High-resolution MRI of intracranial large artery diseases: how to use it in clinical practice?

High-resolution MRI (HRMRI) has emerged as a useful tool for clinical research in recent years. Compared with traditional cranial and vessel imaging, HRMRI provides more additional valuable pathophysiology information that is helpful for the differential diagnosis of intracranial atherosclerosis, dissection and vasculitis. However, there are some points that a neurologist should keep in mind. First, although enhanced vessel wall imaging is widely applied for research purposes, it is not appropriate for routine clinical use. Any injury or inflammation within vessel wall can result in enhancement, which is unspecific for a diagnosis. Second, although plaque components identified on HRMRI arouse researchers' interest, they may have limited positive predictive value for future stroke. Ruptured plaques may have higher prevalence in asymptomatic patients than expected. More prospective observational studies are required. Third, the vessel wall morphology features remain the useful and reliable clue for a diagnosis. It is true that eccentric vessel wall lesions most likely represent atherosclerosis if vessel dissection is easily excluded. For concentric wall lesions, however, the underlying pathophysiology is complicated, either atherosclerotic or non-atherosclerotic. Fourth, HRMRI can show luminal thrombus directly and provide valuable details. All in all, when HRMRI is used by a neurologist, it should not be viewed as the only key for a diagnosis. The diagnosis should be made based on patient history, lab works, other imaging technique and even genetic examinations.