Predicting Vasospasm and Delayed Cerebral Ischemia in Aneurysmal SAH: The Role of Vessel Wall MRI

Aneurysmal SAH (aSAH) is a life-threatening condition associated with angiographic vasospasm, delayed cerebral ischemia (DCI), and other complications that may lead to significant morbidity and mortality. Our study evaluated associations of vessel wall enhancement (VWE) on intracranial vessel wall MRI with rupture status, and predictive value of VWE, conventional imaging, and clinical features for angiographic vasospasm, DCI, which encompasses delayed infarction and symptomatic vasospasm.

A retrospective cohort study included patients who underwent endovascular treatment for ruptured or unruptured intracranial aneurysms with immediate postintervention vessel wall MRI between November 2015 and August 2022. Logistic regression models were used to assess the relationship of VWE with SAH, angiographic vasospasm, and a composite of DCI, delayed infarction, and symptomatic vasospasm after adjustment for clinical and traditional imaging factors. We used adjusted VWE segments as a qualitative variable, defined as the proportion of enhanced vessel segments relative to the total number of evaluable segments per patient.

Among 128 patients (79 ruptured, 49 unruptured), adjusted VWE was significantly higher among patients with ruptured than unruptured aneurysms (OR: 1.62; 95% CI: 1.39-1.99; P < .001). In the rupture cohort, adjusted VWE was the only independent predictor of angiographic vasospasm (OR: 1.12; 95% CI: 1.03-1.23; P = .01). In contrast, the modified Fisher grade and hypertension were independent predictors of DCI (P < .05), whereas adjusted VWE was not.

Qualitative adjusted VWE is associated with SAH and is a reliable, independent predictor of angiographic vasospasm, but is not predictive of DCI. Given the multifactorial nature of SAH-related complications, integrating VWE with conventional imaging and clinical factors may improve risk stratification and predictive assessment.