DWI Reversal Is Associated with Small Infarct Volume in Patients with TIA and Minor Stroke

Asdaghi, Negar; Campbell, Bruce C.V.; Butcher, Ken; Coulter, Jonathan I; Modi, Jayesh; Qazi, Adam; Goyal, Mayank; Demchuk, Andrew M.; Coutts, Shelagh B.

doi:10.3174/ajnr.a3733

Cited by 33 publications

(26 citation statements)

References 37 publications

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“…Reversal of diffusion restriction, although uncommon, has been previously reported in acute stroke, especially in those with smaller baseline lesions. 6,7 In this patient, the imaging biomarkers for TIA/stroke fluctuated on par with the clinical changes ( figure 1). This case demonstrates that a clinical improvement can be associated with resolution of the DWI abnormality and that depending on the timing of the baseline scan, the acute MRI may be negative in the setting of fluctuating neurologic abnormalities.…”

Section: Practical Implicationsmentioning

confidence: 85%

Stuttering lacunar infarction captured on serial MRIs

et al. 2016

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A 61-year-old man with a history of untreated hyperlipidemia presented with acute onset of dysarthria and right-sided weakness. His symptoms had improved but not resolved upon arrival at the hospital (NIH Stroke Scale [NIHSS] score was 4). Brain MRI showed a hyperintense lesion in the medial left pons on diffusionweighted imaging (DWI) with a matching area of hypointensity on apparent diffusion coefficient map. The fluid-attenuated inversion recovery (FLAIR) sequence showed no changes in this area, suggesting a hyperacute lesion. There was no evidence of focal stenosis of the large intracranial vessels (figure 1) or intracranial hemorrhage. Perfusion-weighted imaging demonstrated an area of increased mean transit time (MTT) within the ischemic lesion ( figure 2A). The patient's symptoms had completely resolved after the imaging (NIHSS score 5 0). His symptoms recurred 30 minutes later for only 5 minutes. Brain MRI repeated 2 hours later, while asymptomatic, showed complete resolution of the abovementioned lesions ( figure 2B). Therefore, IV thrombolysis was not indicated. The patient was admitted to the hospital with a diagnosis of TIA for further workup. He was started on aspirin 81 mg and atorvastatin 80 mg daily. Systolic blood pressure values ranged from 103 to 154 mm Hg, with most values between 110 and 140 mm Hg. No clear association between blood pressure and neurologic symptoms was noted during hospital admission. On the third day of hospitalization, the patient was discharged home while he remained asymptomatic and repeat brain MRI was intact ( figure 2C).On the evening of his discharge day, he developed severe dysarthria, right-sided weakness, and ataxia, and he was unable to walk. The symptoms improved slightly, but did not resolve, and the following morning he returned to the hospital with an ataxia-hemiparesis lacunar syndrome (NIHSS score 5 6). MRI showed diffusion restriction in the left pons with corresponding FLAIR hyperintensity and hypoperfusion on MTT maps (figure 2D), suggestive of an acute ischemic stroke. He showed slight improvement over the next 3 days and repeat MRI remained unchanged (figure 2E), and he was discharged to acute rehabilitation. DISCUSSIONIn this case, serial short-interval MRIs depicted radiologic changes associated with the progression of a TIA into a subsequent infarct (figure 1). The patient initially presented with a brief episode of neurologic dysfunction caused by focal brain ischemia, as reflected by restricted diffusion in the pons. Of interest, the symptoms resolved and the imaging abnormalities reversed, which is compatible with the tissue-based definition of a TIA.1 The most likely etiology of the patient's TIA and subsequent stroke was thought to be small vessel atherosclerosis or lipohialinosis given that the clinical and radiologic localization were the same on the first (TIA) and second (stroke) presentations. In addition, diagnostic workup did not Practical ImplicationsThe imaging biomarkers for TIA/stroke can fluctuate on par with the clinical changes ...

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Section: Practical Implicationsmentioning

confidence: 85%

Stuttering lacunar infarction captured on serial MRIs

et al. 2016

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“…DWI reversal is uncommon in large strokes 19 but is much more frequent for the small DWI lesions encountered in TIA and minor stroke. 20 When these lesions do persist, they frequently lead to a nonspecific, small, hyperintense signal in a subcortical area without evidence of cavitation. On a blind reading of a 90-day scan, which is equivalent to ordering a scan in a delayed …”

Section: Discussionmentioning

confidence: 99%

Early Magnetic Resonance Imaging in Transient Ischemic Attack and Minor Stroke

Moreau

Modi

Almekhlafi

et al. 2013

Stroke

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Background and Purpose— The use of magnetic resonance imaging (MRI) after transient ischemic attack (TIA) or minor stroke may be affected by the relative timing of imaging. We measured the impact of scanning an individual patient late versus early after TIA and minor stroke. Methods— Two hundred sixty-three TIA or minor stroke (National Institute of Health Stroke Scale score ≤3) patients with a baseline MRI completed within 24 hours of symptom onset and a follow-up MRI at 90 days were included. Baseline and 90-day scans were assessed independently for the presence of any stroke lesions that could explain the presenting symptoms. The presence and pattern of any stroke lesions were compared at the 2 time points. Results— The presence of a stroke (acute or chronic) in any location was more common on baseline MRI versus 90-day MRI (68% vs 56%; P =0.005). Thirty percent of subjects with negative scans at 90 days had a clearly identifiable stroke at baseline. When interpreted blinded to the baseline scan, the presumed relevant lesion on the 90-day MR scan was the correct lesion in only 53% patients. One-third (34%) of patients had a different lesion pattern on the baseline scan compared with the 90-day scan. Ninety percent (80/89) of these patients had more lesions on the baseline MRI and 10% (9/89) had new lesions on the 90-day MRI. Conclusions— Delayed MRI after TIA or minor stroke reduces the diagnostic yield and results in missed understanding of the lesion pattern. MRI of minor stroke and TIA patients should occur early after symptom onset, and delayed imaging should be interpreted with caution.

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“…In our study, final infarct volumes were virtually not smaller than the baseline DWI, supporting that sustained DWI lesion reversal is infrequent in patients accept reperfusion therapy within 6 h after stroke onset. A recent study just demonstrated that DWI reversal is rarely seen but more likely to occur in those with smaller baseline lesions, which should not significantly affect the accuracy of penumbra definition .…”

Section: Discussionmentioning

confidence: 99%