Blood Flow Mimicking Aneurysmal Wall Enhancement: A Diagnostic Pitfall of Vessel Wall MRI Using the Postcontrast 3D Turbo Spin-Echo MR Imaging Sequence

Kalsoum, E.; Negrier, Amandine Chabernaud; Tuilier, Titien; Benaïssa, A.; Blanc, Raphaël; Gallas, S.; Lefaucheur, Jean Pascal; Gaston, André; Lopes, Renaud; Brugières, Pierre; Hodel, Jérôme

doi:10.3174/ajnr.a5616

Cited by 37 publications

(20 citation statements)

References 15 publications

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“…A hyperintense appearance originating from unsuppressed blood could therefore potentially be mistaken for aneurysm wall, which is an important pitfall of MR VWI. 5,8 The aim of this phantom study was to assess the contribution of slow flow to wall-like enhancement in 3D TSE VWI, both with and without MSDE and DANTE preparation pulses.…”

mentioning

confidence: 99%

Insufficient slow-flow suppression mimicking aneurysm wall enhancement in magnetic resonance vessel wall imaging: a phantom study

Cornelissen

Leemans

Coolen

et al. 2019

Neurosurgical Focus

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OBJECTIVEMR vessel wall imaging (VWI) is increasingly performed in clinical settings to support treatment decision-making regarding intracranial aneurysms. Aneurysm wall enhancement after contrast agent injection is expected to be related to aneurysm instability and rupture status. However, the authors hypothesize that slow-flow artifacts mimic aneurysm wall enhancement. Therefore, in this phantom study they assess the effect of slow flow on wall-like enhancement by using different MR VWI techniques.METHODSThe authors developed an MR-compatible aneurysm phantom model, which was connected to a pump to enable pulsatile inflow conditions. For VWI, 3D turbo spin echo sequences—both with and without motion-sensitized driven equilibrium (MSDE) and delay alternating with nutation for tailored excitation (DANTE) preparation pulses—were performed using a 3-T MR scanner. VWI was acquired both before and after Gd contrast agent administration by using two different pulsatile inflow conditions (2.5 ml/sec peak flow at 77 and 48 beats per minute). The intraluminal signal intensity along the aneurysm wall was analyzed to assess the performance of slow-flow suppression.RESULTSThe authors observed wall-like enhancement after contrast agent injection, especially in low pump rate settings. Preparation pulses, in particular the DANTE technique, improved the performance of slow-flow suppression.CONCLUSIONSNear-wall slow flow mimics wall enhancement in VWI protocols. Therefore, VWI should be carefully interpreted. Preparation pulses improve slow-flow suppression, and therefore the authors encourage further development and clinical implementation of these techniques.

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mentioning

confidence: 99%

Insufficient slow-flow suppression mimicking aneurysm wall enhancement in magnetic resonance vessel wall imaging: a phantom study

Cornelissen

Leemans

Coolen

et al. 2019

Neurosurgical Focus

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show abstract

“…2,8,9,19 In addition, intraaneurysmal flow has a completely different pattern than the laminar flow in the intracranial vessels, and this has been acknowledged to be an important pitfall in correctly appraising enhancement of the aneurysm wall in clinical practice. 6,14 In this clinical report, we consider possible underlying mechanisms contributing to aneurysm wall enhancement by evaluating imaging data obtained using multiple modalities in patients suspected of having an SAH.…”

mentioning

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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“…8 Moreover, as previously discussed, flow artifact, contrast extravasation, and stagnant flow could mimic wall enhancement on HR-VWI. 52 Furthermore, there is no consensus on the standard definition of wall enhancement. Some studies have evaluated only 'circumferential' wall enhancement while others have included aneurysms with 'partial' wall enhancement.…”

Section: Gaps and Future Researchmentioning

confidence: 99%

Vessel wall imaging in intracranial aneurysms

Samaniego

Roa

Hasan

2019

J NeuroIntervent Surg

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High-resolution vessel wall imaging (HR-vwi) is becoming a useful tool in the characterization and identification of unstable unruptured brain aneurysms. However, it has not been validated for clinical use. The current evidence on HR-vwi techniques for characterization of brain aneurysms is described in this review. Specific imaging approaches such as aneurysm wall contrast enhancement, MRi-quantitative susceptibility mapping, and 7T MRi are described in detail.

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Blood Flow Mimicking Aneurysmal Wall Enhancement: A Diagnostic Pitfall of Vessel Wall MRI Using the Postcontrast 3D Turbo Spin-Echo MR Imaging Sequence

Cited by 37 publications

References 15 publications

Insufficient slow-flow suppression mimicking aneurysm wall enhancement in magnetic resonance vessel wall imaging: a phantom study

Insufficient slow-flow suppression mimicking aneurysm wall enhancement in magnetic resonance vessel wall imaging: a phantom study

Vessel wall enhancement of intracranial aneurysms: fact or artifact?

Vessel wall imaging in intracranial aneurysms

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