Reversal of Large Ischemic Injury on Hyper-Acute Diffusion MRI

Reversal of early ischemic injury on diffusion-weighted MRI (DWI) occurs rarely. In a stroke patient who abruptly developed stupor and left hemiparesis, DWI scanned 78 min after onset demonstrated a large ischemic injury in the right hemisphere with a DWI-ASPECTS (Albert Stroke Program Early Computed Tomography Score) of 5 points, although baseline brain CT was perfectly normal. MR angiography (MRA) showed an occlusion of the right middle cerebral artery trunk, and the patient received intravenous thrombolysis 105 min after onset. A second MRA 30 h later showed complete vessel recanalization, and DWI demonstrated a perfect reversal of the initial large ischemic injury, associated with very small thrombus-fragmented cortical surface infarctions. Outcome at 3 months was a modified Rankin Scale score of 0, and the fluid-attenuated inversion recovery image showed only a small final infarction at the cortical surface. Hyper-acute DWI-defined large ischemic injury may very rarely represent a nearly perfect reversible area, and it may be a therapeutic target.

[1]  R. Bammer,et al.  Relationships between cerebral perfusion and reversibility of acute diffusion lesions in DEFUSE: insights from RADAR. , 2009, Stroke.

[2]  A. Demchuk,et al.  Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy , 2000, The Lancet.

[3]  S. Warach,et al.  Magnetic Resonance Imaging Criteria for Thrombolysis in Acute Cerebral Infarct , 2005, Stroke.

[4]  P. Barber,et al.  Ischemic diffusion lesion reversal is uncommon and rarely alters perfusion-diffusion mismatch , 2010, Neurology.

[5]  S. Lehéricy,et al.  Diffusion-weighted MRI in acute stroke within the first 6 hours , 2010, Neurology.

[6]  K. Kimura,et al.  Reversible diffusion-weighted lesion in a TIA patient without arterial recanalization: A case report , 2008, Journal of the Neurological Sciences.

[7]  A. Demchuk,et al.  Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. , 2000, Lancet.

[8]  Y. Shinohara,et al.  Alteplase at 0.6 mg/kg for Acute Ischemic Stroke Within 3 Hours of Onset: Japan Alteplase Clinical Trial (J-ACT) , 2006, Stroke.

[9]  C. Weiller,et al.  Predictors of Apparent Diffusion Coefficient Normalization in Stroke Patients , 2004, Stroke.

[10]  Jeffry R Alger,et al.  Late secondary ischemic injury in patients receiving intraarterial thrombolysis , 2002, Annals of neurology.

[11]  J. Eastwood,et al.  Does Diffusion-Weighted Imaging Represent the Ischemic Core? An Evidence-Based Systematic Review , 2009, American Journal of Neuroradiology.