When to expect negative diffusion-weighted images in stroke and transient ischemic attack

Background and Purpose-The frequency of DWI negative cerebral ischemia and clinical factors associated with such a circumstance is not well understood. Methods-We performed MRI including diffusion-weighted imaging (DWI) in patients with stroke and transient ischemic attack (TIA) within 24 hours of symptom onset and again at 30 days. Results-Of 401 patients, 103 (25.6%) had an initial negative DWI study. In the DWI negative group, among the stroke patients, 6/ 26 (23.1%) had infarcts on follow-up MRI (4 lacunar and 2 posterior circulation syndromes) and 1 had a rMTT deficit. Among the TIA patients, 4/63 (6.3%) showed rMTT deficits and 2/63 (3.2%) had infarcts on follow-up MRI. Conclusions-Baseline perfusion weighted imaging sequences may detect ischemia in a small proportion of DWI negative cases. Only those with brain stem location or lacunar syndrome were DWI negative initially and yet had a follow-up imaging confirmation of infarct or a final clinical diagnosis of stroke.