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LETTERS TO EDITOR
Year : 2019  |  Volume : 67  |  Issue : 2  |  Page : 588-589

Magnetic resonance vessel wall imaging in intracranial atherosclerotic disease simulating vasculitis


1 Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
2 Department of Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

Date of Web Publication13-May-2019

Correspondence Address:
Dr. P N Sylaja
Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram - 695 011, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.258031

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How to cite this article:
Arun K, Nagesh C, Kesavadas C, Sreedharan SE, Sylaja P N. Magnetic resonance vessel wall imaging in intracranial atherosclerotic disease simulating vasculitis. Neurol India 2019;67:588-9

How to cite this URL:
Arun K, Nagesh C, Kesavadas C, Sreedharan SE, Sylaja P N. Magnetic resonance vessel wall imaging in intracranial atherosclerotic disease simulating vasculitis. Neurol India [serial online] 2019 [cited 2019 May 22];67:588-9. Available from: http://www.neurologyindia.com/text.asp?2019/67/2/588/258031




Sir,

High-resolution magnetic resonance (MR) vessel wall imaging (VWI) is an emerging technique which allows direct visualization of the vessel wall enabling the differentiation between various intracranial vasculopathies.[1],[2],[3] The typical appearance of intracranial atherosclerotic disease (ICAD) on VWI is an eccentric, heterogeneously enhancing, outward remodeling lesion with heterogeneous T2 signal in the involved vessel.[4],[5] However, vasculitis shows thickening and multifocal homogeneous, smooth, intense, concentric enhancement. Recently, rare reports of ICAD patients demonstrating diffuse circumferential wall enhancement, mimicking vasculitis have been reported.[4],[5] Additional T2-weighted images can discriminate between the two entities showing the T2 hyperintensity related to the atherosclerotic plaque, a feature not seen in vasculitis. We present a patient with ICAD who showed a diffuse concentric enhancement in VWI mimicking vasculitis.

A 48-year old hypertensive and diabetic male patient presented with an acute left-sided weakness with facial deviation and dysarthria with a history of recurrent right hemispheric transient ischemic attacks (TIAs). Neurological examination revealed a subtle dysarthria, left hemianopia, left upper motor neuron facial palsy, left-sided sensory hypoaesthesia, and a drift of the left upper limb and lower limb with a National Institute of Health Stroke Scale score of 7. Computed tomography (CT) of the head showed multiple infarcts in the right middle cerebral artery territory [Figure 1]a. CT angiography showed stenosis of the right proximal M2 branch of the middle cerebral artery (MCA) [Figure 1]b and [Figure 1]c. Postcontrast T1 images showed eccentric contrast enhancement at the site of MCA stenosis with concentric enhancement both proximally and distally, along with bilateral vertebral arteries showing diffuse concentric enhancement [Figure 1]f,[Figure 1]g,[Figure 1]h,[Figure 1]i. Axial proton density and sagittal T2 images showed an isointense eccentric plaque showing T2 hyperintensity that was suggestive of ICAD [Figure 1]d and [Figure 1]e.
Figure 1: Axial plain CT scan (a) shows well-formed infarcts in the right caudate nucleus and right posterior watershed regions. Axial CT scan (b) and coronal time of flight MR (c) angiography show focal narrowing of the right M2 MCA superior division. Axial proton density (d) and sagittal T2 (e) images show an isointense eccentric plaque with the luminal surface showing T2 hyperintensity. Postcontrast T1, coronal (f) and sagittal (g) images show a strong eccentric contrast enhancement (solid arrows) at the site of narrowing with concentric enhancement both proximally and distally (empty arrows in f and h). The left vertebral artery shows a smooth narrowing (white arrow in i) secondary to an eccentric plaque with a T2 hyperintense luminal margin (white arrow in j), which shows concentric enhancement similar to the MCA with gradual progression to become more classically eccentric (arrows in k and l)

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The pattern of thickening and post gadolinium enhancement [Figure 1]f,[Figure 1]g,[Figure 1]h,[Figure 1]i, [Figure ]j,[Figure ]k,[Figure ]l is used to differentiate between vasculitis and ICAD. However, there are reports of ICAD showing concentric diffuse enhancement similar to vasculitis. In this scenario, T2 VWI helps to differentiate the underlying disease, which shows a T2 high signal on an atherosclerotic plaque.[4] A possible explanation of the diffuse enhancement may be related to the profound inflammatory response in the vascular bed during the plaque growth.[3] The inflammation leads to an increased endothelial permeability, facilitating the entry of contrast agents from the plasma.[3] This case is presented to highlight that ICAD can have a diffuse concentric enhancement on VWI, which may lead to a false diagnosis of vasculitis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Harsha KJ, Jagtap SA, Kapilamoorthy TR, Kesavadas C, Thomas B, Radhakrishnan N. CNS small vessel vasculitis: Distinct MRI features and histopathological correlation. Neurol India 2017;65:1291-4  Back to cited text no. 1
    
2.
Rastogi H. Central nervous system vasculitis imaging: Simplified. Neurol India 2017;65:1221-2  Back to cited text no. 2
    
3.
Ryu CW, Jahng GH, Shin HS. Gadolinium enhancement of atherosclerotic plaque in the middle cerebral artery: Relation to symptoms and degree of stenosis. AJNR 2014;35:2306-10.  Back to cited text no. 3
    
4.
Zhu XJ, Wang W, Liu ZJ. High-resolution magnetic resonance vessel wall imaging for intracranial arterial stenosis. Chin Med J (Engl) 2016;129:1363-70.  Back to cited text no. 4
    
5.
Mossa-Basha M, Hwang WD, De Havenon A, Hippe D, Balu N, Becker KJ, et al. Multicontrast high-resolution vessel wall magnetic resonance imaging and its value in differentiating intracranial vasculopathic processes. Stroke 2015;46:1567-73.  Back to cited text no. 5
    


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