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. 2022 Mar 2;29(3):235–242. doi: 10.1177/15910199221082847

The use of SNAP and T1-weighted VISTA in cervical artery dissection

Shuiwei Xia 1,*, Yajie Wang 2,*, Xianli Lv 3, Chunmiao Chen 1, Junguo Hui 1, Xulu Wu 1, Zufei Wang 1, Huijun Chen 2,✉, Jiansong Ji 1,✉
PMCID: PMC10369114  PMID: 35234066

Abstract

Background and Purpose

Some cervical artery dissection (CAD) can't be easily confirmed by commonly used angiography techniques in clinical practice. We aimed to compare the abilities of the vessel wall magnetic resonance imaging (MRI) techniques including simultaneous noncontrast angiography and intraplaque hemorrhage (SNAP) sequence and T1-weighted volumetric isotropic turbo spin echo acquisition (T1-w VISTA) sequence alone for evaluating CAD.

Materials and Methods

From July 2017 to October 2020, 59 patients underwent MRI examinations including SNAP and T1-w VISTA sequences for cervical artery pathologies. SNAP and T1-w VISTA images were retrospectively and independently reviewed to evaluate their diagnostic performances of CAD by using the final diagnosis as the reference standard which was established by clinical history, physical examination, and all available images. The agreement between T1-w VISTA and SNAP in the identification of the imaging features of CAD, including intramural hematoma (IMH), intimal flap, and double lumen, were compared. The IMH-wall contrasts by T1-w VISTA and SNAP were also compared.

Results

CAD was confirmed in 43 of the 59 patients. T1-w VISTA and SNAP showed the same diagnostic performance, and their consistencies with the final diagnosis were good (κ = 0.776, p < 0.001). The sensitivity and specificity in CAD diagnosis were 0.978 and 0.750 for T1-w VISTA and SNAP. The IMH, intimal flap, and double lumen observed on SNAP were also determined by T1-w VISTA (κ = 1.000, p < 0.001 for all). The SNAP sequence showed higher IMH-wall contrast than T1-w VISTA (7.34 ± 4.56 vs. 3.12 ± 1.17, p < 0.001).

Conclusions

SNAP and T1-w VISTA sequences had the same performance in CAD diagnosis, thus they were both recommended. In addition, SNAP showed better IMH-wall contrast than T1-w VISTA.

Keywords: Cervical artery dissection, simultaneous noncontrast angiography and intraplaque hemorrhage, volumetric isotropic turbo spin echo acquisition, intramural hematoma

Introduction

Cervical artery dissection (CAD) is one of the common causes of stroke in young adults.1,2 Early and accurate diagnosis of CAD is of great importance for clinical treatment decision-making.1,3

Except for the clinical symptoms of the patients, various imaging techniques play important roles in the diagnosis of CAD. In clinical practice, duplex ultrasound, magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), computed tomography angiography (CTA) and digital subtraction angiography (DSA) have been used to confirm CAD.4–8

Although the angiographic appearance of dissection, such as luminal stenosis and pseudoaneurysm, can be characterized by angiography imaging methods, the vessel wall features of the dissection including intramural hematoma (IMH) can't be distinguished on angiography imaging and may occur with atypical angiographic morphology. 9 Thus, vessel wall imaging, which is sensitive to identify IMH, has drawn more and more attention.10,11 A previous study has used 3D fast spin-echo T1-weighted black-blood vessel wall MRI method (called VISTA by Philips, CUBE by General Electric, SPACE by Siemens) alone to diagnose CAD due to its comprehensive neck coverage, isotropic high spatial resolution, and better blood suppression. 10

However, there are other studies that recommended using T1-weighted magnetic resonance (MR) vessel wall sequence combined with MRA for CAD diagnosis in order to identify both vessel wall and luminal characteristics of the dissection. 1 In recent years, 3D simultaneous noncontrast angiography and intraplaque hemorrhage MR imaging (SNAP) sequence has been proposed for the carotid atherosclerotic disease evaluation. 12 The ability of the SNAP technique to provide both MR angiography and heavy T1-weighted vessel wall imaging in a single sequence made it meet the requirements to provide luminal and vessel wall information simultaneously thus had great potential to diagnose CAD.13,14

Although using a single imaging scan in CAD diagnosis, such as SNAP and T1-w VISTA, has the advantage of fast imaging and low cost, their advantages and limitations have not been explored and compared in the one cohort. Thus, in this study, we aim to compare the performance of SNAP and T1-w VISTA sequences in the evaluation of CAD.

