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title: "Vessel Wall Abnormalities"
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docid: "850dc563-30b3-4627-87bc-fd858bccf896"
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authors:
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- key: "2bca6b86-1eca-4e93-b997-4e18913686a7"
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value: "Hediyeh Baradaran, MD, MS"
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- key: "f6dcad15-b660-4243-a242-a9845c929101"
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value: "J. Scott McNally, MD, PhD"
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breadcrumbs:
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-
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name: "Brain"
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slug: "brain"
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treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
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-
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name: "Differential Diagnosis"
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slug: "differential-diagnosis"
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treeNodeId: "a7fdd139-664e-4bb8-8d18-400e4733ff60"
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-
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name: "Arteries"
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slug: "arteries"
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treeNodeId: "f5fee8ee-062f-41f2-b449-efcca9fb78f9"
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-
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name: "Anatomically Based Differentials"
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slug: "anatomically-based-differentials"
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treeNodeId: "9955b05e-9840-401a-b3da-4039f8b22a35"
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-
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name: "Vessel Wall Abnormalities"
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slug: "vessel-wall-abnormalities"
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treeNodeId: null
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category: "Brain"
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documentVersionId: "9cf47507-a8f6-447a-8848-ac23bd794e2d"
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imageCount: 18
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lastUpdated: "02/22/23"
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pageDescription: "Vessel Wall Abnormalities"
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pageKeywords: "Brain, Differential Diagnosis, Arteries, Anatomically Based Differentials, Vessel Wall Abnormalities"
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pageTitle: "Vessel Wall Abnormalities | STATdx"
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enhancedTitle: "Vessel Wall Abnormalities"
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type: "DDX"
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references: true
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breadcrumbs:
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- "Brain"
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- "Differential Diagnosis"
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- "Arteries"
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- "Anatomically Based Differentials"
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- "Vessel Wall Abnormalities"
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---
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# ESSENTIAL INFORMATION
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- ## Key Differential Diagnosis Issues
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- **Clinical history**
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- History can narrow DDx, but it is often absent initially
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- **Stroke**
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- DDx includes extra/intracranial atherosclerosis, dissection, vasospasm, reversible cerebral vasoconstriction syndrome (RCVS)
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- **Subarachnoid hemorrhage (SAH)**
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- DDx includes aneurysm (or other vascular lesion/arteriovenous malformation) vs. RCVS vs. vasculitis
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- Imaging can narrow differential, guide treatment
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- Vessel wall MR (vwMR) protocol
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- 3T MR, sub mm, 3D volumetric images
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- Precontrast: Time of flight (TOF), T2 SPACE, DANTE T1 SPACE, MPRAGE
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- Postcontrast: DANTE T1 SPACE, TOF
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- ## Helpful Clues for Common Diagnoses
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- **Atherosclerosis, Extracranial**
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- **Location**
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- Usually at branch points (e.g., carotid bifurcations)
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- Oscillatory shear stress at branch points predisposes to endothelial dysfunction and atrioventricular septal defect (ASVD)
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- **Lumen imaging (CTA or MRA)**
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- Plaque thickness
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- Positive remodeling occurs prior to stenosis
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- Increased soft plaque → lipid → necrosis → intraplaque hemorrhage
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- Stenosis
