The Characteristics of Extracranial Internal Carotid Artery and Their Relationship With Surgical Outcomes in Patients With Moyamoya Disease: A Combined Head-and-Neck Vessel Wall MR Imaging Study

Abstract

Background: The features of intracranial arteries in patients with Moyamoya disease (MMD) have been widely investigated. However, the MR characteristics of extracranial internal carotid artery (EICA) and their effect on outcomes of revascularization treatment are not fully understood.

Purpose: To investigate the characteristics of EICA and their relationship with outcomes of revascularization treatment in adult patients with MMD based on higher-resolution MRI (HRMRI).

Study type: Prospective interventional outcomes.

Subjects: Two hundred eighty-eight consecutive patients with MMD (mean age: 43.7 ± 11.2 years; 140 male).

Field strength/sequence: Turbo inversion recovery magnitude T1-weighted imaging and turbo spin echo (TSE) T2-weighted imaging, three-dimensional time-of-flight MR angiography, T2-fluid attenuated inversion recovery, and 3D T1-SPACE vessel wall imaging at 3.0 T.

Assessment: The HRMRI characteristics of EICA were determined. The relationship between the characteristics of EICA (proximal stenosis, diffuse wall thickening, carotid plaques, and luminal thrombosis) and stroke outcomes of revascularization treatment in patients with MMD was analyzed. The discriminative ability of EICA characteristics in combination with intracranial carotid artery features (involvement of vessel segments, bilateral involvement, and Suzuki stage) to determine stroke outcomes was compared with that of intracranial artery features alone during a mean 8.0 months follow-up period.

Statistical tests: Cox proportional hazards models and Kaplan-Meier curves to calculate the hazard ratios (HRs) for stroke with 95% confidence intervals (CIs). Area under the receiver operating characteristic curve (AUC) for assessing discriminative performance. A P value <0.05 was considered statistically significant.

Results: During a mean 8.0 ± 2.2 months follow-up, of the 288 participants, 137 had proximal stenosis (47.6%), 106 had diffuse wall thickening (36.8%), 60 had carotid plaques (20.8%), and 27 had luminal thrombosis (9.4%) of EICA. Of these features, proximal stenosis (HR = 2.86; 95% CI = 1.13-7.29) and diffuse wall thickening (HR = 2.62; 95% CI = 1.16-5.94) of EICA were significantly associated with stroke after surgery, before and after adjusting for confounding factors. In discriminating the stroke outcomes after surgery, combining characteristics of EICA with features of intracranial arteries resulted in a significant incremental improvement (DeLong test, P < 0.05) in the AUC over that obtained with features of intracranial arteries alone (AUC: 0.73 vs. 0.60-0.64).

Conclusion: Proximal stenosis and diffuse wall thickening of EICA were significantly associated with stroke outcomes after surgery in patients with MMD. Our findings suggest that understanding the characteristics of EICA has added value for intracranial vessels in predicting future events after surgery in patients with MMD.

Evidence level: 2 TECHNICAL EFFICACY: Stage 4.

Keywords: carotid artery; moyamoya disease; prognosis; stroke.