European Journal of Cardiovascular Medicine

Ischemic stroke is the leading cause of death and disability in the modern world. The condition, which affects around 85% of all stroke cases, is caused by a blockage in the cerebral blood supply which leads to damage to neurons and loss of function. The narrowing or blockage of blood vessels, can be caused by atherosclerosis, thromboembolism, or small vessel disease. The morbidity and economic burden caused by stroke-related consequences can be greatly reduced with appropriate intervention, which is why it is crucial to identify persons at risk for stroke early to initiate preventive measures [1-3].

A key component of the pathophysiology of stroke is carotid atherosclerosis. Cerebrovascular events can occur in people who have certain anatomical or functional abnormalities in the carotid arteries, which are important blood channels that carry oxygenated blood to the brain. Increases in CIMT, which represent the intimal and medial artery wall thickness, are linked to endothelial dysfunction, arterial stiffness, and plaque formation, all of which raise the risk of stroke [3-5].

An increased risk of ischemic stroke is significantly associated with higher CIMT, according to multiple large-scale epidemiological studies. Higher CIMT readings are associated with an increased risk of cerebrovascular and cardiovascular events, according to the research studies. This risk exists even in the absence of obvious clinical disease [4-6].

Standardized cut-off values for stroke risk assessment are still being investigated, even though there is increasing evidence that CIMT can predict ischemic strokes on its own. Stroke risk increases gradually with increasing CIMT elevation, even at subclinical levels, according to some publications, while other studies link a CIMT threshold of ≥0.9 mm to a substantially greater risk of stroke. Hence, more study is required to determine the best CIMT cut-off for identifying high-risk patients and directing clinical decision-making about preventive actions against stroke [7-9].

The major goal of this research is to determine how well CIMT predicts ischemic stroke by comparing CIMT results in patients with stroke and healthy controls and how it relates to more traditional risk variables. We are also interested in finding the right CIMT threshold that can be useful to screen for stroke risk, which will allow for earlier diagnosis and treatment to lower the risk of stroke and its consequences [8-10].

This case-control study was conducted at Department of Radiology, Kamineni Academy of Medical Sciences And Research Centre, LB Nagar, Hyderabad, Telangana, India between February 2024 to January 2025. In this study 200 participants were involved, comprising 100 first ischemic stroke cases diagnosed on CT/MRI and 100 matched controls based on age and sex. CIMT was assessed using high-resolution B-mode ultrasonography done on Philips HD 11XE at the common carotid artery (CCA), carotid bulb, and internal carotid artery (ICA) on both sides. We took a mean of the CIMT values from these sites. Demographic profiles, vascular risk factors, and lipid profiles of patients were documented. Statistical analysis utilized SPSS version 25, employing logistic regression to evaluate the predictive value of CIMT for ischemic stroke. A p-value less than 0.05 was deemed statistically significant.

Inclusion Criteria:

• Age 40–80 years with confirmed first ischemic stroke on CT/MRI brain scan.
• Age and sex-matched healthy controls.
• Presence of at least one vascular risk factor
• Provided informed consent.

Exclusion Criteria:

• Hemorrhagic stroke or non-ischemic causes.
• Recurrent strokes on CT/MRI.
• Carotid artery occlusion.
• Chronic kidney disease or inflammatory disorders.
• Severe obesity (BMI >40 kg/m²) or long-term steroid use.
• Poor ultrasound image quality for CIMT measurement.

Ischemic stroke patients had a significantly greater mean CIMT (1.08 ± 0.22 mm) compared to controls (0.75 ± 0.17 mm, p < 0.001).

Table 1: Comparison of CIMT between Stroke Patients and Controls

The CIMT values of stroke patients and healthy controls differ significantly, as seen in Table 1. A considerably higher CIMT was seen in stroke patients compared to controls (p < 0.001), suggesting a clear association between ischemic stroke and increased CIMT. Thicker carotid intima-media layers are associated with an increased risk of ischemic stroke, showing a robust relationship between CIMT and this condition.

Association of CIMT with Risk Factors:

Hypertensive, diabetic, and dyslipidemic patients had substantially higher CIMT than healthy controls. It appears that these factors, that enhance the likelihood of a stroke, have a positive association with thicker walls of carotid arteries. 

Table 2: CIMT Based on Risk Factors

The impact of conventional stroke risk variables on CIMT is seen in Table 2. The CIMT was 1.14 mm in hypertension patients and 0.83 mm in non-hypertensive people (p = 0.004). Diabetes (p = 0.006) and dyslipidaemia (p = 0.003) both showed similar tendencies, indicating that these diseases are linked to thicker carotid intima-media.

ROC Curve Analysis for CIMT as a Stroke Predictor:

Analysed using ROC curves, the predictive value of CIMT for ischemic stroke was determined. The results showed that a CIMT threshold of ≥0.9 mm had a sensitivity of 80.0% and a specificity of 76.0%, which means that it can accurately predict the risk of stroke.

