Extensive Diffusion Restriction Research Articles

Severe Hypoglycemic Brain Injury Associated with Diffuse Restricted Diffusion on MRI Brain Sparing Cerebellar Lobes (P10-7.006)

<h3>Objective:</h3> Report a case of severe hypoglycemia-induced brain injury in an adult with MRI brain showing extensive diffusion restriction mimicking hypoxic brain injury. <h3>Background:</h3> Hypoglycemia is commonly seen in clinical practice, with most often benign outcome when appropriately treated. However, severe hypoglycemia may be associated with transient or permanent neurologic deficits. Irreversible diffuse brain injury is more often documented in the pediatric population, in particular neonatal, though devastating injury can also happen in adults. Energy deprivation and other chemical cascades lead to neuronal necrosis. Though some overlap exists and imaging shares some similarities, neurochemistry and brain lesion distribution of hypoglycemia differs markedly from ischemia. We present a case of severe, prolonged hypoglycemia leading to diffuse hypoglycemic brain injury. <h3>Design/Methods:</h3> Case report <h3>Results:</h3> 71-year-old male with history of insulin-dependent diabetes and depression with suicidal ideations who presented to the emergency room (ER) after being found unconscious with a serum glucose of 14 mg/dl. The patient was intubated for airway protection due to GCS at 9 but without significant hypoxia, saturating 93% on room air. Despite aggressive glucose replacement, he had several hypoglycemic episodes on a 27-hour span. Laboratory testing was remarkable only for elevated creatinine kinase of 3047 mg/dl, and presence of cannabis on urine drug screen. Patient remained comatose, with only preserved corneal reflexes after weaned off sedation. Non-epileptic myoclonus was also observed, confirmed by EEG. MRI brain revealed diffuse restricted diffusion, predominantly in the cerebral cortex and deep basal ganglia but sparing cerebellar lobes. Patient did not survive. <h3>Conclusions:</h3> Severe hypoglycemia leads to energy depletion and neuronal death with some overlap with ischemic brain injury though significant radiologic differences can help differentiate both pathophysiologic processes. Cerebellar involvement is uncommon compared to ischemic injury due to highly effective glucose transporter which can help differentiate both types of injury. <b>Disclosure:</b> Dr. Ribeiro has nothing to disclose. Dr. Gatchoff has nothing to disclose. Dr. Delpirou Nouh has nothing to disclose. Dr. Moon has nothing to disclose.

Association between the extent of diffusion restriction on brain diffusion-weighted imaging and neurological outcomes after an out-of-hospital cardiac arrest

BackgroundThis study evaluated the association between the extent of diffusion restriction on brain diffusion-weighted imaging (DWI) and neurological outcomes in patients who underwent targeted temperature management (TTM) after an out-of-hospital cardiac arrest (OHCA). MethodsPatients who underwent brain magnetic resonance imaging within 10 days of OHCA between 2012 and 2021 were analysed. The extent of diffusion restriction was described according to the modified DWI Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS). The 35 predefined brain regions were assigned a score if diffuse signal changes were concordantly present in DWI scans and apparent diffusion coefficient maps. The primary outcome was an unfavourable neurological outcome at 6 months. The sensitivity, specificity, and receiver operating characteristic (ROC) curves for the measured parameters were analysed. Cut-off values were determined to predict the primary outcome. The predictive cut-off DWI-ASPECTS was internally validated using five-fold cross-validation. ResultsOf the 301 patients, 108 (35.9%) had 6-month favourable neurological outcomes. Patients with unfavourable outcomes had higher whole-brain DWI-ASPECTS (median, 31 [26–33] vs. 0 [0–1], P < 0.001) than those with favourable outcomes. The area under the ROC curve (AUROC) of whole-brain DWI-ASPECTS was 0.957 (95% confidence interval [CI] 0.928–0.977). A cut-off value of ≥8 for unfavourable neurological outcomes had specificity and sensitivity of 100% (95% CI 96.6–100) and 89.6% (95% CI 84.4–93.6), respectively. The mean AUROC was 0.956. ConclusionMore extensive diffusion restriction on DWI-ASPECTS in patients with OHCA who underwent TTM was associated with 6-month unfavourable neurological outcomes.Running title: Diffusion restriction and neurological outcomes after cardiac arrest.

The Clinical Response of California Serogroup Virus Neuroinvasive Disease in a Pediatric Patient to Intravenous Immunoglobulin (IVIG) Therapy

Objective NA. Background California serogroup (CSG) viruses are commonly associated with neurologic disease. There are few cases of CSG viruses where IVIG has been proven to help. We report a young child with neuroinvasive CSG virus encephalitis treated with IVIG and associated outcome. Design/Methods A retrospective chart review. Results A 6 year old boy, previously healthy presented with fluctuating mental status with vomiting, fatigue, and fever starting six days prior to presentation. He began to have repetitive movements of rubbing his nose, and twisting movements of the upper extremities with mild eye deviation to the left with no EEG correlate. He required PICU admission for desaturations and altered mental status requiring intubation with sedation. He was found to have positive serum IgG and IgM antibody titers 1:128 of CSG viruses. IgG and IgM antibody titers of CSG viruses was negative (&lt;1:1) in CSF. Of note he was positive for human metapneumovirus IgM antibodies. His serum and CSF NMDA was negative suggesting California encephalitis is not likely associated with NMDA encephalitis. His MRI brain resulted with extensive diffusion restriction throughout the frontal, parietal, and temporal cortex as well as non-diffusion restricting signal abnormality involving the basal ganglia and brainstem, suggesting a para-infectious encephalitis. He received IVIG given his worsening mental status starting on day 14 of admission. Neurological symptoms gradually improved after IVIG treatment. Despite therapies he displayed difficulties with focus and attention. 6 months after initial presentation his routine EEG showed frequent, sleep activated, 1-3 seconds bursts of irregular generalized spikes-and-slow wave complexes. Patient was continued on levetiracetam with no seizures. Conclusions This report highlights a severe case of encephalitis with CSG viruses. Although it is not clear whether time or IVIG helped in this patient case, it seemed to have shortened his acute altered mental status although he still has long-term learning difficulties.

