Detecting Basilar Artery Wall Pathology in Isolated Pontine Infarction With Short-TE SWI Magnitude Images

BACKGROUND: Intracranial atherosclerotic ischemic stroke often involves plaques without luminal stenosis. Existing imaging techniques struggle to detect vessel wall pathology effectively. This study evaluates short–echo time susceptibility-weighted imaging magnitude images (STE-MI) for identifying cerebral microbleeds and reducing artifacts around the basilar artery (BA) compared with susceptibility-weighted angiography (SWAN), enabling its application in detecting BA wall pathology in acute isolated pontine infarction, particularly in patients with nonstenotic noncardioembolic disease. METHODS: This study presents a retrospective analysis of an ongoing prospective observational brain vascular imaging study focused on intracranial atherosclerosis in patients with acute ischemic stroke. Conducted from March 2022 to March 2025, imaging was performed using a 3.0 T magnetic resonance imaging scanner with advanced protocols, including SWAN and STE-MI sequences. The study evaluated cerebral microbleed detection, artifact reduction, and vessel wall imaging quality, with interobserver agreement assessed using Cohen κ . Clinical data, including risk factors and demographic information, were analyzed alongside imaging findings. RESULTS: Among 33 subjects, STE-MI detected 86% of the microbleeds identified by SWAN, with excellent interobserver agreement (Cohen κ =0.828). Blooming artifacts around the BA were minimized in 96.9% of 2475 cases using STE-MI, compared with only 5.5% with SWAN ( P =3.469×10 −18 ). Of the 16 patients with nonstenotic noncardioembolism with isolated pontine infarction, 12 were male, with a mean age of 68.1 years (SD=7.7). Among these patients, 10 (62.5%) exhibited extraluminal BA pathology on STE-MI (mixed hypo-/intermediate intensity in 6 cases, hypointensity in 4 cases), correlating with diffusion-weighted imaging lesion locations (Cohen κ =0.833). Univariate logistic regression analysis identified triglycerides ( P =0.033) and smoking ( P =0.041) as significant risk factors. CONCLUSIONS: STE-MI effectively minimizes artifacts and detects BA wall pathology in acute isolated pontine infarction, particularly in nonstenotic noncardioembolic stroke. This approach may enhance the identification of culprit lesions, potentially improving risk stratification and guiding targeted therapeutic strategies.