Vessel Wall Enhancement and High-Sensitivity CRP as Prognostic Markers in Non-Cardioembolic Ischemic Stroke: A Prospective Cohort Study

Objective Eccentric vessel wall enhancement (EVWE) and high-sensitivity C-reactive protein (hs-CRP) are inflammatory biomarkers associated with atherosclerotic disease. We investigated their prognostic value in patients with acute ischemic stroke receiving guideline-adherent medical treatment. Methods In this prospective observational cohort study, patients with acute non-cardioembolic ischemic stroke underwent vessel wall MRI and hs-CRP testing. The primary outcome was subsequent ischemic stroke during the follow-up period. The median follow-up duration was 21 months. Kaplan-Meier survival and Cox regression analysis was used to determine the associations between EVWE, hs-CRP levels, and subsequent ischemic stroke. Results Among 191 patients, 81 (42.4%) had EVWE. EVWE positivity showed a trend towards a lower risk of subsequent ischemic stroke compared to EVWE negativity (HR 0.32, 95% CI 0.12–0.87; P = 0.061). Hs-CRP levels were not significantly associated with recurrent stroke risk. The combination of EVWE positivity and low hs-CRP levels (< 1.25 mg/L) was associated with the most favorable outcome, while EVWE negativity and high hs-CRP levels (≥ 1.25 mg/L) were associated with the worst outcome (HR 0.143, 95% CI 0.04–0.50; P = 0.031). Conclusions In patients with acute ischemic stroke receiving optimal medical therapy, EVWE positivity may paradoxically indicate a lower risk of recurrent stroke. The combination of EVWE and hs-CRP status provides prognostic information, with EVWE positivity and low hs-CRP levels associated with the most favorable outcome. These findings highlight the potential role of integrating imaging and serum inflammatory biomarkers in risk stratification and management of acute ischemic stroke patients.