Hyperacute bilateral thalamic infarction not presented on initial diffusion weighted magnetic resonance imaging

In patients with hyperacute infarctions, there are situations in which initial diffusion-weighted magnetic resonance imaging (DW MRI) fails to explain the patient's neurological status. In the present case, the patient visited the emergency room about 15 minutes after the onset of symptoms and his initial neurological status was not explained by DW MRI. We injected intravenous tissue plasminogen activator on the basis of non-enhanced brain computed tomography. However, the degrees of neurological improvement were insignificant and follow up DW MRI showed multiple acute infarctions in the pons, midbrain, and bilateral thalamus. A rare case of acute bilateral thalamic infarction, this article summarizes initial management and clinical outcome.

Magnetic resonance imaging (MRI) is the best way to detect early signs of cerebral ischaemia and intracranial haemorrhage . Rapid MRI sequences reduce the length of the investigation, giving valuable information with an acceptable time in terms of patient care. For this reason, MRI is increasingly used to select candidates for thrombolysis. After a few minutes, acute arterial ischaemic stroke (AIS) appears as hyperintense on diffusion-weighted imaging (DWI), with a corresponding reduction of the apparent diffusion coefficient (ADC). However, DWI may also be negative at the very beginning of an ischaemic stroke, as it requires several tens of minutes for the cytotoxic oedema to return hyperintensity.

If AIS represents the most common cause of new sudden neurological deficit, other diseases mimicking ischaemic strokes represent up to one-third of cases  and are termed ‘stroke mimics’. It is important to promptly identify these differential diagnoses to avoid inappropriate urgent treatment, but also to prevent inadequate long-term prevention treatment. Though computed tomography (CT) scanning is the standard technique in many stroke centres around the world and has demonstrated its effectiveness in the decision-making process for the treatment of AIS, MRI with DWI has a better sensitivity to depict small acute ischaemic cerebral lesions, but also offers the possibility, at the same time, to identify differential diagnoses to stroke in case of a sudden neurological deficit.


Jin Eun

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