Vessel wall MRI characteristics of endovascularly treated aneurysms: association with angiographic vasospasm

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OBJECTIVE

The aim of this paper was to evaluate the association between intracranial vessel wall MRI enhancement characteristics and the development of angiographic vasospasm in endovascularly treated aneurysm patients.

METHODS

Consecutive cases of both ruptured and unruptured intracranial aneurysms that were treated endovascularly, followed by intracranial vessel wall MRI in the immediate postoperative period, were included. Two raters blinded to clinical data and follow-up imaging independently evaluated for the presence, pattern, and intensity of wall enhancement. Development of angiographic vasospasm was independently evaluated. Delayed cerebral ischemia; cerebral infarct; procedural details; and presence and grade of subarachnoid, parenchymal, and intraventricular hemorrhage were evaluated. Statistical associations were determined on a per–vessel segment and per-patient basis.

RESULTS

Twenty-nine patients with 30 treated aneurysms (8 unruptured and 22 ruptured) were included in this study. Interobserver agreement was substantial for the presence of enhancement (κ = 0.67) and nearly perfect for distribution (κ = 0.87) and intensity (κ = 0.84) of wall enhancement. Patients with ruptured aneurysms had a significantly greater number of enhancing segments than those with unruptured aneurysms (29.9% vs 7.2%; OR 5.5, 95% CI 2.2–13.7). For ruptured cases, wall enhancement was significantly associated with subsequent angiographic vasospasm while controlling for grade of hemorrhage (adjusted OR 3.9, 95% CI 1.7–9.4). Vessel segments affected by balloon, stent, or flow-diverter use demonstrated greater enhancement than those not affected (OR 22.7, 95% CI 5.3–97.2 for ruptured; and OR 12.9, 95% CI 3.3–49.8 for unruptured).

CONCLUSIONS

Vessel wall enhancement after endovascular treatment of ruptured aneurysms is associated with subsequent angiographic vasospasm.

ABBREVIATIONS ACA = anterior cerebral artery; aSAH = aneurysmal SAH; DCI = delayed cerebral ischemia; GEE = generalized estimating equations; ICA = internal carotid artery; IVWM = intracranial vessel wall MRI; MCA = middle cerebral artery; SAH = subarachnoid hemorrhage; SPACE = sampling perfection with application of optimized contrast enhancement; TCD = transcranial Doppler.

Article Information

Correspondence Mahmud Mossa-Basha: University of Washington, Seattle, WA. mmossab@uw.edu.

INCLUDE WHEN CITING Published online September 21, 2018; DOI: 10.3171/2018.4.JNS172829.

M.M.B. and T.J.H. contributed equally to this work.

Disclosures Mr. Hippe: research grants for statistical work on other projects from GE Healthcare, Philips Healthcare, Toshiba America Medical Systems, and Siemens Medical Solutions USA.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    IVWM enhancement associated with balloon-assisted coiling. Magnified right ICA injection digital unsubtracted (A) and subtracted (B) anteroposterior (AP) angiograms demonstrating coiling of a right posterior communicating artery aneurysm (short arrows) with balloon assistance (long arrows) in the right terminal ICA. Pre- (C) and postcontrast (D) axial IVWM scans obtained on day 1 postcoiling, demonstrating circumferential enhancement involving the right terminal ICA (arrowheads). Note the intrinsic T1 hyperintense signal adjacent to the artery on C, representing SAH, and note the lack of enhancement in the normal left M1 segment for reference.

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    IVWM enhancement associated with subsequent vasospasm. Modified Fisher grade 4 aSAH seen on a noncontrast head CT scan (A). Digital subtraction angiogram, lateral view, of the left vertebral artery injection (B) showing a prominent ruptured posterior inferior cerebellar artery aneurysm (black arrow). Digital subtraction angiogram, AP view, of the right ICA catheter injection (C) showing normal appearance of the right MCA. Sagittal T1-weighted pre- (D) and postcontrast (E) IVWM scans showing circumferential wall thickening and enhancement of the right MCA (arrowheads). Digital subtraction angiogram, AP view, of the right ICA catheter injection (F) obtained 1 week later, showing severe vasospasm (short arrows) involving multiple arterial segments, including multifocal involvement of the right MCA. Prior to angiography, the patient had developed DCI, and follow-up MRI showed acute infarcts in both MCA territories and the left cerebellum on diffusion-weighted imaging (not shown).

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    IVWM enhancement at the time of vasospasm. Axial noncontrast head CT scan (A) showing sulcal SAH (arrow) at the right anterior skull base, corresponding to modified Fisher grade 1 hemorrhage. Digital subtraction angiogram, AP view, the left ICA catheter injection (B), showing a prominent anterior communicating artery aneurysm projecting to the right (short arrow), which was the source of subarachnoid blood. Coronal maximum intensity projection MR angiogram (C) obtained 10 days after treatment, showing focal high-grade stenosis of the right supraclinoid ICA (arrowhead) that was not present on the initial catheter angiogram (not shown). Axial T1-weighted IVWM scans obtained before (D) and after (E) contrast images acquired at the same time as panel C, revealing wall thickening and circumferential enhancement (thick arrows) corresponding to the focus of stenosis. Contemporary diffusion-weighted imaging (not shown) showed a right MCA territory acute infarct. Follow-up MR angiogram (F) acquired 6 months after treatment, showing resolution of stenosis.

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