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Clinical Implications of Sulcal Enhancement on Postcontrast Fluid Attenuated Inversion Recovery Images in Patients with Acute Stroke Symptoms.

Lee H, Kim E, Lee KM, Kim JH, Bae YJ, Choi BS, Jung C - Korean J Radiol (2015)

Bottom Line: Seventy-seven acute stroke patients without any DWI abnormalities were found.The patients with HARM without diffusion abnormalities were significantly older, compared with patients with an imaging-negative stroke (mean, 73.1 years vs. 55.9 years; p < 0.001).Patients with HARM without diffusion abnormalities are older and have similarly favorable short-term neurological outcomes, compared with the patients with imaging-negative stroke.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 463-707, Korea.

ABSTRACT

Objective: Hyperintense acute reperfusion marker (HARM) without diffusion abnormalities is occasionally found in patients with an acute stroke. This study was to determine the prevalence and clinical implications of HARM without diffusion abnormalities.

Materials and methods: There was a retrospective review of magnetic resonance images 578 patients with acute strokes and identified those who did not have acute infarction lesions, as mapped by diffusion-weighted imaging (DWI). These patients were classified into an imaging-negative stroke and HARM without diffusion abnormalities groups, based on the DWI findings and postcontrast fluid attenuated inversion recovery images. The National Institutes of Health Stroke Scale (NIHSS) scores at admission, 1 day, and 7 days after the event, as well as clinical data and risk factors, were compared between the imaging-negative stroke and HARM without diffusion abnormalities groups.

Results: Seventy-seven acute stroke patients without any DWI abnormalities were found. There were 63 patients with an imaging-negative stroke (accounting for 10.9% of 578) and 13 patients with HARM without diffusion abnormalities (accounting for 2.4% of 578). The NIHSS scores at admission were higher in HARM without diffusion abnormalities group than in the imaging-negative stroke group (median, 4.5 vs. 1.0; p < 0.001), but the scores at 7 days after the event were not significantly different between the two groups (median, 0 vs. 0; p = 1). The patients with HARM without diffusion abnormalities were significantly older, compared with patients with an imaging-negative stroke (mean, 73.1 years vs. 55.9 years; p < 0.001).

Conclusion: Patients with HARM without diffusion abnormalities are older and have similarly favorable short-term neurological outcomes, compared with the patients with imaging-negative stroke.

No MeSH data available.


Related in: MedlinePlus

87-year-old man with right lower extremity weakness.A. Initial brain MRI shows focal linear contrast enhancement at both of inferior occipital sulci (arrows) on postcontrast FLAIR image, which is early hyperintense acute reperfusion marker sign. B. There is no evidence of acute infarction on diffusion-weighted image. C, D. Contrast is still present in cerebrospinal fluid space from previous images performed 23 hours prior on first follow-up FLAIR images, which is feature of classic HARM. E, F. Second follow-up MRI obtained 48 h after initial MRI shows no contrast present on FLAIR images. FLAIR = fluid attenuated inversion recovery
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Figure 3: 87-year-old man with right lower extremity weakness.A. Initial brain MRI shows focal linear contrast enhancement at both of inferior occipital sulci (arrows) on postcontrast FLAIR image, which is early hyperintense acute reperfusion marker sign. B. There is no evidence of acute infarction on diffusion-weighted image. C, D. Contrast is still present in cerebrospinal fluid space from previous images performed 23 hours prior on first follow-up FLAIR images, which is feature of classic HARM. E, F. Second follow-up MRI obtained 48 h after initial MRI shows no contrast present on FLAIR images. FLAIR = fluid attenuated inversion recovery

Mentions: Table 2 shows the detailed clinical information of all cases of HARM without diffusion abnormalities. In total, 14 episodes of HARM without diffusion abnormalities occurred in 13 patients. One patient had two episodes of HARM without diffusion abnormalities within 2 years, with the second episode occurring 3 months after a complete recovery from the first attack. None of the patients had undergone an intravenous tissue plasminogen activator treatment. The patients presented with various chief complaints and most showed vague symptoms that could not be localized neurologically. Furthermore, their symptoms did not seem to be relevant to the types or locations of HARM. The initial MRIs showed no significant abnormalities on DWI, PWI, or MRA, except for early HARM signs in these patients. No intracranial hemorrhages were found on gradient echo images in any of the patients. The follow-up MRI protocol was not standardized with respect to time. A total of nine patients out of 14 episodes with early HARM sign underwent follow-up MRIs; follow-up MRIs were performed within 24 hours after the stroke-like episode in three patients, after 24 hours in four patients, and both within 24 hours and after 24 hours in two patients. In patients with early HARM signs, focal linear contrast leakage on initial postcontrast FLAIR imaging became diffuse in follow-up MRIs performed within the next 24 hours (Fig. 2), while patients whose follow-up MRIs were obtained between 24 hours and 7 days after the initial MRIs showed a small amount of contrast leakage or no detectable contrast in the CSF space (Fig. 3). Contrast leakage was seen in every five patient who underwent follow-up MRI within 24 hours and remained in only one of the six patients whose follow-up MRIs were performed between 24 hours and 7 days. None of the patients had symptoms or signs suggesting meningitis or leptomeningeal seeding, which can show similar MRI features to those of early HARM, and three patients underwent CSF studies that yielded negative results. All patients of HARM without diffusion abnormalities reached full recovery with this conservative management.


