Perihematomal diffusion restriction as a common finding in large intracerebral hemorrhages in the hyperacute phase

Abstract

PurposeThere is growing evidence that a perihematomal area of restricted diffusion (PDR) exists in intraparenchymal hemorrhages (IPH) within 1 week of symptom onset (SO). Here, we study characteristics and the clinical impact of the PDR in patients with hyperacute (≤ 6 hours from SO) IPH by means of apparent diffusion coefficient (ADC).MethodsThis monocentric, retrospective study includes 83 patients with first-ever primary IPH from 09/2002-10/2015. 3D volumetric segmentation was performed for the IPH, PDR, and perihematomal edema (PHE) on fluid-attenuated inversion recovery, T2*/susceptibility weighted images, and ADC images.ResultsA PDR was seen in 56/83 patients (67.5%) presenting with hyperacute IPH. Multivariate logistic regression analysis revealed every 10-year increase of age (HR 1.929, 95% CI 1.047–3.552, P = .035) and male gender (HR 5.672, 95% CI 1.038–30.992, P = .045) as significant predictors of the presence of a PDR, but not IPH size, IPH location, nor National Institutes of Health Stroke Scale Score (NIHSS) at admission. We found no difference in NIHSS at discharge, hematoma removal, or mortality rate in PDR-positive patients. ADC values of the PDR show a step-wise normalization with increasing time from SO.ConclusionsOccurrence of a PDR is a common finding in supratentorial hyperacute IPH, but shows no adverse short-term clinical impact. It may represent transient oligemic and metabolic changes.

Molecular, Pathological, Clinical, and Therapeutic Aspects of Perihematomal Edema in Different Stages of Intracerebral Hemorrhage

“…Furthermore, a clinical study observed PHE with magnetic resonance imaging (MRI) in 56 of 83 patients with ICH within 6 hours after the onset of the disease. Subsequently, it attributed the restricted diffusion perihematomal area to transient oligemic and metabolic changes [ 27 ]. Using multimodal images including diffusion-weighted magnetic resonance imaging (DWI), apparent diffusion coefficient (ADC) maps, perfusion-weighted magnetic resonance imaging (PWI), and proton magnetic resonance spectroscopic (MRS) images, researchers also revealed that hypoperfusion in the perihematomal tissues might be caused by reduced metabolic demand (diaschisis) rather than ischemia [ 28 – 31 ].…”

“…Sur1-Trpm4, NKCC1, AQP4, the Na + -H + exchanger, and the Na + -Ca 2+ exchanger also drive the formation of cytotoxic edema [ 79 ]. Therefore, it is speculated that the imaging characteristics of PHE in patients may be similar to those of cytotoxic edema within 1-3 days [ 14 , 27 ]. However, as previously illustrated, ionic edema is also characterized by extravasation of ions and accumulation of extracellular fluid (similar to interstitial edema) [ 12 , 78 ].…”

“…However, the chances are high that the imaging features of ionic edema will resemble those of interstitial edema that present as a normal to low signal on DWI and a mild high signal on ADC maps It shows a normal to low signal on the DWI and a mild high signal on the ADC maps in perihematomal tissue. If the imaging features of ionic edema are finally verified to be similar to those of interstitial edema in perihematomal tissue, it will be challenging to distinguish it from vasogenic edema [12,14,27,78,[87][88][89] Abbreviations: ICH: intracerebral hemorrhage; BBB: blood-brain barrier; Sur1-Trpm4: sulfonylurea receptor 1-transient receptor potential melastatin 4; NKCC1: Na + -K + -2Cl − cotransporter protein-1; AQP4: aquaporin 4; RBCs: red blood cells; CT: computerized axial tomography; T1WI: T1-weighted MRI; T2WI: T2-weighted MRI; FLAIR: fluid-attenuated inversion recovery image; DWI: diffusion-weighted magnetic resonance imaging; ADC: apparent diffusion coefficient maps.…”