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Ahn SJ, Taoka T, Moon WJ, Naganawa S. Contrast-Enhanced Fluid-Attenuated Inversion Recovery in Neuroimaging: A Narrative Review on Clinical Applications and Technical Advances. J Magn Reson Imaging 2022; 56:341-353. [PMID: 35170148 DOI: 10.1002/jmri.28117] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 12/15/2022] Open
Abstract
While contrast-enhanced fluid-attenuated inversion recovery (FLAIR) has long been regarded as an adjunct sequence to evaluate leptomeningeal disease in addition to contrast-enhanced T1-weighted imaging, it is gradually being used for more diverse pathologies beyond leptomeningeal disease. Contrast-enhanced FLAIR is known to be highly sensitive to low concentrations of gadolinium within the fluid. Accordingly, recent research has suggested the potential utility of contrast-enhanced FLAIR in various kinds of disease, such as Meniere's disease, seizure, stroke, traumatic brain injury, and brain metastasis, in addition to being used for visualizing glymphatic dysfunction. However, its potential applications have been reported sporadically in an unorganized manner. Furthermore, the exact mechanism for its superior sensitivity to low concentrations of gadolinium has not been fully understood. Rapidly developing magnetic resonance technology and unoptimized parameters for FLAIR may challenge its accurate application in clinical practice. This review provides the fundamental mechanism of contrast-enhanced FLAIR, systematically describes its current and potential clinical application, and elaborates on technical considerations for its optimization. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 5.
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Affiliation(s)
- Sung Jun Ahn
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Toshiaki Taoka
- Department of Innovative Biomedical Visualization (iBMV), Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Won-Jin Moon
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, South Korea
| | - Shinji Naganawa
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Althaus K, Kasel M, Ludolph AC, Kassubek J, Kassubek R. HARM revisited: Etiology of subarachnoid hyperintensities in brain FLAIR MRI. Int J Stroke 2022; 17:1121-1128. [PMID: 34983275 DOI: 10.1177/17474930211064754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The hyperintense acute reperfusion marker (HARM) describes a phenomenon with a hyperintense signal in the subarachnoid space in Fluid-Attenuated Inversion Recovery (FLAIR) magnetic resonance imaging (MRI) sequences, presumably based on blood-brain barrier breakdown in acute stroke with reperfusion. However, this imaging phenomenon was described in other medical conditions. AIM Determination of the prevalence and associated clinical findings of this phenomenon in a large sample of patients with different neurological conditions. METHODS This is retrospective, single-center, observational study of 23,948 cerebral MRIs acquired in a Neurological University Clinic over 5 years. The prevalence of HARM, the underlying diagnosis, and damage pattern were examined by chart analysis; MRI was analyzed regarding the type of acute lesions, extent of microangiopathic lesions, and whether gadolinium-based contrast agent (GBCA) was given. RESULTS Among the MRI data, 84 images (0.35%) from 61 patients were HARM-positive without a subarachnoid signal abnormality in any other sequence. Etiologies were heterogeneous; 35 patients had a cerebrovascular disease (CVD; 19 patients received recanalization therapy), 12 patients had an inflammatory central nervous system (CNS) disease and 14 patients had epilepsy. GBCA was applied to 64% of the patients. CONCLUSION HARM was a rare radiological finding in a range of different neurological pathologies, not limited to stroke, or to previous reperfusion therapy and was not dependent on previous GBCA administration. Our data suggest that the term is too narrow in terms of the concepts of the underlying pathology. We propose to use the term FLAIR Subarachnoid Hyperintensity ("FLASH") phenomenon which might better reflect the observation that the radiological sign can be associated with a variety of central neurological conditions without a straightforward association with therapy.
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Affiliation(s)
| | - Martin Kasel
- Department of Neurology, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | | | - Jan Kassubek
- Department of Neurology, University of Ulm, Ulm, Germany
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Lee JY, Lee KM, Kim HG, Woo HG, Lee JS, Kim EJ. The Clinical Significance of the Hyperintense Acute Reperfusion Marker Sign in Subacute Infarction Patients. Diagnostics (Basel) 2021; 11:diagnostics11112161. [PMID: 34829508 PMCID: PMC8625489 DOI: 10.3390/diagnostics11112161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose: The hyperintense acute reperfusion marker (HARM) is characterized by the delayed enhancement of the subarachnoid or subpial space observed on postcontrast fluid-attenuated inversion recovery (FLAIR) images, and is considered a cerebral reperfusion marker for various brain disorders, including infarction. In this study, we evaluated the cerebral distribution patterns of HARM for discriminating between an enhancing subacute infarction and an enhancing mass located in the cortex and subcortical white matter. Materials and methods: We analyzed consecutive patients who experienced a subacute ischemic stroke, were hospitalized, and underwent conventional brain magnetic resonance imaging including postcontrast FLAIR within 14 days from symptom onset, as well as those who had lesions corresponding to a clinical sign detected by diffusion-weighted imaging and postcontrast T1-weighted imaging between May 2019 and May 2021. A total of 199 patients were included in the study. Of them, 94 were finally included in the subacute infarction group. During the same period, 76 enhancing masses located in the cortex or subcortical white matter, which were subcategorized as metastasis, malignant glioma, and lymphoma, were analyzed. We analyzed the overall incidence of HARM in subacute ischemic stroke cases, and compared the enhancement patterns between cortical infarctions and cortical masses. Results: Among 94 patients with subacute stroke, 78 patients (83%) presented HARM, and among 76 patients with subcortical masses, 48 patients (63%) presented peripheral rim enhancement. Of 170 subcortical enhancing lesions, 88 (51.8%) showed HARM, and 78 (88.6%) were determined to be subacute infarction. Among 94 patients with subacute stroke, 48 patients (51%) had diffusion restrictions, and HARM was found in 39 patients (81.2%). Of the 46 patients (49%) without diffusion restriction, 39 patients (84.8%) showed HARM. Conclusions: The presence of HARM was significantly associated with subacute infarctions. For the masses, a peripheral rim enhancement pattern was observed around the mass rather than the cerebral sulci on postcontrast FLAIR.
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Affiliation(s)
- Ji Young Lee
- Department of Medicine, Graduate School, Kyung Hee University, #23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea;
| | - Kyung Mi Lee
- Department of Radiology, College of Medicine, Kyung Hee University Hospital, Kyung Hee University, #23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea; (H.-G.K.); (E.J.K.)
- Correspondence: ; Tel.: +82-2-958-8623; Fax: +82-2-968-0787
| | - Hyug-Gi Kim
- Department of Radiology, College of Medicine, Kyung Hee University Hospital, Kyung Hee University, #23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea; (H.-G.K.); (E.J.K.)
| | - Ho-Geol Woo
- Department of Neurology, College of Medicine, Kyung Hee University Hospital, Kyung Hee University, #23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea; (H.-G.W.); (J.S.L.)
| | - Jin San Lee
- Department of Neurology, College of Medicine, Kyung Hee University Hospital, Kyung Hee University, #23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea; (H.-G.W.); (J.S.L.)
| | - Eui Jong Kim
- Department of Radiology, College of Medicine, Kyung Hee University Hospital, Kyung Hee University, #23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea; (H.-G.K.); (E.J.K.)
