Intracranial MR Vessel Wall Imaging: Barriers to Clinical Implementation-AJR Expert Panel Review

MR vessel wall imaging is an advanced technique for evaluating intracranial arterial pathology by directly depicting abnormalities of the vessel wall, including abnormalities that may precede, accompany, or occur without luminal findings on routine angiographic imaging. Despite increasing clinical interest and a growing evidence base, intracranial MR vessel wall imaging remains inconsistently implemented and underutilized in routine practice. In this AJR Expert Panel Narrative Review, we evaluate the barriers that limit implementation and effective utilization of VWI in the clinical environment for evaluation of intracranial arterial pathology, so that these can be addressed with future efforts. The discussed barriers to broader adoption span four major domains: technical implementation, education and expertise, clinical workflow and communication, and evidence generation. Addressing these barriers will require coordinated efforts among radiologists, technologists, referring clinicians, MRI physicists, and vendors. The goal is not simply greater use of intracranial MR vessel wall imaging, but appropriate utilization. Broader adoption will require moving this from a technique primarily found at specialized centers to a reproducible, widely available clinical service through standardized acquisition, coordinated education, workflow integration, and multicenter evidence demonstrating management impact and patient benefit.