A Mismatch Between the Abnormalities in Diffusion- and Susceptibility-Weighted Magnetic Resonance Imaging May Represent an Acute Ischemic Penumbra with Misery Perfusion

doi:10.1016/j.jstrokecerebrovasdis.2012.12.009

Journal of Stroke and Cerebrovascular Diseases

Volume 22, Issue 8, November 2013, Pages 1428-1431

https://doi.org/10.1016/j.jstrokecerebrovasdis.2012.12.009 Get rights and content

Susceptibility-weighted imaging (SWI) has recently attracted attention for its ability to investigate acute stroke pathophysiology. SWI detects an increased ratio of deoxyhemoglobin to oxyhemoglobin in cerebral venous compartments, which can illustrate cerebral misery perfusion with a compensatory increase of oxygen extraction fraction in the hypoperfused brain. In this study we make the first case report of blunt cervical trauma leading to a stroke, demonstrating the disparity between diffusion-weighted imaging (DWI) and SWI changes, or DWI-SWI mismatch, in the acute ischemic brain. The area of mismatch between a smaller DWI cytotoxic edema and a larger SWI misery perfusion in our patient matured into a complete infarction with time. The DWI-SWI mismatch may signify the presence of an ischemic penumbra, and provide information about viability of the brain tissue at risk of potential infarction if without early reperfusion.

Section snippets

Case Report

A 54-year-old man was injured by a factory machine. A slow-moving round compressor crushed the man at his left neck and at the right parietal of his head. Immediately after, he was safely rescued. However, his colleagues found him to be in a state of confusion, and took him to a local hospital. The head and neck computed tomographic (CT) scans on arrival at the hospital showed no marked abnormality. He had no neurological deficits but the Glasgow Coma Scale was E4V4M6. The mild consciousness

Discussion

Cerebral misery perfusion signifies a critical hypoperfusion that leads to a metabolic compensation state with increased oxygen extraction fraction.⁵ This compensation state results in remarkably increased deoxyhemoglobin concentration in the venous system in the ischemic tissue. The MRI study in our patient, who suffered blunt cervical trauma that induced an ICA occlusion, showed an acute cerebral ischemic change of DWI-SWI mismatch, to be precise, a discrepancy between a smaller DWI cytotoxic

Conclusion

The area of mismatch between a smaller DWI cytotoxic edema and a larger area with SWI hypo-intense veins in our patient matured into a complete infarction with time. The DWI-SWI mismatch may signify the presence of an ischemic penumbra with misery perfusion, and provide information about viability of the brain tissue at risk of potential infarction.

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Cited by (32)

