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Identifying the Symptomatic Aneurysm in Patients With Multiple Intracranial Aneurysms. BACKGROUND AND OBJECTIVES: Identification of the symptomatic aneurysm in patients with multiple intracranial aneurysms (MIAs) represents a challenge. Aneurysm wall enhancement is a potential imaging biomarker to assess symptomatic status among intracranial aneurysms. We aimed to use aneurysm wall enhancement in the identification of symptomatic aneurysms in patients with MIAs. METHODS: Patients who underwent high-resolution 3 Tesla magnetic resonance imaging between 2018 and 2024 at 3 institutions-one in the United States and 2 in China-were included in the analysis. Eligible patients had MIAs, with at least 1 aneurysm classified as symptomatic. Morphological measurements were obtained from angiography studies. Three-dimensional circumferential aneurysm wall enhancement (3D-CAWE) was assessed for all aneurysms. Multivariate logistic regression was used to identify variables independently associated with symptomatic status. RESULTS: Thirty patients with 82 MIAs were included, 30/82 (36.6%) were symptomatic and 52/82 (63.3%) were asymptomatic. Aneurysmal size (adjusted odds ratio [aOR]: 1.5, 95% CI: 0.95-2.8, P = .1) and size ratio (aOR: 2.2, 95% CI: 0.8-3.2, P = .2) were not associated with symptomatic presentation. Symptomatic aneurysms were more likely to have a higher 3D-CAWE (aOR: 1.15, 95% CI: 1.05-1.24, P = .01) when compared with asymptomatic aneurysms. Receiver operating characteristic analysis revealed that a 3D-CAWE cutoff point of 1.02 has a specificity of 88% and negative predictive value of 79% in detecting symptomatic aneurysms among patients with MIAs. CONCLUSION: 3D-CAWE can be used in the identification of symptomatic aneurysms in patients with MIAs.