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- Carotid stenosis is measured by North American Symptomatic Carotid Endarterectomy Trial (NASCET) (a-b)/a: "a" = diameter of downstream ICA, and "b" = diameter at level of stenosis
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- Watch for near occlusion [e.g., downstream ICA < 3 mm or < external carotid artery (ECA)]
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- Millimeter stenosis measurement can also be used
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- Ulceration
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- CTA has high accuracy for detecting ulcerations measuring > 2 mm
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- Intraluminal thrombus
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- Rare, but if present, highly associated with acute infarction (positive predictive value: ~ 1)
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- Identified by donut sign on CTA or MRA
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- Calcification
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- Indicates atherosclerosis
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- Calcification itself may be stable but often adjacent to unstable components
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- Calcification pattern can indicate unstable plaque (e.g., spotty calcification)
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- Thin, adventitial calcification (< 2 mm) coupled with thick, soft plaque (> 2 mm) (rim sign) is associated with intraplaque hemorrhage
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- **vwMR**
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- Carotid intraplaque hemorrhage
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- American Heart Association (AHA) type VIb plaque (intraplaque rupture)
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- Highly associated with acute ipsilateral infarcts
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- High annual stroke risk (15-45%) despite medication
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- Best detected by heavily T1-weighted sequences; MPRAGE has ↑↑ signal-to-noise, spatial resolution, and accuracy compared to T1 FS or 3D TOF
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- MPRAGE-positive plaque: > 2x signal intensity of adjacent muscle, validated by histology
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- Lipid-rich necrotic core (LRNC)
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- Nonenhancing on DANTE T1 SPACE post contrast
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- Can also be detected as T2-hyperintense plaque
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- LRNC decreases after 1-2 years of statins
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- Fibrous cap (FC)
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- FC thinning (< 100 μm) or rupture indicates instability
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- FC (collagen-rich tissue) enhances on delayed T1 postcontrast black blood images, but detection of rupture can be difficult
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- **Atherosclerosis, Intracranial**
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- **Location**
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- Branch points predisposed
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- Proximal > distal branches
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- **Lumen imaging**
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- Focal stenosis, multifocal stenoses, lumen irregularities, ectasia
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- Stenosis measured by warfarin-aspirin symptomatic intracranial disease (WASID) criteria
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- **vwMR**
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- High T2 signal → lipid/necrotic core
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- High T1 signal → intraplaque hemorrhage (not as common as in extracranial plaque)
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- Enhancement → unstable/active atherosclerotic plaque
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- Highly associated with acute territorial stroke
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- High repeat stroke risk despite medical therapy (15-30% per year)
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- Calcification on CT/CTA → atherosclerosis
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- **Dissection**
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- **Location**
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- Extracranial > > intracranial
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- Vertebral > carotid arteries
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- Carotid arteries: Distal cervical ICAs > common carotid arteries (CCAs)
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- Vertebral arteries: V1/V3 > V2/V4 segments
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- **Lumen imaging**
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- Biffl grading system
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- Grade I: Mild irregularity with < 25% narrowing
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- Grade II: > 25% narrowing, dissection flap, intramural hematoma, or intraluminal thrombus
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- Grade III: Pseudoaneurysm
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- Grade IV: Occlusion
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- Grade V: Transection
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- **vwMR**
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- Intramural hematoma
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- Often, intramural hematoma is not present or detectable in dissection