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4
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Wouters A, Scheldeman L, Dupont P, Cheng B, Ebinger M, Jensen M, Endres M, Gerloff C, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Boutitie F, Thijs V, Thomalla G, Fiebach J, Lemmens R. Hyperintense acute reperfusion marker associated with hemorrhagic transformation in the WAKE-UP trial. Eur Stroke J 2021; 6:128-133. [PMID: 34414287 DOI: 10.1177/23969873211007686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 03/14/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction Hyperintense acute reperfusion marker (HARM) is an indicator of early disruption of the blood-brain-barrier. Our aim was to investigate the incidence of HARM in patients with a diffusion weighted imaging (DWI) - fluid attenuated inversion recovery (FLAIR) mismatch and determine the association between this marker and hemorrhagic complications as well as clinical outcome. Patients and Methods We included patients from the Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke (WAKE-UP) trial who underwent baseline perfusion weighted imaging (PWI). HARM was defined as a hyperintense signal in the cerebrospinal fluid space on FLAIR imaging at 24 h after baseline imaging. We compared baseline characteristics in patients with and without HARM and investigated the association between HARM and any hemorrhagic transformation (HT) and parenchymal hematoma (PH) in a multivariate logistic regression. We also explored HARM as an independent predictor of poor outcome, defined as a modified Rankin Scale of 3-6 at 90 days. Results HARM was present in 14 of 223 (6%) patients with a DWI-FLAIR mismatch and baseline characteristics were similar in patients with vs without HARM. HARM showed an independent relationship with any HT (OR 6.67; 95%CI 1.72-26.58) and any PH (OR 6.92; 95%CI 1.34-29.49). The rate of HARM was similar in patients with good and poor outcome (5%, p = 0.90). Conclusion In the WAKE-UP trial, the incidence of HARM was only 6% at 24 h. An association was present between HARM and hemorrhagic complications, but no relationship with functional outcome was observed.
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Affiliation(s)
- Anke Wouters
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium.,Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Leuven, Belgium.,Laboratory of Neurobiology, Center for Brain & Disease Research, VIB, Leuven, Belgium.,Department of Neurology, University of Amsterdam, Amsterdam, the Netherlands
| | - Lauranne Scheldeman
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium.,Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Leuven, Belgium.,Laboratory of Neurobiology, Center for Brain & Disease Research, VIB, Leuven, Belgium
| | - Patrick Dupont
- Laboratory for Cognitive Neurology, Department of Neurosciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Ebinger
- Centrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Endres
- Centrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité- Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Glasgow, UK
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, Lyon, France.,Hospices Civils de Lyon, Lyon, France
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut d'Investigació Biomedica de Girona (IDIBGI), Parc Hospitalari Marti i Julia de Salt - Edifici M2, Girona, Spain
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France.,Université Lyon 1, Villeurbanne, France.,Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, CNRS, Villeurbanne, France
| | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Victoria, Australia.,Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jochen Fiebach
- Klinik und Hochschulambulanz für Neurologie, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium.,Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Leuven, Belgium.,Laboratory of Neurobiology, Center for Brain & Disease Research, VIB, Leuven, Belgium
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5
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Förster A, Ramos A, Wenz H, Böhme J, Groden C, Alonso A. GLOS and HARM in patients with transient neurovascular symptoms with and without ischemic infarction. J Neuroradiol 2021; 49:244-249. [PMID: 33836217 DOI: 10.1016/j.neurad.2021.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 03/28/2021] [Accepted: 03/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Gadolinium leakage in ocular structures (GLOS) on fluid attenuated inversion recovery images (FLAIR) is a novel imaging marker in acute ischemic stroke and other neurological disorders. METHODS In patients with transient neurovascular symptoms who underwent repeated MRI with intravenous contrast agent administration, the presence of acute ischemic lesions on diffusion-weighted images (DWI) as well as the frequency and pattern of blood-brain barrier and blood-retina barrier impairment as demonstrated by the hyperintense acute reperfusion marker (HARM) and GLOS respectively on postcontrast FLAIR were evaluated. RESULTS Overall 28 patients with transient neurovascular symptoms (median age 70.5 years; 18 (64.3%) male) were included. Follow-up MRI was performed within 35 (IQR 21-47) hours after the initial MRI. On DWI, acute ischemic lesions were observed in 22 (78.6%). On contrast-enhanced FLAIR, GLOS was observed in 12 (42.9%) patients: in 1 (3.6%) only in the anterior chamber, and in 11 (39.3%) in the anterior chamber and vitreous body. HARM was observed in 3 (10.7%) patients. In one patient without ischemic lesion on DWI or HARM on FLAIR, GLOS was observed in the anterior chamber and vitreous body. Presence of GLOS was associated with higher age (p = 0.04) and detection of HARM (p = 0.03). CONCLUSIONS In patients with transient neurovascular symptoms, GLOS is a frequent finding and associated with HARM on contrast-enhanced FLAIR. As GLOS was observed in one patient without an ischemic lesion or HARM, it might be useful as an additional imaging marker.
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Affiliation(s)
- A Förster
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany.
| | - Ana Ramos
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - H Wenz
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - J Böhme
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - C Groden
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - A Alonso
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
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Arba F, Rinaldi C, Caimano D, Vit F, Busto G, Fainardi E. Blood-Brain Barrier Disruption and Hemorrhagic Transformation in Acute Ischemic Stroke: Systematic Review and Meta-Analysis. Front Neurol 2021; 11:594613. [PMID: 33551955 PMCID: PMC7859439 DOI: 10.3389/fneur.2020.594613] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/07/2020] [Indexed: 01/17/2023] Open
Abstract
Introduction: Hemorrhagic transformation (HT) is a complication of reperfusion therapy for acute ischemic stroke. Blood–brain barrier (BBB) disruption is a crucial step toward HT; however, in clinical studies, there is still uncertainty about this relation. Hence, we conducted a systematic review and meta-analysis to summarize the current evidence. Methods: We performed systematic review and meta-analysis of observational studies from January 1990 to March 2020 about the relation between BBB disruption and HT in patients with acute ischemic stroke with both computed tomography (CT) and magnetic resonance (MR) assessment of BBB. The outcome of interest was HT at follow-up imaging evaluation (within 48 h from symptom onset). We pooled data from available univariate odds ratios (ORs) in random-effects models with DerSimonian–Laird weights and extracted cumulative ORs. Results: We included 30 eligible studies (14 with CT and 16 with MR), N = 2,609 patients, with 88% and 70% of patients included in CT and MR studies treated with acute stroke therapy, respectively. The majority of studies were retrospective and had high or unclear risk of bias. BBB disruption was measured with consistent methodology in CT studies, whereas in MR studies, there was more variability. All CT studies provided a BBB disruption cutoff predictive of HT. Four CT and 10 MR studies were included in the quantitative analysis. We found that BBB disruption was associated with HT with both CT (OR = 3.42; 95%CI = 1.62–7.23) and MR (OR = 9.34; 95%CI = 3.16–27.59). There was a likely publication bias particularly for MR studies. Conclusion: Our results confirm that BBB disruption is associated with HT in both CT and MR studies. Compared with MR, CT has been more uniformly applied in the literature and has resulted in more consistent results. However, more efforts are needed for harmonization of protocols and methodology for implementation of BBB disruption as a neuroradiological marker in clinical practice.
