stroke. Methods: Prospective data from a HR-VWI cohort of adult patients with acute ischemic stroke or transient ischemic attack were retrospectively analyzed. Quantitative and qualitative measurements of atherosclerotic plaques along the middle cerebral arteries (MCAs), the basilar artery (BA), and the vertebral arteries (VAs) were conducted on HR-VWI. Vessels with stenotic degrees over 30% were identified on the matched time-of-flight magnetic resonance angiography (TOF-MRA) and visually classified into normal, irregular, stenotic, and occluded. The sensitivity, specificity, positive and negative predictive values for TOF-MRA in detecting abnormal vessels were calculated by using quantification on the basis of HR-VWI findings as the reference standard. Results: One hundred and one patients (median age, 64 years old; 62.4% males) were included in this study. A total of 292 plaques were identified, with 152 in the MCAs, 35 in the BA, and 105 in the VAs. The VAs possessed significantly higher enhancement index (EI) (median 38.37 vs. 18.40, p <0.001), more plaques with positive remodeling (76.2% vs. 57.2%, p = 0.002) and intraplaque hypo-intensity (43.8% vs. 12.5%, p <0.001) than the MCAs. The MCAs presented with more intraplaque hemorrhage (IPH) (20.4% vs. 8.6%, p = 0.014) than the VAs. The sensitivity and specificity of TOF-MRA for evaluating luminal stenosis were 89.0 (82.5–93.4) and 66.7 (24.1–94.0) in anterior circulation, respectively, and were 75.2 (66.7–82.2) and 27.3 (7.3–60.7) in posterior circulation, respectively. Conclusion: Our findings might elucidate the clinical events and outcomes in anterior and posterior circulation stroke. Posterior circulation atherosclerosis had higher EI and more plaques with hypo-intensity, suggesting a heavier atherosclerosis burden. Positive remodeling pattern in posterior circulation atherosclerosis might create an impression of “wider” vascular lumen, leading to possible underestimation of atherosclerosis burden of posterior circulation on TOF-MRA as compared to HR-VWI. Besides, anterior circulation atherosclerosis with IPH might be associated with plaque rupture and artery-to-artery embolism. Future studies are needed to verify these findings.

Holmstedt CA, Turan TN, Chimowitz MI. Atherosclerotic intracranial arterial stenosis: risk factors, diagnosis, and treatment. Lancet Neurol. 2013;12(11):1106–14.
Almallouhi E, Al Kasab S, Yamada L, Martin RH, Turan TN, Chimowitz MI. Relationship between vascular risk factors and location of intracranial atherosclerosis in the SAMMPRIS trial. J Stroke Cerebrovasc Dis. 2020;29(5):104713.
Zürcher E, Richoz B, Faouzi M, Michel P. Differences in ischemic anterior and posterior circulation strokes: a clinico-radiological and outcome analysis. J Stroke Cerebrovasc Dis. 2019;28(3):710–8.
Kim JS, Nah HW, Park SM, Kim SK, Cho KH, Lee J, et al. Risk factors and stroke mechanisms in atherosclerotic stroke: intracranial compared with extracranial and anterior compared with posterior circulation disease. Stroke. 2012;43(12):3313–8.
Lee SH, Han JH, Jung I, Jung JM. Do thrombolysis outcomes differ between anterior circulation stroke and posterior circulation stroke? A systematic review and meta-analysis. Int J Stroke. 2020;15(8):849–57.
Yang WJ, Fisher M, Zheng L, Niu CB, Paganini-Hill A, Zhao HL, et al. Histological characteristics of intracranial atherosclerosis in a Chinese population: a postmortem study. Front Neurol. 2017;8:488.
Zheng L, Yang WJ, Niu CB, Zhao HL, Wong KS, Leung TWH, et al. Correlation of adventitial vasa vasorum with intracranial atherosclerosis: a postmortem study. J Stroke. 2018;20(3):342–9.
Jiang H, Ren K, Li T, Qian C, Gong S, Wang T, et al. Correlation of the characteristics of symptomatic intracranial atherosclerotic plaques with stroke types and risk of stroke recurrence: a cohort study. Ann Transl Med. 2022;10(12):658.
Li S, Song X, Hu Q, Zhao J, Du H, Yan Y, et al. Association of plaque features with infarct patterns in patients with acutely symptomatic middle cerebral artery atherosclerotic disease. J Stroke Cerebrovasc Dis. 2021;30(5):105724.
Hou Z, Li M, Lyu J, Xu Z, Liu Y, He J, et al. Intraplaque enhancement is associated with artery-to-artery embolism in symptomatic vertebrobasilar atherosclerotic diseases. Front Neurol. 2021;12:680827.
Yang WJ, Abrigo J, Soo YOY, Wong S, Wong KS, Leung TWH, et al. Regression of plaque enhancement within symptomatic middle cerebral artery atherosclerosis: a high-resolution MRI study. Front Neurol. 2020;11:755.
Li J, Yang WJ, Zheng L, Du H, Chu WCW, Leung TWH, et al. Vertebrobasilar junction angle over 90°: a potential imaging marker associated with vertebrobasilar atherosclerosis. Front Neurosci. 2021;15:789852.
Wang M, Wu F, Yang Y, Miao H, Fan Z, Ji X, et al. Quantitative assessment of symptomatic intracranial atherosclerosis and lenticulostriate arteries in recent stroke patients using whole-brain high-resolution cardiovascular magnetic resonance imaging. J Cardiovasc Magn Reson. 2018;20(1):35.
