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    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">M.H.T. Zwartbol</span>, <span class="highwire-citation-author" data-delta="1">A.G. van der Kolk</span> and <span class="highwire-citation-author" data-delta="2">M.I. Geerlings</span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">May 2020,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">41 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(5) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E32; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A6516 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-75160--6697185590" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">M.H.T. Zwartbol </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Department of Radiology</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=M.H.T.%2BZwartbol%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Zwartbol%20M&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AM.H.T.%2BZwartbol%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0001-5779-3150" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for M.H.T. Zwartbol</a></li></ul></div><div class="author-tooltip-1"><div class="author-tooltip-name">A.G. van der Kolk </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Department of Radiology</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=A.G.%2Bvan%2Bder%2BKolk%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=van%20der%20Kolk%20A&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AA.G.%2Bvan%2Bder%2BKolk%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0002-8267-8848" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for A.G. van der Kolk</a></li></ul></div><div class="author-tooltip-2"><div class="author-tooltip-name">M.I. Geerlings </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>b</span>Julius Center for Health Sciences and Primary CareUniversity Medical Center Utrecht and UtrechtUniversityUtrecht, the Netherlands</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=M.I.%2BGeerlings%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Geerlings%20M&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AM.I.%2BGeerlings%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0002-4037-036X" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for M.I. Geerlings</a></li></ul></div></div></div>  </div>

  
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    <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" data-highwire-cite-ref-tooltip-instance="highwire_reflinks_tooltip" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article fulltext-view "><span class="highwire-journal-article-marker-start"></span><p id="p-1">We thank Dr Alexander and colleagues for their interest in our work and appreciate the opportunity to respond to their concerns.<sup><a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a></sup></p><p id="p-2">A concern is raised regarding the interpretation of our results, which led us to conclude that our findings do not support “a different etiology” between extracranial atherosclerosis (ECAS) and intracranial atherosclerosis (ICAS). We agree with the data used to substantiate their concern, including data on histopathology and etiology, but do not share their opinion that our findings are contradictory. As described in our article—and noted by Alexander et al—there are several limitations to our study design, which is why we tried to carefully word our conclusion to avoid overinterpretation of our results. We showed that there is a relationship between ICAS and several clinical markers of ECAS, suggesting a similar etiology; or in other words (used in the article), our (limited) results do not support a different etiology. However, there are indeed differences in etiology and pathophysiology, which we do not claim to contradict. Apparently, we were not able to successfully convey this subtle difference to all readers.</p><p id="p-3">As carefully described by Alexander et al, ICAS is a complex disease with many facets, and intracranial vessel wall MR imaging (vwMRI) facilitates our attempts to elucidate parts of this disease process. We agree that vwMRI can provide us with information not only on the presence or absence of atherosclerotic plaques but also on plaque components and the (from extracranial atherosclerosis) well-known “vulnerable plaque.” However, most vessel wall lesions encountered in our populations, Caucasian subjects, which Alexander et al justly noted were not specifically mentioned in our article, are too small to accurately measure, let alone characterize, apart from the presence or absence of enhancement.<sup><a id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2</a></sup> It would indeed also have been of interest to correlate vessel wall lesion locations with cerebrovascular symptoms, but this would necessitate a different study population—with more (cerebrovascular) symptomatic patients—to reach any statistically significant results.</p><p id="p-4">Finally, we would like to provide our whole-hearted support for the suggestion of Alexander et al to “refocus the need for tissue validation of vwMRI.” The ease of characterizing extracranial carotid atherosclerotic plaques is in stark contrast with the difficulty of performing the same analyses in intracranial plaques, which is mainly caused by the lack of methods to compare in vivo–acquired vwMRI with ex vivo histopathology. Nonetheless, sequence validation is essential for our conception of how we should interpret vessel wall lesions on vwMRI and how we should incorporate intracranial vwMRI in clinical practice. We would like to thank Alexander and colleagues for their critical review and compliment them on highlighting the possibilities of vwMRI and opportunities for further research.</p><div class="section ref-list" id="ref-list-1"><h2 class="">References</h2><ol class="cit-list ref-use-labels"><li><span class="ref-label">1.</span><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1. in text" id="ref-1">↵</a><div class="cit ref-cit ref-journal" id="cit-41.5.E32.1" data-doi="10.3174/ajnr.A6308"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Zwartbol</span>  <span class="cit-name-given-names">MHT</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Geerlings</span>  <span class="cit-name-given-names">MI</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Ghaznawi</span>  <span class="cit-name-given-names">R</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Intracranial atherosclerotic burden on 7T MRI is associated with markers of extracranial atherosclerosis: the SMART-MR study</span>. <abbr class="cit-jnl-abbrev">AJNR Am J Neuroradiol</abbr> <span class="cit-pub-date">2019</span>;<span class="cit-vol">40</span>:<span class="cit-fpage">2016</span><a href="http://%E2%80%93">–</a><span class="cit-lpage">22</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.3174/ajnr.A630]8</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>31806592</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYWpuciI7czo1OiJyZXNpZCI7czoxMDoiNDAvMTIvMjAxNiI7czo0OiJhdG9tIjtzOjE5OiIvYWpuci80MS81L0UzMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">2.</span><a class="rev-xref-ref" href="#xref-ref-2-1" title="View reference 2. in text" id="ref-2">↵</a><div class="cit ref-cit ref-journal" id="cit-41.5.E32.2" data-doi="10.1161/STROKEAHA.119.026497"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">van Hespen</span>  <span class="cit-name-given-names">KM</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Zwanenburg</span>  <span class="cit-name-given-names">JJM</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Harteveld</span>  <span class="cit-name-given-names">AA</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Intracranial vessel wall magnetic resonance imaging does not allow for accurate and precise wall thickness measurements</span>. <abbr class="cit-jnl-abbrev">Stroke</abbr> <span class="cit-pub-date">2019</span>;<span class="cit-vol">50</span>:<span class="cit-fpage">e283</span><a href="http://%E2%80%93">–</a><span class="cit-lpage">84</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.1161/STROKEAHA.119.026497</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>31446885</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1161/STROKEAHA.119.026497&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=31446885&amp;link_type=MED&amp;atom=%2Fajnr%2F41%2F5%2FE32.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li></ol></div><ul class="copyright-statement"><li class="fn" id="copyright-statement-1">© 2020 by American Journal of Neuroradiology</li></ul><span class="highwire-journal-article-marker-end"></span></div><span class="related-urls"></span></div></div>  </div>

  
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