Predicting Vasospasm and Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage: The Role of Vessel Wall MRI.

Abstract

Background and purpose: Aneurysmal subarachnoid hemorrhage is a life-threatening condition associated with angiographic vasospasm, delayed cerebral ischemia, and other complications that may lead to significant morbidity and mortality. Our study evaluated associations of vessel wall enhancement on intracranial vessel wall MRI with rupture status, and predictive value of vessel wall enhancement, conventional imaging, and clinical features for angiographic vasospasm, delayed cerebral ischemia, which encompasses delayed infarction and symptomatic vasospasm.

Materials and methods: A retrospective cohort study included patients who underwent endovascular treatment for ruptured or unruptured intracranial aneurysms with immediate post-intervention vessel wall MRI between November 2015 and August 2022. Logistic regression models were used to assess the relationship of vessel wall enhancement with SAH, angiographic vasospasm, and a composite of delayed cerebral ischemia, delayed infarction, and symptomatic vasospasm after adjustment for clinical and traditional imaging factors. We used adjusted vessel wall enhancement segments as a qualitative variable, defined as the proportion of enhanced vessel segments relative to the total number of evaluable segments per patient.

Results: Among 128 patients (79 ruptured, 49 unruptured), adjusted vessel wall enhancement was significantly higher among patients with ruptured than unruptured aneurysms (OR=1.62, 95%CI=1.39-1.99, p<0.001). In the rupture cohort, adjusted vessel wall enhancement was the only independent predictor of angiographic vasospasm (OR=1.12, 95%CI=1.03-1.23, p=0.01). In contrast, the modified Fisher grade and hypertension were independent predictors of delayed cerebral ischemia (p<0.05), whereas adjusted vessel wall enhancement was not.

Conclusions: Qualitative adjusted vessel wall enhancement is associated with SAH and is a reliable, independent predictor of angiographic vasospasm, but is not predictive of delayed cerebral ischemia. Given the multifactorial nature of SAH-related complications, integrating vessel wall enhancement with conventional imaging and clinical factors may improve risk stratification and predictive assessment.

Abbreviations: aSAH= Aneurysmal Subarachnoid Hemorrhage. ASVWE= Adjusted Segmental Vessel Wall Enhancement. DCI= Delayed Cerebral Ischemia. DI= Delayed Infarction. IA= Intracranial Aneurysm. IVWM= Intracranial Vessel Wall MRI. mFisher= Modified Fisher Grade. OR=Odds Ratio. VWE= Vessel Wall Enhancement.