Relationship Between Aneurysm Wall Enhancement in Vessel Wall Magnetic Resonance Imaging and Rupture Risk of Unruptured Intracranial Aneurysms

Lv, Nan; Karmonik, Christof; Chen, Shiyue; Wang, Xinrui; Fang, Yibin; Huang, Qinghai; Liu, Jianmin

doi:10.1093/neuros/nyy310

Cited by 49 publications

(33 citation statements)

References 20 publications

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“…An association between wall enhancement and aneurysm size in unruptured intracranial aneurysms has been shown in several studies. 1,11,12,26 However, a large aneurysm size hinders reliable assessment of aneurysm wall enhancement as lower velocities are to be expected in larger aneurysms. Wall-mimicking artifacts can be caused by insufficient flow suppression, which may lead to an overestimation of aneurysm wall enhancement with possible false-positive findings (pseudo-enhancement) in large aneurysms.…”

Section: Discussionmentioning

confidence: 99%

Vessel wall enhancement of intracranial aneurysms: fact or artifact?

Cornelissen

Leemans

Slump

et al. 2019

Neurosurgical Focus

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OBJECTIVEFor patients with subarachnoid hemorrhage (SAH) and multiple intracranial aneurysms, it is often challenging to identify the ruptured aneurysm. Some investigators have asserted that vessel wall imaging (VWI) can be used to identify the ruptured aneurysm since wall enhancement after contrast agent injection is presumably related to inflammation in unstable and ruptured aneurysms. The aim of this study was to determine whether additional factors contribute to aneurysm wall enhancement by assessing imaging data in a series of patients.METHODSPatients with symptoms of SAH who subsequently underwent VWI in the period between January 2017 and September 2018 were eligible for study inclusion. Three-dimensional turbo spin-echo sequences with motion-sensitized driven-equilibrium preparation pulses were acquired using a 3-T MRI scanner to visualize the aneurysm wall. Identification of the ruptured aneurysm was based on aneurysm characteristics and hemorrhage distributions on MRI. Complementary imaging data (CT, DSA, MRI) were used to assess potential underlying enhancement mechanisms. Additionally, aneurysm luminal diameter measurements on MRA were compared with those on contrast-enhanced VWI to assess the intraluminal contribution to aneurysm enhancement.RESULTSSix patients with 14 aneurysms were included in this series. The mean aneurysm size was 5.8 mm (range 1.1–16.9 mm). A total of 10 aneurysms showed enhancement on VWI; 5 ruptured aneurysms showed enhancement, and 1 unruptured but symptomatic aneurysm showed enhancement on VWI and ruptured 1 day later. Four unruptured aneurysms showed enhancement. In 6 (60%) of the 10 enhanced aneurysms, intraluminal diameters appeared notably smaller (≥ 0.8 mm smaller) on contrast-enhanced VWI compared to their appearance on multiple overlapping thin slab acquisition time of flight (MOTSA-TOF) MRA and/or precontrast VWI, suggesting that enhancement was at least partially in the aneurysm lumen itself.CONCLUSIONSSeveral factors other than the hypothesized inflammatory response contribute to aneurysm wall enhancement. In 60% of the cases in this study, enhancement was at least partially caused by slow intraaneurysmal flow, leading to pseudo-enhancement of the aneurysm wall. Notwithstanding, there seems to be clinical value in differentiating ruptured from unruptured aneurysms using VWI, but the hypothesis that we image the inflammatory cell infiltration in the aneurysm wall is not yet confirmed.

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Section: Discussionmentioning

confidence: 99%

Vessel wall enhancement of intracranial aneurysms: fact or artifact?

