Neurointervention.  2023 Mar;18(1):38-46. 10.5469/neuroint.2023.00017.

Strong Contrast Stagnation of Unilateral Vertebral Artery on Three-Dimensional Black Blood-Enhanced MRI Predicts Acute Medulla Infarction

• Cho SM
• Park SY
• Kwak HS
• Hwang SB

• KMID: 2539945
• DOI: http://doi.org/10.5469/neuroint.2023.00017

Abstract

Purpose
This study aimed to evaluate angiographic and contrast enhancement (CE) patterns on three-dimensional (3D) black blood (BB) contrast-enhanced MRI in patients with acute medulla infarction.
Materials and Methods
From January 2020 to August 2021, we retrospectively analyzed stroke 3D BB contrast-enhanced magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) findings of patients visiting the emergency room for symptom evaluation of acute medulla infarction. In total, 28 patients with acute medulla infarction were enrolled in this study. Four types of 3D BB contrast-enhanced MRI and MRA were classified as follows: 1=unilateral contrast-enhanced vertebral artery (VA)+no visualization of VA on MRA; 2=unilateral enhanced VA+hypoplastic VA; 3=no enhanced VA+unilateral complete occlusion of VA; 4=no enhanced VA+normal VA (including hypoplasia) on MRA.
Results
Of the 28 patients with acute medulla infarction, 7 (25.0%) showed delayed positive findings after 24 hours on diffusion-weighted imaging (DWI). Of these patients, 19 (67.9%) showed CE of the unilateral VA on 3D BB contrast-enhanced MRI (type 1 and 2). Of the 19 patients with CE of VA on 3D BB contrast-enhanced MRI, 18 showed no visualization of enhanced VA on MRA (type 1), and 1 showed hypoplastic VA. Of the 7 patients with delayed positive findings on DWI, 5 showed CE of the unilateral VA and no visualization of the enhanced VA on MRA (type 1). Symptom onset to door time or initial MR check time was significantly shorter in the groups with delayed positive findings on DWI (P<0.05).
Conclusion
Unilateral CE on 3D BB contrast-enhanced MRI and no visualization of the VA on MRA are related to the recent occlusion of the distal VA. These findings suggest that the recent occlusion of the distal VA is related to acute medulla infarction, including delayed visualization on DWI.

Keyword

Stroke; Magnetic resonance imaging; Vertebral artery

Figure

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  Fig. 1. Four types of asymmetrical vertebral artery (VA) geometry on black blood enhanced manetic resonance (MR) and MR angiography (MRA). (A) Type 1=unilateral contrast-enhanced VA (arrow)+no visualization of VA on MRA. (B) Type 2=unilateral contrast-enhanced VA (arrow)+hypoplastic VA. (C) Type 3=no enhanced VA+unilateral complete occlusion of VA. (D) Type 4=no enhanced VA+normal VA (including hypoplasia) on MRA.

• 

  Fig. 2. A middle aged patient with left extremity weakness. (A) Initial diffusion-weighted imaging showing an acute infarction in the right lateral medulla (arrow). (B) Manetic resonance (MR) angiography shows no visualization of the right vertebral artery (VA) and faint visualization of the distal VA (arrow). (C) Axial 3-dimensional black-blood contrast-enhanced MR imaging (MRI) showing strong enhancement of the right VA (arrow). Note the black lumen of the left VA (asterisk). (D) Coronal reformatted contrast-enhanced MRI showing a long segment and strong contrast stagnation of the right VA (arrows).

• 

  Fig. 3. A middle aged patient with acute headache and dizziness. (A) Initial diffusion-weighted imaging (DWI) does not show abnormal signal intensity. (B) Manetic resonance (MR) angiography shows no visualization of the left vertebral artery (VA) and faint visualization of the distal VA (arrow). (C) Axial 3-dimensional black-blood contrast-enhanced MR imaging (MRI) showing strong enhancement of the left VA (arrow). Note the black lumen of the right VA (asterisk). (D) Coronal reformatted contrast-enhanced MRI showing a long segment and strong contrast stagnation of the left VA (arrows). (E) DWI 1 day later showing focal diffusion restriction in the left medulla (arrow).

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  Fig. 4. Illustration of acute medulla infarction after occlusion of the distal vertebral artery (VA). (A) Normal VA. (B) Contrast stagnation of the distal VA after acute occlusion of the distal VA (arrows). (C) Acute medulla infarction due to contrast stagnation acute occlusion of the distal VA (arrow). Delayed visualization of acute medulla infarction on diffusion-weighted imaging is associated with ischemic changes after occlusion of the distal VA.

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