Materials and methods

Patients

This retrospective study was approved by the local institutional review board, and the requirement for informed consent was waived. Patients who had suspected cervical artery dissection symptoms including head or neck pain (n = 22), dizziness (n = 20), vomiting (n = 2), sensory or motor disorders (n = 39), transient ischemic attack (n = 9), or ischemic stroke (n = 32) and underwent both SNAP and T1-w VISTA imaging from July 2017 to October 2020 were enrolled. Patients with poor SNAP or T1-w VISTA image quality were excluded. In total, 63 patients met the inclusion criteria. After excluding 4 patients with poor image quality, 59 patients (age 57.59 ± 11.92 years; 47 males) were finally included in this study. The demographic and clinical characteristics of the patients were summarized in Table 1. Smoking, alcohol use, hypertension, hyperlipidemia, and diabetes were found in 34 (57.6%), 26 (44.1%), 26 (44.1%), 10 (16.9%), and 6 (10.2%) of the patients, respectively.

Table 1.

Demographic and clinical characteristics of the patients.

Characteristics Mean ± SD or No. (%)
Age, years 57.59 ± 11.92
Sex, male 47 (79.7%)
Smoking 34 (57.6%)
Alcohol use 26 (44.1%)
Hypertension 26 (44.1%)
Hyperlipidemia 10 (16.9%)
Diabetes 6 (10.2%)
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SD, standard deviation.

Radiological explorations

All patients were scanned on a 3.0 T MR scanner (Ingenia CX, Philips Healthcare, Best, the Netherlands) with a custom-designed 36-channel neurovascular coil. 3D T1-w VISTA and 3D SNAP sequences were performed for all patients without contrast administration. The scan parameters of the 3D T1-w VISTA sequence were: coronal acquisition, repetition time/echo time (TR/TE) = 600.0/30.7 ms, flip angle = 90°, FOV = 250 × 160 × 48 mm3, spatial resolution = 0.8 × 0.8 × 0.8 mm3. The 3D SNAP sequence was acquired with the following scan parameters: coronal acquisition, TR/TE = 10.0/4.9 ms, flip angle = 11°/5°, FOV = 250 × 160 × 48 mm3, spatial resolution = 0.8 × 0.8 × 0.8 mm3. The scan durations of the T1-w VISTA and SNAP sequences were 4 min 21 s and 5 min 18 s, respectively.

All available radiological examination images including DSA, CTA, ultrasound, and other MR sequences such as time-of-flight (TOF), black blood T1-turbo spin echo (BB T1-TSE), BB T2-TSE, contrast-enhanced BB T1-TSE, contrast-enhanced T1-w VISTA were collected (Table 2).

Table 2.

The number of patients who had DSA, CTA, ultrasound, and MRI images used for the final diagnosis of the cervical artery dissection (CAD).

CAD (n = 43) Non-CAD (n = 16)
DSA 19 8
CTA 43 16
Ultrasound 17 10
MRI
 TOF 17 2
 SNAP 43 16
 T1-w VISTA 43 16
 BB T1-TSE 1 4
 BB T1-TSE 2 4
 CE BB T1-TSE 1 4
 CE T1-w VISTA 32 15
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DSA, digital subtraction angiography; CTA, computed tomography angiography; MRI, magnetic resonance imaging; TOF, time-of-flight; SNAP, simultaneous noncontrast angiography and intraplaque hemorrhage; VISTA, volumetric isotropic turbo spin echo acquisition; BB, black blood; TSE, turbo spin echo; CE, contrast-enhanced.

CAD definitions

CAD was defined as dissection that occurred on carotid arteries or vertebral arteries. 15 All the MR images were reconstructed on a workstation (Extended MR WorkSpace, Version 2.0.3.3, Philips Healthcare). Multiplanar reconstruction and curved planar reformation were applied for T1-w VISTA images. The diagnosis of CAD based on T1-w VISTA was according to the presence of typical vessel wall characteristics of the dissection, including IMH, intimal flap and double lumen.10,16 IMH was defined when hyperintense wall thickening was present. 11 The intimal flap was defined as a line signal crossing the lumen that extended to the sidewall. 17 The double lumen represented the true and false lumens. 18 The signal intensity ratio between IMH and the normal vessel wall (defined as IMH-wall contrast) of the T1-w VISTA sequence was calculated.

