Magnetic Resonance Vessel Wall Imaging

Gadolinium enhancement of an aneurysm wall on MRI was associated with aneurysm rupture. In patients with two aneurysms and SAH, this type of imaging can play an important role in determining the order of aneurysm treatment 1).

Xu et al. compared and evaluate the predictive performance of qualitative and quantitative wall enhancement (aneurysm wall enhancement [AWE], circumferential aneurysmal wall enhancement [CAWE], wall enhancement ratio [WER]) on high-resolution magnetic resonance imaging (MRI) of the vessel wall to predict the presence of UIA.

Original articles describing the depiction of aneurysmal wall enhancement on 3.0-T or 1.5-T high-resolution vessel wall imaging were retrieved from the Web of Science, Medline/PubMed, the Cochrane Library, and EMBASE databases up to 15 February 2022. The combined sensitivity, specificity, and summary area under the receiver operating characteristic curve (AUC) were calculated, and meta-regression analysis was performed.

In total, 12 original articles involving 1619 intracranial aneurysms (IAs) were included. The combined sensitivity and specificity of AWE, CAWE, and WER were 91% and 67%, 59% and 83%, and 86% and 75%, respectively, in the diagnosis of UIA. The summary AUC values of these items were, in order from high to low, 0.88 (WER), 0.84 (AWE), and 0.77 (CAWE), and the differences among them were significant (z = 2.976, P = 0.003 and z = 2.950, P = 0.003). The meta-regression analysis identified average size and 2D/3D magnetic imaging technology as possible sources of heterogeneity.

Qualitative and quantitative wall enhancement showed moderate accuracy in predicting UIA, and WER had the highest accuracy among them in this meta-analysis. Two covariates were found to explain the heterogeneity 2)

Vessel wall MRI requires high spatial and contrast resolution to depict thin arterial walls discrete from their surrounding tissues. Several techniques to achieve this resolution are applied to sequences weighted towards various tissue contrasts (T1-weighted images before and after contrast medium most commonly, T2-weighted images, or proton density-weighted images) 3) 4) 5) 6).

A prospective observational study was performed including all consecutive patients presenting with a saccular intracranial aneurysm at Vall d'Hebron University Hospital between October 2017 and May 2019. The patients underwent high-resolution 3 T MRI, and their aneurysms were classified into asymptomatic, symptomatic, and ruptured. A histological and immunohistochemical study was performed in a subgroup of patients (n = 20, of which 15 presented with WE). Multiple regression analyses were performed to identify predictors of rupture and aneurysm symptoms.

A total of 132 patients were enrolled in the study. We were present in 36.5% of aneurysms: 22.9% asymptomatic, 76.9% symptomatic, and 100% ruptured. Immunohistochemical markers associated with WE were CD3 T cell receptor (p = 0.05) and CD45 leukocyte common antigen (p = 0.05). Moreover, WE is an independent predictor of symptomatic and ruptured aneurysms (p < 0.001).

Aneurysms with WE present multiple histopathological changes that may contribute to wall disruption and represent the pathophysiological basis of radiological WE. Moreover, WE is an independent diagnostic predictor of aneurysm symptoms and rupture 7)

37 patients diagnosed with VAD were evaluated by MR imaging in the acute phase of onset between January 2014 and May 2019. The clinical onset of VAD was categorized into 3 subtypes: (1) incidentally detected (incidental group), (2) sudden headache without cerebral ischemia and/or intracranial hemorrhage (headache group), and (3) hemorrhagic onset (hemorrhage group). Three-dimensional T1-weighted fast spin-echo sequences were obtained before and after contrast material injection, and the contrast ratio (CR) of the aneurysm wall against the pituitary stalk was calculated as the indicator of Circumferential enhancement along the aneurysm wall (CEAW) by magnetic resonance (MR) vessel wall imaging.

The contrast ratio (CR) values of VAD in the hemorrhage group were significantly higher than those in the headache group (0.95 vs. 0.65, p < 0.05), and the headache group had significantly higher CR values than the incidental group (0.65 vs. 0.56, p < 0.05). On receiver operating characteristic curve analysis, the optimal cutoff value of CR to distinguish the hemorrhage group from the headache group was 0.83 and that to distinguish the headache group from the incidental group was 0.61.

The extent of CEAW precisely reflected the deleterious impact of VAD in the acute stage, including hemorrhagic presentation. The predictive value of CEAW for the prognosis of unruptured VAD should be evaluated in future studies 8).

Wall enhancement of intracranial aneurysms in vessel wall magnetic resonance imaging (MRI) has been linked to aneurysm progression. The clinical significance of aneurysm enhancement after embolization has not yet been investigated. The goal of this study was to identify factors associated with aneurysm wall enhancement and reperfusion after embolization.