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- T1-hyperintense signal indicates subacute dissection (methemoglobin)
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- Acute trauma: No T1-hyperintense signal and rarely hyperdense on CT
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- **Vasospasm**
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- Location
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- Usually, it is worst closest to source of SAH
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- Lumen imaging: Multifocal narrowing
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- vwMR: Negative = no T2 signal, no or mild enhancement
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- **Aneurysm**
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- Location
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- Occurs most often at branch points
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- If linear vessel segment, think pseudoaneurysm
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- Lumen imaging
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- Most often saccular
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- Irregularities and focal outpouchings more associated with instability
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- Rupture risk increases with size
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- vwMR
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- Wall enhancement associated with unstable aneurysm
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- Can identify SAH source if multiple aneurysms
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- **Pseudoaneurysm**
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- Location
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- Not often at branch points
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- Often adjacent to skull base fracture or dura
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- Common type is dorsal variant ICA blister aneurysm
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- Lumen imaging
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- Broad-based bulge, no neck, fusiform, irregular
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- Rapidly change in size over hours or days
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- vwMR
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- Avid wall enhancement at site of wall breakdown
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- ## Helpful Clues for Less Common Diagnoses
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- **Reversible Cerebral Vasoconstriction Syndrome**
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- Location: Multifocal, diffuse
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- Lumen imaging: Multiple alternating stenoses
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- vwMR: Negative = no T2 signal, no or mild enhancement
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- **Vasculitis**
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- Location: Multifocal, diffuse
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- Lumen imaging: Multiple alternating stenoses
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- vwMR: Avid wall enhancement, no/mild T2 signal
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- **Carotid Web**
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- Location: Posterolateral carotid bifurcation
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- Lumen imaging: Linear filling defect
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- ## Helpful Clues for Rare Diagnoses
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- **Perivascular Infection**
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- Location
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- Often direct spread from sinuses or mastoid air cells
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- Lumen imaging
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- Smooth or irregular stenosis
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- ± pseudoaneurysm, intraluminal thrombus
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- May require DSA for full delineation
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- vwMR: Wall enhancement with invasion
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- **Perivascular Tumor**
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- Location: Direct spread from adjacent tumor
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- Lumen imaging: Vessel narrowing, ± pseudoaneurysm, thrombus
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- vwMR: Thick, irregular wall enhancement
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## References
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# Selected References
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1. [El-Masri S et al: Systematic review and meta-analysis of ipsilateral and contralateral carotid web prevalence in embolic supratentorial strokes of undetermined source. J Clin Neurosci. 107:118-23, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=36535218%5Bpmid%5D)
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1. [Chung CY et al: Imaging intracranial aneurysms in the endovascular era: surveillance and posttreatment follow-up. Radiographics. 42(3):789-805, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35333634%5Bpmid%5D)
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1. [Culleton S et al: MRI detection of carotid intraplaque hemorrhage and postintervention cognition. AJNR Am J Neuroradiol. 43(12):1762-9, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36357151%5Bpmid%5D)
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1. [Fanning NF et al: Thromboembolism from carotid web. Radiology. 221504, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36378034%5Bpmid%5D)
