High resolution vessel wall MR imaging in prestenotic intracranial atherosclerotic disease

Vessel wall MR imaging (VWI) may be able to highlight vulnerable intracranial atherosclerosis with vessel wall enhancement thereby serving as a biomarker for symptomatic prestenotic intracranial atherosclerotic disease. We present a case of intracranial hemorrhage presumably due to intracranial atherosclerotic disease (ICAD) identified by VWI and silent on lumen-based imaging modalities. A 66-year-old female presented with sudden onset headache and dysarthria. A head CT showed intracranial hemorrhage centered in the right basal ganglia. Further imaging by CT angiography, MR angiography and a conventional catheter angiogram were negative. MRI of the brain, including VWI, showed abnormal enhancement in the right middle cerebral artery vessel wall, suggesting intracranial atherosclerotic changes in a prestenotic vessel. As a potential noninvasive screening test, VWI could impact patients with ICAD and become part of a stroke risk stratification algorithm.