Yang WJ, Wasserman BA, Zheng L, Huang ZQ, Li J, Abrigo J, et al. Understanding the clinical implications of intracranial arterial calcification using brain CT and vessel wall imaging. Front Neurol. 2021;12:619233.
Qiao Y, Anwar Z, Intrapiromkul J, Liu L, Zeiler SR, Leigh R, et al. Patterns and implications of intracranial arterial remodeling in stroke patients. Stroke. 2016;47(2):434–40.
Zhao DL, Deng G, Xie B, Ju S, Yang M, Chen XH, et al. High-resolution MRI of the vessel wall in patients with symptomatic atherosclerotic stenosis of the middle cerebral artery. J Clin Neurosci. 2015;22(4):700–4.
Li F, McDermott MM, Li D, Carroll TJ, Hippe DS, Kramer CM, et al. The association of lesion eccentricity with plaque morphology and components in the superficial femoral artery: a high-spatial-resolution, multi-contrast weighted CMR study. J Cardiovasc Magn Reson. 2010;12(1):37.
Xu WH, Li ML, Gao S, Ni J, Yao M, Zhou LX, et al. Middle cerebral artery intraplaque hemorrhage: prevalence and clinical relevance. Ann Neurol. 2012;71(2):195–8.
Yang WJ, Chen XY, Zhao HL, Niu CB, Zhang B, Xu Y, et al. Postmortem study of validation of low signal on fat-suppressed T1-weighted magnetic resonance imaging as marker of lipid core in middle cerebral artery atherosclerosis. Stroke. 2016;47(9):2299–304.
Donners SJA, Toorop RJ, de Kleijn DPV, de Borst GJ. A narrative review of plaque and brain imaging biomarkers for stroke risk stratification in patients with atherosclerotic carotid artery disease. Ann Transl Med. 2021;9(15):1260.
Dieleman N, Yang W, Abrigo JM, Chu WCW, van der Kolk AG, Siero JCW, et al. Magnetic resonance imaging of plaque morphology, burden, and distribution in patients with symptomatic middle cerebral artery stenosis. Stroke. 2016;47(7):1797–802.
Lee YK, Kwak HS, Chung GH, Hwang SB. Lipid-rich necrotic core of basilar artery atherosclerotic plaque: contrast-enhanced black blood imaging on vessel wall imaging. Diagnostics. 2019;9(3):69.
Wang D, Shang ZY, Cui Y, Yang BQ, Ntaios G, Chen HS. Characteristics of intracranial plaque in patients with non-cardioembolic stroke and intracranial large vessel occlusion. Stroke Vasc Neurol. 2023;8(5):387–98.
Zarrinkoob L, Ambarki K, Wåhlin A, Birgander R, Eklund A, Malm J. Blood flow distribution in cerebral arteries. J Cereb Blood Flow Metab. 2015;35(4):648–54.
Denswil NP, van der Wal AC, Ritz K, de Boer OJ, Aronica E, Troost D, et al. Atherosclerosis in the circle of Willis: spatial differences in composition and in distribution of plaques. Atherosclerosis. 2016;251:78–84.
Ritz K, Denswil NP, Stam OCG, van Lieshout JJ, Daemen MJAP. Cause and mechanisms of intracranial atherosclerosis. Circulation. 2014;130(16):1407–14.
Chen XY, Wong KS, Lam WWM, Zhao HL, Ng HK. Middle cerebral artery atherosclerosis: histological comparison between plaques associated with and not associated with infarct in a postmortem study. Cerebrovasc Dis. 2008;25(1–2):74–80.
Burke AP, Kolodgie FD, Farb A, Weber D, Virmani R. Morphological predictors of arterial remodeling in coronary atherosclerosis. Circulation. 2002;105(3):297–303.
Saloner D. The AAPM/RSNA physics tutorial for residents. An introduction to MR angiography. Radiographics. 1995;15(2):453–65.
Kim DK, Verdoorn JT, Gunderson TM, Huston Iii J, Brinjikji W, Lanzino G, et al. Comparison of non-contrast vessel wall imaging and 3-D time-of-flight MRA for atherosclerotic stenosis and plaque characterization within intracranial arteries. J Neuroradiol. 2020;47(4):266–71.
Huo X, Raynald, Gao F, Ma N, Mo D, Sun X, et al. Characteristic and prognosis of acute large vessel occlusion in anterior and posterior circulation after endovascular treatment: the ANGEL registry real world experience. J Thromb Thrombolysis. 2020;49(4):527–32.
Hendrix P, Killer-Oberpfalzer M, Broussalis E, Melamed I, Sharma V, Mutzenbach S, et al. Mechanical thrombectomy for anterior versus posterior circulation large vessel occlusion stroke with emphasis on posterior circulation outcomes. World Neurosurg. 2022;158:e416–22.
Jiang S, Liu Q, Zhang C, Chen K, Dou W, Wang X. High-resolution vessel wall MRI in assessing postoperative restenosis of intracranial atherosclerotic disease before drug-coated balloon treatment: an outcome prediction study. J Magn Reson Imaging. 2023;58(1):69–78.
Ma N, Xu Z, Lyu J, Li M, Hou Z, Liu Y, et al. Association of perforator stroke after basilar artery stenting with negative remodeling. Stroke. 2019;50(3):745–9.
You do not currently have access to this content.