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Affiliation(s)
| | - Chiara Rinaldi
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Danilo Caimano
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Federica Vit
- NEUROFARBA Department, University of Florence, Florence, Italy
| | | | - Enrico Fainardi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Bernardo-Castro S, Sousa JA, Brás A, Cecília C, Rodrigues B, Almendra L, Machado C, Santo G, Silva F, Ferreira L, Santana I, Sargento-Freitas J. Pathophysiology of Blood-Brain Barrier Permeability Throughout the Different Stages of Ischemic Stroke and Its Implication on Hemorrhagic Transformation and Recovery. Front Neurol 2020; 11:594672. [PMID: 33362697 PMCID: PMC7756029 DOI: 10.3389/fneur.2020.594672] [Citation(s) in RCA: 190] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/09/2020] [Indexed: 12/25/2022] Open
Abstract
The blood-brain barrier (BBB) is a dynamic interface responsible for maintaining the central nervous system homeostasis. Its unique characteristics allow protecting the brain from unwanted compounds, but its impairment is involved in a vast number of pathological conditions. Disruption of the BBB and increase in its permeability are key in the development of several neurological diseases and have been extensively studied in stroke. Ischemic stroke is the most prevalent type of stroke and is characterized by a myriad of pathological events triggered by an arterial occlusion that can eventually lead to fatal outcomes such as hemorrhagic transformation (HT). BBB permeability seems to follow a multiphasic pattern throughout the different stroke stages that have been associated with distinct biological substrates. In the hyperacute stage, sudden hypoxia damages the BBB, leading to cytotoxic edema and increased permeability; in the acute stage, the neuroinflammatory response aggravates the BBB injury, leading to higher permeability and a consequent risk of HT that can be motivated by reperfusion therapy; in the subacute stage (1-3 weeks), repair mechanisms take place, especially neoangiogenesis. Immature vessels show leaky BBB, but this permeability has been associated with improved clinical recovery. In the chronic stage (>6 weeks), an increase of BBB restoration factors leads the barrier to start decreasing its permeability. Nonetheless, permeability will persist to some degree several weeks after injury. Understanding the mechanisms behind BBB dysregulation and HT pathophysiology could potentially help guide acute stroke care decisions and the development of new therapeutic targets; however, effective translation into clinical practice is still lacking. In this review, we will address the different pathological and physiological repair mechanisms involved in BBB permeability through the different stages of ischemic stroke and their role in the development of HT and stroke recovery.
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Affiliation(s)
| | - João André Sousa
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Ana Brás
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Carla Cecília
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Bruno Rodrigues
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Luciano Almendra
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Cristina Machado
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Gustavo Santo
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Fernando Silva
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Lino Ferreira
- Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - Isabel Santana
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - João Sargento-Freitas
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
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Freeze WM, van der Thiel M, de Bresser J, Klijn CJM, van Etten ES, Jansen JFA, van der Weerd L, Jacobs HIL, Backes WH, van Veluw SJ. CSF enhancement on post-contrast fluid-attenuated inversion recovery images; a systematic review. NEUROIMAGE-CLINICAL 2020; 28:102456. [PMID: 33053497 PMCID: PMC7559862 DOI: 10.1016/j.nicl.2020.102456] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/20/2020] [Accepted: 09/26/2020] [Indexed: 11/26/2022]
Abstract
CSF enhancement on post-contrast FLAIR images is a novel marker for BBB leakage. This neuroradiological marker is frequently observed in neurological diseases. Post-contrast FLAIR CSF enhancement is associated with higher age and brain atrophy. There is large methodological heterogeneity between studies that use this technique. We provide recommendations for future methodological standardization.
Cerebrospinal fluid (CSF) enhancement on T2-weighted post-contrast fluid-attenuated inversion recovery (pcT2wFLAIR) images is a relatively unknown neuroradiological marker for gadolinium-based contrast agent extravasation due to blood–brain barrier (BBB) disruption. We systematically reviewed human studies reporting on CSF enhancement on pcT2wFLAIR images to provide a comprehensive overview of prevalence of this new biomarker in healthy and diseased populations as well as its etiology and optimal detection methodology. We extracted information on the prevalence of CSF enhancement, its vascular risk factor and neuroimaging correlates, and methodological attributes of each study. Forty-four eligible studies were identified. By pooling data, we found that the prevalence of CSF enhancement was 82% (95% confidence interval (CI) 80–89) in meningitis (4 studies, 65 patients), 73% (95%CI 62–81) in cases with (post-) acute intracerebral hemorrhage (2 studies, 77 cases), 64% (95% CI 54–73) in cases who underwent surgery for aneurysm treatment (2 studies, 99 patients), 40% (95% CI 30–51) in cases who underwent surgery for carotid artery disease treatment (3 studies, 76 patients), 27% (95% CI 25–30) in cases with acute ischemic stroke (9 studies, 1148 patients), 21% (95% CI 17–23) in multiple sclerosis (6 studies, 897 patients), and 13% (95% CI 7–21) in adult controls (4 studies, 112 cases). Presence of CSF enhancement was associated with higher age in eleven studies, with lobar cerebral microbleeds in one study, and with cerebral atrophy in four studies. PcT2wFLAIR imaging represents a promising method that can provide novel perspectives on BBB leakage into CSF compartments, with the potential to reveal important new insights into the pathophysiological mechanisms of varying neurological diseases.
