AccScience Publishing / AN / Volume 2 / Issue 4 / DOI: 10.36922/an.1238

Fried-Breadstick sign: A novel marker for healthy vasculature in magnetic resonance angiography

Yannan Yu1,2 Yu-Yuan Xu1 Xue Man1 Ming-Li Li3 Bo Hou3 Shan Gao1 Feng Feng3 David S Liebeskind2 Wei-Hai Xu1*
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1 Department of Neurology, State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
2 Neurovascular Imaging Research Core and UCLA Stroke Center, Los Angeles, California, USA
3 Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
Advanced Neurology 2023, 2(4), 1238
Submitted: 4 July 2023 | Accepted: 28 November 2023 | Published: 21 December 2023
© 2023 by the Author(s). This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution 4.0 International License ( )

The Fried-Breadstick sign is characterized as a continuous signal loss at the center of the intracranial internal carotid artery (ICA) on time-of-flight magnetic resonance angiography (TOF-MRA). In this study, we present a novel imaging marker on TOF-MRA and investigate its potential association with ICA-middle cerebral artery (ICA-MCA) atherosclerosis and ischemic stroke. Vessel wall magnetic resonance imaging data were obtained from patients with recent clinical stroke or asymptomatic patients with suspected middle cerebral artery (MCA) atherosclerosis, covering the period from January 2007 to August 2015. We conducted a comparative analysis of ICA stenosis, MCA atherosclerosis and stenosis degree, and the terminal ICA bifurcation angle between ICA-MCAs with and without the Fried-Breadstick sign, involving a total of 1,005 ICA-MCAs from 553 patients. The Fried-Breadstick sign exhibited a higher prevalence in non-to-mild stenotic ICAs (57.5% vs. 9.8% in severely stenotic ICA, P < 0.001) and plaque-free MCAs (53.2% vs. 26.6% in MCAs with plaque, P < 0.001). Factors independently associated with the presence of the Fried-Breadstick sign included MCA stenosis degree (odds ratio [OR]: 0.85/10% increase, 95% confidence interval [CI]: 0.80 – 0.90), ICA stenosis (compared to non-to-mild stenosis, moderate stenosis: OR: 0.39, 95% CI: 0.28 – 0.54, severe stenosis: OR: 0.10, 95% CI: 0.06 – 0.17), and terminal ICA bifurcation angle (OR: 0.86/10° increase, 95% CI: 0.79 – 0.93). In atherosclerotic MCAs without luminal narrowing, the Fried-Breadstick sign was also less frequently observed than in plaque-free MCAs (34.6% vs. 53.2%, P = 0.012). In conclusion, the presence of the Fried-Breadstick sign is associated with healthier ICA-MCAs devoid of stenosis or plaque. The Fried-Breadstick sign may signify healthy ICA-MCA hemodynamics, serving as a potential screening tool for intracranial atherosclerosis without incurring additional cost or risk.

Intracranial atherosclerosis
Middle cerebral artery
Vessel wall magnetic resonance imaging
Magnetic resonance angiography
National Science Fund for Distinguished Young Scholars
National Natural Science Foundation of China
National Key Technologies R&D Program of China
  1. Wong LK, 2006, Global burden of intracranial atherosclerosis. Int J Stroke, 1: 158–159.


  1. Wu C, Schnell S, Vakil P, et al., 2017, In vivo assessment of the impact of regional intracranial atherosclerotic lesions on brain arterial 3D hemodynamics. AJNR Am J Neuroradiol, 38: 515–522.


  1. Pu Y, Lan L, Leng X, et al., 2017, Intracranial atherosclerosis: From anatomy to pathophysiology. Int J Stroke, 12: 236–245.


  1. Chatzizisis YS, Coskun AU, Jonas M, et al., 2007, Role of endothelial shear stress in the natural history of coronary atherosclerosis and vascular remodeling: Molecular, cellular, and vascular behavior. J Am Coll Cardiol, 49: 2379–2393.


  1. Kokkalis E, Aristokleous N, Houston JG, 2016, Haemodynamics and flow modification stents for peripheral arterial disease: A review. Ann Biomed Eng, 44: 466–476.


