Clinical interpretation of high-resolution vessel wall MRI of intracranial arterial diseases

Intracranial arterial pathology has traditionally been evaluated with luminal imaging. Recently, high-resolution vessel wall imaging (HR-VWI) with MRI has facilitated submillimetre evaluation of the arterial walls. This technique can help differentiate various causes of intracranial steno-occlusive disease, identify culprit atherosclerotic plaques with a recent cerebral infarct, locate vessel wall pathology in areas with minimal or no narrowing on luminal imaging, predict aneurysm stability and identify a ruptured aneurysm when multiple aneurysms are present. Interpretation of HR-VWI examinations requires a solid understanding of the pathophysiology, clinical features, serum and cerebrospinal fluid laboratory findings, treatment administered and fundamental patterns of VWI abnormalities that may be encountered with the intracranial vasculopathies. This pictorial essay aimed to illustrate the essential findings of common conditions encountered with HRVWI including intracranial atherosclerosis, moyamoya disease, intracranial vasculitis, varicella zoster vasculopathy, reversible cerebral vasoconstriction syndrome and aneurysms.