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Affiliation(s)
- Whitney M Freeze
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Neuropsychology and Psychiatry, Alzheimer Center Limburg, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Merel van der Thiel
- Department of Neuropsychology and Psychiatry, Alzheimer Center Limburg, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands; Department of Radiology and Nuclear Medicine, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Ellis S van Etten
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jacobus F A Jansen
- Department of Radiology and Nuclear Medicine, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Louise van der Weerd
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Human Genetics, Leiden University Medical Center, Leiden, the Netherlands
| | - Heidi I L Jacobs
- Department of Neuropsychology and Psychiatry, Alzheimer Center Limburg, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands; Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Walter H Backes
- Department of Radiology and Nuclear Medicine, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Susanne J van Veluw
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Neurology, J. Philip Kistler Stroke Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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9
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Förster A, Wenz H, Böhme J, Groden C, Alonso A. Asymmetrical Gadolinium Leakage in Ocular Structures in Stroke Due to Internal Carotid Artery Stenosis or Occlusion. Clin Neuroradiol 2018; 30:221-228. [DOI: 10.1007/s00062-018-0754-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/05/2018] [Indexed: 01/20/2023]
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10
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Nadareishvili Z, Luby M, Leigh R, Shah J, Lynch JK, Hsia AW, Benson RT, Latour LL. An MRI Hyperintense Acute Reperfusion Marker Is Related to Elevated Peripheral Monocyte Count in Acute Ischemic Stroke. J Neuroimaging 2018; 28:57-60. [PMID: 28722240 PMCID: PMC5760433 DOI: 10.1111/jon.12462] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/04/2017] [Accepted: 07/05/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND AND PURPOSE Blood-brain barrier (BBB) disruption detected on magnetic resonance imaging (MRI) in acute ischemic stroke as a hyperintense acute reperfusion marker (HARM) is associated with upregulation of matrix metalloproteinase-9 (MMP-9). Although activated leukocytes, including monocytes, are the main source of MMPs, limited data exist to support relationship between leukocyte activation and BBB disruption in patients with acute ischemic stroke. The goal of this study is to investigate the relationship between neutrophils, lymphocytes, and monocytes with BBB disruption detected as HARM (+) in patients with acute ischemic stroke. METHODS We conducted a retrospective analysis of prospectively collected data in patients who did not receive any reperfusion therapy with acute (<12 hours) ischemic stroke. MRI scans were obtained at baseline, 24 hours, and 5 days. HARM was evaluated on the 24-hour follow-up scan. RESULTS Thirty-three patients were studied. HARM was detected in 27% of patients. Median volumes of baseline perfusion (mean transit time [MTT]) deficit (219.4 mL vs. 158.4 mL, P = .029) and DWI infarct growth at 24 hours (18.50 mL vs. .14 mL, P = .017), as well as the median absolute numbers (1 × 103 /mm3 ) of monocytes, were significantly higher in HARM (+) versus HARM (-) patients (0.9 vs. 0.6, p = 0.011). CONCLUSION Increased monocyte count associated with HARM supports importance of systemic inflammation in BBB disruption in acute ischemic stroke.
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Affiliation(s)
- Zurab Nadareishvili
- Section on Stroke Diagnostics and Therapeutics, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
- Suburban Hospital NIH Stroke Center, Johns Hopkins Medicine, Bethesda, MD
| | - Marie Luby
- Section on Stroke Diagnostics and Therapeutics, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Richard Leigh
- Section on Stroke Diagnostics and Therapeutics, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Jignesh Shah
- Section on Stroke Diagnostics and Therapeutics, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
- Department of Neurology, University of Louisville, Louisville, KY
| | - John K Lynch
- Section on Stroke Diagnostics and Therapeutics, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Amie W Hsia
- Section on Stroke Diagnostics and Therapeutics, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
- Medstar Washington Hospital Stroke Center, Washington, DC
| | - Richard T Benson
- Section on Stroke Diagnostics and Therapeutics, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
- Medstar Washington Hospital Stroke Center, Washington, DC
| | - Lawrence L Latour
- Section on Stroke Diagnostics and Therapeutics, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
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Choi HY, Lee KM, Kim HG, Kim EJ, Choi WS, Kim BJ, Heo SH, Chang DI. Role of Hyperintense Acute Reperfusion Marker for Classifying the Stroke Etiology. Front Neurol 2017; 8:630. [PMID: 29276498 PMCID: PMC5727375 DOI: 10.3389/fneur.2017.00630] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 11/13/2017] [Indexed: 02/04/2023] Open
Abstract
Purpose The hyperintense acute reperfusion marker (HARM) is a delayed enhancement of the subarachnoid or subpial space observed on post-contrast fluid-attenuated inversion recovery (FLAIR) images and is associated with permeability changes to the blood–brain barrier in acute stroke. We investigated the relationship between HARM and stroke etiology based on the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification. In addition, we evaluated the relationship between HARM and stroke locations with respect to vascular territories and anatomic compartments. Materials and methods We recruited 264 consecutive patients (109 women; mean age 68.63 years) who were diagnosed with acute ischemic stroke and underwent brain magnetic resonance imaging (MRI) including post-contrast FLAIR and DWI within 7 days of symptom onset from May 2015 to March 2016 for this retrospective study. Post-contrast FLAIR images were obtained 5 min after gadolinium administration. The mean time interval between the onset of stroke symptoms and MRI acquisition in total included patients was 18 h and 7 min (median 12 h and 57 min, range 2–127 h). We analyzed the overall incidence and distribution patterns of HARM in acute ischemic stroke cases and compared the relative incidence and distribution patterns of HARM between the subgroups of stroke etiology based on conventional TOAST classification. We obtained odds ratio (OR) of HARM in different stroke locations based on vascular territories and anatomical compartments. This study was approved by our institutional review board. Results Among the 264 patients, 67 (25.38%) patients were HARM positive and 197 (74.62%) patients were HARM negative. There was significant difference in HARM incidence among the stroke subgroups (p < 0.001). Small vessel occlusion (SVO) was associated with the HARM-negative group (p < 0.001), while large artery atherosclerosis (LAA) and cardioembolism (CE) were associated with the HARM-positive group (p = 0.001). Also, regional pattern of HARM on the same vascular territory as the acute infarction was dominantly demonstrated regardless of stroke etiology. The OR for HARM from middle cerebral artery (MCA) infarction was 1.868 [95% confidence interval (CI): 1.025–3.401]. The OR for HARM from cortical infarction was 9.475 (95% CI: 4.754–18.883) compared to other anatomic compartments. Conclusion The presence of the HARM was significantly associated with embolic infarctions including LAA and CE. Conversely, SVO was exclusively associated with the absence of the HARM. Second, MCA and cortical infarction showed a more pronounced HARM compared to infarctions at other vascular territories and anatomic compartments. According to the results in the current study, we speculate that the presence of HARM on post-contrast FLAIR images was associated with specific stroke causes especially in embolic causes.
