Pitfalls of MR Angiography due to slow flow in large Aneurysm

This case illustrates a potential pitfall of Non contrast 3D TOF MRA imaging. Contrast enhanced CT study shows a focal aneurysmal dilatation of basilar, but the non contrast 3 D TOF MR Angiography of Brain of same patient fails the aneurysm is not depicted well on lateral view.

The non visualization of aneurysm may be due to slow flow owing to its large size or thrombus formation in the aneurysm because vascular imaging in Non contrast 3D TOF MRA depends on flow related signal from a rapid blood flow in a vessel. In this study the ICAs and basilar show normal flow related signals but the large aneurysm sac appears nearly isointense with nearby static brain.
CT Angiography or MR Angiography with contrast has considerable value in such cases because it is not dependent on flow velocity to create contrast and signals.

Reference: Practical MR Physics and case file of MR artifacts and pitfalls, Alexander C. Mamourian, MD