Targeting the culprit: vessel wall magnetic resonance imaging for evaluating stroke

Abstract

The pathogenesis of many strokes originates in the vessel wall. Despite this, most traditional imaging focuses on the vascular lumen. Vessel-wall magnetic resonance imaging (VWMRI) is useful for establishing the etiology of intracranial stenosis. It also provides information regarding atherosclerotic plaque composition and thus plaque vulnerability, which is an indication of its potential to cause a stroke. In this review we focus on the characteristics of VWMRI findings in various arteriopathies related to intracranial artery stenosis, and discuss the clinical implications of these findings.

Vessel Wall Magnetic Resonance Imaging in Cerebrovascular Diseases

“…Recent advances in MRI technology and the diffusion of high magnetic field devices made VW-MRI widely available. Its value in the differential diagnosis of intracranial vasculopathy is already recognized, and VW-MRI may be included in the diagnostic workup of several patients, as it provides adjunctive information not obtainable with traditional luminal-based imaging techniques [ 3 , 125 ]. Further applications, like risk stratification in patients with intracranial atherosclerotic disease and intracranial aneurysms, offering the potential to tailor the best therapeutic approach in fields is of great interest, but it requires larger prospective studies [ 129 ].…”

“…Atherosclerosis of cervical and intracranial arteries is a common cause of ischemic stroke [ 22 , 23 ]. The atheromatic plaque progression and its surface fissuring leads to cerebral tissue infarct through artery-to-artery embolization, in situ thrombosis, hemodynamic impairment or branches occlusion [ 3 , 24 ]. Current guidelines rely on plaque stenosis severity and symptoms for stratifying the stroke risk and for selecting patients for the best medical therapy or interventional treatments [ 25 , 26 ].…”

“…Pathognomonic features of IAD are intramural hematoma, intimal flap and double lumen, and all can be identified using VW-MRI [ 3 ]. In a recent meta-analysis, the reported frequency of intramural hematoma, vessel wall enhancement, aneurysmal dilatation, and intimal flap/double lumen sign differs, being, respectively, 86%, 75%, 71% and 47% [ 68 ].…”

“…The definition of stroke etiology is mandatory to predict the prognosis and recurrence risk and guide therapeutic decisions [ 1 , 2 ]. The pathogenesis of cerebrovascular diseases often originates inside the vessel walls, therefore, standard luminal based imaging modalities lack the capability to visualize these pathological processes, unless they are associated with significant luminal changes [ 3 ]. This is particularly true for intracranial arteries, which have smaller diameter and thinner vessel walls, that are beyond the resolution of standard diagnostic techniques [ 4 ].…”

Acute Stroke Caused by Large Vessel Vasculitis in a Patient with Systemic Lupus Erythematosus

“…However, since clinical disease activity and vessel wall MR imaging findings in intracranial artery vasculitis are not always correlated, the effect of specific treatments on vessel wall MR imaging, such as corticosteroid administration, can be observed. 10 The initial thickening and concentric contrast in multiple cerebral arteries improved after 3-months of treatment. This indicates that the cause of vascular stenosis in this case was vasculitis, not a vulnerable plaque.…”