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Affiliation(s)
- Hee Young Choi
- Department of Radiology, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul, South Korea
| | - Kyung Mi Lee
- Department of Radiology, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul, South Korea
| | - Hyug-Gi Kim
- Department of Radiology, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul, South Korea
| | - Eui Jong Kim
- Department of Radiology, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul, South Korea
| | - Woo Suk Choi
- Department of Radiology, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul, South Korea
| | - Bum Joon Kim
- Department of Neurology, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul, South Korea
| | - Sung Hyuk Heo
- Department of Neurology, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul, South Korea
| | - Dae-Il Chang
- Department of Neurology, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul, South Korea
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12
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Bouts MJ, Tiebosch IA, Rudrapatna US, van der Toorn A, Wu O, Dijkhuizen RM. Prediction of hemorrhagic transformation after experimental ischemic stroke using MRI-based algorithms. J Cereb Blood Flow Metab 2017; 37:3065-3076. [PMID: 28155583 PMCID: PMC5536810 DOI: 10.1177/0271678x16683692] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Estimation of hemorrhagic transformation (HT) risk is crucial for treatment decision-making after acute ischemic stroke. We aimed to determine the accuracy of multiparametric MRI-based predictive algorithms in calculating probability of HT after stroke. Spontaneously, hypertensive rats were subjected to embolic stroke and, after 3 h treated with tissue plasminogen activator (Group I: n = 6) or vehicle (Group II: n = 7). Brain MRI measurements of T2, T2*, diffusion, perfusion, and blood-brain barrier permeability were obtained at 2, 24, and 168 h post-stroke. Generalized linear model and random forest (RF) predictive algorithms were developed to calculate the probability of HT and infarction from acute MRI data. Validation against seven-day outcome on MRI and histology revealed that highest accuracy of hemorrhage prediction was achieved with a RF-based model that included spatial brain features (Group I: area under the receiver-operating characteristic curve (AUC) = 0.85 ± 0.14; Group II: AUC = 0.89 ± 0.09), with significant improvement over perfusion- or permeability-based thresholding methods. However, overlap between predicted and actual tissue outcome was significantly lower for hemorrhage prediction models (maximum Dice's Similarity Index (DSI) = 0.20 ± 0.06) than for infarct prediction models (maximum DSI = 0.81 ± 0.06). Multiparametric MRI-based predictive algorithms enable early identification of post-ischemic tissue at risk of HT and may contribute to improved treatment decision-making after acute ischemic stroke.
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Affiliation(s)
- Mark Jrj Bouts
- 1 Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands.,2 Athinoula A Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA.,3 Leiden Institute for Brain and Cognition, Institute of Psychology, Leiden University, Leiden, The Netherlands.,4 Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ivo Acw Tiebosch
- 1 Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Umesh S Rudrapatna
- 1 Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Annette van der Toorn
- 1 Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ona Wu
- 2 Athinoula A Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Rick M Dijkhuizen
- 1 Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
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13
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Villringer K, Sanz Cuesta BE, Ostwaldt AC, Grittner U, Brunecker P, Khalil AA, Schindler K, Eisenblätter O, Audebert H, Fiebach JB. DCE-MRI blood–brain barrier assessment in acute ischemic stroke. Neurology 2016; 88:433-440. [DOI: 10.1212/wnl.0000000000003566] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 10/31/2016] [Indexed: 02/05/2023] Open
Abstract
Objective:To quantitatively evaluate blood–brain barrier changes in ischemic stroke patients using dynamic contrast-enhanced (DCE) MRI.Methods:We examined 54 stroke patients (clinicaltrials.govNCT00715533, NCT02077582) in a 3T MRI scanner within 48 hours after symptom onset. Twenty-eight patients had a follow-up examination on day 5–7. DCE T1 mapping and Patlak analysis were employed to assess BBB permeability changes.Results:Median stroke Ktrans values (0.7 × 10−3 min−1 [interquartile range (IQR) 0.4–1.8] × 10−3 min−1) were more than 3-fold higher compared to median mirror Ktrans values (0.2 × 10−3 min−1, IQR 0.1–0.7 × 10−3 min−1, p < 0.001) and further increased at follow-up (n = 28, 2.3 × 10−3 min−1, IQR 0.8–4.6 × 10−3 min−1, p < 0.001). By contrast, mirror Ktrans values decreased over time with a clear interaction of timepoint and stroke/mirror side (p < 0.001). Median stroke Ktrans values were 2.5 times lower than in hemorrhagic transformed regions (0.7 vs 1.8 × 10−3 min−1; p = 0.055). There was no association between stroke Ktrans values and the delay from symptom onset to baseline examination, age, and presence of hyperintense acute reperfusion marker.Conclusion:BBB in acute stroke patients can be successfully assessed quantitatively. The decrease of BBB permeability in unaffected regions at follow-up may be an indicator of global BBB leakage even in vessel territories remote from the index infarct.
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14
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Simpkins AN, Dias C, Leigh R. Identification of Reversible Disruption of the Human Blood-Brain Barrier Following Acute Ischemia. Stroke 2016; 47:2405-8. [PMID: 27462115 DOI: 10.1161/strokeaha.116.013805] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 06/28/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Animal models of acute cerebral ischemia have demonstrated that diffuse blood-brain barrier (BBB) disruption can be reversible after early reperfusion. However, irreversible, focal BBB disruption in humans is associated with hemorrhagic transformation in patients receiving intravenous thrombolytic therapy. The goal of this study was to use a magnetic resonance imaging biomarker of BBB permeability to differentiate these 2 forms of BBB disruption. METHODS Acute stroke patients imaged with magnetic resonance imaging before, 2 hours after, and 24 hours after treatment with intravenous tissue-type plasminogen activator were included. The average BBB permeability of the acute ischemic region before and 2 hours after treatment was calculated using a T2* perfusion-weighted source images. Change in average permeability was compared with percent reperfusion using linear regression. Focal regions of maximal BBB permeability from the pretreatment magnetic resonance imaging were compared with the occurrence of parenchymal hematoma (PH) formation on the 24-hour magnetic resonance imaging scan using logistic regression. RESULTS Signals indicating reversible BBB permeability were detected in 18/36 patients. Change in average BBB permeability correlated inversely with percent reperfusion (P=0.006), indicating that early reperfusion is associated with decreased BBB permeability, whereas sustained ischemia is associated with increased BBB disruption. Focal regions of maximal BBB permeability were significantly associated with subsequent formation of PH (P=0.013). CONCLUSIONS This study demonstrates that diffuse, mild BBB disruption in the acutely ischemic human brain is reversible with reperfusion. This study also confirms prior findings that focal severe BBB disruption confers an increased risk of hemorrhagic transformation in patients treated with intravenous tissue-type plasminogen activator.
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Affiliation(s)
- Alexis N Simpkins
- From the Neuro Vascular Brain Imaging Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Christian Dias
- From the Neuro Vascular Brain Imaging Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Richard Leigh
- From the Neuro Vascular Brain Imaging Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD.