Increased internal cerebral vein diameter is associated with age
2021, Clinical Imaging
Citation Excerpt :
A series of subsequent studies demonstrated an association between decreased CBF and asymmetrically prominent cortical or deep medullary veins. The reason was that an imbalance of oxygen supply and demand in the hypoperfused tissue and an increased oxygen extraction fraction caused a relatively increased ratio of deoxyhaemoglobin to oxyhaemoglobin in cortical and medullary veins, which further led to dilated veins on SWI [28–37]. Another mechanism could be increased venous volume due to vasodilatation induced by regional ischaemia [38].
A recent study described the relationship between cerebral venous diameter and white matter hyperintensity (WMH) volume. However, the adults were not further grouped; therefore, we aimed to compare across age groups and use susceptibility-weighted imaging (SWI) to explore whether there is also a relationship between a larger cerebral draining venous diameter and age, which could provide evidence of a temporal relationship.
We retrospectively analysed data collected from 405 subjects (90 youths, 166 middle-aged participants, and 149 elderly subjects) and respectively used T2-weighted fluid-attenuated inversion recovery (FLAIR) and SWI to assess WMHs and venous diameter.
An increased internal cerebral vein (ICV) diameter was associated with age in different WMH groups (F = 3.453, 10.437, 11.746, and 21.723, respectively, all p < 0.001; multiple comparisons all p < 0.05), whereas the effect of the anterior septal vein (ASV) was opposite (F = 1.046, 1.210, 0.530, and 0.078, respectively, p > 0.05). There was a positive correlation between the ICV diameter and age with increasing WMH severity (R = 0.727, 0.709, 0.754, and 0.830, respectively, all p < 0.001). A statistically significant relationship between the thalamostriate vein (TSV) diameter and age was observed only in the moderate and severe WMH groups (F = 4.070 and 3.427, respectively, all p < 0.05; multiple comparisons all p < 0.05).
Our study demonstrates that increased TSV and ICV diameters are associated with age with increasing WMH severity, especially the ICV diameter using SWI.
Interactive effect of susceptibility-diffusion mismatch and recanalization status on clinical outcome in large vessel occlusion stroke
2020, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Since deoxyhemoglobin is a paramagnetic substance with high magnetic susceptibility, asymmetric prominent hypointense vessels appear on SWI, which is now called prominent vessel sign (PVS).4,5 Previous studies have reported that PVS on SWI can provide perfusion information comparable to PWI, and SWI–DWI mismatch can indicate ischaemic penumbra.6-8 Although SWI appears to be an alternative to PWI, its application value in recanalization therapy for patients with acute ischemic stroke remains unclear and needs to be investigated.
Objective: To investigate the interactive effect of susceptibility-diffusion mismatch and recanalization status on clinical outcome in patients with acute ischemic stroke due to large vessel occlusion.
Methods: In this prospective study, consecutive ischemic stroke patients admitted within 24 h from symptom onset underwent emergency multimodal MRI at admission, including diffusion-weighted imaging (DWI), susceptibility-weighted imaging (SWI), and time-of-flight magnetic resonance angiography (TOF-MRA). Patients with large vessel occlusion within the anterior circulation were recruited. Follow-up MRI was performed within 24 h after recanalization therapy (intravenous thrombolysis, endovascular therapy, or both). Multivariable logistic regression analysis was performed to estimate the interaction between SWI-DWI mismatch score and recanalization status on clinical outcome.
Results: A total of 90 patients were enrolled. A multiplicative interaction between SWI-DWI mismatch score and recanalization status on clinical outcome was observed (P=0.037). The interaction term "SWI-DWI mismatch score × successful recanalization" was significantly associated with favorable outcome (modified Rankin Scale score of 0-2 at 90 days; adjusted odds ratio [aOR], 2.162; 95% confidence interval [CI], 1.046-4.468). Stratified analysis showed that the likelihood of favorable outcome increased with the increase of SWI-DWI mismatch score in the successful recanalization group (OR, 2.140; 95% CI, 1.376-3.326), while there was no significant relationship between SWI-DWI mismatch score and clinical outcome in the unsuccessful recanalization group (OR, 1.212; 95% CI, 0.933-1.574).
Conclusions: The effects of SWI-DWI mismatch and recanalization status on clinical outcome were realized through their interaction. In anterior circulation stroke due to large vessel occlusion, patients with both high SWI-DWI mismatch scores and successful recanalization were more likely to achieve a favorable outcome, while patients with unsuccessful recanalization, or with successful recanalization but low SWI-DWI mismatch scores, were less likely to have a good prognosis.
