Clinical Significance of Circumferential Aneurysmal Wall Enhancement in Symptomatic Patients with Unruptured Intracranial Aneurysms: a High-resolution MRI Study

Fu, Qichang; Guan, Sheng; Liu, Chao; Wang, Keyan; Cheng, Jingliang

doi:10.1007/s00062-017-0598-4

Cited by 41 publications

(20 citation statements)

References 22 publications

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“…In another publication focusing on unruptured aneurysms only, circumferential aneurysm wall enhancement was observed more frequently in symptomatic (70%) than in asymptomatic (27%) aneurysms. 5 Patients with symptomatic aneurysms in that study had presented with either sentinel headaches or third nerve palsy. Occasionally, wall enhancement on VWI has been associated with inflammatory cell invasion in unruptured aneurysms, as shown by Larsen and colleagues using histological analysis.…”

Section: Discussionmentioning

confidence: 91%

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: 91%

Vessel wall enhancement of intracranial aneurysms: fact or artifact?

Cornelissen

Leemans

Slump

et al. 2019

Neurosurgical Focus

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“…In total, 53 aneurysms were classified as unstable at aneurysm wall enhancement has the potential to provide an additional, individual-based indicator of aneurysm stability. For instance, CAWE, which has both thin (grade 2) and thick (grade 3) circumferential enhancement, has been associated with instability (7)(8)(9)(10)15,16) but also with low specificity. On the basis of a thorough evaluation of enhancement patterns, we devised a four-grade classification aimed at evaluating their relative accuracies in identifying unstable aneurysms and demonstrated that the highest grade of vessel-wall MR enhancement according to this classification had a high specificity to distinguish stable from unstable aneurysms with potential direct implications in patient management.…”

Section: Resultsmentioning

confidence: 99%

Circumferential Thick Enhancement at Vessel Wall MRI Has High Specificity for Intracranial Aneurysm Instability

et al. 2018

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Purpose To identify wall enhancement patterns on vessel wall MRI that discriminate between stable and unstable unruptured intracranial aneurysm (UIA). Materials and Methods Patients were included from November 2012 through January 2016. Vessel wall MR images were acquired at 3 T in patients with stable (incidental and nonchanging over 6 months) or unstable (symptomatic or changing over 6 months) UIA. Each aneurysm was evaluated by using a four-grade classification of enhancement: 0, none; 1, focal; 2, thin circumferential; and 3, thick (>1 mm) circumferential. Inter- and intrareader agreement for the presence and the grade of enhancement were assessed by using κ statistics and 95% confidence interval (CI). The sensitivity, specificity, and negative and positive predictive values of each enhancement grade for differentiating stable from unstable aneurysms was compared. Results The study included 263 patients with 333 aneurysms. Inter- and intrareader agreement was excellent for both the presence of enhancement (κ values, 0.82 [95% CI: 0.67, 0.99] and 0.87 [95% CI: 0.7, 1.0], respectively) and enhancement grade (κ = 0.92 [95% CI: 0.87, 0.95]). In unruptured aneurysms (n = 307), grade 3 enhancement exhibited the highest specificity (84.4%; 233 of 276; 95% CI: 80.1%, 88.7%; P = .02) and negative predictive value (94.3%; 233 of 247) for differentiating between stable and unstable lesions. There was a significant association between grade 3 enhancement and aneurysm instability (P < .0001). Conclusion In patients with intracranial aneurysm, a thick (>1 mm) circumferential pattern of wall enhancement demonstrated the highest specificity for differentiating between stable and unstable aneurysms. © RSNA, 2018.

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“…In patients with subarachnoid hemor-rhage and multiple aneurysms, MR imaging can help discriminate the responsible aneurysm. Fu et al 2 proposed that circumferential aneurysmal wall enhancement on high-resolution MR vessel wall imaging (HR-VWI) is correlated with headaches and third nerve palsy caused by unruptured aneurysms. Two previous studies indicated that as an indicator of inflammation, the aneurysm wall enhancement on HR-VWI postgadolinium T1WI has the potential for discriminating unstable aneurysms from stable ones.…”

mentioning

confidence: 99%

Low Wall Shear Stress Is Associated with Local Aneurysm Wall Enhancement on High-Resolution MR Vessel Wall Imaging

Wang¹,

Qi²,

et al. 2018

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE: Some retrospective studies have found that the aneurysm wall enhancement on high-resolution MR vessel wall postgadolinium T1WI has the potential to distinguish unstable aneurysms. This study aimed to identify hemodynamic characteristics that differ between the enhanced and nonenhanced areas of the aneurysm wall on high-resolution MR vessel wall postgadolinium T1WI. MATERIALS AND METHODS: TOF-MRA and high-resolution MR vessel wall T1WI of 25 patients were fused to localize the enhanced area of the aneurysm wall. Using computational fluid dynamics, we studied the aneurysm models. Mean static pressure, mean wall shear stress, and oscillatory shear index were compared between the enhanced and nonenhanced areas. RESULTS: The aneurysmal enhanced area had lower wall shear stress (P Ͻ .05) and a lower oscillatory shear index (P ϭ .021) than the nonenhanced area. In addition, the whole aneurysm had lower wall shear stress (P Ͻ .05) and a higher oscillatory shear index (P ϭ .007) than the parent artery. CONCLUSIONS: This study suggests that there are hemodynamic differences between the enhanced and nonenhanced areas of the aneurysm wall on high-resolution MR vessel wall postgadolinium T1WI. ABBREVIATIONS: HR-VWI ϭ high-resolution MR vessel wall imaging; OSI ϭ oscillatory shear index; P ϭ mean static pressure; WSS ϭ wall shear stress

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Clinical Significance of Circumferential Aneurysmal Wall Enhancement in Symptomatic Patients with Unruptured Intracranial Aneurysms: a High-resolution MRI Study

Abstract: Our study demonstrates that CAWE correlated with sentinel headaches and third nerve palsy caused by unruptured aneurysms, and this may be an additional clue to distinguish the cause of these symptoms.

Cited by 41 publications

References 22 publications

Vessel wall enhancement of intracranial aneurysms: fact or artifact?

Vessel wall enhancement of intracranial aneurysms: fact or artifact?

Circumferential Thick Enhancement at Vessel Wall MRI Has High Specificity for Intracranial Aneurysm Instability

Low Wall Shear Stress Is Associated with Local Aneurysm Wall Enhancement on High-Resolution MR Vessel Wall Imaging

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