Intracranial Vessel Wall MRI in Clinical Practice: Technical Considerations, Current and Emerging Applications, and Clinical Pearls and Pitfalls

Despite considerable advancements in imaging techniques, patients with stroke or intracranial hemorrhage may lack a specific diagnosis, even after an extensive diagnostic evaluation. One of the main underlying reasons for this shortcoming is that neurovascular imaging approaches have traditionally focused on the vessel lumen. Luminal imaging lacks both sensitivity and specificity in many clinical scenarios because luminal compromise may occur at advanced stages of disease and frequently does not offer insights about the underlying pathologic process. Most of the disease processes originate in the vessel wall, which has previously been technically difficult to image. MR imaging is an ideal technique for vessel wall imaging due to its versatility and exquisite soft-tissue contrast. Due to recent progress in imaging techniques, the translation of intracranial vessel wall MR imaging from research applications to routine clinical practice has become possible. The goal of this article was to familiarize readers with the technical underpinnings, normal findings, and current clinical applications of intracranial vessel wall MR imaging as well as to discuss limitations, pitfalls, and future perspectives for this exciting new imaging tool.

Learning Objective: Understand the technical requirements and clinical implementation details of intracranial vessel wall MR imaging, recognize normal findings and the imaging appearances of common disease processes, and identify imaging pitfalls and current limitations.