Cornelissen

Leemans

Slump

et al. 2019

Neurosurgical Focus

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“…Therefore, risk stratification of patients diagnosed with an unruptured intradural aneurysm is crucial, but optimal management remains controversial. Recently, published data suggest an association of wall enhancement in intracranial saccular aneurysms on MR vessel wall imaging with a higher risk for rupture [4][5][6][7]. Specifically, thick circumferential wall enhancement has been linked to a higher risk of rupture [4].…”

Section: Introductionmentioning

confidence: 99%

Multimodal validation of focal enhancement in intracranial aneurysms as a surrogate marker for aneurysm instability

et al. 2020

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Purpose Circumferential enhancement on MR vessel wall imaging has been proposed as a biomarker of a higher risk of rupture in intracranial aneurysms. Focal enhancement is frequently encountered in unruptured aneurysms, but its implication for risk stratification and patient management remains unclear. This study investigates the association of focal wall enhancement with hemodynamic and morphological risk factors and histologic markers of wall inflammation and degeneration. Methods Patients with an unruptured middle cerebral artery aneurysm who underwent 3D rotational angiography and 3T MR vessel wall imaging showing focal wall enhancement were included. Hemodynamic parameters were calculated based on flow simulations and compared between enhanced regions and the entire aneurysm surface. Morphological parameters were semiautomatically extracted and quantitatively associated with wall enhancement. Histological analysis included detection of vasa vasorum, CD34, and myeloperoxidase staining in a subset of patients. Results Twenty-two aneurysms were analyzed. Enhanced regions were significantly associated with lower AWSS, lower maxOSI, and increased LSA. In multivariate analysis, higher ellipticity index was an independent predictor of wall enhancement. Histologic signs of inflammation and degeneration and higher PHASES score were significantly associated with focal enhancement. Conclusion Focal wall enhancement is colocalized with hemodynamic factors that have been related to a higher rupture risk. It is correlated with morphological factors linked to rupture risk, higher PHASES score, and histologic markers of wall destabilization. The results support the hypothesis that focal enhancement could serve as a surrogate marker for aneurysm instability.

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“…For example, several groups have shown that wall enhancement status is correlated with aneurysm size, location, morphology, and the PHASES score, a five-year rupture risk prediction tool dependent on patient-and aneurysm-specific parameters. 48,[55][56][57] Unfortunately, the findings are not concordant in all studies, but likely reflects small patient cohorts. In addition, Backes et al 49 showed that aneurysm size was a strong determinant of wall enhancement even in a group of predominantly small, unruptured aneurysms <7 mm.…”

Section: Unruptured Intracranial Aneurysmsmentioning

confidence: 90%

“…Most small, incidental aneurysms do not enhance (typically 70%). 28,31,48,49 When enhancement is seen in incidental aneurysms, it is more often mild. 31,32 While marked variability exists in the manner of assessing and grading ''enhancement,'' i.e.…”

Section: Ruptured Intracranial Aneurysmsmentioning

confidence: 99%

Vessel wall magnetic resonance imaging in intracranial aneurysms: Principles and emerging clinical applications

et al. 2019

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Intracranial high-resolution vessel wall magnetic resonance imaging is an imaging paradigm that complements conventional imaging modalities used in the evaluation of neurovascular pathology. This review focuses on the emerging utility of vessel wall magnetic resonance imaging in the characterization of intracranial aneurysms. We first discuss the technical principles of vessel wall magnetic resonance imaging highlighting methods to determine aneurysm wall enhancement and how to avoid common interpretive pitfalls. We then review its clinical application in the characterization of ruptured and unruptured intracranial aneurysms, in particular, the emergence of aneurysm wall enhancement as a biomarker of aneurysm instability. We offer our perspective from a high-volume neurovascular center where vessel wall magnetic resonance imaging is in routine clinical use.

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Relationship Between Aneurysm Wall Enhancement in Vessel Wall Magnetic Resonance Imaging and Rupture Risk of Unruptured Intracranial Aneurysms

Abstract: 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.

Cited by 49 publications

References 20 publications

Vessel wall enhancement of intracranial aneurysms: fact or artifact?

Vessel wall enhancement of intracranial aneurysms: fact or artifact?

Multimodal validation of focal enhancement in intracranial aneurysms as a surrogate marker for aneurysm instability

Vessel wall magnetic resonance imaging in intracranial aneurysms: Principles and emerging clinical applications

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