  1. Stonebridge PA, Brophy CM, 1991, Spiral laminar flow in arteries? Lancet, 338: 1360–1361.


  1. Van der Kolk AG, Zwanenburg JJ, Brundel M, et al, 2015, Distribution and natural course of intracranial vessel wall lesions in patients with ischemic stroke or TIA at 7.0 tesla MRI. Eur Radiol, 25: 1692–700.


  1. Huang YN, Gao S, Li SW, et al., 1997, Vascular lesions in Chinese patients with transient ischemic attacks. Neurology, 48: 524–525.


  1. Yu YN, Li ML, Xu YY, et al., 2018, Middle cerebral artery geometric features are associated with plaque distribution and stroke. Neurology, 91: e1760–e1769.


  1. Van Tyen R, Saloner D, Jou LD, et al., 1994, MR imaging of flow through tortuous vessels: A numerical simulation. Magn Reson Med, 31: 184–195.


  1. Bradley WG Jr., Waluch V, 1985, Blood flow: Magnetic resonance imaging. Radiology, 154: 443–450. https://doi.org10.1148/radiology.154.2.3966131


  1. Miraux S, Franconi JM, Thiaudiere E, 2006, Blood velocity assessment using 3D bright-blood time-resolved magnetic resonance angiography. Magn Reson Med, 56: 469–473.


  1. Li ML, Xu WH, Song L, et al., 2009, Atherosclerosis of middle cerebral artery: Evaluation with high-resolution MR imaging at 3T. Atherosclerosis, 204: 447–452.


  1. Xu WH, Li ML, Gao S, et al., 2010, In vivo high-resolution MR imaging of symptomatic and asymptomatic middle cerebral artery atherosclerotic stenosis. Atherosclerosis, 212: 507–511.


  1. McHugh ML, 2012, Interrater reliability: The kappa statistic. Biochem Med (Zagreb), 22: 276–282.


  1. Bradley WG Jr., Waluch V, Lai KS, et al., 1984, The appearance of rapidly flowing blood on magnetic resonance images. AJR Am J Roentgenol, 143: 1167–1174.


  1. Bouthillier A, vanLoveren HR, Keller JT, 1996, Segments of the internal carotid artery: A new classification. Neurosurgery, 38: 425–432, discussion 432–433.


  1. Xu YY, Li ML, Gao S, et al., 2016, Non-moyamoya vessel network formation along steno-occlusive middle cerebral artery. Neurology, 86: 1957–1963.


  1. Phan TG, Beare RJ, Jolley D, et al., 2012, Carotid artery anatomy and geometry as risk factors for carotid atherosclerotic disease. Stroke, 43: 1596–1601.


  1. Beier S, Ormiston J, Webster M, et al., 2016, Impact of bifurcation angle and other anatomical characteristics on blood flow-a computational study of non-stented and stented coronary arteries. J Biomech, 49: 1570–1582.


  1. Xu WH, Li ML, Gao S, et al., 2011, Plaque distribution of stenotic middle cerebral artery and its clinical relevance. Stroke, 42: 2957–2959.


  1. Wardlaw JM, Smith EE, Biessels GJ, et al., 2013, Neuroimaging standards for research into small vessel disease and its contribution to ageing and neurodegeneration. Lancet Neurol, 12: 822–838.


  1. Wong KS, Gao S, Chan YL, et al., 2002, Mechanisms of acute cerebral infarctions in patients with middle cerebral artery stenosis: A diffusion-weighted imaging and microemboli monitoring study. Ann Neurol, 52: 74–81.


  1. Ozsarlak O, Van Goethem JW, Maes M, et al., 2004, MR angiography of the intracranial vessels: Technical aspects and clinical applications. Neuroradiology, 46: 955–972.


  1. Kodama T, Watanabe K, 1997, Influence of imaging parameters, flow velocity, and pulsatile flow on three-dimensional time-of-flight MR angiography: Experimental studies. Eur J Radiol, 26: 83–91.


