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Original research
Breaking with a dogma: persisting diffusion restrictions (pDWI) in follow-up after endovascular treatment for stroke
  1. Moritz Roman Hernandez Petzsche1,
  2. Tobias Boeckh-Behrens1,
  3. Kathleen Bernkopf2,
  4. Simone Henze1,
  5. Christian Maegerlein1,
  6. Dominik Sepp1,
  7. Claus Zimmer1,
  8. Silke Wunderlich2,
  9. Benno Ikenberg2,
  10. Maria Teresa Berndt1
  1. 1Department of diagnostic and interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
  2. 2Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
  1. Correspondence to Dr Maria Teresa Berndt, Department of Diagnostic and Interventional Neuroradiology, Technical University of Munich Klinikum rechts der Isar, School of Medicine, 81675 Munchen, Germany; maria.berndt{at}tum.de

Abstract

Background Post-stroke diffusion weighted imaging (DWI) signal transformation of the infarct core, which results in high apparent diffusion coefficient (ADC) values and variable DWI signal intensity, is completed no later than 1 month after onset of ischemia. We observed frequent exceptions to this timeline of change in DWI signal, which led to uncertainties in further clinical patient management.

Methods A prospective single-center study of patients treated with mechanical thrombectomy of a large vessel occlusion in the anterior circulation was conducted. Patients received high-resolution MRI at 3T, including DWI, in the acute post-stroke phase and in the follow-up after 3–12 months.

Results Overall, 78 patients (45 men) of mean age 63.6 years were evaluated. We identified persisting or new diffusion restriction in 29 of the 78 patients (37.2%) on follow-up imaging. Diffusion restrictions in a different location from the infarct core, representing new (sub-)acute ischemia, were observed in four patients (5.1%). Smaller areas of persisting diffusion restriction (pDWI lesions with high DWI signal and reduced ADC values) within the former infarct core were observed in 25 patients (32.1%) without clinical evidence of recurrent stroke, but with worse outcome scores at follow-up compared with patients without pDWI lesions. The presence of pDWI lesions is associated with a large primary infarct core (multivariate regression OR 1.03 (95% CI 1.01 to 1.05); p<0.01), mediating the relationship between pDWI lesions and clinical outcome.

Conclusion Smaller foci of persisting diffusion restriction (pDWI lesions) in the follow-up after endovascular treatment for stroke are frequent and likely represent a slowed ADC signal progression within a formerly large infarct core.

  • Stroke
  • MRI
  • Brain
  • Lesion

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Footnotes

  • Contributors Study conception and design: MRHP, TB-B, MTB with substantial contributions from all authors. Data collection: MRHP, TB-B, CM, KB, SH, BI, DS, SW, CZ, MTB. Analysis and interpretation of results: MRHP, TB-B, MTB with substantial contributions from all authors. Manuscript preparation: MRHP, MTB. All authors critically revised the manuscript for important intellectual content and approved the final version of the manuscript. All authors agree to be accountable for all aspects of the work. MTB acts as the guarantor of this work.

  • Funding This work is supported by a KKF grant from the Technical University of Munich to MRHP.

  • Competing interests Outside the submitted work, CZ has received speaker honoraria from Bayer-Schering. He serves as a co-editor on the advisory board of Clinical Neuroradiology and is president of the German Society of Neuroradiology (DGNR). All the other authors declare no conflict of interest.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.