Comparison of 3- and 20-Gradient Direction Diffusion-Weighted Imaging in a Clinical Subacute Cohort of Patients with Transient Ischemic Attack: Application of Standard Vendor Protocols for Lesion Detection and Final Infarct Size Projection

Inger Havsteen, Christian Ovesen, Lasse Willer, Janus Damm Nybing, Karen Ægidius, Jacob Marstrand, Per Meden, Sverre Rosenbaum, Marie Norsker Folke, Hanne Christensen, Anders Christensen, Inger Havsteen, Christian Ovesen, Lasse Willer, Janus Damm Nybing, Karen Ægidius, Jacob Marstrand, Per Meden, Sverre Rosenbaum, Marie Norsker Folke, Hanne Christensen, Anders Christensen

Abstract

Objective: Diffusion tensor imaging may aid brain ischemia assessment but is more time consuming than conventional diffusion-weighted imaging (DWI). We compared 3-gradient direction DWI (3DWI) and 20-gradient direction DWI (20DWI) standard vendor protocols in a hospital-based prospective cohort of patients with transient ischemic attack (TIA) for lesion detection, lesion brightness, predictability of persisting infarction, and final infarct size.

Methods: We performed 3T-magnetic resonance imaging including diffusion and T2-fluid attenuated inversion recovery (FLAIR) within 72 h and 8 weeks after ictus. Qualitative lesion brightness was assessed by visual inspection. We measured lesion area and brightness with manual regions of interest and compared with homologous normal tissue.

Results: 117 patients with clinical TIA showed 78 DWI lesions. 2 lesions showed only on 3DWI. No lesions were uniquely 20DWI positive. 3DWI was visually brightest for 34 lesions. 12 lesions were brightest on 20DWI. The median 3DWI lesion area was larger for lesions equally bright, or brightest on 20DWI [median (IQR) 39 (18-95) versus 18 (10-34) mm2, P = 0.007]. 3DWI showed highest measured relative lesion signal intensity [median (IQR) 0.77 (0.48-1.17) versus 0.58 (0.34-0.81), P = 0.0006]. 3DWI relative lesion signal intensity was not correlated to absolute signal intensity, but 20DWI performed less well for low-contrast lesions. 3DWI lesion size was an independent predictor of persistent infarction. 3-gradient direction apparent diffusion coefficient areas were closest to 8-week FLAIR infarct size.

Conclusion: 3DWI detected more lesions and had higher relative lesion SI than 20DWI. 20DWI appeared blurred and did not add information.

Clinical trial registration: http://www.clinicaltrials.gov. Unique Identifier NCT01531946.

Keywords: diffusion tensor imaging; diffusion-weighted imaging; infarction; magnetic resonance imaging; transient ischemic attack.

Figures

Figure 1
Figure 1
Regions of interest measurements. Co-registration method for lesion size and signal intensity on 3-gradient direction DWI.
Figure 2
Figure 2
Qualitative lesion brightness on 3- and 20-gradient diffusion imaging. Diffusion-weighted imaging (DWI) lesion shows on 3-gradient DWI (3DWI) (A), 20-gradient DWI (B) shows no certain lesion, but blur. Panels (C,D) equal lesion brightness on 3DWI (C) and 20DWI (D). Panels (E,F) lesion brightest on 20DWI (F).
Figure 3
Figure 3
STROBE diagram of patient in- and exclusion. Other contained patients with peripheral nerve compression (2), ophthalmological symptoms (2), trigeminal neuralgy (1), normal pressure hydrocephalus (1), hyperventilation (1), paresthesia secondary to anemia (1), peripheral extremity embolus (1), food poisoning (1), and secondary refusal (1). Reasons for lack of 20DWI/apparent diffusion coefficient (ADC) were technician error (3), incomplete examination due to restless patient (1), and technical error (1).
Figure 4
Figure 4
Comparison of relative lesion signal intensity (rSI) on 3-gradient direction DWI (3DWI) and 20DWI, N = 76. rSI is the normalized difference between signal intensities in lesions and contralateral homologous normal tissue, i, ipsilateral (lesion); c, contralateral. 3- and 20DWI sequences’ relative lesion signal intensity shows linear correlation. Best linear model fit has 0.7 incline implying that 3DWI has 30% higher relative lesion signal intensity than 20DWI. The dashed reference line has slope 1 indicating where rSI3 = rSI20.
Figure 5
Figure 5
Comparison of difference in relative signal intensity (%SI) to absolute signal intensities on 3-gradient direction DWI (3DWI)- and 20DWI, linear model regression lines with equations, N = 76. Difference in relative signal intensity is uniform for absolute 3DWI lesion signal intensities, but lower for low-signal lesions on 20DWI.
Figure 6
Figure 6
Distribution of lesions according to size measured on 3-gradient direction DWI (3DWI), and the two sequences’ difference in relative signal intensity (%SI), N = 76. The dashed reference line indicates where rSI3 = rSI20. Small lesions show highest variation in the two sequences’ difference in relative signal intensity (%SI), and predominantly highest relative signal intensity on 3DWI (i.e., %SI is negative).
Figure 7
Figure 7
Initial lesions’ median deviation from 8-week infarction area. This figure presents the median deviation between the initial lesion area on the respective sequences, and the area of the final infarction on 8-week magnetic resonance imaging. The smallest deviation (initial 3ADC) is significantly smaller than the deviation yielded by 3-gradient direction DWI (3DWI) or 20DWI. 20ADC and fluid attenuated inversion recovery (FLAIR) yielded deviations not significantly different from 3ADC.
Figure 8
Figure 8
Bland–Altman diagrams per initial sequence (A–E) comparing initial lesion size with 8-week infarct size.