Utility of high-b-value diffusion-weighted magnetic resonance imaging in evaluating reversible medial longitudinal fasciculus syndrome caused by acute brainstem ischemia
2015, Journal of Stroke and Cerebrovascular Diseases
Medial longitudinal fasciculus (MLF) syndrome refers to a gaze disorder characterized by impaired adduction on the ipsilateral side to the injured MLF, with dissociated nystagmus of the contralateral abducting eye. The most common cause of the MLF syndrome is ischemic stroke. However, acute ischemic change in the MLF may be undetectable even on diffusion-weighted magnetic resonance imaging (DW-MRI) partly because of its small size and specific brainstem location.
Herein, we present the first reported case of MLF syndrome in which, compared with the standard-b-value DWI, a higher b-value DWI revealed more clearly a small infarction in the dorsal pons in the acute stage.
We suggest that high-b-value DWI can be a useful diagnostic method for patients with MLF syndrome caused by possible brainstem ischemia and thus supportive for deciding the optimal treatment for such patients.
Comparison of susceptibility-weighted and perfusion-weighted magnetic resonance imaging in the detection of penumbra in acute ischemic stroke
2015, Journal of Neuroradiology
Citation Excerpt :
Some imaging techniques used to detect the ischemic penumbra, such as single-photon emission computed tomography (SPECT), positron emission tomography (PET), and perfusion-weighted imaging (PWI), require radionucleotides or contrast agents, which limits their clinical application [5]. Susceptibility-weighted imaging (SWI) is a relatively new high-resolution magnetic resonance imaging (MRI) technique that has been used to detect the penumbra in stroke patients [6–8]. SWI does not require administration of radionucleotides or contrast agents, but uses paramagnetic susceptibility effects to study metabolic changes in hypoperfused brain tissues [9–12].
To investigate detection of ischemic penumbra in stroke patients with acute cerebral infarction by susceptibility-weighted imaging (SWI) in comparison with perfusion-weighted imaging (PWI).
This study included 18 stroke patients with acute infarction who underwent diffusion-weighted imaging (DWI), SWI, PWI, and magnetic resonance angiography (MRA) within 3 days after symptom onset. The Alberta Stroke Program Early CT Score (ASPECTS) was used to evaluate lesions on DWI, SWI, and PWI. DWI-SWI and DWI-PWI mismatches were calculated.
The DWI-SWI mismatch was not significantly different from the DWI-mean transit time (MTT) mismatch (P = 0.163) in evaluating ischemic penumbra. The susceptibility vessel sign (SVS) in SWI occurred in 11 (61%) of 18 patients with cerebral infarction. Stenosis or occlusion of the affected vessels was identified by MRA in 10 (91%) of the 11 SVS-positive patients. The SVS on SWI was significantly associated with the occurrence of damaged vessels or the presence of thrombus in the affected vessels (P = 0.047).
DWI-SWI mismatch is a good marker for evaluating ischemic penumbra in stroke patients with cerebral infarction. SWI can detect thrombus in the affected vessels, and may be useful for guiding intra-arterial thrombolytic therapy.
Prominent cerebral veins on susceptibility-weighted angiography in acute meningoencephalitis
2023, Brain and Behavior
Comparing Perfusion Data of CE-MRI, SWI, and CTA with MR Perfusion in Stroke
2023, Current Medical Imaging

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: Dr Siesjö is Professor Emeritus.

: Funding sources: None.

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Case ReportA Mismatch Between the Abnormalities in Diffusion- and Susceptibility-Weighted Magnetic Resonance Imaging May Represent an Acute Ischemic Penumbra with Misery Perfusion

Section snippets

Case Report

Discussion

Conclusion

Combined diffusion and perfusion MRI with correlation to single-photon emission CT in acute ischemic stroke: ischemic penumbra predicts infarct growth

Stroke

Contribution of susceptibility-weighted imaging to acute stroke assessment

Stroke

Susceptibility weighted imaging in cerebral hypoperfusion–can we predict increased oxygen extraction fraction?

Neuroradiology

Evidence of misery perfusion and risk for recurrent stroke in major cerebral arterial occlusive diseases from PET

J Neurol Neurosurg Psychiatry

Reversal of focal “misery-perfusion syndrome” by extra-intracranial arterial bypass in hemodynamic cerebral ischemia: a case study with 15O positron emission tomography

Stroke

Case Report
A Mismatch Between the Abnormalities in Diffusion- and Susceptibility-Weighted Magnetic Resonance Imaging May Represent an Acute Ischemic Penumbra with Misery Perfusion