Background: The rate of cerebral infarct recurrence is determined by clinical examination. Routine neurological examination is less sensitive than cerebral imaging in detecting new cerebral lesions. We aimed to determine the rate of new diffusion-weighted imaging (DWI) lesions at 2 time points after stroke and to identify factors associated with them. Methods: Patients who were hospitalized with acute ischemic stroke underwent DWI at 3 time points (within 24, 48 and 144 h after stroke onset, respectively). Scans were made anonymous and reviewed in a random order. Lesions on DWI were delineated manually by blinded investigators. Then, coregistered DWI templates were analyzed for new ischemic lesions on the corresponding follow-up DWI. New lesions had to be separate and lesion growth was not considered. Univariate and multivariable logistic regression analyses were performed to define predictors of new DWI lesions. Results: A total of 159 patients were enrolled in the study. Clinical stroke recurrence was detected in 2.5% of patients. A new cerebral lesion was detected in 5.7% of patients between first and second imaging (first interval) and 23.3% between second and third imaging (second interval). In univariate analyses, thrombolysis and multiple lesion pattern were associated with new lesions within the first interval. Ipsilateral carotid stenosis, multiple lesion pattern, vessel recanalization, atrial fibrillation, older age and higher NIHSS were associated with new lesions within the second interval. In multivariable analysis, ipsilateral carotid stenosis, recanalization and multiple lesion pattern remained independently associated with any new lesions. Conclusions: New DWI lesions occur more often than routine neurological examination suggests. Thrombolysis was associated with very early new DWI lesions within the first interval, ipsilateral carotid stenosis and spontaneous recanalization with new DWI lesions within the second interval.

Lovett JK, Coull AJ, Rothwell PM: Early risk of recurrence by subtype of ischaemic stroke in population-based incidence studies. Neurology 2004;62:569–573.
Grau AJ, Weimar C, Buggle F, et al: Risk factors, outcome, and treatment in subtypes of ischaemic stroke: the German stroke data bank. Stroke 2001;32:2559–2566.
Kolominsky-Rabas PL, Weber M, Gefeller O, Neundoerfer B, Heuschmann PU: Epidemiology of ischaemic stroke subtypes according to TOAST criteria: incidence, recurrence, and long-term survival in ischaemic stroke subtypes: a population-based study. Stroke 2001;32:2735–2740.
Weimar C, Roth MP, Zillessen G, et al, German Stroke Data Bank Collaborators: Complications following acute ischaemic stroke. Eur Neurol 2002;48:133–140.
Fisher CM: Lacunes: small, deep cerebral infarcts. Neurology 1965;15:774–784.
Vermeer SE, Longstreth WT Jr, Koudstaal PJ: Silent brain infarcts: a systematic review. Lancet Neurol 2007;6:611–619.
DeCarli C, Massaro J, Harvey D, et al: Measures of brain morphology and infarction in the Framingham heart study: establishing what is normal. Neurobiol Aging 2005;26:491–510.
Hara M, Ooie T, Yufu K, et al: Silent cortical strokes associated with atrial fibrillation. Clin Cardiol 1995;18:573–574.
Anderson NE, Mason DF, Fink JN, Bergin PS, Charleston AJ, Gamble GD: Detection of focal cerebral hemisphere lesions using the neurological examination. J Neurol Neurosurg Psychiatry 2005;76:545–549.
Fiebach JB, Schellinger PD, Jansen O, et al: CT and diffusion-weighted MR imaging in randomized order: diffusion-weighted imaging results in higher accuracy and lower interrater variability in the diagnosis of hyperacute ischaemic stroke. Stroke 2002;33:2206–2210.
Walters RJ, Holmes PA, Thomas DJ: Silent cerebral ischemic lesions and atrophy in patients with apparently transient cerebral ischemic attacks. Cerebrovasc Dis 2000;10(suppl 4):12–13.
Kang DW, Latour LL, Chalela JA, Dambrosia J, Warach S: Early ischaemic lesion recurrence within a week after acute ischaemic stroke. Ann Neurol 2003;54:66–74.
Kang DW, Latour LL, Chalela JA, Dambrosia JA, Warach S: Early and late recurrence of ischaemic lesion on MRI: evidence for a prolonged stroke-prone state? Neurology 2004;63:2261–2265.
Kang DW, Yoo SH, Chun S, et al: Silent ischaemic lesion recurrence on magnetic resonance imaging predicts subsequent clinical vascular events. Arch Neurol 2006;63:1730–1733.
Coutts SB, Hill MD, Simon JE, Sohn CH, Scott JN, Demchuk AM, VISION Study Group: Silent ischemia in minor stroke and TIA patients identified on MR imaging. Neurology 2005;65:513–517.
Sylaja PN, Coutts SB, Subramaniam S, Hill MD, Eliasziw M, Demchuk AM,VISION Study Group: Acute ischaemic lesions of varying ages predict risk of ischaemic events in stroke/TIA patients. Neurology 2007;68:415–419.
Hotter B, Pittl S, Ebinger M, et al: Prospective study on the mismatch concept in acute stroke patients within the first 24 h after symptom onset – 1000Plus study. BMC Neurol 2009;9:60.
Berger K, Weltermann B, Kolominsky-Rabas P, Meves S, Heuschmann P, Böhner J, Neundörfer B, Hense HW, Büttner T: The reliability of stroke scales. The German version of NIHSS, ESS and Rankin scales (in German). Fortschr Neurol Psychiatr 1999;67:81–93.
Adams HP Jr, Bendixen BH, Kappelle LJ, et al: Classification of subtype of acute ischaemic stroke. Definitions for use in a multicenter clinical trial. TOAST, Trial of Org 10172 in Acute Stroke Treatment. Stroke 2003;24:35–41.
Mazzucco S, Redgrave JN, Schulz UG, Flossmann E, Rothwell PM: Asymptomatic recurrent cerebral ischaemic lesions on diffusion-weighted imaging in the subacute and chronic phase after transient ischaemic attack or minor ischaemic stroke. Cerebrovasc Dis 2007;24:133–135.
Bang OY, Kim GM, Chung CS, Kim SJ, Kim KH, Jeon P, Saver JL, Liebeskind DS, Lee KH: Differential pathophysiological mechanisms of stroke evolution between new lesions and lesion growth: perfusion-weighted imaging study. Cerebrovasc Dis 2010;29:328–335.
Wen HM, Lam WW, Rainer T, et al: Multiple acute cerebral infarcts on diffusion-weighted imaging and risk of recurrent stroke. Neurology 2004;63:1317–1319.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.