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Acute infarction on MRI — SCE Neurology MCQ

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HardNeuroimagingAcute infarction on MRISCE Neurology

A patient develops aphasia 90 minutes before MRI. A small left insular lesion is hyperintense on diffusion-weighted imaging, hypointense on the ADC map and not yet visible on FLAIR. Which tissue process explains this pattern?

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Correct answer: C — Acute cytotoxic oedema from energy failure and restricted intracellular water diffusion

The best answer is “Acute cytotoxic oedema from energy failure and restricted intracellular water diffusion”. Acute ischaemic energy failure causes cell swelling and true restricted diffusion; the DWI–FLAIR mismatch also supports very recent onset. “Vasogenic oedema from blood–brain barrier disruption” is plausible in a different neurological context, but the decisive findings here argue against it. “Chronic gliosis with facilitated extracellular diffusion” is plausible in a different neurological context, but the decisive findings here argue against it. “Mineral deposition causing susceptibility artefact” is plausible in a different neurological context, but the decisive findings here argue against it. “Tumour necrosis with increased free-water motion” is plausible in a different neurological context, but the decisive findings here argue against it.

Reference: NICE NG128 stroke and transient ischaemic attack recommendations: https://www.nice.org.uk/guidance/ng128/chapter/recommendations