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1. [Larson AS et al: Nonstenotic carotid plaques and embolic stroke of undetermined source: a multimodality review. AJNR Am J Neuroradiol. ePub, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36549844%5Bpmid%5D)
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1. [Lehman VT et al: Conventional and high-resolution vessel wall MRI of intracranial aneurysms: current concepts and new horizons. J Neurosurg. 1-13, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28598273%5Bpmid%5D)
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1. [McNally JS et al: Magnetic resonance imaging detection of intraplaque hemorrhage. Magn Reson Insights. 10:1-8, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28469441%5Bpmid%5D)
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1. [Eisenmenger LB et al: Prediction of carotid intraplaque hemorrhage using adventitial calcification and plaque thickness on CTA. AJNR Am J Neuroradiol. 37(8):1496-503, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27102316%5Bpmid%5D)
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1. [McNally JS et al: Intraluminal thrombus, intraplaque hemorrhage, plaque thickness, and current smoking optimally predict carotid stroke. Stroke. 46(1):84-90, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25406146%5Bpmid%5D)
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1. [Mossa-Basha M et al: Multicontrast high-resolution vessel wall magnetic resonance imaging and its value in differentiating intracranial vasculopathic processes. Stroke. 46(6):1567-73, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25953365%5Bpmid%5D)
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1. [Bartlett ES et al: Quantification of carotid stenosis on CT angiography. AJNR Am J Neuroradiol. 27(1):13-9, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16418349%5Bpmid%5D)
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## Images
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### Selected Images
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![CTA shows a left carotid bifurcation/proximal ICA plaque. NASCET stenosis [(a-b)/a] is calculated by subtracting the maximal stenosis (b <img src='img/arrows/CS.png'/>) from the downstream normal-caliber ICA (a <img src='img/arrows/WS.png'/>) and normalizing to the downstream normal ICA (a). A single mm stenosis measurement (b) can alternatively be used. Maximum plaque thickness can also be measured on CTA <img src='img/arrows/CO.png'/>.](images/app.statdx.com_image_thumbnail_f989d945-abad-41d9-b68c-275ef656c54c_annotated_true_size_900_quality_90_679e427c9a49899cecad73baec4cb8abd5628178.jpg)
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**Atherosclerosis, Extracranial**
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*CTA shows a left carotid bifurcation/proximal ICA plaque. NASCET stenosis [(a-b)/a] is calculated by subtracting the maximal stenosis (b <img src='img/arrows/CS.png'/>) from the downstream normal-caliber ICA (a <img src='img/arrows/WS.png'/>) and normalizing to the downstream normal ICA (a). A single mm stenosis measurement (b) can alternatively be used. Maximum plaque thickness can also be measured on CTA <img src='img/arrows/CO.png'/>.*
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![CTA shows a left carotid bifurcation/proximal ICA plaque. NASCET stenosis [(a-b)/a] is calculated by subtracting the maximal stenosis (b <img src='img/arrows/CS.png'/>) from the downstream normal-caliber ICA (a <img src='img/arrows/WS.png'/>) and normalizing to the downstream normal ICA (a). A single mm stenosis measurement (b) can alternatively be used. Maximum plaque thickness can also be measured on CTA <img src='img/arrows/CO.png'/>.](images/app.statdx.com_image_thumbnail_f989d945-abad-41d9-b68c-275ef656c54c_size_174_quality_85_ff3ccf1c1fb72983384b6b81e4d8e7e242cdc5ad.jpg)
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**Atherosclerosis, Extracranial**
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*CTA shows a left carotid bifurcation/proximal ICA plaque. NASCET stenosis [(a-b)/a] is calculated by subtracting the maximal stenosis (b <img src='img/arrows/CS.png'/>) from the downstream normal-caliber ICA (a <img src='img/arrows/WS.png'/>) and normalizing to the downstream normal ICA (a). A single mm stenosis measurement (b) can alternatively be used. Maximum plaque thickness can also be measured on CTA <img src='img/arrows/CO.png'/>.*
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**Atherosclerosis, Extracranial**
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*CTA (and MRA) can also detect ulceration (sagittal <img src='img/arrows/WS.png'/> and axial <img src='img/arrows/WO.png'/>) and intraluminal thrombus (sagittal <img src='img/arrows/CS.png'/> and axial <img src='img/arrows/CO.png'/>).*
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**Atherosclerosis, Extracranial**
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*Intraplaque hemorrhage (IPH) can be detected on MRA. 3D TOF can detect IPH (sagittal <img src='img/arrows/WS.png'/> and axial <img src='img/arrows/WO.png'/>), but TOF and conventional T1 FS MR are less accurate than MPRAGE <img src='img/arrows/CO.png'/> when compared to histology.*
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**Atherosclerosis, Extracranial**
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*While IPH is best detected with MR and heavily T1-weighted sequences, such as MPRAGE <img src='img/arrows/CS.png'/>, IPH can be inferred on CTA with a rim sign <img src='img/arrows/WS.png'/>, which consists of a thin, < 2-mm rim of calcification with ≥ 2-mm central soft plaque. Likelihood of IPH increases with soft plaque thickness.*
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**Atherosclerosis, Intracranial**
