Beyond the Lumen: Role of High-Resolution Magnetic Resonance Vessel Wall Imaging in Assessing Intracranial Aneurysms—A Prospective Observational Study from North India

Intracranial aneurysm rupture leading to subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality. While conventional imaging modalities like computed tomography (CT) angiography and digital subtraction angiography (DSA) are commonly employed, they primarily visualize the lumen rather than the vessel wall itself. Recent advancements in magnetic resonance vessel wall imaging present an opportunity to explore the role of inflammation in aneurysm rupture, thus also potentially serving as a predictor for rupture risk. This study aimed to assess vessel wall enhancement patterns in ruptured and unruptured intracranial aneurysms, correlating these patterns with aneurysm morphology and evaluate the relationship between the PHASES score and enhancement characteristics. Patients with confirmed intracranial aneurysms on CT angiography and/or DSA underwent plain and contrast-enhanced T1 SPACE (sampling perfection with application-optimized contrasts using different flip angle evolution) images to assess vessel wall enhancement, which was classified as absent, focal, or circumferential termed as grade 0, 1, and 2, respectively. Out of 60 patients included in the study, 60% presented with ruptured aneurysms. All ruptured aneurysms showed vessel wall enhancement, which was circumferential in 46.7% cases. In contrast, only 30% of unruptured aneurysms showed any form of enhancement, which was predominantly grade 1. Statistical analysis revealed a significant association between enhancement patterns and rupture status, with a p-value of < 0.001. Vessel wall enhancement was observed in all ruptured aneurysms, thus suggesting a potential role of inflammation in the disruption of aneurysm wall integrity. It may thus also serve as a predictor of aneurysm rupture, enhancing clinical decision-making for patient management.