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Updated: Jun 18, 2025
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A Magnetic Resonance Imaging Protocol for Stroke Onset Time Estimation in Permanent Cerebral Ischemia
Published on: September 16, 2017
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Wake-Up Thrombolysis With Negative Diffusion-Weighted Magnetic Resonance Imaging
Huma Manjra1, Vishal Samboju2, Navdeep Sangha2
1Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
Journal of Medical Cases
|August 2, 2024
Summary
Treat acute stroke symptoms even with negative initial MRI scans. Early intervention, like thrombolytics, is crucial for patients presenting with stroke signs and uncertain symptom onset, especially when using a WAKE-UP protocol.
Area of Science:
- Neurology
- Radiology
Background:
- Acute stroke diagnosis relies heavily on neuroimaging, particularly diffusion-weighted imaging (DWI).
- The WAKE-UP protocol aids in managing stroke patients with unknown symptom onset times.
Observation:
- A 71-year-old female presented with dizziness and double vision upon waking.
- Clinical examination revealed left intranuclear ophthalmoplegia (INO) and gait ataxia.
- Initial magnetic resonance imaging (MRI), including DWI, showed no signs of acute stroke.
Findings:
- Despite negative initial DWI, clinical signs pointed to an ischemic stroke affecting the medial longitudinal fasciculus (MLF).
- The patient received thrombolytic therapy based on clinical suspicion.
- A follow-up MRI 48 hours later confirmed an acute infarct in the left midbrain with a DWI lesion in the MLF.
Implications:
- This case emphasizes treating neurological deficits suggestive of acute stroke, even with initially negative DWI findings.
- It validates the use of the WAKE-UP protocol for stroke patients with undefined symptom onset.
- Timely thrombolysis based on clinical suspicion can lead to favorable outcomes in acute ischemic stroke.
