Bruce Wasserman
Our intracranial vessel wall imaging (VWI) techniques evolved as an extension of our extracranial carotid imaging work, and, consequently, our initial focus had been identifying and characterizing intracranial atherosclerosis.
As we gained experience with this technique, we recognized that another important application was to distinguish atherosclerosis from other intracranial vasculopathies, thereby addressing the relative lack of specificity provided by conventional cerebral angiography.
Driven largely by the stroke neurology service, our attention turned to CNS vasculitis (CNSV); its diagnosis can be especially challenging, given its protean clinical manifestations and angiographic features that overlap with other diseases.
Although we have found VWI to be useful for this, a biopsy is often still needed for confirmation in order to exclude false positives (eg, intravascular lymphoma), especially because steroid treatment for CNSV carries a significant morbidity. We believed that VWI could also help improve the historically low yield of these biopsies by identifying a target with a high probability of being abnormal, which led to this research.
Our referrals for VWI have grown substantially during this investigation, especially for distinguishing intracranial vasculopathies, as its diagnostic value became apparent; however, we are careful to select patients appropriately for biopsy (eg, clinical and VWI suspicion for CNSV).