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*DSA shows ~ 50% narrowing of the midbasilar artery <img src='img/arrows/BS.png'/> in a patient with a pontine infarct. T2-hyperintense plaque <img src='img/arrows/WO.png'/> on vwMR, IPH on MPRAGE <img src='img/arrows/CC.png'/>, and wall enhancement <img src='img/arrows/CO.png'/> on DANTE T1 SPACE indicate active plaque.*
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**Dissection**
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*CTA shows traumatic dissection of the ICA with narrowing <img src='img/arrows/BO.png'/> and associated intramural hematoma on MR <img src='img/arrows/CO.png'/>. Intramural hematoma can be detected on MR using T1 FS MR or MPRAGE. Methemoglobin within intramural hematoma is T1 hyperintense.*
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**Aneurysm**
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*MRA 3D TOF source image shows an anterior communicating artery saccular aneurysm <img src='img/arrows/CS.png'/>. Vessel wall MR (vwMR) images show areas of wall enhancement comparing pre- <img src='img/arrows/WO.png'/> and postcontrast <img src='img/arrows/CO.png'/> DANTE T1 SPACE, thought to be linked to growth and rupture risk.*
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**Pseudoaneurysm**
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*Dorsal variant ICA blister aneurysm, or pseudoaneurysm, is shown on DSA <img src='img/arrows/BS.png'/>. Initial CTA shows mild lumen outpouching <img src='img/arrows/WO.png'/>. vwMR shows that avid wall enhancement is present comparing pre- <img src='img/arrows/WC.png'/> and postcontrast <img src='img/arrows/CO.png'/> DANTE T1 SPACE.*
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**Reversible Cerebral Vasoconstriction Syndrome**
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*Multifocal areas of narrowing <img src='img/arrows/BS.png'/> are shown on DSA in a patient with thunderclap headache. Multifocal anterior circulation narrowing was also present (not shown). vwMR was negative. The patient improved with calcium channel blockers. Imaging appearance is typical of RCVS.*
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**Reversible Cerebral Vasoconstriction Syndrome**
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*In the same patient, CT shows left-sided SAH <img src='img/arrows/WS.png'/>, and DWI MR shows a single punctate recent infarct <img src='img/arrows/CS.png'/>. There was no T2 signal <img src='img/arrows/WO.png'/> or vessel wall enhancement on DANTE T1 SPACE <img src='img/arrows/CO.png'/>. Diagnosis was RCVS.*
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**Vasculitis**
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*DSA in a 40-year-old patient with recurrent strokes and eventual diagnosis of vasculitis shows subtle right middle cerebral artery (MCA) narrowing <img src='img/arrows/WS.png'/>. Avid wall enhancement is present on vwMR DANTE T1 SPACE <img src='img/arrows/CS.png'/> without T2 signal <img src='img/arrows/BS.png'/>.*
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**Carotid Web**
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*CTA images show linear filling defects in the posterolateral carotid bifurcation in 3 different patients <img src='img/arrows/CO.png'/>, consistent with carotid webs. Carotid webs are associated with increased risk of ipsilateral ischemic infarct.*
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**Perivascular Infection**
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*3D TOF C+ MR in a 62-year-old man with left CNVI palsy and Horner syndrome shows left cavernous sinus thrombophlebitis <img src='img/arrows/WO.png'/> and intraluminal clot in the left ICA <img src='img/arrows/WS.png'/>. DSA confirms perivascular infection along the left ICA with intraluminal clot <img src='img/arrows/CS.png'/>.*
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**Perivascular Tumor**
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*A 59-year-old woman presented with left MCA infarcts <img src='img/arrows/WO.png'/> on DTI but elevated CBV along the left insula <img src='img/arrows/WS.png'/>. MR spectroscopy reveals elevated choline <img src='img/arrows/CS.png'/>. Vessel wall enhancement is present on DANTE T1 SPACE <img src='img/arrows/CO.png'/>. This was biopsy-proven GBM with MCA invasion.*
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### Additional Images
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**Vasospasm**
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*In a patient with a ruptured pseudoaneurysm <img src='img/arrows/BS.png'/>, DSA shows multifocal areas of vessel narrowing, consistent with vasospasm <img src='img/arrows/CS.png'/>. vwMR was negative in the areas of narrowing (not shown).*
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**Aneurysm**
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*Right ICA ophthalmic segment saccular aneurysm is shown on DSA <img src='img/arrows/CS.png'/> and 3D TOF MRA <img src='img/arrows/WO.png'/>. Note areas of wall enhancement comparing pre- <img src='img/arrows/WS.png'/> and postcontrast <img src='img/arrows/CO.png'/> DANTE T1 SPACE, thought to be linked to growth and rupture risk.*
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**Reversible Cerebral Vasoconstriction Syndrome**
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*DSA shows multifocal areas of narrowing <img src='img/arrows/WS.png'/> in a patient with thunderclap headache. Multifocal posterior circulation narrowing was also present, and vwMR was negative (not shown). The patient improved with calcium channel blockers. This was RCVS.*
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**Vasculitis**
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*DSA in a 40-year-old patient with recurrent strokes and eventual diagnosis of vasculitis shows severe right subclavian artery narrowing <img src='img/arrows/WS.png'/>. Wall enhancement is present on DANTE T1 SPACE <img src='img/arrows/CS.png'/> without T2 signal <img src='img/arrows/BS.png'/>.*
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