For SNAP, heavy T1-weighted images with negative blood signals were firstly generated using the phase-sensitive reconstruction. 12 Minimum intensity projection (mIP) was applied to the phase-sensitive reconstructed images to generate SNAP MRA. 19 Source SNAP images, heavy T1-weighted images, multiplanar reconstructed, and curved planar reformated images, and SNAP MRA were used for assessment. As SNAP can provide both vessel wall imaging and angiography simultaneously, the diagnosis of the dissection based on the SNAP sequence combined the presence of IMH, intimal flap, and double lumen as in T1-w VISTA and the following luminal criteria: abrupt or tapered lumen stenosis. 6 The IMH-wall contrast of the SNAP sequence was measured on the heavy T1-weighted images using the same method as in T1-w VISTA.

The T1-w VISTA images and the SNAP images were analyzed by two experienced radiologists (12 and 5 years experience in radiology). Blinded to the patient's clinical information, the final diagnosis results and other images, each of the image datasets was reviewed by each of the radiologists independently. Any discrepancies between the reviewers were resolved by consensus. The time interval between the two image datasets review was 1 week. The final diagnosis of CAD was established by clinical history, physical examination, and all available images including DSA, CTA, ultrasound, and all MR images. The dissection location was recorded. The internal carotid artery (ICA) was further subdivided into C1-C7 segments, 20 and the vertebral artery was subdivided into V1-V5 segments. 21

Statistical analysis

The continuous variables were described as mean ± standard deviation (SD), and categorical variables were described as count (percentage). The Cohen κ was used to evaluate the diagnostic coherences between the final diagnosis results and T1-w VISTA, and SNAP, respectively. The sensitivity and specificity of T1-w VISTA and SNAP in the diagnosis of CAD were calculated by using the final diagnosis results as the reference standard. The Cohen κ was also used to assess the interobserver agreements of the two imaging techniques in the diagnosis of CAD. The agreements between T1-w VISTA and SNAP in the identification of characteristics of the dissection including IMH, intimal flap and double lumen were determined using Kappa statistics. The IMH-wall contrast measured on the T1-w VISTA images and the SNAP images was compared using paired t-test or Wilcoxon signed-rank test Kappa statistics were classified as follows: poor (κ ≤ 0.20), fair (κ = 0.21–0.40), moderate (κ = 0.41–0.60), good (κ = 0.61–0.80), and excellent (κ ≥  0.81). 22 p < 0.05 was considered statistically significant. The statistical analyzes were conducted using SPSS (Version 23.0. IBM, Armonk, NY, USA).

Results

According to the comprehensive evaluation, carotid artery dissections were confirmed in 33 patients, and 3 of them had bilateral carotid dissection (1 on the common carotid artery (CCA), 1 involving the CCA and C1 segment of the ICA, 31 on the C1 segment of the ICA, 3 on the C2 segment of the ICA). Vertebral artery dissections were confirmed in 10 patients (4 on the V2 segment, 1 on the V3 segment, 2 on the V4 segment, 3 on the V5 segment). Other 16 patients didn't have dissected cervical arteries.

The sensitivity and specificity of T1-w VISTA and SNAP in CAD diagnosis

For all 59 patients, the CAD diagnostic consistency between SNAP and the final diagnosis (κ = 0.776, p < 0.001), and between T1-w VISTA and the final diagnosis (κ = 0.776, p < 0.001) was good. Table 3 showed the detailed diagnostic performance of SNAP and T1-w VISTA, respectively. The sensitivity and specificity in the diagnosis of CAD were 0.978 and 0.750 for SNAP, and 0.978 and 0.750 for T1-w VISTA. SNAP and T1-w VISTA sequence showed the same diagnostic performance (κ = 1.000, p < 0.001). The interobserver agreements for SNAP (κ = 0.950, p < 0.001) and T1-w VISTA (κ = 1.000, p < 0.001) were all excellent.

Table 3.

