Case - Classic & Delayed Hypoxia
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I'm going to show you a case of
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classic hypoxia changes followed
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by delayed hypoxia a week later.
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So, these are images of a 22-year
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old who had a cardiac arrest after
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a suicide attempt, and these are the
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diffusion-weighted images and ADC maps.
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And you can see there's restricted diffusion
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characterized by hyperintensity on the DWI
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images and hypointensity on the ADC maps,
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the bilateral parietal and occipital lobes,
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also in the thalami, the lentiform nuclei,
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the caudate nuclei, and various areas of
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cortex in the frontal and parietal lobes.
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The white matter looks relatively normal.
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There's not a lot of swelling yet.
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We'll look at the T2 and FLAIR weighted images.
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Again, there's not a lot of swelling,
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the posterior fossa looks normal.
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The areas that had restricted diffusion
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are also bright on FLAIR and T2,
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as I showed you on the DWI, and
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then the flow voids are normal.
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So there's still arterial flow to the brain
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and the venous flow voids are also normal.
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So this is a classic case of hypoxia.
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This patient started to get better and
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then a week later got worse again and
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was imaged again, and what I'm going
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to show you now is delayed hypoxia.
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So these are the diffusion-weighted
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images in the ADC maps and what you can
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see is the cortex is still bright, but
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not doesn't have restricted diffusion.
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That's normal evolution of hypoxia.
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But as you go up, you can see there's
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diffuse involvement of the white matter.
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There's restricted diffusion, splenium of the
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corpus callosum with radiation into the forceps
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minor bilaterally, there's extensive diffusion
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restriction of the periventricular white
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matter, the corpus callosum, the corona radiata.
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And the centrum semiovale characterized
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again by hyperintensity on the DWI and
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marked hypointensity on the ADC maps.
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So this is delayed hypoxia involving
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predominantly with deep white matter with some
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extension into the subcortical white matter.
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We'll take a look at the FLAIR weighted images.
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And the T2 weighted images, again, we can
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see this extensive hyperintensity in the
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center of the valley, corona radiata, corpus
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callosum radiating into the forceps minor.
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There is still some hyperintensity in the deep
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brain nuclei and cortex because that had been
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injured initially, but it's not as prominent.
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The patient still has, um, normal
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arterial and venous flow voids.
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And we'll take a look at the
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SWI images and we don't see.
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The cortical vein sign that you see in
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much really severe cases where there's
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deoxyhemoglobin throughout the veins.
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So this was an example of delayed hypoxia.
Pamela W Schaefer, MD, FACR
Professor of Radiology, Vice Chair of Education
Massachusetts General Hospital
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