What is the clinical evidence from this study?

Study design: Observational. Population: Acute ischemic stroke with acute middle cerebral artery occlusion (n=146). Intervention: Carotid perivascular adipose tissue (PVAT) density vs. Lower PVAT density. Primary outcome: Large-artery atherosclerosis (LAA) etiology (OR 1.048, 95% CI 1.018-1.079, p=0.0016).

What question did this study set out to answer?

The aim is to examine the relationship between carotid perivascular adipose tissue density and large artery atherosclerotic stroke in patients undergoing mechanical thrombectomy.

June 7, 2026Open Access

Carotid Perivascular Adipose Tissue Density as a Marker of Large Artery Atherosclerotic Stroke in Patients Undergoing Mechanical Thrombectomy for Acute Middle Cerebral Artery Occlusion

Q: What does this research mean for the field?

Higher ipsilateral carotid perivascular adipose tissue (PVAT) density is independently associated with large-artery atherosclerosis stroke etiology in patients undergoing mechanical thrombectomy for acute middle cerebral artery occlusion, but does not predict procedural success or short-term clinical outcomes. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Key Result

Higher ipsilateral carotid PVAT density was independently associated with large-artery atherosclerosis stroke etiology (OR 1.048 per 1-HU increase; 95% CI 1.018-1.079; p=0.0016).

Key Points

The aim is to examine the relationship between carotid perivascular adipose tissue density and large artery atherosclerotic stroke in patients undergoing mechanical thrombectomy.
Retrospective analysis of 146 patients with acute ischemic stroke treated with mechanical thrombectomy.
Use of computed tomography angiography to quantify carotid perivascular adipose tissue density.
Classification of stroke etiology according to the TOAST system.
In the large artery atherosclerosis subgroup (n = 38), ipsilateral PVAT density was significantly higher than contralateral density (−64.24 ± 11.74 vs. −78.22 ± 9.13 HU; p < 0.001).
Ipsilateral PVAT density was significantly different across TOAST groups (ANOVA p = 0.004), with a notable difference between LAA and cardioembolism (Δ = 11.19 HU; p = 0.003).
Higher ipsilateral PVAT density was independently associated with LAA stroke etiology (OR 1.048, 95% CI 1.018–1.079; p = 0.0016).

Study Design

Type

Observational (n=146)

Structured PICO

Is carotid PVAT density on CTA associated with large-artery atherosclerotic stroke etiology in patients undergoing mechanical thrombectomy for acute MCA occlusion?

Population

146 patients with acute ischemic stroke treated with mechanical thrombectomy for acute middle cerebral artery occlusion, assessed for 90-day outcomes.

Exposure

Carotid perivascular adipose tissue (PVAT) density measurement on baseline computed tomography angiography (CTA)

Comparator

Contralateral PVAT density and non-LAA stroke etiologies (cardioembolism and other/undetermined)

Outcome

Stroke etiology classified according to the TOAST system (specifically large-artery atherosclerosis [LAA])surrogate

Carotid PVAT density on CTA may serve as a noninvasive marker to identify large-artery atherosclerotic etiology in patients with acute MCA occlusion.

Main Result

Odds Ratio: 1.048 (95% CI 1.018–1.079)

p-value: p=0.0016

Abstract

Background/Objectives: Carotid perivascular adipose tissue (PVAT) density on computed tomography angiography (CTA) is a noninvasive surrogate marker of local vascular inflammation, but its relevance to stroke etiology in a homogeneous cohort of patients undergoing mechanical thrombectomy (MT) remains unclear. Methods: We retrospectively analyzed 146 consecutive patients with acute ischemic stroke treated with MT for acute middle cerebral artery (MCA) occlusion between May 2018 and August 2024. Baseline CTA was used to quantify carotid PVAT density with two 2–3 mm2 circular regions of interest per internal carotid artery (ICA), placed ≥1 mm from the vessel wall. Measurements were performed bilaterally, and the ICA ipsilateral to the occluded MCA was defined as the stroke-side ICA. Etiology was classified according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) system and grouped as large-artery atherosclerosis (LAA), cardioembolism (CE), and other/undetermined (OD/UD). Interobserver agreement was assessed using the intraclass correlation coefficient. Results: The mean age was 72.21 ± 12.39 years; 83.6% of patients achieved successful recanalization (mTICI ≥ 2b), and 47.9% had a favorable 90-day outcome (mRS ≤ 2). In the LAA subgroup (n = 38), ipsilateral PVAT density was significantly higher (less negative) than contralateral PVAT density (−64.24 ± 11.74 vs. −78.22 ± 9.13 HU; p < 0.001). Ipsilateral PVAT density differed significantly across TOAST groups (ANOVA p = 0.004), being higher in LAA than in CE (Δ = 11.19 HU; p = 0.003) and OD/UD (Δ = 9.54 HU; p = 0.004). ROC analysis showed modest discrimination for LAA versus non-LAA stroke (AUC 0.67, 95% CI 0.58–0.75), with an optimal cutoff of −79 HU (sensitivity 92.1%, specificity 40.7%). In multivariable logistic regression, higher ipsilateral PVAT density was independently associated with LAA etiology (per 1-HU increase: OR 1.048, 95% CI 1.018–1.079; p = 0.0016). PVAT density was not associated with recanalization success or 90-day functional outcome. Conclusions: In patients with acute MCA occlusion undergoing MT, higher carotid PVAT density on the stroke side was independently associated with LAA stroke etiology but had limited value for predicting MT success or short-term clinical outcome.