Agreements in the diagnosis of cervical artery dissection (CAD) between SNAP, T1-weighted VISTA, and the final diagnosis.

All Carotid arteries Vertebral arteries
Final diagnosis Final diagnosis Final diagnosis
CAD Non-CAD CAD Non-CAD CAD Non-CAD
SNAP CAD 45 4 36 4 9 0
Non-CAD 1 12 0 12 1 0
Sensitivity = 0.978 Specificity = 0.750 Sensitivity = 1.000 Specificity = 0.750 Sensitivity = 0.900 Specificity = /
T1-w VISTA CAD 45 4 36 4 9 0
Non-CAD 1 12 0 12 1 0
Sensitivity = 0.978 Specificity = 0.750 Sensitivity = 1.000 Specificity = 0.750 Sensitivity = 0.900 Specificity = /
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SNAP, simultaneous noncontrast angiography and intraplaque hemorrhage; VISTA, volumetric isotropic turbo spin echo acquisition.

For patients with carotid artery diseases, SNAP (κ = 0.806, p < 0.001) and T1-w VISTA (κ = 0.806, p < 0.001) both have good CAD diagnostic consistency with the final diagnosis. The sensitivity and specificity in the diagnosis of CAD were 1.000 and 0.750 for SNAP, and 1.000 and 0.750 for T1-w VISTA (Table 3). SNAP and T1-w VISTA sequence showed the same diagnostic performance (κ = 1.000, p < 0.001). The interobserver agreements for SNAP (κ = 0.944, p < 0.001) and T1-w VISTA (κ = 1.000, p < 0.001) were all excellent.

In patients with vertebral artery diseases, the CAD diagnostic consistency between SNAP or T1-w VISTA with the final diagnosis was not calculated because all 10 patients were finally diagnosed as vertebral artery dissection. The specificity was also not calculated. Only one of the 10 patients was not confirmed by SNAP or T1-w VISTA alone. The sensitivity of SNAP or T1-w VISTA was 0.900 in the vertebral artery dissection (Table 3). SNAP and T1-w VISTA sequence showed the same diagnostic performance (κ = 1.000, p < 0.001). The interobserver agreements for SNAP (κ = 1.000, p < 0.001) and T1-w VISTA (κ = 1.000, p < 0.001) were all excellent.

Typical images of patients with CAD were shown in Figure 1 and Figure 2. The dissection can be diagnosed by SNAP and T1-w VISTA independently according to the presence of IMH (Figure 1) or intimal flap (Figure 2). A total of 4 patients without CAD were diagnosed as dissection by using SNAP or T1-w VISTA independently. These 4 patients were finally diagnosed as carotid atherosclerosis with severe lumen stenosis or occlusion (3 originated from the CCA bifurcation and extended to the C1 segment of the ICA, 1 involving the CCA and C1 segment of the ICA). A typical patient with carotid atherosclerosis was shown in Figure 3. The intraluminal thrombus caused by lumen occlusion was incorrectly identified as IMH by SNAP or T1-w VISTA (Figure 3A, B). The dissection of one patient on the V2 segment of the right vertebral artery was not recognized on SNAP or T1-w VISTA images alone due to the limited spatial resolution of the MR images (Figure 4).

Figure 1.

Figure 1.

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Images of a patient with cervical artery dissection (CAD) on the left internal carotid artery (white arrow). (A) Curved planar reformated heavy T1-weighted images and magnetic resonance angiography (MRA) generated by simultaneous noncontrast angiography and intraplaque hemorrhage (SNAP) sequence. The dissection was diagnosed according to the intramural hematoma on the left C2 segment; (B) Curved planar reformated T1-weighted volumetric isotropic turbo spin echo acquisition (VISTA) images. The dissection was also diagnosed according to the presence of the intramural hematoma.

Figure 2.

Figure 2.

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Images of a patient with cervical artery dissection (CAD) on the left internal carotid artery (white arrow). (A) Heavy T1-weighted images and magnetic resonance angiography (MRA) generated by simultaneous noncontrast angiography and intraplaque hemorrhage (SNAP) sequence. The dissection was diagnosed according to the presence of intimal flap; (B) T1-weighted volumetric isotropic turbo spin echo acquisition (VISTA) images. The dissection was also diagnosed according to the presence of the intimal flap; (C) The dissection was further confirmed by digital subtraction angiography (DSA) images.

