Association between leukoaraiosis and cerebral blood flow territory alteration in asymptomatic internal carotid artery stenosis

To test the hypothesis that leukoaraiosis (also known as white matter lesion) is associated with cerebral blood flow territory change as revealed by territorial arterial spin-labeling (TASL) magnetic resonance imaging (MRI) in patients with asymptomatic internal carotid artery stenosis (aICAS). The institutional review board approved this study. Thirty-three patients with aICAS were included prospectively and divided into high-grade (ultrasonographic stenosis ≥70%, n=17) and low-grade (n=16) groups; 16 healthy subjects were also included. Cerebral flow territory was delineated for left ICA, right ICA, and vertebral arteries using TASL MRI and fuzzy clustering. Two licensed neuroradiologists independently and dichotomously rated the hemispherical asymmetry of flow territories. Flow territories were finalised by consensus, and when asymmetry was present, these were divided into normal and abnormal areas where the raters separately assessed leukoaraiosis based on fluid-attenuated inversion recovery images and the Fazekas scale. The inter-rater agreement in the evaluation of flow territory asymmetry with TASL imaging in conjunction with time-of-flight angiogram is substantial (Cohen's kappa=0.82). Multinomial logistic regression (reference group=healthy subjects) indicates that global leukoaraiosis is not a predictor of aICAS after controlling for age, whereas in high-grade patients, the deep white matter lesion is more severe in the area receiving collateral circulation than in the area with normal flow territory (Wilcoxon signed-rank test, p=0.03). TASL MRI is clinically feasible in aICAS and shows that more severe deep white matter lesions are associated with collateral circulation in high-grade patients. •Deep white matter lesion associates with collateral circulation in high-grade aICAS.•Global leukoaraiosis is not predictive of aICAS after controlling for age.•Cross-reference with TOF angiogram improves the inter-rater agreement of TASL imaging.