Advance Access: Circumferential Wall Enhancement on Magnetic Resonance Imaging is Useful to Identify Rupture Site in Patients with Multiple Cerebral Aneurysms

Spontaneous subarachnoid hemorrhage (SAH) is mostly caused by a rupture of intracranial aneurysm. Multiple aneu-rysms are demonstrated in 30% of all patients with SAH.1 A pragmatic dilemma exists in terms of which aneurysm has bled and must be prioritized for treatment. Diagnosis can be made based on clinical (cranial nerve palsies, lateralizing signs) and radiological findings on computed tomography (CT; distribution of SAH or presence of intracerebral hematomas) and cerebral angiography (size and morphology of the aneurysms).2,3 A recent pooled analysis from 6 prospective cohort studies identified association of age, hypertension, history of SAH from another aneurysm, and aneurysm size and location as predictors of rupture.4 On comparing the features of ruptured and unruptured aneurysms, the irregularity of aneurysm shape and the aspect ratio were associated with risk of rupture.3,5,6 However, this classical approach is not enough to determine the ruptured lesion in patients with multiple aneurysms. Misjudgment may result in postoperative rebleeding from the untreated ruptured lesion. Additional diagnostic tools are needed to identify the ruptured site in patients with multiple intracranial aneurysms.

Circumferential enhancement along the aneurysm wall (CEAW) on magnetic resonance (MR) vessel wall imaging was shown more frequently and to be greater in ruptured intracranial aneurysms, compared with unruptured intracranial aneurysms.7-9 Therefore, we compared the degree of CEAW between ruptured and unruptured aneurysms within the same patient with aneurysmal SAH, who had multiple intracranial aneurysms. The objective was to assess the ability of CEAW for identification of the rupture site.

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