References

    1. Amarenco P, Lavallée PC, Labreuche J, Albers GW, Bornstein NM, Canhão P, et al. One-year risk of stroke after transient ischemic attack or minor stroke. N Engl J Med (2016) 374:1533–42.10.1056/NEJMoa1412981
    1. Redgrave JN, Coutts SB, Schulz UG, Briley D, Rothwell PM. Systematic review of associations between the presence of acute ischemic lesions on diffusion-weighted imaging and clinical predictors of early stroke risk after transient ischemic attack. Stroke (2007) 38:1482–8.10.1161/STROKEAHA.106.477380
    1. Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elkins JS, Bernstein AL, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet (2007) 369:283–92.10.1016/S0140-6736(07)60150-0
    1. Ay H, Arsava EM, Johnston SC, Vangel M, Schwamm LH, Furie KL, et al. Clinical- and imaging-based prediction of stroke risk after transient ischemic attack the CIP model. Stroke (2009) 40:181–6.10.1161/STROKEAHA.108.521476
    1. Coutts SB, Eliasziw M, Hill MD, Scott JN, Subramaniam S, Buchan AM, et al. An improved scoring system for identifying patients at high early risk of stroke and functional impairment after an acute transient ischemic attack or minor stroke. Int J Stroke (2008) 3:3–10.10.1111/j.1747-4949.2008.00182.x
    1. Zaharchuk G, Olivot J-M, Fischbein NJ, Bammer R, Straka M, Kleinman JT, et al. Arterial spin labeling imaging findings in transient ischemic attack patients: comparison with diffusion- and bolus perfusion-weighted imaging. Cerebrovasc Dis (2012) 34:221–8.10.1159/000339682
    1. Kleinman JT, Zaharchuk G, Mlynash M, Ogdie AA, Straka M, Lansberg MG, et al. Automated perfusion imaging for the evaluation of transient ischemic attack. Stroke (2012) 43:1556–60.10.1161/STROKEAHA.111.644971
    1. Merwick A, Albers GW, Amarenco P, Arsava EM, Ay H, Calvet D, et al. Addition of brain and carotid imaging to the ABCD2 score to identify patients at early risk of stroke after transient ischaemic attack: a multicentre observational study. Lancet Neurol (2010) 9:1060–9.10.1016/S1474-4422(10)70240-4
    1. Mlynash M, Olivot J-M, Tong DC, Lansberg MG, Eyngorn I, Kemp S, et al. Yield of combined perfusion and diffusion MR imaging in hemispheric TIA. Neurology (2009) 72:1127–33.10.1212/01.wnl.0000340983.00152.69
    1. Purroy F, Begué R, Quílez A, Piñol-Ripoll G, Sanahuja J, Brieva L, et al. The California, ABCD, and unified ABCD2 risk scores and the presence of acute ischemic lesions on diffusion-weighted imaging in TIA patients. Stroke (2009) 40:2229–32.10.1161/STROKEAHA.108.537969
    1. Giles MF, Albers GW, Amarenco P, Arsava EM, Asimos AW, Ay H, et al. Early stroke risk and ABCD2 score performance in tissue- vs time-defined TIA. Neurology (2011) 77:1222–8.10.1212/WNL.0b013e3182309f91
    1. Brazzelli M, Chappell FM, Miranda H, Shuler K, Dennis M, Sandercock PAG, et al. Diffusion-weighted imaging and diagnosis of transient ischemic attack. Ann Neurol (2014) 75:67–76.10.1002/ana.24026
    1. Lavallée PC, Meseguer E, Abboud H, Cabrejo L, Olivot J-M, Simon O, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol (2007) 6:953–60.10.1016/S1474-4422(07)70248-X
