The split apparent diffusion coefficient sign: A novel magnetic resonance imaging biomarker for cortical pathology with possible implications in autoimmune encephalitis

Author:

Ludovichetti Riccardo1,Nierobisch Nathalie1,Achangwa Ngwe Rawlings1,De Vere-Tyndall Anthony1,Fierstra Jorn2,Reimann Regina3,Togni Claudio4,Terziev Robert4ORCID,Galovic Marian4,Kulcsar Zsolt1,Hainc Nicolin1ORCID

Affiliation:

1. Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland

2. Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland

3. Institute of Neuropathology, University Hospital of Zurich, University of Zurich, Switzerland

4. Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland

Abstract

Introduction MRI is the imaging modality of choice for assessing patients with encephalopathy. In this context, we discuss a novel biomarker, the “split ADC sign,” where the cerebral cortex demonstrates restricted diffusion (high DWI signal and low ADC) and the underlying white matter demonstrates facilitated diffusion (high or low DWI signal and high ADC). We hypothesize that this sign can be used as a biomarker to suggest either acute encephalitis onset or to raise the possibility of an autoimmune etiology. Materials and Methods A full-text radiological information system search of radiological reports was performed for all entities known to produce restricted diffusion in the cortex excluding stroke between January 2012 and June 2022. Initial MRI studies performed upon onset of clinical symptoms were screened for the split ADC sign. Results 25 subjects were encountered with a positive split ADC sign (15 female; median age = 57 years, range 18–82). Diagnosis included six herpes simplex encephalitis, three peri-ictal MRI changes, eight PRES, two MELAS, and six autoimmune (3 anti-GABAAR, two seronegative, and one anti-Ma2/Ta). Subjects were imaged at a mean 1.8 days after the onset of symptoms (range 0–8). Discussion We present a novel visual MRI biomarker, the split ADC sign, and highlight its potential usefulness in subjects with encephalopathy to suggest acute disease onset or to raise the possibility of an autoimmune etiology when location-based criteria are applied. When positive, the sign was present on the initial MRI and can therefore be used to help focus further clinical and laboratory workup.

Publisher

SAGE Publications

Subject

Neurology (clinical),Radiology, Nuclear Medicine and imaging,General Medicine

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