Patients who underwent treatment of intracranial aneurysms with coils or the Woven Endobridge (WEB) and follow-up MR vessel wall imaging were included. Enhancement of the treated aneurysms was separately recorded for the following locations: a) wall at the neck, b) wall at the dome, and c) in the aneurysmal cavity. Reperfusion was determined on follow-up digital subtraction angiography (DSA) and MR time of flight (TOF) angiography.

In this study 48 patients with 53 aneurysms were included. Wall enhancement at the neck and the dome of the aneurysm was significantly associated with time between embolization and follow-up MRI under 6 months. Enhancement inside the aneurysmal cavity was significantly associated with a follow-up time longer than 6 months, and with stable aneurysms without reperfusion.

Wall enhancement is a regular feature in intracranial aneurysms after embolization and decreases over time. Enhancement inside the aneurysmal cavity is associated with a stable state and could possibly serve as an imaging marker of completed aneurysm healing 9).

Circumferential enhancement along the aneurysm wall (CEAW) by magnetic resonance (MR) vessel wall imaging has been reported to be a useful indicator for the biological activity of intracranial aneurysms such as growth and rupture.

Aneurysm wall enhancement (AWE) on vessel wall magnetic resonance imaging (VW-MRI) is suggested as a potential marker for wall inflammation, but its relationship with rupture risk of unruptured IAs has not been well described.

Clinical data and VW-MRI images were retrospectively reviewed in patients with unruptured IAs from January 2015 to December 2016 in Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China. MRI Core, Houston Methodist Research Institute, Houston, Texas. One hundred ten patients harboring 140 unruptured IAs were included. The presence of AWE was determined by comparing the postcontrast VW-MRI images with the precontrast ones. The rupture risk based on the PHASES score was calculated for each case. Univariate and multivariate analysis were performed to investigate the association of AWE with rupture risk and other conventional risk factors.

AWE was present in 82 (58.6%) lesions. Unruptured IAs with AWE had significantly larger size (P < .001), more irregular shape (P = .003), and different distribution of locations (P = .023) comparing with aneurysms without AWE. The rupture risk score of AWE group was significantly higher than non-AWE group (P < .001). Aneurysm size (odds ratio = 1.536; 95% confidential interval 1.312-1.798; P < .001) and location (odds ratio = 1.592; 95% confidential interval 1.237-2.049; P < .001) were independently related with AWE in multivariate analysis.

The presence of AWE on VW-MRI was highly associated with conventional rupture-related characteristics, including aneurysmal size and location, and was detected more frequently in unruptured IAs with high rupture risk based on the PHASES score 10).

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Kim NH, Chung GH, Kwak HS, Hwang SB, Lee JM, Park JS. The role of vessel wall imaging in determining the best treatment approach for coexisting aneurysms and subarachnoid hemorrhage. Acta Neurol Belg. 2022 Sep 29. doi: 10.1007/s13760-022-02096-8. Epub ahead of print. PMID: 36173550.
Xu G, Luo N, Deng Y. Qualitative and quantitative wall enhancement associated with unstable intracranial aneurysms: a meta-analysis. Acta Radiol. 2022 Dec 6:2841851221141238. doi: 10.1177/02841851221141238. Epub ahead of print. PMID: 36475308.
Mandell DM, Mossa-Basha M, Qiao Y, Hess CP, Hui F, Matouk C, Johnson MH, Daemen MJ, Vossough A, Edjlali M, Saloner D, Ansari SA, Wasserman BA, Mikulis DJ. Intracranial Vessel Wall MRI: Principles and Expert Consensus Recommendations of the American Society of Neuroradiology. (2017) AJNR. American journal of neuroradiology. 38 (2): 218-229. doi:10.3174/ajnr.A4893
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Dinia L, Vert C, Gramegna LL, Arikan F, Hernández D, Coscojuela P, Martinez-Saez E, Ramón Y Cajal S, Luzi M, Sarria-Estrada S, Salerno A, De Barros A, Gandara D, Quintana M, Rovira A, Tomasello A. Wall enhancement as a biomarker of intracranial aneurysm instability: a histo-radiological study. Acta Neurochir (Wien). 2023 Aug 17. doi: 10.1007/s00701-023-05739-8. Epub ahead of print. PMID: 37589724.
Saito A, Fujimura M, Endo H, Omodaka S, Kanoke A, Sato K, Tominaga T. Diagnostic Value of Contrast-Enhanced Magnetic Resonance Vessel Wall Imaging on the Onset Type of Vertebral Artery Dissection. Cerebrovasc Dis. 2019 Nov 26:1-8. doi: 10.1159/000503852. [Epub ahead of print] PubMed PMID: 31770765.
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Lv N, Karmonik C, Chen S, Wang X, Fang Y, Huang Q, Liu J. Relationship Between Aneurysm Wall Enhancement in Vessel Wall Magnetic Resonance Imaging and Rupture Risk of Unruptured Intracranial Aneurysms. Neurosurgery. 2018 Jul 13. doi: 10.1093/neuros/nyy310. [Epub ahead of print] PubMed PMID: 30011026.
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