Clinical Implications of Sulcal Enhancement on Postcontrast Fluid Attenuated Inversion Recovery Images in Patients with Acute Stroke Symptoms.

Lee H, Kim E, Lee KM, Kim JH, Bae YJ, Choi BS, Jung C - Korean J Radiol (2015)

87-year-old man with right lower extremity weakness.A. Initial brain MRI shows focal linear contrast enhancement at both of inferior occipital sulci (arrows) on postcontrast FLAIR image, which is early hyperintense acute reperfusion marker sign. B. There is no evidence of acute infarction on diffusion-weighted image. C, D. Contrast is still present in cerebrospinal fluid space from previous images performed 23 hours prior on first follow-up FLAIR images, which is feature of classic HARM. E, F. Second follow-up MRI obtained 48 h after initial MRI shows no contrast present on FLAIR images. FLAIR = fluid attenuated inversion recovery
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4499557&req=5

Figure 3: 87-year-old man with right lower extremity weakness.A. Initial brain MRI shows focal linear contrast enhancement at both of inferior occipital sulci (arrows) on postcontrast FLAIR image, which is early hyperintense acute reperfusion marker sign. B. There is no evidence of acute infarction on diffusion-weighted image. C, D. Contrast is still present in cerebrospinal fluid space from previous images performed 23 hours prior on first follow-up FLAIR images, which is feature of classic HARM. E, F. Second follow-up MRI obtained 48 h after initial MRI shows no contrast present on FLAIR images. FLAIR = fluid attenuated inversion recovery
Mentions: Table 2 shows the detailed clinical information of all cases of HARM without diffusion abnormalities. In total, 14 episodes of HARM without diffusion abnormalities occurred in 13 patients. One patient had two episodes of HARM without diffusion abnormalities within 2 years, with the second episode occurring 3 months after a complete recovery from the first attack. None of the patients had undergone an intravenous tissue plasminogen activator treatment. The patients presented with various chief complaints and most showed vague symptoms that could not be localized neurologically. Furthermore, their symptoms did not seem to be relevant to the types or locations of HARM. The initial MRIs showed no significant abnormalities on DWI, PWI, or MRA, except for early HARM signs in these patients. No intracranial hemorrhages were found on gradient echo images in any of the patients. The follow-up MRI protocol was not standardized with respect to time. A total of nine patients out of 14 episodes with early HARM sign underwent follow-up MRIs; follow-up MRIs were performed within 24 hours after the stroke-like episode in three patients, after 24 hours in four patients, and both within 24 hours and after 24 hours in two patients. In patients with early HARM signs, focal linear contrast leakage on initial postcontrast FLAIR imaging became diffuse in follow-up MRIs performed within the next 24 hours (Fig. 2), while patients whose follow-up MRIs were obtained between 24 hours and 7 days after the initial MRIs showed a small amount of contrast leakage or no detectable contrast in the CSF space (Fig. 3). Contrast leakage was seen in every five patient who underwent follow-up MRI within 24 hours and remained in only one of the six patients whose follow-up MRIs were performed between 24 hours and 7 days. None of the patients had symptoms or signs suggesting meningitis or leptomeningeal seeding, which can show similar MRI features to those of early HARM, and three patients underwent CSF studies that yielded negative results. All patients of HARM without diffusion abnormalities reached full recovery with this conservative management.

Bottom Line: Seventy-seven acute stroke patients without any DWI abnormalities were found.The patients with HARM without diffusion abnormalities were significantly older, compared with patients with an imaging-negative stroke (mean, 73.1 years vs. 55.9 years; p < 0.001).Patients with HARM without diffusion abnormalities are older and have similarly favorable short-term neurological outcomes, compared with the patients with imaging-negative stroke.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 463-707, Korea.

ABSTRACT

Objective: Hyperintense acute reperfusion marker (HARM) without diffusion abnormalities is occasionally found in patients with an acute stroke. This study was to determine the prevalence and clinical implications of HARM without diffusion abnormalities.

Materials and methods: There was a retrospective review of magnetic resonance images 578 patients with acute strokes and identified those who did not have acute infarction lesions, as mapped by diffusion-weighted imaging (DWI). These patients were classified into an imaging-negative stroke and HARM without diffusion abnormalities groups, based on the DWI findings and postcontrast fluid attenuated inversion recovery images. The National Institutes of Health Stroke Scale (NIHSS) scores at admission, 1 day, and 7 days after the event, as well as clinical data and risk factors, were compared between the imaging-negative stroke and HARM without diffusion abnormalities groups.

Results: Seventy-seven acute stroke patients without any DWI abnormalities were found. There were 63 patients with an imaging-negative stroke (accounting for 10.9% of 578) and 13 patients with HARM without diffusion abnormalities (accounting for 2.4% of 578). The NIHSS scores at admission were higher in HARM without diffusion abnormalities group than in the imaging-negative stroke group (median, 4.5 vs. 1.0; p < 0.001), but the scores at 7 days after the event were not significantly different between the two groups (median, 0 vs. 0; p = 1). The patients with HARM without diffusion abnormalities were significantly older, compared with patients with an imaging-negative stroke (mean, 73.1 years vs. 55.9 years; p < 0.001).

Conclusion: Patients with HARM without diffusion abnormalities are older and have similarly favorable short-term neurological outcomes, compared with the patients with imaging-negative stroke.

No MeSH data available.


Related in: MedlinePlus