Abstract
BackgroundDiffusion-restricted lesions on diffusion-weighted imaging (DWI) are detected in patients with intracerebral hemorrhage (ICH). In this study, we aimed to determine the fate of DWI lesions in ICH patients and whether the presence of DWI lesions is associated with functional outcome in patients with ICH.MethodsThis prospective study enrolled 153 patients with acute ICH. Baseline MRI scans were performed within 2 weeks after ICH to detect DWI lesions and imaging markers for small vessel disease (SVD). Follow-up MRI scans were performed at 3 months after ICH to assess the fate of the DWI lesions. We analyzed the associations between the characteristics of DWI lesions with clinical features and functional outcome.ResultsSeventeen of the 153 patients (11.1%) had a total of 25 DWI lesions. Factors associated with DWI lesions were high initial systolic and mean arterial blood pressure (MAP) at the emergency room, additional lowering of MAP within 24 hours, and the presence of white matter hyperintensity and cerebral microbleeds. Thirteen of the 25 DWI lesions (52%) were not visible on follow-up T2-weighted or fluid-attenuated inversion recovery images and were associated with high apparent diffusion coefficient value and a sharper decease in MAP. The regression of DWI lesions was associated with good functional outcome.ConclusionsMore than half of the DWI lesions in the ICH patients did not transition to visible, long-term infarction. Only if the DWI lesion finally transitioned to final infarction was a poor functional outcome predicted. A DWI lesion may be regarded as an ischemic change of SVD and does not always indicate certain cerebral infarction or permanent tissue injury.
Highlights
[1] Prior studies have found that lesions with restricted diffusion on diffusion-weighted imaging (DWI) were observed in 13–41% of patients with acute intracerebral hemorrhage (ICH). [2,3,4,5,6,7] The DWI lesions were found to be associated with magnetic resonance imaging (MRI) markers of small vessel diseases (SVD) such as cerebral microbleeds (CMB) [3,4,5,7,8] and white matter hyperintensity (WMH). [3,5,7] Three recent studies found an association between rapid blood pressure reduction and DWI lesions in patients with acute ICH [4,6,7]
The benefit of acute blood pressure reduction, as suggested by American Heart Association guidelines and some clinical trials, [10,11] has been suspected of being reduced by the induction of new ischemic lesions observed on DWI. [4,6,9] whether the presence of a DWI lesion in ICH patients is related to poor functional outcome is still controversial [5]
Patients with DWI lesions had higher systolic blood pressure (SBP) and mean arterial blood pressure (MAP) at the time they arrived at the ER (P = 0.049 and 0.043, respectively); a sharper decrease of the MAP between the time MAP was recorded at the ER and the lowest MAP recorded during the first 24 hours after ICH (P = 0.030)
Summary
Primary intracerebral hemorrhage (ICH) is associated with higher mortality rates and more severe neurological deficits than any other subtype of stroke. [1] Prior studies have found that lesions with restricted diffusion on diffusion-weighted imaging (DWI) were observed in 13–41% of patients with acute ICH. [2,3,4,5,6,7] The DWI lesions were found to be associated with MRI markers of small vessel diseases (SVD) such as cerebral microbleeds (CMB) [3,4,5,7,8] and white matter hyperintensity (WMH). [3,5,7] Three recent studies found an association between rapid blood pressure reduction and DWI lesions in patients with acute ICH [4,6,7]. the underlying physiology as well as potential impact on clinical management and outcomes of DWI lesions are not fully understood, DWI lesions have been generally considered as ischemic infarcts in prior studies. [9] Garg et al [6] found that DWI lesions after ICH are associated with greater acute blood pressure reduction as well as disability and death at 3 months. [9] Garg et al [6] found that DWI lesions after ICH are associated with greater acute blood pressure reduction as well as disability and death at 3 months In another recent study by Kang et al, [5] it was demonstrated that DWI lesions may predict future ischemic stroke, recurrent ICH, and vascular death. Based on these findings, the benefit of acute blood pressure reduction, as suggested by American Heart Association guidelines and some clinical trials, [10,11] has been suspected of being reduced by the induction of new ischemic lesions observed on DWI.
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