title: Paradoxical centrally increased diffusivity in perinatal arterial ischemic stroke.
abstract: BACKGROUND
  Restricted diffusion on acute MRI is the diagnostic standard for perinatal arterial ischemic stroke. In a subset of children with perinatal arterial ischemic stroke, primarily those with large infarct volumes, we noted a core of centrally increased diffusivity with a periphery of restricted diffusion.
  
  
  OBJECTIVE
  Given the paradoxical diffusion-weighted imaging (DWI) appearance observed in some children with perinatal arterial ischemic stroke, we sought to determine its significance and hypothesized that: (1) centrally increased diffusivity is associated with larger infarcts in perinatal arterial ischemic stroke and (2) this tissue is irreversibly injured (infarcted).
  
  
  METHODS
  We reviewed all perinatal arterial ischemic stroke cases in a prospective cohort study from Aug. 1, 2000, to Jan. 1, 2012. Infarct volumes were measured by drawing regions of interest around the periphery of the area of restricted diffusion on DWI. The Mann-Whitney U test was used to compare means between groups.
  
  
  RESULTS
  Of 25 eligible cases, centrally increased diffusivity was seen in 4 (16%). Cases with centrally increased diffusivity had larger average infarct volumes (mean 117,182 mm(3) vs. 36,995 mm(3); P = 0.008), higher average apparent diffusion coefficient (ADC) values in the infarct core (1,679 × 10(-6) mm(2)/s vs. 611 × 10(-6) mm(2)/s, P < 0.0001), and higher ADC ratio (1.2 vs. 0.5, P < 0.0001). At last clinical follow-up, children with perinatal arterial ischemic stroke and centrally increased diffusivity were more often treated for ongoing seizures (75% vs. 0%; P < 0.001) than those without.
  
  
  CONCLUSIONS
  Centrally increased diffusivity was associated with larger stroke volume and the involved tissue was confirmed to be infarcted on follow-up imaging. Radiologists should be aware of this unusual appearance of perinatal arterial ischemic stroke in order to avoid underestimating infarct volume or making an incorrect early diagnosis.
authors.affiliation: Department of Radiology, University of Colorado Anschutz School of Medicine, Aurora, CO, USA. nicholas.stence@childrenscolorado.org.|Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA. nicholas.stence@childrenscolorado.org.
authors.forename: Nicholas V
authors.initials: NV
authors.lastname: Stence
authors.affiliation: Department of Radiology, University of Colorado Anschutz School of Medicine, Aurora, CO, USA.|Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.
authors.forename: David M
authors.initials: DM
authors.lastname: Mirsky
authors.affiliation: Department of Radiology, University of Colorado Anschutz School of Medicine, Aurora, CO, USA.|Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.
authors.forename: Sean C L
authors.initials: SC
authors.lastname: Deoni
authors.affiliation: Department of Pediatrics (Neurology) & OB/GYN, University of Colorado Anschutz School of Medicine, Aurora, CO, USA.|University of Colorado Hemophilia and Thrombosis Center, Aurora, CO, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Armstrong-Wells
mesh_terms: D001921:Brain / Q000473:pathology*; D005260:Female; D006801:Humans; D007090:Image Interpretation, Computer-Assisted / Q000379:methods*; D007231:Infant, Newborn; D007232:Infant, Newborn, Diseases / Q000473:pathology*; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D020521:Stroke / Q000473:pathology*
keywords: Cerebral infarction; Diffusion-weighted imaging; Magnetic resonance imaging; Neonate; Perinatal arterial ischemic stroke