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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA
SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION
DIFFUSION WEIGHTED MAGNETIC RESONANCE
IMAGING WITH APPARENT DIFFUSION COEFFICIENT
MAPS FOR THE EVALUATION OF PATIENTS WITH
ACUTE NEUROLOGICAL DEFICITS
DR.SAMEEHA KHAN
PG IN RADIODIAGNOSIS
AL-AMEEN MEDICAL COLLEGE
BIJAPUR
1
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
1
Name of the candidate
And
Address
(In block letters)
2.
Name of the Institution
3
4
5
Course of study and subject
Date of admission to course
Title of the Topic
6
Brief resume of the intended
work:
6.1 Need for the study
6.2 Review of literature
6.3 Objectives of the study
Material and methods
7.1 Source of data
7.2 Method of collection of
data( including sampling
procedure if any)
7.3 Does the study require any
investigations or interventions
to be conducted on patients,
humans or animals? If so
please describe briefly.
7.4 Has ethical clearance been
obtained from your institution
in case of 7.3.
7.5 Patient’s Consent Form
List of References (About 4-6)
Signature of candidate
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8
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DR.SAMEEHA KHAN
PG IN RADIODIAGNOSIS,
DEPARTMENT OF RADIOLOGY,
AL-AMEEN MEDICAL COLLEGE,
BIJAPUR
AL-AMEEN MEDICAL COLLEGE,
BIJAPUR, KARNATAKA.
M.D. RADIODIAGNOSIS
MAY 2013.
DIFFUSION WEIGHTED
MAGNETIC RESONANCE
IMAGING WITH APPARENT
DIFFUSION COEFFICIENT MAPS
FOR THE EVALUATION OF
PATIENTS WITH ACUTE
NEUROLOGICAL DEFICITS
VIDE ANNEXURE – I
VIDE ANNEXURE – II
VIDE ANNEXURE – III
VIDE ANNEXURE – IV
VIDE ANNEXURE – IV
VIDE ANNEXURE – V
VIDE ANNEXURE – VI
VIDE ANNEXURE – VII
VIDE ANNEXURE – VIII
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10
Remarks of the guide
11
Name & Designation(In block
letters)
11.1 Guide
TO ASSESS THE SIGNIFICANCE
OF DIFFUSION WEIGHTED
MAGNETIC RESONANCE
IMAGING WITH APPARENT
DIFFUSION COEFFICIENT MAPS
FOR THE EVALUATION OF
PATIENTS WITH ACUTE
NEUROLOGICAL DEFICITS
DR.RAMESH .V. MANKARE
MD, DNB RADIODIAGNOSIS
PROFESSOR,
DEPARTMENT OF RADIOLOGY,
AL-AMEEN MEDICAL COLLEGE,
BIJAPUR
11.2 Signature
11.3 Co-Guide
11.4 Signature
11.5 Head of the Department
DR.MUNEER AHMED
MD. RADIODIAGNOSIS
PROFESSOR AND HEAD
DEPARTMENT OF RADIOLOGY,
AL-AMEEN MEDICAL COLLEGE,
BIJAPUR
11.6 Signature
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12.1 Remarks of the chairman
& Principal
12.2 Signature
3
ANNEXURE – I
BRIEF RESUME OF THE INTENDED WORK:6.1 NEED FOR THE STUDY:Diffusion weighted imaging (DWI) is an MRI technique that quantifies the movement
of water molecules at a cellular level. As the diffusion properties of water vary in areas of
necrosis, high cellularity, inflammation and fibrosis, this technique is inherently sensitive to
different pathologies1 and has become a well-established adjunct to standard sequences
during the diagnosis of neurological deficits.
Diffusion is affected by the biophysical properties of tissue cell organization (cell
membranes, fibers and macromolecules), density, microstructure and microcirculation2.
Intracellular water diffusion is more hindered than that in the extracellular spaces which are
lacking natural barriers. Pathological processes which change the volume ratio or physical
nature of intra- and extracellular spaces affect the diffusion of water molecules. Restricted or
impeded diffusion is seen in tissues with high cellularity , e.g. tumors, abscesses, fibrosis and
cytotoxic edema3. Relative free or unimpeded diffusion is encountered in tissues with low
cellularity or tissues with disrupted cell membranes, for example in cysts and necrotic
tissues3,4.
Diffusion coefficients in DWI are reflected in the apparent diffusion coefficient (ADC,
expressed in mm2/s).4,5,6 Regions with restricted mobility of water molecules yield a greater
DW-MRI signal and appear bright. In apparent diffusion coefficient (ADC) maps, regions
that contain high water mobility appear bright 4.
Thus far DWI has been used primarily for the detection of acute cerebral infarction. However
there are other applications in which DWI facilitates diagnostic purpose in the management
4
of neurological deficits as early diagnosis and treatment is necessary to prevent mortality and
morbidity5. With DWI, Acute cerebral ischemia can be diagnosed within 1 hour of the onset
of symptom , much earlier than T2 weighted images 6. This is essential, as intervention in
stroke has a vital role during initial few hours. Diffusion weighted imaging(DWI)is one such
pulse sequence which has emerged as a powerful adjunct to routine magnetic resonance
evaluation ,providing a boost to lesion detection as well as tissue characterisation.
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ANNEXURE – II
6.2 REVIEW OF LITERATURE:Diffusion weighted imaging (DWI) is one of the most recent products of this modern
diagnostic era. Diffusion-weighted magnetic resonance (DW-MR) imaging provides
potentially unique information on the viability of brain tissue7. It provides image contrast that
