Hyperacute Ischemic Stroke Missed by Diffusion-Weighted Imaging
David Lefkowitz
,a,
Michael LaBenza,
Steven R. Nudoa,
Robert E. Stega and
John M. Bertonia
a From the Department of Diagnostic Radiology (D.M.L.), University of Maryland Medical System; the Department of Radiology (M.J.L.), Department of Internal Medicine, Creighton University Medical Center (S.R.N.), and the Department of Neurology (J.M.B., R.E.S.), Creighton University Medical Center, Baltimore, MD.
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FIG. 1. 72-year-old woman scanned 3 and 8 hours post ictus.
A, Diffusion-weighted imaging reveals a questionable area of restricted diffusion in the left frontal lobe, not identified prospectively.
B, Perfusion-weighted imaging demonstrates a large region of delayed time-to-peak (hyperintensity) in the left middle cerebral artery territory.
C, Diffusion-weighted imaging at 8 hours shows acute cortical and subcortical infarcts in the left frontal watershed zone.
D, T2-weighted image at 8 hours shows no abnormality.
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FIG. 2. 81-year-old woman scanned 2 and 19 hours post ictus.
A, Diffusion-weighted imaging at 2 hours shows subtle restricted diffusion in the left deep cerebral structures, not appreciated prospectively.
B and C, Perfusion-weighted imaging bolus-tracking curves (B) for selected regions (C) show approximately 6-second delayed transit to the distal left middle cerebral artery vessels (solid line).
D, MR angiography demonstrates decreased flow-related enhancement in the left middle cerebral artery territory.
E, Diffusion-weighted imaging at 19 hours reveals acute infarct in left basal ganglia and insular cortex.
F, T2*-weighted imaging demonstrates a new 1-cm focus of profound hypointensity in the left putamen, consistent with focal hemorrhage or localized desaturation of hemoglobin.
G, CT scan at 2 days reveals a 1-cm focus of petechial hemorrhage in the left putamen surrounded by ischemic infarct.
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