Differential diagnosis of restricted diffusion confined to the cerebral cortex

doi:10.1016/j.crad.2007.12.018

Clinical Radiology

Volume 63, Issue 11, November 2008, Pages 1245-1253

https://doi.org/10.1016/j.crad.2007.12.018 Get rights and content

Diffusion-weighted MRI (DWI) has become increasingly widely available over recent years and is recognized as a powerful tool in neuroimaging. It is primarily used to identify acute ischaemia in patients presenting with stroke because of the improved sensitivity it offers early in the course of the disease. DWI also contributes useful diagnostic information in a range of other conditions. In this review we describe the magnetic resonance imaging (MRI) features of a number of conditions characterized by cortical diffusion restriction (CDR).

Introduction

An area of intracerebral restricted diffusion has a relatively wide differential diagnosis including infarction, demyelination, abscess, and encephalitis.¹ The clinical history, anatomical distribution and imaging appearances on conventional MRI sequences will frequently distinguish between the different causes of restricted diffusion. This is also true of restricted diffusion limited to the cortical ribbon and this point is illustrated with examples in this review.

Although DWI is well established as a diagnostic tool in the primary assessment of acute stroke, its usefulness is increasingly recognized in neuroradiology as adding significant additional diagnostic information in pathologies other than ischaemia. A DWI sequence takes less than 1 min to acquire on most 1.5 T systems and hence adds little to the duration of the examination.

Section snippets

DWI technique

DWI is usually performed as a spin-echo echoplanar imaging sequence. Two equal magnetic field gradients (referred to in this context as diffusion encoding gradients) are briefly applied on either side of the 180° radiofrequency pulse in the spin-echo sequence. The first gradient de-phases water protons and the second re-phases only those water protons that have not moved a significant distance in the time interval between the de-phasing and re-phrasing gradients. Increased signal on DWI,

The pathophysiological significance of restricted diffusion

In biological tissues, the diffusion of water molecules can be restricted by cell and organelle membranes and various macromolecules. As a result, the diffusion of intracellular water molecules is more restricted than that of extracellular water molecules. The relative abundance of intra- versus extracellular water in an area of brain tissue, therefore, has an important impact on the overall diffusivity of water in that part of the brain.² Bulk movement of water from the extracellular to the

Cortical infarction

Ischaemia is the most common cause of restricted diffusion. It is thought that the perfusion threshold for maintaining brain tissue viability is approximately 20 ml/100 cortical g/min. If perfusion falls below this level, for a significant period of time, it will lead to cytotoxic oedema and hence restricted diffusion. Predominately cortical involvement in infarction can be explained in a number of ways. Grey matter is more sensitive to relative hypoxic/ischaemic insults than white matter.4, 6

Conclusion

CRD is a striking imaging finding with a limited differential diagnosis. Acute arterial infarction due to arterial occlusion is by far the most common cause of this appearance, but it also occurs in venous infarction, watershed infarction, viral encephalitis, meningitis, CJD, mitochondrial cytopathies, and the post-ictal state. The clinical context and anatomical distribution of the changes are useful in distinguishing between the different conditions. Given the short time taken to perform a

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Pictorial reviewDifferential diagnosis of restricted diffusion confined to the cerebral cortex

Introduction

Section snippets

DWI technique

The pathophysiological significance of restricted diffusion

Cortical infarction

Conclusion

Imaging tutorial: differential diagnosis of bright lesions on diffusion-weighted MR images

RadioGraphics

Histopathological correlates of abnormal water diffusion in cerebral ischaemia: diffusion weighted MR imaging and light and electron microscopic study

Radiology

Diffusion-weighted MR imaging of the brain

Radiology

A study of the apparent diffusion coefficient of grey and white matter in human ischaemic stroke

Neuroreport

Cerebral infarction: time course of signal intensity changes on diffusion-weighted MR images

AJR Am J Roentgenol

The effect of profound systemic hypotension on the brain of M. Rhesus: physiological and pathological observations

Brain

Diffusion-weighted MR imaging of global cerebral anoxia

AJNR Am J Neuroradiol

Stroke patterns in unilateral atherothrombotic occlusion of the internal carotid artery

Stroke

What causes lacunar stroke?

J Neurol Neurosurg Psychiatry

Localized reversible reduction of apparent diffusion coefficient in transient hypoglycemia-induced hemiparesis

Stroke

Cerebral cortical laminar necrosis on diffusion-weighted MRI in hypoglycaemic encephalopathy

Diabet Med

Magnetic resonance imaging and diffusion-weighted imaging changes after hypoglycemic coma

J Neuroimaging

Diffusion-weighted MRI in cortical ischaemia

Neuroradiology

Cortical laminar necrosis related to prolonged focal status epilepticus

J Neurol Neurosurg Psychiatry

Changes on diffusion-weighted MRI with focal motor status epilepticus: case report

Neuroradiol

Status epilepticus and peri-ictal imaging

Epilepsia

Pictorial review
Differential diagnosis of restricted diffusion confined to the cerebral cortex