is dependent on the molecular motion of water, which may be substantially altered by
different diseases. Numerous studies have shown that ADCs in ischemic areas are lower by
50% or more than those of normal brain areas , and they appear as bright areas (i.e. hyper
intensities) on the DWI. Studies have shown that changes in the ADC occur as early as 10
minutes following onset of ischemia. DWI shows exquisite sensitivity to ischemic stroke.
Cerebral infarction (the death of neurons, glia and vessels) is caused either by insufficient
inflow of blood carrying oxygen (O2) and nutrients, or reduced out flow to remove metabolic
products. It basically comprises two patho-physiological processes; the first is a loss of the
supply of O2 and glucose secondary to vascular occlusion, and the second is changes in
cellular metabolism, with disintegration of cell membranes , cerebral blood flow (CBF),
cerebral blood volume (CBV), cerebral metabolic rate of oxygen (CMR O2), and cerebral
metabolic rate of glucose values7,8,. Within the ischemic cerebro-vascular bed, there are two
major zones of injury: the core ischemic zone and ischemic penumbra9. The penumbra is the
region characterized by reversible function failure if reperfusion is restored in time and can
be visualized by using advanced magnetic resonance imaging technique as combined
diffusion and perfusion weighted images. Mismatches between perfusion and diffusion
weighted images can estimate the ischemic penumbra. This concept immediately opens up
the therapeutic time window during which restoration of flow and neuronal protection from
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ischemic damage might prevent both immediate cell death and the recruitment of Neurons for
apoptosis10.
DWI helps to characterize the disease load in multiple sclerosis better than
conventional methods like T1 images and FLAIR images11 . DWI helps to differentiate
toxoplasmosis from lymphomas as the former shows significantly greater diffusion12.
Enhancing lesions of the brain include abscesses and tumors. The center of abscesses show
restricted diffusion and thus high signal intensity on DWI as compared to tumors which show
low signal intensity. Thus DWI helps differentiate the two4 . Arachnoid cysts and epidermoid
tumors have similar images on T1 and T2 weighted MRI images. DWI differentiates between
the two as arachnoid cysts have low signal intensity as compared to epidermoid tumors4,5,6.
During early brain myelination, diffusion restriction in normal white matter increases17 .
When used with ADC maps, DWI can provide an objective measure of hypoxicischemic injury to the brain in neonates13. Although several studies have described the ability
of DWI to help differentiate various brain tumors and to help grade gliomas, further studies
are needed to define these features clearly14. Till date, the diagnostic contribution of diffusion
weighted magnetic resonance imaging has been well studied in the brain where it has
established and has significant role to play in the diagnosis and characterization of various
diseases of the brain. It promises to provide additional information and contribute
significantly in the detection and characterization of various intracranial lesions.
Since there is an urgent need for the further research in this area, it is proposed to
carry out this study in our institution and study the role of diffusion weighted imaging in the
evaluation of various intracranial pathologies. As DW imaging improves and becomes more
widespread, it is expected to play a greater role in the diagnosis of hyper acute and acute
stroke and in the differentiation of stroke from other disease processes that manifest with
acute neurologic deficits15. DW MR imaging will also play a greater role in the management
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of stroke and may be helpful in the selection of patients for thrombolysis and in the
evaluation of new neuro-protective agents15,16. It may prove to be valuable in the evaluation
of a wide variety of other disease processes, as it will applied in our study.
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ANNEXURE-III
6.3 OBJECTIVES OF THE STUDY:
The present study is aimed to define the brain lesions in clinically suspected neurological
deficits patients with the help of diffusion weighted magnetic resonance imaging and further
assessment of the following
1. Evaluation of CNS lesions by Diffusion weighted imaging.
2. To study the diffusion characteristics of various CNS lesions in the form of mean
ADC values and to correlate mean ADC values of various intra axial and extra axial
lesions.
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ANNEXURE-IV
7. MATERIAL AND METHODS
7.1 SOURCE OF DATA:
The cases will be recruited from Al-Ameen Medical College Hospital, Bijapur and Govt.
District Hospital, Bijapur. Patients referred to Department of Radiology, Al-Ameen Medical
College with acute neurological deficits.
INCLUSION CRITERIA.
Patients referred for the MRI examination of acute neurological deficits, irrespective of age
and sex.
EXCLUSION CRITERIA.

