Eccentric Vessel Wall Enhancement and hs-CRP as Prognostic Markers in Acute Ischemic Stroke: A Prospective Cohort Study

Background and Purpose: 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. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This prospective observational cohort study was approved by the Institutional Review Board of The Catholic University of Korea (OC23RISI0149). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Upon reasonable request to the corresponding author, aggregate data can be shared