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15
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Förster A, Wenz H, Böhme J, Al-Zghloul M, Groden C. Hyperintense Acute Reperfusion Marker on FLAIR in Posterior Circulation Infarction. PLoS One 2016; 11:e0157738. [PMID: 27326459 PMCID: PMC4915711 DOI: 10.1371/journal.pone.0157738] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 06/05/2016] [Indexed: 11/19/2022] Open
Abstract
Purpose In the present study, we aimed to investigate the frequency of blood brain barrier injury in posterior circulation infarction as demonstrated by the hyperintense acute reperfusion marker (HARM) on fluid attenuated inversion recovery images (FLAIR). Methods From a MRI report database we identified patients with posterior circulation infarction who underwent MRI, including perfusion-weighted images (PWI), within 12 hours after onset and follow-up MRI within 24 hours and analyzed diffusion-weighted images (DWI), PWI, FLAIR, and MR angiography (MRA). On FLAIR images, the presence of HARM was noted by using pre-specified criteria (focal enhancement in the subarachnoid space and/or the ventricles). Results Overall 16 patients (median age of patients 68.5 (IQR 55.5–82.75) years) with posterior circulation infarction were included. Of these, 13 (81.3%) demonstrated PCA occlusion, and 3 (18.7%) patients BA occlusion on MRA. Initial DWI demonstrated ischemic lesions in the thalamus (68.8%), splenium (18.8%), hippocampus (75%), occipital lobe (81.3%), mesencephalon (18.8%), pons (18.8%), and cerebellum (50%). On follow-up MRA recanalization was noted in 10 (62.5%) patients. On follow-up FLAIR images, HARM was observed in 8 (50%) patients. In all of these, HARM was detected remote from the acute ischemic lesion. HARM was more frequently observed in patients with vessel recanalization (p = 0.04), minor infarction growth (p = 0.01), and smaller ischemic lesions on follow-up DWI (p = 0.05). Conclusions HARM is a frequent finding in posterior circulation infarction and associated with vessel recanalization, minor infarction growth as well as smaller infarction volumes in the course. Neuroradiologists should be cognizant of the fact that HARM may be present on short interval follow-up FLAIR images in patients with acute ischemic infarction who initially underwent MRI and received intravenous gadolinium-based contrast agents.
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Affiliation(s)
- Alex Förster
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
- * E-mail:
| | - Holger Wenz
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Johannes Böhme
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Mansour Al-Zghloul
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christoph Groden
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
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16
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Hyperintense Acute Reperfusion Marker on FLAIR in a Patient with Transient Ischemic Attack. Case Rep Radiol 2016; 2016:9829823. [PMID: 27127673 PMCID: PMC4834154 DOI: 10.1155/2016/9829823] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/28/2016] [Indexed: 11/17/2022] Open
Abstract
The hyperintense acute reperfusion marker (HARM) has initially been described in acute ischemic stroke. The phenomenon is caused by blood-brain barrier disruption following acute reperfusion and consecutive delayed gadolinium enhancement in the subarachnoid space on fluid attenuated inversion recovery (FLAIR) images. Here we report the case of an 80-year-old man who presented with transient paresis and sensory loss in the right arm. Initial routine stroke MRI including diffusion- and perfusion-weighted imaging demonstrated no acute pathology. Follow-up MRI after three hours demonstrated subarachnoid gadolinium enhancement in the left middle cerebral artery territory consistent with HARM that completely resolved on follow-up MRI three days later. This case illustrates that even in transient ischemic attack patients disturbances of the blood-brain barrier may be present which significantly exceed the extent of acute ischemic lesions on diffusion-weighted imaging. Inclusion of FLAIR images with delayed acquisition after intravenous contrast agent application in MRI stroke protocols might facilitate the diagnosis of a recent acute ischemic stroke.
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17
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Early Stage of Hyperintense Acute Reperfusion Marker on Contrast-Enhanced FLAIR Images in Patients With Acute Stroke. AJR Am J Roentgenol 2016; 206:1272-5. [PMID: 27010867 DOI: 10.2214/ajr.15.14857] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Hyperintense acute reperfusion marker (HARM) is defined as delayed CSF enhancement on FLAIR images in patients with acute stroke and was observed in follow-up FLAIR images after initial MRI with contrast material administration. We hypothesized that different imaging findings of HARM could be present depending on the timing of FLAIR imaging after contrast material administration. SUBJECTS AND METHODS Of 218 consecutive patients with acute stroke or transient ischemic attack over 3 months, 12 with linear contrast enhancement on the cortical surface in initial FLAIR images underwent serial FLAIR imaging. Initial FLAIR images were obtained 5 minutes after contrast material administration, and follow-up unenhanced FLAIR images were obtained 2.5-29 hours (mean, 13.2 hours) after initial FLAIR imaging. The enhancement patterns between initial and follow-up FLAIR images were compared. RESULTS In all 12 patients, initial contrast-enhanced FLAIR images showed focal or multifocal linear contrast enhancement along the cortical surface near acute infarctions. On follow-up unenhanced FLAIR images, initial cortical enhancement spread diffusely and filled the subarachnoid space. CONCLUSION HARM in acute stroke can be detected earlier than previously reported on initial contrast-enhanced FLAIR images. Different imaging findings of HARM depend on the timing of FLAIR imaging after contrast material administration.
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18
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Lee EK, Lee EJ, Kim S, Lee YS. Importance of Contrast-Enhanced Fluid-Attenuated Inversion Recovery Magnetic Resonance Imaging in Various Intracranial Pathologic Conditions. Korean J Radiol 2016; 17:127-41. [PMID: 26798225 PMCID: PMC4720800 DOI: 10.3348/kjr.2016.17.1.127] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 10/29/2015] [Indexed: 11/30/2022] Open
Abstract
Intracranial lesions may show contrast enhancement through various mechanisms that are closely associated with the disease process. The preferred magnetic resonance sequence in contrast imaging is T1-weighted imaging (T1WI) at most institutions. However, lesion enhancement is occasionally inconspicuous on T1WI. Although fluid-attenuated inversion recovery (FLAIR) sequences are commonly considered as T2-weighted imaging with dark cerebrospinal fluid, they also show mild T1-weighted contrast, which is responsible for the contrast enhancement. For several years, FLAIR imaging has been successfully incorporated as a routine sequence at our institution for contrast-enhanced (CE) brain imaging in detecting various intracranial diseases. In this pictorial essay, we describe and illustrate the diagnostic importance of CE-FLAIR imaging in various intracranial pathologic conditions.
