Journal List > Investig Magn Reson Imaging > v.23(3) > 1135550

Choi, Park, Lee, Ryu, and Jahng: The Role of Double Inversion Recovery Imaging in Acute Ischemic Stroke



The purpose of this study was to investigate if double inversion recovery (DIR) imaging can have a role in the evaluation of brain ischemia, compared with diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) imaging.

Materials and Methods

Sixty-seven patients within 48 hours of onset, underwent MRI scans with FLAIR, DWI with b-value of 0 (B0) and 1000 s/mm2, and DIR sequences. Patients were categorized into four groups: within three hours, three to six hours, six to 24 hours, and 24 to 48 hours after onset. Lesion-to-normal ratio (LNR) value was calculated and compared among all sequences within each group, by the Friedman test and conducted among all groups, for each sequence by the Kruskal-Wallis test. In qualitative assessment, signal intensity changes of DIR, B0, and FLAIR based on similarity with DWI and image quality of each sequence, were graded on a 3-point scale, respectively. Scores for detectability of lesions were compared by the McNemar's test.


LNR values from DWI were higher than DIR, but not statistically significant in all groups (P > 0.05). LNR values of DIR were significantly higher than FLAIR within 24 hours of onset (P < 0.05). LNR values were significantly different between, before, and after six hours onset time for DIR (P = 0.016), B0 (P = 0.008), and FLAIR (P = 0.018) but not for DWI (P = 0.051). Qualitative analysis demonstrated that detectability of DIR was higher, compared to that of FLAIR within 4.5 hours and six hours of onset (P < 0.05). Also, the DWI quality score was lower than that of DIR, particularly relative to infratentorial lesions.


DIR provides higher detectability of hyperacute brain ischemia than B0 and FLAIR, and does not suffer from susceptibility artifact, unlike DWI. So, DIR can be used to replace evaluation of the FLAIR-DWI mismatch.


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Fig. 1.
Representative magnetic resonance imaging (MRI) images scanned 24 hours after symptom onset, in the case of 50 years-old female with infarction in the right pons. Diffusion-weighted imaging (DWI) ambiguously shows the ischemic lesion in the right pons, but double inversion recovery (DIR) depicts the lesion more clearly than the other sequences. From left to right, images are from (a) DWI, (b) DWI with b-value of 0s/mm2 (B0), (c) Apparent diffusion coefficient (ADC), (d) Fluid-attenuated inversion recovery (FLAIR) and (e) DIR. Note that the LNR values of each sequence are as follow: DWI = 43.5, DIR = 22.7, FLAIR = 9.4, and B0 = 5.8.
Fig. 2.
Representative magnetic resonance imaging (MRI) images, collected three hours after symptom onset of 71 years-old female. There is ischemic infarction, in the right middle cerebral artery (MCA) territory. Diffusion-weighted imaging (DWI) depicts the lesion more clearly than the other sequences; Double inversion recovery (DIR) also depicts the lesion better than fluid-attenuated inversion recovery (FLAIR) and DWI with b-value of 0s/mm2 (B0) sequences. From left to right, images are from (a) B0, (b) DWI, (c) Apparent diffusion coefficient (ADC), (d) DIR and (e) FLAIR. Note that LNR values of each sequence are as follow: DWI = 32.8, DIR = 60.3, FLAIR = 10.2, and B0 = 22.2.
Fig. 3.
Graphs of mean lesion-to-normal ratio (LNR) values, of each sequence within all groups (Group I through Group IV).
Fig. 4.
Examples of two patients with infratentorial infarctions, for qualitative assessment of image quality in each sequence. Top row: An age 50 male who underwent magnetic resonance imaging (MRI) scan at 20 hours after left ataxia. A typical susceptibility artifact (white arrows) is visible on (a) diffusion-weighted imaging (DWI), without affecting diagnosis of a small (< 2 cm) hyperintense lesion in the right pons (Score 2). In (b) double inversion recovery (DIR), a lesion is identified at a location corresponding to that of DWI, without anatomic distortion (Score 3). Bottom row: Images of an age 81 female presenting left side weakness and speech disturbance, were obtained within 48 hours after symptom onset. (a) DWI shows considerable geometric distortion by susceptibility artifact, leading to underestimation of right paramedian pontine infarction (arrowhead) (Score 1). Also, itself may be mistaken for an artifact. In contrast, (b) DIR shows definite high signal intensity lesion in the right pons (Score 3).
Table 1.
Number of Patients by Symptom Onset Time and Lesion-to-Normal Ratio Values in Each Sequence Separated to Onset Times
Characteristics Group I (n = 18) Group II (n = 15) Group III (n = 26) Group IV (n = 8) Total (n = 67) P value
Onset time (hours) ≤ 3 > 3 and ≤ 6 > 6 and ≤ 24 24 < and ≤ 48    
  2.3 ± 0.7 4.9 ± 0.9 15.9 ± 6.1 39.1 ± 10.1 12.6 ± 12.5  
Age (years) 64.5 (54.25–71) 76 (63–82) 69.5 (52.75–75.75) 74 (60.5–81.75) 70 (55–77) 0.197*
Male/Female (n) 8/10 13/2 16/10 4/4 41/26 0.077
Lesion-to-normal ratio (LNR)
 DWI 57.7 (36.3–64.1) 49.4 (25.3–81.7) 67.3 (48.5–90.0) 58.0 (33.1–80.7) 59.6 (37.5–79.0) 0.174*
 DIR 29.4 (22.6–46.2) 35.0 (19.3–48.9) 57.8 (35.8–64.2) 48.8 (18.2–59.0) 41.0 (25.1–60.5) 0.098*
 FLAIR 13.8 (10.3–27.9) 16.8 (4.7–29.6) 24.6 (16.0–43.0) 18.0 (13.8–31.3) 19.5 (12.7–31.5) 0.090*
 B0 15.0 (7.6–17.9) 11.2 (8.7–17.5) 23.6 (13.9–32.8) 13.6 (4.6–22.1) 15.9 (9.6–22.6) 0.007*
P < 0.001 < 0.001 < 0.001 < 0.001    

