Advancements in imaging of intracranial atherosclerotic disease: beyond the arterial lumen to the vessel wall

Abstract Intracranial atherosclerotic disease (ICAD) significantly increases the risk of ischemic stroke. It involves the accumulation of plaque within arterial walls and narrowing or blockage of blood vessel lumens. Accurate imaging is crucial for the diagnosis and management of ICAD at both acute and chronic stages. However, imaging the small, tortuous intracranial arterial walls amidst complex structures is challenging. Clinicians have employed diverse approaches to improve imaging quality, with a particular emphasis on optimizing the acquisition of images using new techniques, enhancing spatial and temporal resolution of images, and refining post-processing techniques. ICAD imaging has evolved from depicting lumen stenosis to assessing blood flow reserve and identifying plaque components. Advanced techniques such as fractional flow reserve (FFR), high-resolution vessel wall magnetic resonance (VW-MR), optical coherence tomography (OCT), and radial wall strain (RWS) now allow direct visualization of flow impairment, vulnerable plaques, and blood flow strain to plaque, aiding in the selection of high-risk stroke patients for intervention. This article reviews the progression of imaging modalities from lumen stenosis to vessel wall pathology and compares their diagnostic value for risk stratification in ICAD patients.