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Affiliation(s)
- Eun Kyoung Lee
- Department of Radiology, Dongguk University Ilsan Hospital, Goyang 10326, Korea.; Department of Radiology, College of Medicine, Kangwon National University, Chuncheon 24289, Korea
| | - Eun Ja Lee
- Department of Radiology, Dongguk University Ilsan Hospital, Goyang 10326, Korea
| | - Sungwon Kim
- Department of Radiology, Dongguk University Ilsan Hospital, Goyang 10326, Korea
| | - Yong Seok Lee
- Department of Radiology, Dongguk University Ilsan Hospital, Goyang 10326, Korea
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19
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Lee H, Kim E, Lee KM, Kim JH, Bae YJ, Choi BS, Jung C. Clinical Implications of Sulcal Enhancement on Postcontrast Fluid Attenuated Inversion Recovery Images in Patients with Acute Stroke Symptoms. Korean J Radiol 2015; 16:906-13. [PMID: 26175592 PMCID: PMC4499557 DOI: 10.3348/kjr.2015.16.4.906] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 04/13/2015] [Indexed: 11/24/2022] Open
Abstract
Objective Hyperintense acute reperfusion marker (HARM) without diffusion abnormalities is occasionally found in patients with an acute stroke. This study was to determine the prevalence and clinical implications of HARM without diffusion abnormalities. Materials and Methods There was a retrospective review of magnetic resonance images 578 patients with acute strokes and identified those who did not have acute infarction lesions, as mapped by diffusion-weighted imaging (DWI). These patients were classified into an imaging-negative stroke and HARM without diffusion abnormalities groups, based on the DWI findings and postcontrast fluid attenuated inversion recovery images. The National Institutes of Health Stroke Scale (NIHSS) scores at admission, 1 day, and 7 days after the event, as well as clinical data and risk factors, were compared between the imaging-negative stroke and HARM without diffusion abnormalities groups. Results Seventy-seven acute stroke patients without any DWI abnormalities were found. There were 63 patients with an imaging-negative stroke (accounting for 10.9% of 578) and 13 patients with HARM without diffusion abnormalities (accounting for 2.4% of 578). The NIHSS scores at admission were higher in HARM without diffusion abnormalities group than in the imaging-negative stroke group (median, 4.5 vs. 1.0; p < 0.001), but the scores at 7 days after the event were not significantly different between the two groups (median, 0 vs. 0; p = 1). The patients with HARM without diffusion abnormalities were significantly older, compared with patients with an imaging-negative stroke (mean, 73.1 years vs. 55.9 years; p < 0.001). Conclusion Patients with HARM without diffusion abnormalities are older and have similarly favorable short-term neurological outcomes, compared with the patients with imaging-negative stroke.
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Affiliation(s)
- Hyukjoon Lee
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 463-707, Korea
| | - Eunhee Kim
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 463-707, Korea
| | - Kyung Mi Lee
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 463-707, Korea. ; Department of Radiology, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul 130-701, Korea
| | - Jae Hyoung Kim
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 463-707, Korea
| | - Yun Jung Bae
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 463-707, Korea
| | - Byoung Se Choi
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 463-707, Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 463-707, Korea
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20
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Ostwaldt AC, Rozanski M, Schaefer T, Ebinger M, Jungehülsing GJ, Villringer K, Fiebach JB. Hyperintense acute reperfusion marker is associated with higher contrast agent dosage in acute ischaemic stroke. Eur Radiol 2015; 25:3161-6. [PMID: 25899419 DOI: 10.1007/s00330-015-3749-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/04/2015] [Accepted: 03/27/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The hyperintense acute reperfusion marker (HARM) on fluid-attenuated inversion recovery (FLAIR) images is associated with blood-brain barrier (BBB) permeability changes. The aim of this study was to examine the influence of contrast agent dosage on HARM incidence in acute ischaemic stroke patients. METHODS We prospectively included 529 acute ischaemic stroke patients (204 females, median age 71 years). Patients underwent a first stroke-MRI within 24 hours from symptom onset and had a follow-up on day 2. The contrast agent Gadobutrol was administered to the patients for perfusion imaging or MR angiography. The total dosage was calculated as ml/kg body weight and ranged between 0.04 and 0.31 mmol/kg on the first examination. The incidence of HARM was evaluated on day 2 FLAIR images. RESULTS HARM was detected in 97 patients (18.3%). HARM incidence increased significantly with increasing dosages of Gadobutrol. Also, HARM positive patients were significantly older. HARM was not an independent predictor of worse clinical outcome, and we did not find an association with increase risk of haemorrhagic transformation. CONCLUSIONS A higher dosage of Gadobutrol in acute stroke patients on initial MRI is associated with increased HARM incidence on follow-up. MRI studies on BBB should therefore standardize contrast agent dosages. KEY POINTS • Hyperintense acute reperfusion marker on MRI indicates blood-brain barrier disruption. • This observational study on stroke patients characterizes HARM. • Incidence depends on contrast agent dosage on the previous day. • HARM is also associated with older age and poor kidney function. • Interpretation of HARM must take dosage into consideration.
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Affiliation(s)
- Ann-Christin Ostwaldt
- Academic Neuroradiology, Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.
| | - Michal Rozanski
- Academic Neuroradiology, Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.,Department of Neurology, Charité Universitätsmedizin, Charitéplatz 1, 10117, Berlin, Germany
| | - Tabea Schaefer
- Academic Neuroradiology, Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Martin Ebinger
- Academic Neuroradiology, Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.,Department of Neurology, Charité Universitätsmedizin, Charitéplatz 1, 10117, Berlin, Germany
| | - Gerhard J Jungehülsing
- Jüdisches Krankenhaus Berlin, Stiftung des Bürgerlichen Rechts, Heinz-Galinski-Straße 1, 13347, Berlin, Germany
| | - Kersten Villringer
- Academic Neuroradiology, Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Jochen B Fiebach
- Academic Neuroradiology, Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
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Kau T, Hauser M, Obmann SM, Niedermayer M, Weber JR, Hausegger KA. Flat detector angio-CT following intra-arterial therapy of acute ischemic stroke: identification of hemorrhage and distinction from contrast accumulation due to blood-brain barrier disruption. AJNR Am J Neuroradiol 2014; 35:1759-64. [PMID: 24948498 DOI: 10.3174/ajnr.a4021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flat panel detector CT in the angiography suite may be valuable for the detection of intracranial hematomas; however, abnormal contrast enhancement frequently mimics hemorrhage. We aimed to assess the accuracy of flat panel detector CT in detecting/excluding intracranial bleeding after endovascular stroke therapy and whether it was able to reliably differentiate hemorrhage from early blood-brain barrier disruption. MATERIALS AND METHODS Seventy-three patients were included for retrospective evaluation following endovascular stroke therapy: 32 after stent-assisted thrombectomy, 14 after intra-arterial thrombolysis, and 27 after a combination of both. Flat panel CT images were assessed for image quality and the presence and type of intracranial hemorrhage and BBB disruption by 2 readers separately and in consensus. Follow-up by multisection head CT, serving as the reference standard, was evaluated by a single reader. RESULTS Conventional head CT revealed intracranial hematomas in 12 patients (8 subarachnoid hemorrhages, 7 cases of intracerebral bleeding, 3 SAHs plus intracerebral bleeding). Image quality of flat panel detector CT was considered sufficient in all cases supratentorially and in 92% in the posterior fossa. Regarding detection or exclusion of intracranial hemorrhage, flat panel detector CT reached a sensitivity, specificity, positive and negative predictive values, and accuracy of 58%, 85%, 44%, 91%, and 81%, respectively. Maximum attenuation measurements were not valuable for the differentiation of hemorrhage and BBB disruption. CONCLUSIONS Flat panel CT after endovascular stroke treatment was able to exclude the rare event of an intracranial hemorrhage with a high negative predictive value. Future studies should evaluate the predictive value of BBB disruptions in flat panel detector CT for the development of relevant hematomas.
