The Para-ISS Dural Space Enhancement Sign: A Novel MRI Finding Independently Associated With Intracranial Atherosclerotic Burden

Para-ISS dural space enhancement (PISE) is detected in 609/811 patients (75.1%) on contrast-enhanced intracranial vessel-wall MRI, with detection rising with age and plaque grade.

• Why it matters: A dural enhancement sign centered on the inferior sagittal sinus had not been defined, limiting MRI-based assessment of intracranial atherosclerotic burden and its possible dural mechanisms.
• What they did: In 811 patients from consecutive VWI exams (May 2015–December 2025), PISE was defined as enhancement strictly at the falx free margin adjacent to the ISS, exceeding the ISS lumen, and tested against 47 variables using FDR-corrected univariate tests plus cross-validated multivariable models.
• The result: PISE is independently linked to intracranial atherosclerotic burden, including vulnerable plaque (OR=8.29) and a graded plaque trend (38.7% -> 77.2% -> 90.3%; Z=11.09), supporting an atherosclerosis-related dural mechanism and enabling prospective validation.

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