Age and Lesion-to-normal ratio (LNR) are median with interquartile range (Q1-Q3). Duration from symptom onset time are presented as mean ± standard deviation. P † tested by Friedman test P* tested by Kruskal Wallis test Values in bold indicate statistical significance. B0 = DWI with b-value = 0 s/mm2 was regarded as T2W images; DIR = double inversion recovery; DWI = diffusion weighted image with the b-value of 1000 s/mm 2; FLAIR = fluid-attenuated inversion recovery

Table 2.
The Result of Comparing the LNR Values among the Four Sequences in Each Group
Group (onset, h) Friedman test Post-hoc Wilcoxon signed-rank test
DWI vs. DIR DWI vs. FLAIR DWI vs. B0 DIR vs. FLAIR DIR vs. B0 FLAIR vs. B0
I (≤ 3) < 0.001 0.429 0.002 0.002 0.007 0.029 > 0.999
II (> 3 and ≤ 6) < 0.001 0.106 0.008 0.045 0.012 0.231 > 0.999
III (> 6 and ≤ 24) < 0.001 0.086 < 0.001 < 0.001 < 0.001 < 0.001 > 0.999
IV (24 < and ≤ 48) < 0.001 > 0.999 0.117 0.117 0.251 0.117 > 0.999

Each cell shows the P value. Bonferroni-corrected P-values are reported for Post-hoc Wilcoxon signed-rank test. Bold font indicates statistical significance. B0 = DWI with b-value = 0 s/mm 2 was regarded as T2W images; DIR = double inversion recovery; DWI = diffusion weighted image with the b-value of 1000 s/mm2; FLAIR = fluid-attenuated inversion recovery; LNR = lesion-to-normal ratio

Table 3.
The Predictive Performance of Each Imaging Sequence Based on Diffusion Restrictive Lesion in Patients with Hyperacute Phase of Ischemic Stroke
Onset (hours) DIR FLAIR B0 McNemar (P value)
+ + + DIR vs. FLAIR DIR vs. B0
≤ 3 2 16 7 11 12 6 0.0736 0.0044
> 3 1 48 2 47 7 42    
≤ 4.5 2 23 8 17 15 10 0.0412 0.0009
> 4.5 1 41 1 41 4 38    
≤ 6 3 30 9 24 17 16 0.0412 0.0005
> 6 0 34 0 34 2 32    

Positive (+) was defined as Grade 1 plus 2. That is, the patients with subtle or definite signal intensity changes in the region corresponding to the acute ischemic lesion on DWI were included. Negative (−) was defined as no signal intensity change in each sequence (Grade 0 only). Bold font indicates statistical significance. B0 = DWI with b-value = 0 s/mm2 was regarded as T2W images; DIR = double inversion recovery; DWI = diffusion weighted image with the b-value of 1000 s/mm2; FLAIR = fluid-attenuated inversion recovery

Table 4.
The Patient Proportion According to the Quality Scores of Each Imaging Sequence
Quality score DIR DWI FLAIR B0
Total / Infratentorial lesion (n = 67 / n = 7)
1 (poor) 2 / 0 4 / 3 3 / 0 6 / 1
2 (fair) 9 / 1 18 / 2 4 / 1 2 / 1
3 (good) 57 / 6 45 / 2 60 / 6 59 / 5

Score 1 was defined as a considerable artifact that affects the evaluation of the lesion. Score 2 was defined as a little artifact or low resolution not impairing diagnostic quality, and score 3 was defined as no artifact and good image quality enough to detect the lesion. B0 = DWI with b-value = 0 s/mm2 was regarded as T2W images; DIR = double inversion recovery; DWI = diffusion weighted image with the b-value of 1000 s/mm2; FLAIR = fluid attenuated inversion recovery

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