    1. Uno H, Nagatsuka K, Kokubo Y, Higashi M, Yamada N, Umesaki A, et al. Detectability of ischemic lesions on diffusion-weighted imaging is biphasic after transient ischemic attack. J Stroke Cerebrovasc Dis (2015) 24:1059–64.10.1016/j.jstrokecerebrovasdis.2014.12.037
    1. Chien D, Kwong KK, Gress DR, Buonanno FS, Buxton RB, Rosen BR. MR diffusion imaging of cerebral infarction in humans. AJNR Am J Neuroradiol (1992) 13:1097–102.
    1. Gaudinski MR, Henning EC, Miracle A, Luby M, Warach S, Latour LL. Establishing final infarct volume: stroke lesion evolution past 30 days is insignificant. Stroke (2008) 39:2765–8.10.1161/STROKEAHA.107.512269
    1. Tourdias T, Renou P, Sibon I, Asselineau J, Bracoud L, Dumoulin M, et al. Final cerebral infarct volume is predictable by MR imaging at 1 week. AJNR Am J Neuroradiol (2011) 32:352–8.10.3174/ajnr.A2271
    1. Ringer TM, Neumann-Haefelin T, Sobel RA, Moseley ME, Yenari MA. Reversal of early diffusion-weighted magnetic resonance imaging abnormalities does not necessarily reflect tissue salvage in experimental cerebral ischemia. Stroke (2001) 32:2362–9.10.1161/hs1001.096058
    1. Fiehler J, Foth M, Kucinski T, Knab R, von Bezold M, Weiller C, et al. Severe ADC decreases do not predict irreversible tissue damage in humans. Stroke (2002) 33:79–86.10.1161/hs0102.100884
    1. Cheung JS, Wang E, Lo EH, Sun PZ. Stratification of heterogeneous diffusion MRI ischemic lesion with kurtosis imaging – evaluation of mean diffusion and kurtosis MRI mismatch in an animal model of transient focal ischemia. Stroke (2012) 43:2252–4.10.1161/STROKEAHA.112.661926
    1. Asdaghi N, Campbell BCV, Butcher KS, Coulter JI, Modi J, Qazi A, et al. DWI reversal is associated with small infarct volume in patients with TIA and minor stroke. AJNR Am J Neuroradiol (2014) 35:660–6.10.3174/ajnr.A3733
    1. Calamante F, Tournier J-D, Jackson GD, Connelly A. Track-density imaging (TDI): super-resolution white matter imaging using whole-brain track-density mapping. Neuroimage (2010) 53:1233–43.10.1016/j.neuroimage.2010.07.024
    1. Christidi F, Karavasilis E, Samiotis K, Bisdas S, Papanikolaou N. Fiber tracking: a qualitative and quantitative comparison between four different software tools on the reconstruction of major white matter tracts. Eur J Radiol Open (2016) 3:153–61.10.1016/j.ejro.2016.06.002
    1. Lerner A, Mogensen MA, Kim PE, Shiroishi MS, Hwang DH, Law M. Clinical applications of diffusion tensor imaging. World Neurosurg (2014) 82:96–109.10.1016/j.wneu.2013.07.083
    1. Koontz NA, Wiggins RH. Differentiation of benign and malignant head and neck lesions with diffusion tensor imaging and DWI. AJR Am J Roentgenol (2017) 208:1110–5.10.2214/AJR.16.16486
    1. Tong T, Zhenwei Y, Xiaoyuan F. Transient ischemic attack and stroke can be differentiated by analyzing the diffusion tensor imaging. Korean J Radiol (2011) 12:280–8.10.3348/kjr.2011.12.3.280
    1. Kim J, Na DG, Chang K-H, Song IC, Choi SH, Son KR, et al. Serial MR analysis of early permanent and transient ischemia in rats: diffusion tensor imaging and high b value diffusion weighted imaging. Korean J Radiol (2013) 14:307–15.10.3348/kjr.2013.14.2.307
    1. Nael K, Trouard TP, Lafleur SR, Krupinski EA, Salamon N, Kidwell CS. White matter ischemic changes in hyperacute ischemic stroke. Stroke J Cereb Circ (2015) 46:413–8.10.1161/STROKEAHA.114.007000