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Affiliation(s)
- T Kau
- From the Institute of Diagnostic and Interventional Radiology (T.K., M.H., M.N., K.A.H.)
| | - M Hauser
- From the Institute of Diagnostic and Interventional Radiology (T.K., M.H., M.N., K.A.H.)
| | - S M Obmann
- Department of Neurology (S.M.O., J.R.W.), Klinikum Klagenfurt, Klagenfurt, Austria
| | - M Niedermayer
- From the Institute of Diagnostic and Interventional Radiology (T.K., M.H., M.N., K.A.H.)
| | - J R Weber
- Department of Neurology (S.M.O., J.R.W.), Klinikum Klagenfurt, Klagenfurt, Austria
| | - K A Hausegger
- From the Institute of Diagnostic and Interventional Radiology (T.K., M.H., M.N., K.A.H.)
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22
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Ostwaldt AC, Rozanski M, Schmidt WU, Nolte CH, Hotter B, Jungehuelsing GJ, Villringer K, Fiebach JB. Early time course of FLAIR signal intensity differs between acute ischemic stroke patients with and without hyperintense acute reperfusion marker. Cerebrovasc Dis 2014; 37:141-6. [PMID: 24481492 DOI: 10.1159/000357422] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 11/19/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In animal models of stroke, the time course of blood-brain barrier (BBB) disruptions has been elaborately studied. In human patients, leakage of gadolinium into cerebrospinal fluid (CSF) space, visualized on MRI fluid attenuated inversion recovery (FLAIR) images, is considered a sign of BBB disruptions. It was termed 'hyperintense acute reperfusion marker' (HARM) and was associated with hemorrhages. However, the time course of the leakage is unknown and difficult to study in human patients. Also, the association of HARM with signal intensities and enhancement in the parenchyma on FLAIR images has not been thoroughly researched. METHODS We analyzed imaging data of acute ischemic stroke patients who underwent repetitive MRI examinations within the first 36 h after the time of symptom onset. HARM was evaluated on FLAIR images. Regions of interest (ROI) of the hyperintensities on diffusion-weighted imaging (DWI) were determined for each time point and mirrored to the contralateral side. The ROI were furthermore corrected for CSF-filled space, using apparent diffusion coefficient (ADC) images. The corrected ROI were used to determine mean signal intensities of the lesions relative to the contralateral side on FLAIR, ADC and B0 images for each time point. RESULTS The 18 included patients (5 females; median age: 69 years; median NIHSS score: 5) received 3-5 MRI examinations on the first day and 1-2 examinations on day 2 after stroke. Eight of the patients (44.4%) showed HARM on at least 1 examination. In 6 of these patients, HARM was already seen at the second examination, at the earliest 3.5 h after symptom onset. The HARM-positive patients had higher relative signal intensities (rSI) on FLAIR images in the parenchyma corresponding to the DWI-positive tissue compared with the HARM-negative patients. This difference between groups was statistically significant for the 2nd and 3rd examination (medians of 4.31 and 6.37 h from symptom onset, p < 0.001 and p = 0.005, respectively). No significant difference in rSI between groups was seen for ADC or B0 images. CONCLUSION HARM does not only represent a contrast medium leakage from the pial system into the CSF space. It is accompanied by a markedly increased rSI in the early ischemic lesion on FLAIR images, which is likely due to parenchymal enhancement. The lack of differences on B0 images excludes a pure T2 effect.
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Affiliation(s)
- Ann-Christin Ostwaldt
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
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Merino JG, Latour LL, Tso A, Lee KY, Kang DW, Davis LA, Lazar RM, Horvath KA, Corso PJ, Warach S. Blood-brain barrier disruption after cardiac surgery. AJNR Am J Neuroradiol 2012; 34:518-23. [PMID: 22918429 DOI: 10.3174/ajnr.a3251] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE CNS complications are often seen after heart surgery, and postsurgical disruption of the BBB may play an etiologic role. The objective of this study was to determine the prevalence of MR imaging-detected BBB disruption (HARM) and DWI lesions after cardiac surgery. MATERIALS AND METHODS All patients had an MRI after cardiac surgery. For half the patients (group 1), we administered gadolinium 24 hours after surgery and obtained high-resolution DWI and FLAIR images 24-48 hours later. We administered gadolinium to the other half (group 2) at the time of the postoperative scan, 2-4 days after surgery. Two stroke neurologists evaluated the images. RESULTS Of the 19 patients we studied, none had clinical evidence of a stroke or delirium at the time of the gadolinium administration or the scan, but 9 patients (47%) had HARM (67% in group 1; 30% in group 2; P = .18) and 14 patients (74%) had DWI lesions (70% in group 1; 78% in group 2; P = 1.0). Not all patients with DWI lesions had HARM, and not all patients with HARM had DWI lesions (P = .56). CONCLUSIONS Almost half the patients undergoing cardiac surgery have evidence of HARM, and three-quarters have acute lesions on DWI after surgery. BBB disruption is more prevalent in the first 24 hours after surgery. These findings suggest that MR imaging can be used as an imaging biomarker to assess therapies that may protect the BBB in patients undergoing heart surgery.
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Affiliation(s)
- J G Merino
- Section on Stroke Diagnostics and Therapeutics, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA.
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Köhrmann M, Struffert T, Frenzel T, Schwab S, Doerfler A. The hyperintense acute reperfusion marker on fluid-attenuated inversion recovery magnetic resonance imaging is caused by gadolinium in the cerebrospinal fluid. Stroke 2011; 43:259-61. [PMID: 21980209 DOI: 10.1161/strokeaha.111.632356] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The hyperintense acute reperfusion marker (HARM) on fluid-attenuated inversion recovery MRI is believed to be caused by gadolinium-based contrast agents crossing a disrupted blood-brain barrier. However, this hypothesis has never been directly verified in humans. METHODS In this study, we analyzed cerebrospinal fluid samples of patients with HARM on imaging regarding the presence and concentration of gadolinium-based contrast agents. RESULTS Gadobutrol was found in concentrations of approximately 50 μmol/L. Using phantom MRI experiments, we demonstrate that the detected concentrations are consistent with the observed HARM imaging pattern. CONCLUSIONS Our study yields first direct evidence in humans that the imaging phenomenon HARM is indeed caused by leakage of gadolinium-based contrast agents into the cerebrospinal fluid.
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Affiliation(s)
- Martin Köhrmann
- Department of Neurology, University Hospital of Erlangen, Erlangen, Germany.
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