Table 3: ROC Analysis for CIMT in Predicting Ischemic Stroke

An effective predictor of ischemic stroke with an AUC of 0.83 (p < 0.001) is a CIMT threshold of ≥0.9 mm, as shown in Table 3's ROC curve analysis. This provides more evidence that CIMT is a valid screening technique for ischemic stroke risk assessment.

Rosvall et al., 2005 in this study assessed carotid intima-media thickness (CIMT) as a predictor of ischemic stroke and its relationship with traditional vascular risk factors [11]. The results indicated that patients with ischemic stroke exhibited significantly elevated CIMT values in comparison to healthy controls (1.08 ± 0.22 mm vs. 0.75 ± 0.17 mm, p < 0.001), supporting the hypothesis that increased CIMT serves as a robust marker of atherosclerosis and a predictor of stroke risk. Chambless et al., 2000; Inaba et al., 2012 reported the findings corroborate earlier research that identifies CIMT as a preliminary marker of subclinical vascular alterations that may precede cerebrovascular incidents [12, 13].

Wannarong et al., 2013 in their study demonstrated a significant association with major cardiovascular risk factors, including

hypertension, diabetes mellitus, and dyslipidaemia, which are recognized contributors to vascular dysfunction and atherogenesis [14].  Willeit et al., 2020; Simon et al., 2002 in their study reported that among stroke patients, individuals with hypertension demonstrated the highest carotid intima-media thickness (CIMT) values (1.14 ± 0.21 mm), followed by those with diabetes (1.12 ± 0.24 mm) and dyslipidaemia (1.16 ± 0.23 mm). Statistically significant differences were observed when compared to patients without these conditions (p < 0.01). The findings align with previous studies indicating a positive correlation between CIMT and systemic inflammation, endothelial dysfunction, and lipid accumulation in arterial walls [15, 16].

Stein et al., 2008; reported the predictive accuracy of CIMT for ischemic stroke was validated through receiver operating characteristic (ROC) analysis, yielding an AUC of 0.83 (p < 0.001). A CIMT threshold of ≥0.9 mm demonstrated 80.0% sensitivity and 76.0% specificity, highlighting its efficacy as a screening instrument for stroke risk evaluation [17]. Spence et al., 2002; Kitamura et al., 2004 in their study reinforced the increasing evidence that CIMT measurement can function as a non-invasive and cost-effective approach for the early identification of individuals at elevated risk for cerebrovascular events, supplementing conventional risk factor evaluations [18, 19].

Mitchell et al., 2005; in their study reported the clinical implications of these findings indicate that routine CIMT measurement may be integrated into stroke prevention programs, particularly for high-risk populations. Baldassarre et al., 2012; Nambi et al., 2010 reported significant association with modifiable risk factors, implementing lifestyle changes and rigorously managing hypertension, diabetes, and dyslipidaemia may contribute to the deceleration of CIMT progression and a decrease in stroke incidence [20-22].

Amarenco et al., 2006; Nasr et al., 2018 in their study demonstrated that CIMT serves as a significant indicator of ischemic stroke risk and is closely linked to conventional vascular risk factors. The measurement of CIMT can function as an early warning mechanism for stroke prevention, enabling prompt intervention and strategies for risk reduction [26-28].

This study indicates that carotid intima-media thickness (CIMT) serves as a significant predictor of ischemic stroke, as stroke patients show significantly elevated CIMT values in comparison to healthy controls (1.08 ± 0.22 mm vs. 0.75 ± 0.17 mm, p < 0.001). CIMT exhibited a significant correlation with major vascular risk factors such as hypertension, diabetes mellitus, and dyslipidaemia, underscoring its potential as an indicator of early atherosclerotic changes. Receiver operating characteristic (ROC) curve analysis demonstrated the predictive accuracy of CIMT, presenting an AUC of 0.83 and an optimal cut-off value of ≥0.9 mm, which resulted in 80.0% sensitivity and 76.0% specificity for predicting ischemic stroke. The findings underscore the potential of CIMT as a non-invasive and cost-effective screening method for identifying individuals at elevated risk for ischemic stroke. The significant correlation between CIMT and modifiable risk factors suggests that regular CIMT measurement in high-risk populations may facilitate early detection and enhance stroke prevention strategies. Larger multi-center studies are necessary to establish standardized CIMT thresholds and evaluate its long-term predictive value.

1.       Bots ML, Evans GW, Riley WA, Grobbee DE. Carotid intima-media thickness measurements in observational and intervention studies. Stroke. 2003;34(12):2951-2954.

2.       O'Leary DH, Polak JF. Intima-media thickness: a tool for atherosclerosis imaging and event prediction. Am J Cardiol. 2002;90(10C):18L-21L.

3.       Lorenz MW, Markus HS, Bots ML, Rosvall M, Sitzer M. Prediction of clinical cardiovascular events with carotid intima-media thickness. Circulation. 2007;115(4):459-467.

4.       Touboul PJ, Hennerici MG, Meairs S, Adams H, Amarenco P, Bornstein N, et al. Mannheim carotid intima-media thickness consensus. Cerebrovasc Dis. 2004;18(4):346-349.