  1. Saloner D, van Tyen R, Dillon WP, et al., 1996, Central intraluminal saturation stripe on MR angiograms of curved vessels: Simulation, phantom, and clinical analysis. Radiology, 198: 733–739.


  1. Stonebridge PA, 2011, Three-dimensional blood flow dynamics: Spiral/helical laminar flow. Methodist Debakey Cardiovasc J, 7: 21–26.


  1. Stonebridge PA, Suttie SA, Ross R, et al., 2016, Spiral laminar flow: A survey of a three-dimensional arterial flow pattern in a group of volunteers. Eur J Vasc Endovasc Surg, 52: 674–680.


  1. Gallo D, Steinman DA, Bijari PB, et al., 2012, Helical flow in carotid bifurcation as surrogate marker of exposure to disturbed shear. J Biomech, 45: 2398–2404.


  1. Stonebridge PA, Buckley C, Thompson A, et al., 2004, Non spiral and spiral (helical) flow patterns in stenoses. In vitro observations using spin and gradient echo magnetic resonance imaging (MRI) and computational fluid dynamic modeling. Int Angiol, 23: 276–283.


  1. Mustert BR, Williams DM, Prince MR, 1998, In vitro model of arterial stenosis: Correlation of MR signal dephasing and trans-stenotic pressure gradients. Magn Reson Imaging, 16: 301–310.


  1. Wilcock DJ, Jaspan T, Worthington BS, 1995, Problems and pitfalls of 3-D TOF magnetic resonance angiography of the intracranial circulation. Clin Radiol., 50(8): 526–532.


  1. Antoniadis AP, Giannopoulos AA, Wentzel JJ, et al., 2015, Impact of local flow haemodynamics on atherosclerosis in coronary artery bifurcations. EuroIntervention, 11 Suppl V: V18–V22.


  1. Giannoglou GD, Antoniadis AP, Koskinas KC, et al., 2010, Flow and atherosclerosis in coronary bifurcations. EuroIntervention, 6 Suppl J: J16–J23.


  1. Denswil NP, van der Wal AC, Ritz K, et al., 2016, Atherosclerosis in the circle of Willis: Spatial differences in composition and in distribution of plaques. Atherosclerosis, 251: 78–84.


  1. Ziyrek M, Sertdemir AL, Duran M, 2020, Effect of coronary artery bifurcation angle on atherosclerotic lesion localization distance to the bifurcation site. J Saudi Heart Assoc, 32: 399–407.


  1. Turan TN, Kicielinski KP, 2021, Asymptomatic intracranial atherosclerotic stenosis: The risk above the carotids. J Am Coll Cardiol, 78: 572–574.


  1. Caplan LR, 2015, Lacunar infarction and small vessel disease: Pathology and pathophysiology. J Stroke, 17: 2–6.


  1. Pasi M, Cordonnier C. 2020, Clinical relevance of cerebral small vessel diseases. Stroke, 51: 47–53.


  1. Kwon HM, Lynn MJ, Turan TN, et al., 2016, Frequency, risk factors, and outcome of coexistent small vessel disease and intracranial arterial stenosis: Results from the stenting and aggressive medical management for preventing recurrent stroke in intracranial stenosis (SAMMPRIS) trial. JAMA Neurol, 73: 36–42.


  1. Salgado AV, Ferro JM, Gouveia-Oliveira A, 1996, Long-term prognosis of first-ever lacunar strokes. A hospital-based study. Stroke, 27: 661–666.


  1. Groen HC, Gijsen FJ, Van der Lugt A, et al., 2007, Plaque rupture in the carotid artery is localized at the high shear stress region: A case report. Stroke, 38: 2379–2381.


  1. Donnan GA, Bladin PF, Berkovic SF, et al., 1991, The stroke syndrome of striatocapsular infarction. Brain, 114: 51–70.


  1. Decavel P, Vuillier F, Moulin T, 2012, Lenticulostriate infarction. Front Neurol Neurosci, 30: 115–119.
Conflict of interest
The authors declare no conflict of interest.
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Advanced Neurology, Electronic ISSN: 2810-9619 Published by AccScience Publishing