Added Value of 3D Proton-Density Weighted Images in Diagnosis of Intracranial Arterial Dissection

Background: An early and reliable diagnosis of intracranial arterial dissection is important to reduce the risk of neurological complication. The purpose of this study was to assess the clinical usefulness of three-dimensional high-resolution MRI (3D-HR-MRI) including pre- and post-contrast T1-weighted volumetric isotropic turbo spin echo acquisition with improved motion-sensitized driven equilibrium preparation (3D-iMSDE-T1) and proton-density weighted image (3D-PD) in detecting dissection and to evaluate the added value of 3D-PD in diagnosing intracranial arterial dissection. Methods: We retrospectively recruited patients who underwent 3D-HR-MRI with clinical suspicion of arterial dissection. Among them, we selected patients who were diagnosed with definite dissection according to the Spontaneous Cervicocephalic Arterial Dissections Study criteria. For each patient, the presence of intimal flap, intramural hematoma, and vessel dilatation were evaluated independently by two neuroradiologists on each sequence. Interobserver agreement was assessed. Results: Seventeen patients (mean age: 41 ± 10 [SD] years; 13 men) were diagnosed with definite dissection. The intimal flaps were more frequently detected on 3D-PD (88.2%, 15/17) than on 3D-iMSDE-T1 (29.4%, 5/17), and post-contrast 3D-iMSDE-T1 (35.3%, 6/17; P = 0.006 and P = 0.004, respectively). No significant difference was found in the detection rate of intramural hematomas (59-71%) and vascular dilatations (47%) on each sequence. Interobserver agreement for detection of dissection findings showed almost perfect agreement (k = 0.84-1.00), except for detection of intimal flaps on pre-contrast 3D-iMSDE-T1 (k = 0.62). After addition of 3D-PD to pre- and post-contrast 3D-iMSDE-T1, more patients were diagnosed with definite dissection with the initial MRI (88.2% vs. 47.1%; P = 0.039). Conclusions: The intimal flap might be better visualized on the 3D-PD sequence than the 3D-iMSDE-T1 sequences, allowing diagnosis of definite dissection without follow-up imaging.ope