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Infarction in the brain

Case Study
Busch, Hans-Peter, M.D. Trier, Brüderkrankenhaus Germany
Hoffmann, Georg Trier, Brüderkrankenhaus Germany

Patient history:

A 75-year-old male patient was presented to the MR department of Krankenhaus der Barmherzigen Brueder in Trier, Germany with signs of infarctions. A comprehensive brain examination, including diffusion weighted imaging and (contrast-enhanced) angiography of the Circle of Willis was performed.

MR examination:

The first scan of the examination is a survey scan. A fast T2-weighted TSE sequence is used, providing images in 3 orthogonal directions. Total scan time of this sequence remains below 1 minute, and the images provide sufficient information for accurate planning.

 

The basic ExamCard that is performed in case infarction is suspected, contains axial T2-weighted TSE, axial T1-weighted SE and coronal T2-weighted FLAIR, all with full brain coverage. Additionally, a sagittal T2-weighted TSE with thin slices is performed covering the brain stem. Axial single shot diffusion weighted imaging is acquired. And, if pathology is revealed in the sagittal T2-weighted TSE through the brainstem, diffusion weighted imaging is also acquired coronally. SENSE is used to reduce echo train length, thereby reducing image distortions and blurring effects. Finally, if the infarction is older than 8 days, a post-contrast T1-weighted SE sequence is acquired, in the axial plane.

 

As three infarcted regions - probably of embolic origin - were found in these basic imaging sequences, angiography was performed additionally. A 3D high-resolution multi-chunk inflow sequence was performed. SENSE was used to reduce scan time, while maintaining high spatial resolution. Contrast-enhanced MRA of the Circle of Willis was also performed. a 2D-BolusTrak sequence was acquired to trigger the start of the 3D-high resolution scan with the arrival of the contrast bolus.

MR images and interpretation:

Axial T2W_TSE Image reveals infarcted regions in the right thalamus and in the right posterior lobe.Axial T1W_SE Coronal T2W_FLAIR Cross-sections through the infarction in the right thalamus, the right hippocampus and the right posterior lobe.
Axial T2W_TSE
Axial T1W_SE
Coronal T2W_FLAIR
Image reveals infarcted regions in the right thalamus and in the right posterior lobe.
Cross-sections through the infarction in the right thalamus, the right hippocampus and the right posterior lobe.
Sagittal T2W_TSE DW_SSh Single shot DWI with b-value = 800. 
SENSE is used to reduce echo train length.
Sagittal T2W_TSE
DW_SSh
Single shot DWI with b-value = 800. SENSE is used to reduce echo train length.

 

Both T2-weighted TSE and T2-weighted FLAIR clearly show high signal intensity in the infarcted regions. High signal is present in the infarcted regions in the diffusion weighted images. As the normal brain structure is damaged by the infarctions, less diffusion will occur, and the signal drop that is a measure for the amount of diffusion, becomes less.

 

3D_inflow Axial MIP.3D_inflow Sagittal and coronal MIP.3D_inflow Radial MIP through the basilar artery.
3D_inflow
3D_inflow
3D_inflow
Axial MIP.
Sagittal and coronal MIP.
Radial MIP through the basilar artery.

 

The radial MIP reconstruction of the high resolution 3D_inflow sequence shows a high grade stenosis of the distal left vertebral artery and an occlusion of the distal right vertebral artery as probable origin of the embolic infarctions.

 

2D_BolusTrak Final dynamic showing arrival of contrast bolus in the carotids.CE_MRA Transverse MIP.CE_MRA Radial MIP reconstructions.
2D_BolusTrak
CE_MRA
CE_MRA
Final dynamic showing arrival of contrast bolus in the carotids.
Transverse MIP.
Radial MIP reconstructions.

 

Finally, contrast-enhanced MRA of the Circle of Willis was performed. A 2D-BolusTrak timing sequence is used to time the start of the high resolution 3D angiography. This is a dynamic coronal sequence, acquired with the system's Body coil. A complex subtraction is performed, and every dynamic is displayed in real-time. This allows us to visualize the arrival of the contrast bolus, and, once the desired level in the carotids is reached, the high-resolution angio scan is started by one single push of the button. Even though total scan time of the contrast enhanced MRA is 42 seconds, the venous enhancement is not too high, because CENTRA k-space filling is used. The occlusion resp. stenosis of the vertebral arteries is visualized in this sequence as well.



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Apr 29, 2005

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