Establishing susceptibility weighted imaging for evaluating intracranial calcium scoring in stroke patients

Intracranial atherosclerotic disease (ICAD) is a leading cause of ischemic stroke and is characterized by the buildup of atherosclerotic plaques in the intracranial arteries, leading to luminal stenosis and calcification. Effective diagnosis and stratification of ICAD are critical for optimizing stroke prevention and management. The ICAD scoring system is a critical tool for predicting stroke as it enables precise risk stratification by integrating imaging findings with clinical factors. By identifying patients at high risk of stroke based on stenosis severity and calcification patterns, the scoring system enhances early intervention and tailored management, significantly improving patient outcomes and reducing the incidence of stroke. Susceptibility- weighted imaging phase (SWIp) and cone-beam computed tomography (CBCT) differ significantly in their imaging mechanisms and clinical applications. SWIp is a magnetic resonance imaging (MRI) technique that excels in detecting subtle calcifications and venous vasculature due to its sensitivity to differences in magnetic susceptibility. In contrast, CBCT is an X-ray-based modality that provides high- resolution, three-dimensional images of bony structures and calcifications but lacks the ability to visualize venous vasculature or detect smaller calcifications as effectively as SWIp. These differences make SWIp more suitable for assessing severe stenosis and stratifying stroke risk, while CBCT performs better in detecting moderate stenosis and providing structural details of calcifications. This study aims to evaluate the diagnostic accuracy of SWIp compared to CBCT for assessing intracranial calcifications, predicting stenosis severity and establishing an ICAD scoring system. The objectives of this study were to identify the locations and grades of intracranial calcifications, estimate the sensitivity and specificity of CBCT and SWIp for ICAD diagnosis, generate cutoff values for stenosis prediction and develop a scoring system for stratifying stroke risk. A prospective cross-sectional study was conducted at Hospital Sultan Abdul Aziz Shah, Universiti Putra Malaysia, involving 146 stroke patients who underwent both CBCT and SWIp imaging from January 2022 to December 2023. The prevalence of intracranial calcifications was 87.7% and 92.5% for CBCT and SWIp, respectively. For stenosis grading, CBCT detected minimum- to-mild, moderate and severe stenosis at 18.5%, 58.9% and 10.3%, while SWIp reported 2.7%, 33.8% and 57.5%, respectively. SWIp demonstrated superior diagnostic performance for severe stenosis, with sensitivity and specificity of 93% and 52%, compared to CBCT’s 100% and 60%. However, CBCT exhibited higher sensitivity for moderate stenosis (99%) compared to SWIp (89%). These findings underscore the complementary strengths of both modalities, with SWIp offering greater accuracy for severe stenosis due to its ability to visualize venous vasculature and detect subtle calcifications often missed by CBCT. Furthermore, the ICAD scoring system developed in this study, based on SWIp parameters, effectively correlated imaging findings with clinical risk factors, enhancing stroke risk prediction. In conclusion, SWIp demonstrated superior diagnostic accuracy for severe stenosis and stroke risk stratification, making it an invaluable tool for ICAD assessment. This study advocates integrating SWIp into routine clinical practice to complement CBCT for improved stroke prevention and management strategies.

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