Vessel Wall Imaging In The Management Of Subarachnoid Hemorrhage And Multiple Intracranial Aneurysms

Aneurysmal subarachnoid hemorrhage is a significant cause of morbidity and mortality, with a mortality rate approaching 25% and high rates of permanent neurologic deficits in survivors.1 A high priority in the management of these critically ill patients is to identify the site of rupture and urgently secure the aneurysm, either through endovascular coiling or microsurgical clipping. The ruptured aneurysm should be treated as early as reasonably possible to prevent a potentially catastrophic rehemorrhage.1,2The presence of multiple intracranial aneurysms in the setting of aneurysmal subarachnoid hemorrhage, which occurs in 15%-35% of patients, can create a significant dilemma in the management of these patients because determining the most likely site of rupture and which aneurysm requires immediate treatment can be difficult.3 Assessment has traditionally relied on the distribution of subarachnoid hemorrhage and localizing the cranial neuropathy and any focal hematomas in relation to the aneurysms. The size and morphology of the aneurysm may also help determine the culprit lesion, with larger size and irregular shape being more suspicious. While certainly helpful, these methods are indirect and inexact.Magnetic resonance vessel wall imaging (MR-VWI), an emerging technique for evaluating intracranial vascular disease, may offer additional benefit in the workup of patients with subarachnoid hemorrhage.4,5 By imaging the wall of the vessel, as opposed to the lumen and intraluminal contents, this technique can identify a site of focal inflammation and offers an alternative method of characterization to traditional angiography techniques.We present the case of a patient with subarachnoid hemorrhage and multiple intracranial aneurysms followed by a brief discussion of the basic principles and other clinical uses of MR-VWI.