A systematic review of application of frequency-domain optical coherence tomography in cerebral large artery atherosclerosis.

Objective: Frequency-domain optical coherence tomography (FD-OCT) is an emerging intravascular imaging modality that offers exceptional spatial resolution in interventional neuroradiology. We aimed to systematically review clinical studies on the applications of FD-OCT in cerebral large artery atherosclerosis (LAA).

Methods: A systematic literature review of PubMed, Embase, and Cochrane Library was conducted to identify eligible studies published before 1 March, 2025. Eligible studies included all clinical articles written in English that reported the applications of FD-OCT in patients diagnosed with LAA.

Results: A total of 50 studies with 1134 patients were included. FD-OCT was considered to be a feasible intravascular imaging modality as successful imaging could be achieved in 87.0% of patients with a 1.2% periprocedural complication rate. Unsuccessful FD-OCT imaging was attributed primarily to its current limitations, particularly inadequate blood clearance and failure to navigate the tortuous cerebrovascular anatomy or stenosis. The majority of the included studies (35/50) employed FD-OCT to evaluate extracranial atherosclerotic stenosis. FD-OCT could better stratify subsequent stroke risk by adequately identifying features of plaque vulnerability such as thin-cap fibroatheroma, neovascularization, and cholesterol crystal. Through accurately assessing stent-vessel interaction, FD-OCT has the potential to guide the selection of tailored interventions during carotid artery stenting. Recent research (10/50) has shown its potential utility for intracranial atherosclerotic stenosis, including culprit lesion differentiation, peri-intervention evaluation, and mechanistic insight into pathophysiology of stenosis and in-stent restenosis. As for acute ischemic stroke, FD-OCT following thrombectomy can potentially guide the selection of tailored adjunctive treatments to optimize clinical outcomes by assessing the intrinsic properties of the culprit lesion.

Conclusions: FD-OCT has emerged as a valuable intravascular imaging tool for evaluating the intrinsic properties of culprit lesions and stent-vessel interactions, showing substantial potential in the diagnosis, evaluation, and treatment of cerebral LAA.