Korean J Radiol.  2015 Aug;16(4):906-913. 10.3348/kjr.2015.16.4.906.

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

• KMID: 2155566
• DOI: http://doi.org/10.3348/kjr.2015.16.4.906

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.

Keyword

Hyperintense acute reperfusion marker; HARM without diffusion abnormalities; Postcontrast FLAIR imaging; Acute stroke

MeSH Terms

Aged
Aged, 80 and over
Blood-Brain Barrier/pathology
Contrast Media
Diffusion Magnetic Resonance Imaging/*methods
Female
Humans
Image Enhancement/*methods
Male
Middle Aged
Retrospective Studies
Risk Factors
Stroke/cerebrospinal fluid/*diagnosis/pathology
Treatment Outcome
United States
Contrast Media

Figure

• 

  Fig. 1 Flow chart shows patients' selection process in this study. CE-FLAIR = contrast-enhanced FLAIR images, DWI = diffusion-weighted imaging, FLAIR = fluid attenuated inversion recovery, HARM = hyperintense acute reperfusion marker on contrast-enhanced FLAIR, ICH = intracerebral hemorrhage, SAH = subarachnoid hemorrhage, SDH = subdural hemorrhage

• 

  Fig. 2 75-year-old woman with global aphasia. Initial brain MRI shows linear contrast enhancement (arrows) on brain surface on postcontrast FLAIR imaging, which is early hyperintense acute reperfusion marker sign (A). There is no evidence of acute infarction on diffusion-weighted image (B), and no intracranial hemorrhage on gradient echo image (C). There is contrast present from previous images performed 7 hours prior in cerebrospinal fluid space on follow-up FLAIR image, which is feature of classic HARM (D-F). FLAIR = fluid attenuated inversion recovery

• 

  Fig. 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

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