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Abstract
Intracranial vessel wall MRI (IVWM) is a new diagnostic imaging approach with the goal of evaluating intracranial vascular pathology by directly visualizing arterial vessel wall abnormalities with MR sequences, preferably at 3 Tesla field strength, that suppress blood and have excellent spatial resolution. The differentiation of intracranial vascular pathology has historically relied on luminal imaging techniques that depict the alteration of flow created by atherosclerotic stenosis or vasospasm. With IVWM, it is possible to identify distinct radiologic findings of the pathology within the intracranial vessel wall itself, ranging from arterial dissection to vasculitis. Futhermore, IVWM imaging characteristics, such as post-contrast enhancement, can elucidate the temporal relationship between imaging findings and clinical pathology; and may predict future behavior of unruptured aneurysms or atherosclerotic plaques. We present a review of the basic IVWM imaging techniques and the relevant published literature on IVWM, with a focus on evidence-based diagnostic indications for IVWM and discussion of the strengths and weaknesses of each indication. Finally, we discuss how IVWM can be used to differentiate between intracranial pathology and future directions for IVWM research.
Highlights
Intracranial vessel wall MRI (IVWM) is a new diagnostic imaging approach with the goal of evaluating intracranial vascular pathology by directly visualizing arterial vessel wall abnormalities with MR sequences, preferably at 3 Tesla field strength, that suppress blood and have excellent spatial resolution.Body: The differentiation of intracranial vascular pathology has historically relied on luminal imaging techniques that depict the alteration of flow created by atherosclerotic stenosis or vasospasm
We present a review of the basic IVWM imaging techniques and the relevant published literature on IVWM, with a focus on evidence-based diagnostic indications for IVWM and discussion of the strengths and weaknesses of each indication
A larger study of 117 patients, with 61 ruptured and 83 unruptured intracranial aneurysms (IA), used an Motion-sensitive driven equilibrium (MSDE) 3D pre- and post-contrast protocol that detected “strong/faint enhancement” in 73.8/24.6 % of the ruptured IAs and only 4.8/13.3 % of the unruptured IAs [53]. These results suggest that IA wall enhancement on 3D T1- or proton density (PD)-weighted post-contrast IVWM could serve as a marker for aneurysm rupture in the 12– 20 % of subarachnoid hemorrhage patients found to have multiple IAs, further investigation is necessary considering that early studies have indicated that unstable unruptured aneurysms may show wall enhancement [54, 55]
Summary
IVWM is not currently in wide clinical use, but the conditions for this transition are in place. 2D black blood IVWM techniques are readily available on all MRIs and can be performed at high resolution on 3T systems. 2D black blood IVWM techniques are readily available on all MRIs and can be performed at high resolution on 3T systems. All major MRI manufacturers have a 3D VRFA sequence that can be used at 3T, available as either a research or product sequence depending on the scanner make and model, allowing for black blood intracranial imaging with the requisite ability to construct multiplanar images with isotropic sub-millimeter resolution. At a minimum a TOF MRA and T1- or PD-weighted sequence with pre- and post-contrast imaging is required for IVWM, additional information can be obtained by including a T2-weighted sequence and, in certain clinical scenarios, a 3D T1-weighted gradient echo sequence optimized for the detection of mural hemorrhage such as MP-RAGE. Author details 1Department of Neurology, University of Utah, Salt Lake City, USA. Author details 1Department of Neurology, University of Utah, Salt Lake City, USA. 2Department of Neurosurgery, University of Utah, Salt Lake City, USA. 3Department of Radiology, University of Washington, Seattle, USA
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