Figure 3.

Figure 3.

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Images of a patient without cervical artery dissection (CAD) but with right internal carotid artery occlusion caused by carotid atherosclerosis (white arrow). (A) Heavy T1-weighted images and magnetic resonance angiography (MRA) generated by simultaneous noncontrast angiography and intraplaque hemorrhage (SNAP) sequence; (B) T1-weighted volumetric isotropic turbo spin echo acquisition (VISTA) images. The intraluminal thrombus caused by lumen occlusion was incorrectly identified as intramural hematoma of the dissection by SNAP or T1-w VISTA.

Figure 4.

Figure 4.

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Images of a patient with cervical artery dissection (CAD) on the right vertebral artery (white arrow). (A) Curved planar reformated heavy T1-weighted images and magnetic resonance angiography (MRA) generated by simultaneous noncontrast angiography and intraplaque hemorrhage (SNAP) sequence; (B) Curved planar reformated T1-weighted volumetric isotropic turbo spin echo acquisition (VISTA) images. The dissection was not diagnosed by SNAP or T1-weighted VISTA images alone due to the limited spatial resolution; (C) The dissection was confirmed by the computed tomography angiography (CTA) images according to the tapered, irregular, and stenosis of the right vertebral artery.

Vessel wall characteristic

Typical vessel wall characteristics of the dissection including IMH, intimal flap, and double lumen were observed in 24 (52.2%), 26 (56.5%), and 26 (56.5%) dissected arteries using SNAP images. The three types of characteristics found on SNAP images were also accurately determined by T1-w VISTA (κ = 1.000, p < 0.001 for all). The IMH-wall contrast measured on the SNAP images was significantly higher than that by T1-w VISTA (7.34 ± 4.56 vs. 3.12 ± 1.17, p < 0.001).

Discussion

In this study, the clinical ability of single scan techniques, including SNAP and T1-w VISTA alone in CAD diagnosis has been compared. SNAP sequence and T1-w VISTA sequence showed the same diagnostic performance in CAD diagnosis. Furthermore, although the SNAP and T1-w VISTA sequences showed the same capability in the identification of the dissecting characteristics including IMH, intimal flap, and double lumen based on the data of this study, SNAP images had significantly higher IMH-wall contrast than T1-w VISTA images. Thus, the SNAP sequence may be more useful for early diagnosis of dissection, monitoring the treatment response, and guiding the treatment duration in follow-up studies.

To our knowledge, this study was the first one to compare the performance of the SNAP sequence and T1-w VISTA sequence alone in the evaluation of CAD. The main advantage of the SNAP sequence is that it can provide the luminal images and the vessel wall images in a single sequence, 12 thus it is suitable for the diagnosis of CAD. Several studies have also proved its ability to diagnose CAD by comparing it with MR multisequences techniques.13,14 However, the performance between SNAP which can provide both luminal and vessel wall information, and T1-w VISTA which can only provide vessel wall information, has not been investigated. In this study, we found SNAP and T1-w VISTA sequences had the same performance in the diagnosis of CAD, and the same ability in the identification of vessel wall characteristics of the dissection including IMH, intimal flap, and double lumen. This suggested that the vessel wall imaging may be enough and more useful in the diagnosis of the dissection, and the angiography images provided by SNAP images was of little significance to CAD diagnosis. However, the SNAP sequence showed better IMH-wall contrast than T1-w VISTA. IMH is an important characteristic in the diagnosis of dissection. The shortened T1 value of the IMH made it showed hyperintensity on T1-weighted images. In this study, although the T1-w VISTA sequence showed the same ability as SNAP in IMH detection, the significantly higher IMH-wall contrast of the SNAP sequence than T1-w VISTA may be useful to recognize the early vessel wall change and the signal intensity change of the IMH in follow-up studies. The original study of SNAP also showed the intraplaque hemorrhage (IPH)-wall contrast can be increased by another 35% using SNAP sequence compared to magnetization prepared-rapid gradient echo (MP-RAGE) sequence. 12 The improved IMH-wall contrast made SNAP potentially to be more sensitive in detecting smaller or fragmented or obsolete IMH, and easier to delineate the boundary of the IMH.12,23