Neonatal encephalopathy and potential lost opportunities: when the story fits, please cool

‘Sarah is a baby girl born by an emergency caesarean section following a period of observation for non-reassuring cardiotocographic recordings. She was initially ‘flat’ and received positive pressure ventilation for...

Association of MRI Brain Injury With Outcome After Pediatric Out-of-Hospital Cardiac Arrest.

To determine the association between the extent of diffusion restriction and T2/fluid-attenuated inversion recovery (FLAIR) injury on brain MRI and outcomes after pediatric out-of-hospital cardiac arrest (OHCA). Diffusion restriction and T2/FLAIR injury were described according to the pediatric MRI modification of the Alberta Stroke Program Early Computed Tomography Score (modsASPECTS) for children from 2005 to 2013 who had an MRI within 14 days of OHCA. The primary outcome was unfavorable neurologic outcome defined as ≥1 change in Pediatric Cerebral Performance Category (PCPC) from baseline resulting in a hospital discharge PCPC score 3, 4, 5, or 6. Patients with unfavorable outcomes were further categorized into alive with PCPC 3-5, dead due to withdrawal of life-sustaining therapies for poor neurologic prognosis (WLST-neuro), or dead by neurologic criteria. We evaluated MRI scans from 77 patients (median age 2.21 [interquartile range 0.44, 13.07] years) performed 4 (2, 6) days postarrest. Patients with unfavorable outcomes had more extensive diffusion restriction (median 7 [4, 10.3] vs 0 [0, 0] regions, p < 0.001) and T2/FLAIR injury (5.5 [2.3, 8.2] vs 0 [0, 0.75] regions, p < 0.001) compared to patients with favorable outcomes. Area under the receiver operating characteristic curve for the extent of diffusion restriction and unfavorable outcome was 0.96 (95% confidence interval [CI] 0.91, 0.99) and 0.92 (95% CI 0.85, 0.97) for T2/FLAIR injury. There was no difference in extent of diffusion restriction between patients who were alive with an unfavorable outcome and patients who died from WLST-neuro (p = 0.11). More extensive diffusion restriction and T2/FLAIR injury on the modsASPECTS score within the first 14 days after pediatric cardiac arrest was associated with unfavorable outcomes at hospital discharge.

Unexpected Recovery of Function After Severe Traumatic Brain Injury: The Limits of Early Neuroimaging-Based Outcome Prediction

Prognostication in the early stage of traumatic coma is a common challenge in the neuro-intensive care unit. We report the unexpected recovery of functional milestones (i.e., consciousness, communication, and community reintegration) in a 19-year-old man who sustained a severe traumatic brain injury. The early magnetic resonance imaging (MRI) findings, at the time, suggested a poor prognosis. During the first year of the patient's recovery, MRI with diffusion tensor imaging and T2*-weighted imaging was performed on day 8 (coma), day 44 (minimally conscious state), day 198 (post-traumatic confusional state), and day 366 (community reintegration). Mean apparent diffusion coefficient (ADC) and fractional anisotropy values in the corpus callosum, cerebral hemispheric white matter, and thalamus were compared with clinical assessments using the Disability Rating Scale (DRS). Extensive diffusion restriction in the corpus callosum and bihemispheric white matter was observed on day 8, with ADC values in a range typically associated with neurotoxic injury (230-400 × 10(-6 )mm(2)/s). T2*-weighted MRI revealed widespread hemorrhagic axonal injury in the cerebral hemispheres, corpus callosum, and brainstem. Despite the presence of severe axonal injury on early MRI, the patient regained the ability to communicate and perform activities of daily living independently at 1 year post-injury (DRS = 8). MRI data should be interpreted with caution when prognosticating for patients in traumatic coma. Recovery of consciousness and community reintegration are possible even when extensive traumatic axonal injury is demonstrated by early MRI.

Acute Marchiafava‐Bignami Disease with Extensive Diffusion Restriction and Early Recovery: Case Report and Review of the Literature

Marchiafava-Bignami disease (MBD) is a neurological disorder that has been found to be associated with chronic alcoholism and malnutrition. MBD classically results in acute edema and demyelination of the corpus callosum. Edema of the complete corpus callosum has been described to be an unfavorable prognostic factor. We present an acute onset of MBD with diffusion restriction of the complete corpus callosum and symmetric bilateral extension into the semioval center, that almost completely resolved clinically as well as in MRI only 3 days later. With early detection and treatment, the prognosis of MBD may be good even in cases with severe diffusion restriction of the complete corpus callosum.