Vessel-wall MRI in thunderclap headache: A useful tool to answer the riddle?

Abstract

Background Finding an intracranial aneurysm (IA) during a thunderclap headache (TCH) attack, represents a problem because it is necessary to distinguish whether the aneurysm is responsible for the headache as a warning leak or as an incidental finding. High-Resolution Vessel-Wall (HRVW) MRI sequences have been proposed to assess the stability of the wall, as it permits to detect the presence of aneurysmal wall enhancement (AWE). In fact, AWE has been confirmed due to inflammation, recognizable preceding rupture. Case 1: A 37-year-old woman with a migraine more intense than her usual. A CTA revealed a 10 mm AComA aneurysm without subarachnoid hemorrhage (SAH) and HRVW-MRI excluded AWE. The patient’s headache improved, and therefore, the aneurysm was considered an incidental finding, and the headache diagnosed as TCH attack. Subsequently, the aneurysm was surgically clipped, and typical migraine relapsed was reported at follow-up (FU). Case 2: A 67-year-old woman with no history of headaches underwent CTA for an abrupt onset of headache. A 7 mm right carotid-ophthalmic aneurysm with no sign of SAH was discovered. HRVW-MRI demonstrated AWE and thus, a TCH attack for a warning leak of an unstable wall was suspected. Endovascular coiling was immediately performed and at FU any further headache attack was reported. Conclusions HRVW-MRI is useful in case of finding aneurysm as the cause of headaches, particularly the TCH attack. In fact, HRVW-MRI could assess the stability of the aneurysms wall, allowing different patient management and eventually the aneurysmal treatment.

Vessel Wall MRI: clinical implementation in cerebrovascular disorders—technical aspects

“…We have reported our experience in the set of a VW MRI sequence, a novel imaging tool that has been evolving in recent years for the diagnosis and treatment decision of different cerebrovascular pathologies, such as aneurysms [ 7 , 11 , 15 ] (Fig. 1 ), CNS vasculitis (Fig.…”

“…Moreover, we have set parameters to reach isotropic 3D imaging, good CFS, and blood suppressions, and to reduce scanning time (to avoid patient’ motion-induced artifacts) [ 11 , 12 ] for a total scanning time of 7 min 10 s.…”

Vessel‐wall MRI in primary headaches: The role of neurogenic inflammation

“…Patients were scanned on the same 3T scanner (MagnetomSkyra; Siemens Healthcare, Erlangen, Germany). A three‐dimensional (3D) High‐Resolution Vessel Wall MRI (field of view 160 mm, time echo 38 ms, time repetition 1000 ms and anisotropic voxels of 0.3 × 0.3 × 0.6 mm) was performed before and after the administration of 0.1 mmol/kg of gadolinium contrast agent (ProHance; Bracco, Milano, Italy), as previously described 12 . The VW‐MRI protocol also included 3D T1‐w, fluid attenuation inversion recovery T2‐w, susceptibility weighted imaging and TOF (with maximum intensity projection reconstructions), and two‐dimensional (2D) axial T2‐w and diffusion weighted imaging sequences.…”

“…[6][7][8][9] In fact, in a substantial proportion of secondary headaches, such as sentinel headache in case of aneurysm rupture or in case of reversible cerebral vasoconstriction syndrome or vasculitis, an inflammatory process in the vessel wall has been demonstrated to be responsible for the symptoms 10 and VW-MRI has been proposed as a useful tool to assess the causes. 8,[10][11][12] As in primary headaches disorders the pain is sustained by neurogenic inflammation, we wondered if VW-MRI could differentiate between different primary headaches and if a specific enhancement pattern is present as for secondary headaches. Moreover, we wondered if the neurogenic inflammation theory of migraine or cluster headache (CH) could finally be supported by the only currently available technique capable of visualizing the remodeling inside vessel walls.…”

“…Among different neuroradiological techniques, vessel‐wall magnetic resonance imaging (VW‐MRI) has emerged as a promising magnetic resonance imaging (MRI) sequence that allows detecting wall changes and reflects the inflammatory remodeling of the vessel walls despite different etiologies 6–9 . In fact, in a substantial proportion of secondary headaches, such as sentinel headache in case of aneurysm rupture or in case of reversible cerebral vasoconstriction syndrome or vasculitis, an inflammatory process in the vessel wall has been demonstrated to be responsible for the symptoms 10 and VW‐MRI has been proposed as a useful tool to assess the causes 8,10–12 …”