Elsevier

World Neurosurgery

Volume 112, April 2018, Pages 186-198
World Neurosurgery

Literature Review
Intracranial Vessel Wall Imaging with Magnetic Resonance Imaging: Current Techniques and Applications

https://doi.org/10.1016/j.wneu.2018.01.083Get rights and content

Vessel wall magnetic resonance imaging (VW-MRI) is a modern imaging technique with expanding applications in the characterization of intracranial vessel wall pathology. VW-MRI provides added diagnostic capacity compared with conventional luminal imaging methods. This review explores the principles of VW-MRI and typical imaging features of various vessel wall pathologies, such as atherosclerosis, dissection, and vasculitis. Radiologists should be familiar with this important imaging technique, given its increasing use and future relevance to everyday practice.

Introduction

Intracranial vessel wall magnetic resonance imaging (VW-MRI) encompasses a noninvasive suite of advanced imaging techniques that have evolved as a useful adjunct to conventional imaging techniques, such as computed tomography angiography, magnetic resonance angiography (MRA), and digital subtraction angiography (DSA). VW-MRI uses a variety of techniques and sequences to produce images of the intracranial vessel wall with superior spatial and contrast resolution compared with conventional imaging methods that focus predominantly on the vessel lumen.1

VW-MRI has the potential to identify previously occult mural lesions involving the intracranial arterial circulation, and to further characterize underlying pathological processes, such as atherosclerosis, aneurysm, dissection, and vasculitis. For example, arterial stenoses may result from a number of different etiologies and may benefit from further morphological classification with VW-MRI. As a result, VW-MRI can improve patient care by increasing diagnostic accuracy and reducing diagnostic delays.2

This broad review examines the current imaging techniques of VW-MRI, as well as the typical imaging features of intracranial atherosclerosis, aneurysm, dissection, vasculitis, reversible cerebral vasoconstriction syndrome (RCVS), and moyamoya disease (MMD), with an emphasis on the added value of VW-MRI.

Section snippets

Imaging Techniques

Imaging of the intracranial vessel wall is challenging owing to the small caliber and tortuosity of the intracranial vessels.1, 2 Visualizing the normal and pathological intracranial vessel wall requires very high spatial and contrast resolution to depict the inner and outer layers.3, 4 The wall thickness of a normal middle cerebral artery (MCA) is estimated to vary between 0.2 and 0.7 mm, which at the lower limit may be smaller than the smallest voxel achievable currently in a normal clinical

Normal Vessel Wall

Careful examination of the normal healthy vessel wall is important to allow a comparison of the suspected diseased vessel to the normal internal control. Vessel wall thickness and remodeling are biomarkers of artery status.4, 28, 29 Imaging the thicker proximal vessel wall of the circle of Willis, such as the proximal MCA, is easier than more distal vessels such as the M2/3 MCA branches and anterior and posterior cerebral arteries.3, 4 A healthy vessel wall is regular, uniformly thick, and does

Ruptured Versus Unruptured Aneurysms

Despite the paucity of evidence, some reports suggest that VW-MRI may have the capacity to identify a ruptured intracranial aneurysm from among multiple potential culprit aneurysms.9 A ruptured aneurysm usually demonstrates a thickened vessel wall with enhancement.20, 61, 62, 63 A study of 117 patients by Nagahata et al.20 identified vessel wall enhancement in up to 73% of ruptured aneurysms compared with enhancement in <5% of unruptured aneurysms. VW-MRI is especially useful in cases of

Intracranial Arterial Dissection

Intracranial arterial dissection is a rare entity that can present as ischemia, SAH, or massive aneurysm.3 Up to one-half of patients with intracranial arterial dissection present with an ischemic event, and close to one-third present with SAH.68 The most common sites of dissection are the M1 segment of the MCA, the intracranial vertebral arteries (V4 segment), and the supraclinoid ICA.1

Patients with subintimal dissection more commonly present with ischemic stroke secondary to thromboembolism,

Vasculitis

Intracranial vasculitis is an uncommon pathology involving inflammation and necrosis of arterial walls of various sizes, either as a primary etiology or secondary to autoimmune or infectious processes.9 On VW-MRI, vasculitis can demonstrate enhancement and segmental mural thickening of multiple vessels, which are often found to be uniform, circular, and enclosing the border of the vessel.35, 36, 80, 81 The mechanism of enhancement in vasculitis is proposed to be related to intramural contrast

RCVS

RCVS is caused by shortening of smooth muscle, resulting in overlapping of muscle cells9, 84 within intracranial arterial walls, and shares clinical and radiologic similarities with vasculitis. It is most common in young and middle-aged women. Risk factors include smoking, alcohol, stimulant drug abuse, eclampsia, and the postpartum period.85, 86 Patients with RCVS often present with acute, severe, short-duration, and intermittent “thunderclap” headache with or without neurologic deficit.85, 86

MMD

MMD is an idiopathic disease that results in gradual stenosis of the distal ICA and proximal circle of Willis branches.1, 2 The area of involvement is surrounded by abnormal vessels forming a collateral network secondary to the ischemic stress response of the brain.17 The exact pathophysiology of the disease is unknown; however, a genetic background is strongly suspected, and a gene increasing the susceptibility for MMD in Asians has been discovered.91 Histopathology demonstrates medial

Pediatric Applications of VW-MRI

VW-MRI may have a role, albeit a limited one, in the diagnosis of intracranial pathologies in children. Periarterial enhancement is a normal finding in pediatric imaging. A retrospective study of the MRI of medium-to-large intracranial arteries in children age 4 months to 16 years with no suspicion of intracranial pathology demonstrated periarterial enhancement as straight, flat, noncircumferential, and symmetric with the contralateral vessels. It is more commonly found at the M1 segment of the

Other Potential Applications of VW-MRI

VW-MRI may aid the selection of patients with symptomatic stenosis for percutaneous intracranial transluminal angioplasty and stenting, a likely impactful field of future research. VW-MRI is superior to conventional imaging in establishing the etiology of arterial stenoses and in excluding lesions, such as vasculitis and MMD, that are not treated with stenting. Second, the rate of intracranial endovascular procedural complications, such as intracerebral hemorrhage and perforator territory

Limitations

Most of the current literature on vessel imaging is derived from imaging assessment of extracranial arteries, such as the carotids and coronaries,2, 4 with a relative paucity of data on intracranial arteries. There are limited published imaging data providing histopathological correlation4; rather, most studies on intracranial arteries are based on either ex vivo studies or postmortem autopsy owing to the obvious practical challenge and clinical disincentives of obtaining in vivo samples.

Recommendations

We recommend the use of VW-MRI as an adjunct when conventional luminal imaging methods and/or the clinical picture are inconclusive in determining intracranial vessel wall pathologies. VW-MRI is further recommended for follow-up of disease activity in cases of atherosclerosis and vasculitis, as well as in identification of culprit aneurysms in cases of multiple aneurysms.

The 3-T MRI scanner offers a balance between resource availability and image resolution compared with 1.5-T and 7-T scanners.

Conclusions

VW-MRI provides a useful adjunct to conventional intracranial vessel imaging and offers a novel opportunity for differentiation of intracranial arterial pathologies. Optimization of techniques, high-field (3-T) scanner availability, and access to relevant scan sequences remain key factors limiting its widespread clinical application. Nonetheless, the ability to provide new information on a wide spectrum of disease processes makes VW-MRI clinically important, and this technique holds great

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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