5.       Polak JF, O'Leary DH. Carotid intima-media thickness as a surrogate for and predictor of CVD. Glob Heart. 2016;11(3):295-312.

6.       Touboul PJ, Labreuche J, Vicaut E, Amarenco P. Carotid intima-media thickness, plaques, and stroke risk: a meta-analysis. Stroke. 2010;41(5):1348-1354.

7.       de Groot E, van Leuven SI, Duivenvoorden R, Meuwese MC, Akdim F, Bots ML, et al. Measurement of carotid intima-media thickness to assess progression and regression of atherosclerosis. Nat Clin Pract Cardiovasc Med. 2008;5(5):280-288.

8.       Lorenz MW, von Kegler S, Steinmetz H, Markus HS, Sitzer M. Carotid intima-media thickening indicates a higher vascular risk across a wide age range. Neurology. 2006;67(1):56-61.

9.       Rundek T, Arif H, Boden-Albala B, Elkind MSV, Paik MC, Sacco RL. Carotid intima-media thickness predicts incident stroke. Stroke. 2008;39(6):1593-1598.

10.    Mackinnon AD, Jerrard-Dunne P, Sitzer M, Buehler A, von Kegler S, Markus HS. Rates and determinants of carotid IMT progression. Stroke. 2004;35(9):2150-2154.

11.    Rosvall M, Janzon L, Berglund G, Engstrom G, Hedblad B. Incidence of stroke is related to carotid IMT in subjects with high and low cardiovascular risk. Stroke. 2005;36(10):2072-2076.

12.    Chambless LE, Folsom AR, Clegg LX, Sharrett AR, Shahar E, Nieto FJ, et al. Carotid wall thickness is predictive of clinical cardiovascular events. Am J Epidemiol. 2000;151(5):478-487.

13.    Inaba Y, Chen JA, Bergmann SR. Carotid plaque, intima-media thickness, and cardiovascular events. JACC Cardiovasc Imaging. 2012;5(10):921-931.

14.    Wannarong T, Parraga G, Buchanan D, Fenster A, House A, Shoamanesh A, et al. Progression of carotid plaque volume predicts cardiovascular events. Stroke. 2013;44(7):1859-1865.

15.    Willeit P, Tschiderer L, Allara E, Reuber K, Seekircher L, Gao LU, et al. Carotid intima-media thickness progression and risk of vascular events. Ann Intern Med. 2020;172(7):464-473.

16.    Simon A, Gariepy J, Chironi G, Megnien JL, Levenson J. Intima-media thickness: A new tool for diagnosis and treatment of cardiovascular risk. J Hypertens. 2002;20(2):159-169.

17.    Stein JH, Korcarz CE, Hurst RT, Lonn E, Kendall CB, Mohler ER, et al. Use of carotid ultrasound to identify subclinical vascular disease and evaluate cardiovascular risk. Circulation. 2008;118(5):586-603.

18.    Spence JD, Eliasziw M, DiCicco M, Hackam DG, Galil R, Lohmann T. Carotid plaque area: A more direct measure of atherosclerosis than IMT. Lancet. 2002;359(9311):1962-1967.

19.    Kitamura A, Iso H, Imano H, Ohira T, Okada T, Sato S, et al. Carotid IMT and stroke subtypes in a general Japanese population. Stroke. 2004;35(11):2788-2793.

20.    Mitchell GF, Vita JA, Larson MG, Parise H, Keyes MJ, Warner E, et al. Cross-sectional relations of peripheral microvascular function, cardiovascular disease risk factors, and aortic stiffness. Hypertension. 2005;45(2):224-229.

21.    Baldassarre D, De Faire U, Amato M, Pucci G, Volpe M, Veglia F, et al. Carotid intima-media thickness and plaque in cardiovascular risk prediction. Atherosclerosis. 2012;223(2):342-344.

22.    Nambi V, Chambless L, He M, Folsom AR, Mosley T, Boerwinkle E, et al. Carotid IMT and presence or absence of plaque improve cardiovascular risk prediction. J Am Coll Cardiol. 2010;55(15):1600-1607.

23.    Den Ruijter HM, Peters SA, Anderson TJ, Britton AR, Dekker JM, Eijkemans MJ, et al. Common carotid IMT measurement and cardiovascular risk prediction. JAMA. 2012;308(8):796-803.

24.    Van der Meer IM, Bots ML, Hofman A, del Sol AI, van der Kuip DA, Witteman JC. Predictive value of CIMT for myocardial infarction and stroke. J Clin Epidemiol. 2004;57(9):974-980.

25.    Mathiesen EB, Joakimsen O, Bonaa KH. Prevalence of carotid artery stenosis and plaque in a general population. Stroke. 2001;32(3):629-635.

26.    Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension. J Hypertens. 2013;31(7):1281-1357.

27.    Amarenco P, Bogousslavsky J, Callahan A, Goldstein LB, Hennerici M, Rudolph AE, et al. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med. 2006;355(6):549-559.

28.    Nasr N, Nasr B, Alanazy MH. Predictive value of carotid intima-media thickness in ischemic stroke risk assessment. Int J Stroke. 2018;13(8):819-828.