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June 01, 1999; 52 (9) Article

Normal diffusion-weighted MRI during stroke-like deficits

H. Ay, F.S. Buonanno, G. Rordorf, P.W. Schaefer, L.H. Schwamm, O. Wu, R.G. Gonzalez, K. Yamada, G.A. Sorensen, W.J. Koroshetz
First published June 1, 1999, DOI: https://doi.org/10.1212/WNL.52.9.1784
H. Ay
From the Stroke Service of the Neurology Department (Drs. AyBuonanno, Rordorf, Koroshetz, and Schwamm, and O. Wu) and Neuroradiology Division (Drs. Schaefer, Gonzalez, Yamada, and Sorensen), Massachusetts General Hospital and Harvard Medical School, Boston, MA.
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F.S. Buonanno
From the Stroke Service of the Neurology Department (Drs. AyBuonanno, Rordorf, Koroshetz, and Schwamm, and O. Wu) and Neuroradiology Division (Drs. Schaefer, Gonzalez, Yamada, and Sorensen), Massachusetts General Hospital and Harvard Medical School, Boston, MA.
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G. Rordorf
From the Stroke Service of the Neurology Department (Drs. AyBuonanno, Rordorf, Koroshetz, and Schwamm, and O. Wu) and Neuroradiology Division (Drs. Schaefer, Gonzalez, Yamada, and Sorensen), Massachusetts General Hospital and Harvard Medical School, Boston, MA.
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P.W. Schaefer
From the Stroke Service of the Neurology Department (Drs. AyBuonanno, Rordorf, Koroshetz, and Schwamm, and O. Wu) and Neuroradiology Division (Drs. Schaefer, Gonzalez, Yamada, and Sorensen), Massachusetts General Hospital and Harvard Medical School, Boston, MA.
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L.H. Schwamm
From the Stroke Service of the Neurology Department (Drs. AyBuonanno, Rordorf, Koroshetz, and Schwamm, and O. Wu) and Neuroradiology Division (Drs. Schaefer, Gonzalez, Yamada, and Sorensen), Massachusetts General Hospital and Harvard Medical School, Boston, MA.
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O. Wu
From the Stroke Service of the Neurology Department (Drs. AyBuonanno, Rordorf, Koroshetz, and Schwamm, and O. Wu) and Neuroradiology Division (Drs. Schaefer, Gonzalez, Yamada, and Sorensen), Massachusetts General Hospital and Harvard Medical School, Boston, MA.
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R.G. Gonzalez
From the Stroke Service of the Neurology Department (Drs. AyBuonanno, Rordorf, Koroshetz, and Schwamm, and O. Wu) and Neuroradiology Division (Drs. Schaefer, Gonzalez, Yamada, and Sorensen), Massachusetts General Hospital and Harvard Medical School, Boston, MA.
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K. Yamada
From the Stroke Service of the Neurology Department (Drs. AyBuonanno, Rordorf, Koroshetz, and Schwamm, and O. Wu) and Neuroradiology Division (Drs. Schaefer, Gonzalez, Yamada, and Sorensen), Massachusetts General Hospital and Harvard Medical School, Boston, MA.
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G.A. Sorensen
From the Stroke Service of the Neurology Department (Drs. AyBuonanno, Rordorf, Koroshetz, and Schwamm, and O. Wu) and Neuroradiology Division (Drs. Schaefer, Gonzalez, Yamada, and Sorensen), Massachusetts General Hospital and Harvard Medical School, Boston, MA.
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W.J. Koroshetz
From the Stroke Service of the Neurology Department (Drs. AyBuonanno, Rordorf, Koroshetz, and Schwamm, and O. Wu) and Neuroradiology Division (Drs. Schaefer, Gonzalez, Yamada, and Sorensen), Massachusetts General Hospital and Harvard Medical School, Boston, MA.
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Citation
Normal diffusion-weighted MRI during stroke-like deficits
H. Ay, F.S. Buonanno, G. Rordorf, P.W. Schaefer, L.H. Schwamm, O. Wu, R.G. Gonzalez, K. Yamada, G.A. Sorensen, W.J. Koroshetz
Neurology Jun 1999, 52 (9) 1784; DOI: 10.1212/WNL.52.9.1784

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Abstract

Background: Diffusion-weighted MRI (DWI) represents a major advance in the early diagnosis of acute ischemic stroke. When abnormal in patients with stroke-like deficit, DWI usually establishes the presence and location of ischemic brain injury. However, this is not always the case.

Objective: To investigate patients with stroke-like deficits occurring without DWI abnormalities in brain regions clinically suspected to be responsible.

Methods: We identified 27 of 782 consecutive patients scanned when stroke-like neurologic deficits were still present and who had normal DWI in the brain region(s) clinically implicated. Based on all the clinical and radiologic data, we attempted to arrive at a pathophysiologic diagnosis in each.

Results: Best final diagnosis was a stroke mimic in 37% and a cerebral ischemic event in 63%. Stroke mimics (10 patients) included migraine, seizures, functional disorder, transient global amnesia, and brain tumor. The remaining patients were considered to have had cerebral ischemic events: lacunar syndrome (7 patients; 3 with infarcts demonstrated subsequently) and hemispheric cortical syndrome (10 patients; 5 with TIA, 2 with prolonged reversible deficits, 3 with infarction on follow-up imaging). In each of the latter three patients, the regions destined to infarct showed decreased perfusion on the initial hemodynamically weighted MRI (HWI).

Conclusions: Normal DWI in patients with stroke-like deficits should stimulate a search for nonischemic cause of symptoms. However, more than one-half of such patients have an ischemic cause as the best clinical diagnosis. Small brainstem lacunar infarctions may escape detection. Concomitant HWI can identify some patients with brain ischemia that is symptomatic but not yet to the stage of causing DWI abnormality.

  • Received August 21, 1998.
  • Accepted in final form January 2, 1999.
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