    1. Ye C, Ma HT, Wu J, Yang P, Chen X, Yang Z, et al. DWI-based neural fingerprinting technology: a preliminary study on stroke analysis. Biomed Res Int (2014) 2014:725052.10.1155/2014/725052
    1. Cauley KA, Thangasamy S, Dundamadappa SK. Improved image quality and detection of small cerebral infarctions with diffusion-tensor trace imaging. AJR Am J Roentgenol (2013) 200:1327–33.10.2214/AJR.12.9816
    1. Ay H, Koroshetz WJ, Benner T, Vangel MG, Wu O, Schwamm LH, et al. Transient ischemic attack with infarction: a unique syndrome? Ann Neurol (2005) 57:679–86.10.1002/ana.20465
    1. Qin L, van Gelderen P, Derbyshire JA, Jin F, Lee J, de Zwart JA, et al. Prospective head-movement correction for high-resolution MRI using an in-bore optical tracking system. Magn Reson Med (2009) 62:924–34.10.1002/mrm.22076
    1. Kober T, Gruetter R, Krueger G. Prospective and retrospective motion correction in diffusion magnetic resonance imaging of the human brain. Neuroimage (2012) 59:389–98.10.1016/j.neuroimage.2011.07.004
    1. Dold C, Zaitsev M, Speck O, Firle EA, Hennig J, Sakas G. Prospective head motion compensation for MRI by updating the gradients and radio frequency during data acquisition. Med Image Comput Comput Assist Interv (2005) 8:482–9.
    1. Andre JB, Bresnahan BW, Mossa-Basha M, Hoff MN, Smith CP, Anzai Y, et al. Toward quantifying the prevalence, severity, and cost associated with patient motion during clinical MR examinations. J Am Coll Radiol (2015) 12:689–95.10.1016/j.jacr.2015.03.007
    1. Galinovic I, Puig J, Neeb L, Guibernau J, Kemmling A, Siemonsen S, et al. Visual and region of interest-based inter-rater agreement in the assessment of the diffusion-weighted imaging-fluid-attenuated inversion recovery mismatch. Stroke (2014) 45:1170–2.10.1161/STROKEAHA.113.002661
    1. Song SS, Latour LL, Ritter CH, Wu O, Tighiouart M, Hernandez DA, et al. A pragmatic approach using MRI to treat ischemic strokes of unknown onset time in a thrombolytic trial. Stroke (2012) 43:2331–5.10.1161/STROKEAHA.111.630947
    1. Windham BG, Deere B, Griswold ME, Wang W, Bezerra DC, Shibata D, et al. Small brain lesions and incident stroke and mortality: a cohort study. Ann Intern Med (2015) 163:22–31.10.7326/M14-2057
    1. Warach S. New imaging strategies for patient selection for thrombolytic and neuroprotective therapies. Neurology (2001) 57:S48–52.10.1212/WNL.57.suppl_2.S48
    1. Thomalla G, Rossbach P, Rosenkranz M, Siemonsen S, Krützelmann A, Fiehler J, et al. Negative fluid-attenuated inversion recovery imaging identifies acute ischemic stroke at 3 hours or less. Ann Neurol (2009) 65:724–32.10.1002/ana.21651
    1. Ziegler A, Ebinger M, Fiebach JB, Audebert HJ, Leistner S. Judgment of FLAIR signal change in DWI-FLAIR mismatch determination is a challenge to clinicians. J Neurol (2012) 259:971–3.10.1007/s00415-011-6284-6
    1. Makin SDJ, Doubal FN, Dennis MS, Wardlaw JM. Clinically confirmed stroke with negative diffusion-weighted imaging magnetic resonance imaging longitudinal study of clinical outcomes, stroke recurrence, and systematic review. Stroke (2015) 46:3142–8.10.1161/STROKEAHA.115.010665

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren