Transient Neurologic Deficit without Vascular Pathology Correlates with Reversible Focal Hypoperfusion on Arterial Spin Labeled Perfusion Imaging

Abstract

We present the case of a 16-year-old boy with altered mental status and magnetic resonance imaging demonstrating left hemispheric hypoperfusion without evidence of stroke, based on arterial spin labeling (ASL) and dynamic contrast-enhanced perfusion imaging. Vessel imaging on magnetic resonance angiography and computed tomography angiography, in addition to an echocardiogram, showed no evidence of an embolic source. Electroencephalography showed left posterior temporal slowing. Within 8 hours, he was awake and alert but with receptive aphasia, and within 24 hours his symptoms completely resolved. Repeat ASL perfusion imaging demonstrated complete resolution of the perfusion abnormality, and diffusion imaging revealed no areas of infarct. This report demonstrates the correlation between a transient neurologic deficit and reversible focal hypoperfusion measured by ASL cerebral perfusion.

Keywords

arterial spin labeling - magnetic resonance imaging - focal hypoperfusion

• References

• 1 Mackay MT, Yock-Corrales A, Churilov L, Monagle P, Donnan GA, Babl FE. Accuracy and reliability of stroke diagnosis in the pediatric emergency department. Stroke 2017; 48 (05) 1198-1202
• 2 Vilela P, Rowley HA. Brain ischemia: CT and MRI techniques in acute ischemic stroke. Eur J Radiol 2017; 96: 162-172
• 3 Telischak NA, Detre JA, Zaharchuk G. Arterial spin labeling MRI: clinical applications in the brain. J Magn Reson Imaging 2015; 41 (05) 1165-1180
• 4 Wang J, Licht DJ. Pediatric perfusion MR imaging using arterial spin labeling. Neuroimaging Clin N Am 2006; 16 (01) 149-167
• 5 Chen J, Licht DJ, Smith SE. , et al. Arterial spin labeling perfusion MRI in pediatric arterial ischemic stroke: initial experiences. J Magn Reson Imaging 2009; 29 (02) 282-290
• 6 Silva AC, Kim SG. Pseudo-continuous arterial spin labeling technique for measuring CBF dynamics with high temporal resolution. Magn Reson Med 1999; 42 (03) 425-429
• 7 Mani S, Pauly J, Conolly S, Meyer C, Nishimura D. Background suppression with multiple inversion recovery nulling: applications to projective angiography. Magn Reson Med 1997; 37 (06) 898-905
• 8 Dixon WT, Sardashti M, Castillo M, Stomp GP. Multiple inversion recovery reduces static tissue signal in angiograms. Magn Reson Med 1991; 18 (02) 257-268
• 9 Ye FQ, Frank JA, Weinberger DR, McLaughlin AC. Noise reduction in 3D perfusion imaging by attenuating the static signal in arterial spin tagging (ASSIST). Magn Reson Med 2000; 44 (01) 92-100
• 10 Mutsaerts HJ, Steketee RM, Heijtel DF. , et al. Inter-vendor reproducibility of pseudo-continuous arterial spin labeling at 3 Tesla. PLoS One 2014; 9 (08) e104108
• 11 Alsop DC, Detre JA, Golay X. , et al. Recommended implementation of arterial spin-labeled perfusion MRI for clinical applications: a consensus of the ISMRM perfusion study group and the European consortium for ASL in dementia. Magn Reson Med 2015; 73 (01) 102-116
• 12 Alsop DC, Detre JA. Reduced transit-time sensitivity in noninvasive magnetic resonance imaging of human cerebral blood flow. J Cereb Blood Flow Metab 1996; 16 (06) 1236-1249
• 13 Pocecco M, Ronfani L. ; Italian Collaborative Paediatric Diabetologic Group. Transient focal neurologic deficits associated with hypoglycaemia in children with insulin-dependent diabetes mellitus. Acta Paediatr 1998; 87 (05) 542-544
• 14 Wattoo MA, Liu HH. Alternating transient dense hemiplegia due to episodes of hypoglycemia. West J Med 1999; 170 (03) 170-171
• 15 Gaxiola-Valdez I, Singh S, Perera T, Sandy S, Li E, Federico P. Seizure onset zone localization using postictal hypoperfusion detected by arterial spin labelling MRI. Brain 2017; 140 (11) 2895-2911
• 16 Olesen J, Larsen B, Lauritzen M. Focal hyperemia followed by spreading oligemia and impaired activation of rCBF in classic migraine. Ann Neurol 1981; 9 (04) 344-352
• 17 Olesen J, Friberg L, Olsen TS. , et al. Timing and topography of cerebral blood flow, aura, and headache during migraine attacks. Ann Neurol 1990; 28 (06) 791-798
• 18 Cadiot D, Longuet R, Bruneau B. , et al. Magnetic resonance imaging in children presenting migraine with aura: association of hypoperfusion detected by arterial spin labelling and vasospasm on MR angiography findings. Cephalalgia 2018; 38 (05) 949-958
• 19 Bosemani T, Burton VJ, Felling RJ. , et al. Pediatric hemiplegic migraine: role of multiple MRI techniques in evaluation of reversible hypoperfusion. Cephalalgia 2014; 34 (04) 311-315
• 20 Haller S, Zaharchuk G, Thomas DL, Lovblad KO, Barkhof F, Golay X. Arterial spin labeling perfusion of the brain: emerging clinical applications. Radiology 2016; 281 (02) 337-356
• 21 Hoge RD, Atkinson J, Gill B, Crelier GR, Marrett S, Pike GB. Linear coupling between cerebral blood flow and oxygen consumption in activated human cortex. Proc Natl Acad Sci U S A 1999; 96 (16) 9403-9408
• 22 Wiegers EC, Becker KM, Rooijackers HM. , et al. Cerebral blood flow response to hypoglycemia is altered in patients with type 1 diabetes and impaired awareness of hypoglycemia. J Cereb Blood Flow Metab 2017; 37 (06) 1994-2001
• 23 Cordonnier C, Oppenheim C, Lamy C, Meder JF, Mas JL. Serial diffusion and perfusion-weighted MR in transient hypoglycemia. Neurology 2005; 65 (01) 175-175
• 24 Shintani S, Tsuruoka S, Shiigai T. Hypoglycaemic hemiplegia: a repeat SPECT study. J Neurol Neurosurg Psychiatry 1993; 56 (06) 700-701
• 25 Abdul-Rahman A, Agardh CD, Siesjø BK. Local cerebral blood flow in the rat during severe hypoglycemia, and in the recovery period following glucose injection. Acta Physiol Scand 1980; 109 (03) 307-314