The main cause of misdiagnosis for T1-w VISTA and SNAP was the difficulty in distinguishing intraluminal thrombus caused by carotid atherosclerosis with severe luminal stenosis or occlusion and the IMH caused by dissection. This may be because the components of acute intraluminal thrombus and IMH are the same, thus they displayed similar signal characteristics on SNAP or T1-w VISTA images. The results of our study coincided with a previous study, which demonstrated that the unequivocal distinction between intramural hematoma and intraluminal thrombus may not be adequate by T1-w VISTA alone in patients with total occlusion. 10 In our study, the misdiagnosis for T1-w VISTA and SNAP mostly occurred when lesions originated from the bifurcation of the CCA, which indicated that the location of the lesions may influence the diagnosis accuracy. Under these circumstances, comprehensive imaging evaluation using multiple sequences and multiple imaging modalities is essential. The missed diagnosis of the dissection using T1-w VISTA and SNAP occurred on the vertebral artery. The smaller size of the vertebral artery compared to the carotid artery made it difficult to be imaged under the currently used spatial resolution in MR imaging. The previous study also demonstrated a significant preference to use computed tomography (CT)/CTA for vertebral artery than MR imaging/MRA. 9

In this study, the diagnosis of dissection using SNAP or T1-w VISTA was defined as the presence of IMH, intimal flap, and double lumen. The presence of pseudoaneurysm was not treated as a sufficient condition for CAD diagnosis. This is because other than arterial dissection, pseudoaneurysm can arise from varying causes which include vasculitides (e.g. Behcet disease), 24 infections (e.g. mycotic carotid arterial pseudoaneurysm), 25 and iatrogenic complication following procedures (e.g. following carotid endarterectomy). 25 Thus, we believed that pseudoaneurysm is not necessarily dissections.

Except for the use of SNAP and T1-w VISTA sequences in cervical artery dissection, previous studies also showed their great potential in the evaluation of carotid atherosclerotic plaque,12,26 intracranial atherosclerotic plaque,27–29 intracranial artery dissection, 17 intracranial aneurysms, 30 and other vascular diseases. 31 The application of SNAP and T1-w VISTA on intracranial small vessels would further benefit the clinical diagnosis. Certainly, their sensitivity and specificity still need to be explored in the future.

This study still has some limitations. Firstly, the small sample size was the main limitation of this study. Second, other imaging modalities including DSA imaging was not obtained from all the enrolled patients. Although DSA still remains the gold standard for characterizing artery dissection, 4 its invasive procedure and the risk of complications were the major concerns. In addition, further investigations are needed to assess the ability of the single sequence techniques in CAD follow-up studies.

Conclusions

In this study, the SNAP sequence and T1-w VISTA sequence have the same diagnostic performance in CAD diagnosis. The SNAP sequence also showed the same capability in the identification of the dissecting characteristics including IMH, intimal flap, and double lumen. Thus, both SNAP and T1-w VISTA sequences were recommended in the diagnosis of CAD. In addition, SNAP showed better IMH-wall contrast than T1-w VISTA.

Footnotes

Contributorship statement: Study concept and design, all authors; acquisition of data, Shuiwei Xia, Chunmiao Chen, Junguo Hui, Xulu Wu, Zufei Wang; analysis and interpretation of data, Shuiwei Xia, Yajie Wang, Xianli Lv, Chunmiao Chen, Junguo Hui, Xulu Wu, Zufei Wang; drafting of the manuscript, Shuiwei Xia, Yajie Wang, Xianli Lv, Huijun Chen, Jiansong Ji; critical revision of the manuscript for important intellectual content, all authors; statistical analysis, Shuiwei Xia, Yajie Wang; obtained funding, Shuiwei Xia; study supervision, Huijun Chen, Jiansong Ji; responsible for the overall content as guarantor, Huijun Chen, Jiansong Ji.

Research ethics and patient consent: This retrospective study was approved by the Institutional Review Board of Lishui Hospital of Zhejiang University (No.2021-179), and the requirement for informed consent was waived.

Data availability: The data from this study are available from the corresponding author upon reasonable request

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Public Welfare Project of Zhejiang Province (grant number LGF20H220002), Medical and Health Research Project of Zhejiang Province (grant number 2021KY417).

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