High Resolution Magnetic Resonance Vessel Wall Imaging: A Valuable Addition to Stroke Work-Up

Intracranial High-Resolution Vessel Wall (HRVW) MRI is sometimes used alongside standard ischemic stroke (IS) work-up, yet its clinical and therapeutic interests remain debated. We aimed to assess the intracranial HRVW-MRI findings in IS patients and their impact on the IS etiologic classification as well as on treatment modifications.

We retrospectively analyzed consecutive patients who underwent an intracranial HRVW-MRI within 2 weeks from stroke onset at a single comprehensive stroke center. The HRVW-MRI was considered for IS patients with intracranial stenosis or of undetermined origin following standard IS work-up. We compared IS etiology according to the TOAST classification before and after HRVW MRI and identified treatment changes.

Among the 316 included patients (mean age = 65 years ±16.9), HRVW-MRI was performed to evaluate intracranial stenosis in 134 (42%), and IS of undetermined etiology without stenosis in 177 (56%). HRVW-MRI modified the TOAST classification in 17% of cases. Following HRVW-MRI, the proportion of strokes attributed to presumed atheromatous origin increased from 28.2% to 38.3% (p < 0.001), and those due to other determined etiologies rose from 7.3% to 12.7% (p < 0.001), while undetermined strokes decreased from 50.9% to 35.4% (p < 0.001). Etiological reclassifications were comparable in the subgroups of patients with intracranial stenosis and those with initially undetermined etiology. HRVW-MRI prompted therapeutic changes in 7% of cases.

HRVW-MRI significantly affected the IS etiologic classification and had implications in subsequent therapeutic management. Further prospective studies are warranted to determine the clinical utility of HRVW-MRI in IS etiological work-up.