Patients with cardiac pacemakers , prosthetic heart valves , any metallic orthopedic
implants or patients on artificial respiration.

Patients with congenital lesions.

Patients with bony calvarial lesions.
SAMPLE SIZE:
It’s a one and half year study from January 2014 to July 2015. The total number of 50
subjects will be those referred to Department of Radiology with history of acute neurological
deficits.
7.2 METHOD OF COLLECTION OF DATA:
1. Details of the study protocol will be explained to the subjects.
2. Informed consent will be obtained (After clearance from ethical committee).
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3. The study will be conducted on 50 patients referred to the department of radio
diagnosis for the MRI evaluation of acute neurological deficits.
4. MRI examination of brain will be performed using SIEMENS – MAGNETOM
ESSENZA 1.5 TESLA.
5. The MRI evaluation of the lesion will be done to note the size/ shape, site, margins,
appearance and vascularity and relation with the adjacent structures.
MRI PROTOCOL:
T 1W
T2W
FLAIR*
FOV
250
250
250
SLICE THICKNESS
5mm
5mm
5mm
SPACING
30-40
30-40
30-40
TR
500-550
4000-4500
9000-9500
TE
8-15
80-90
80-120
BAND WIDTH
161Hz/Px
172 Hz/Px
190 Hz/Px
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*FLAIR – FLUID ATTENUATED INVERSION RECOVERY.
PARAMETERS OF DIFFUSION WEIGHTED IMAGING:
19-20 slices with 30-40% distance factor
Slice thickness-5 mm
TR- 3500-4200
TE-100-111
FOV lead -250
SCAN TIMING -51sec
VOXEL SIZE-128X128
B VALUE-0-1000 s/mm2
ECHO SPACING- 1.03 ms
BAND WIDTH –1056 Hz/Px
CONTRAST USED:
MAGNEVIST (Gadopentetate Dimeglumine Injection- 0.5 mmol/ ml solution).
Dose – 0.2ml / kg body weight.
STATISTICAL METHODS USED :
Descriptive statistics –

Frequency and percentage distribution.

Graphical and diagrammatic presentation.

Mean and standard deviation.
Inferential statistics
Chi square test for association.

T test for comparison
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ANNEXURE-V
7.3 Does the study require any investigations or interventions to be conducted on
patients, humans or animals? If so please describe briefly.
YES

INTRAVENOUS CONTRAST ( MRI contrast agent )
NOTE: There is no animal experiment involved in the study.
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ANNEXURE-VI
7.4. Ethical clearance from the institution:
ETHICAL COMMITTEE
AL-AMEEN MEDICAL COLLEGE, BIJAPUR
The following study entitled “ Diffusion Weighted Magnetic Resonance Imaging with
Apparent Diffusion Coefficient Maps for the evaluation of patients with Acute
Neurological Deficits ” by Dr. Sameeha Khan P.G. student in Department of RadioDiagnosis belonging to 2013 batch has been cleared from ethical committee of this
institution for the purpose of dissertation work.
Chairman
Ethical committee
Al-Ameen Medical College, Bijapur
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ANNEXURE-VII
AL-AMEEN MEDICAL COLLEGE BIJAPUR
7.5: CONSENT FORM
Patient’s statement
I voluntarily accept admission to the Department of Radio-Diagnosis for the
performance of the studies. The nature, demands and hazards involved in these studies have
been fully explained to me. I understand that I may withdraw from these studies at any time
for any reason. I/ guardian of the patient ( if less than 18 years) confirm that I have given my
consent voluntarily to take part in the research study. I fully understand the safety issues
concerning MRI and give my consent for the test. I also give consent for contrast
administration if necessary, the immediate and delayed complication of contrast have been
fully explained to me in my language .I consent to the release of scientific data resulting from
my participation in this study to the Principal Investigator for use by him/her for scientific
purposes. The principal Investigator assures my anonymity. I understand that the record of
this experiment becomes part of my medical record and is protected as a confidential
document. I understand that this record will only be available to physicians and investigators
involved with this study. Other staff may be authorized by the Head to review the record for
administrative purposes or for monitoring the quality of patient care. In the unlikely event of
physical injury resulting from participation in this research, I understand that medical
treatment will be available from the AMC hospital, including first aid, emergency treatment
and follow–up care as needed. However, no compensation can be provided for medical care
apart from the foregoing. I further understand that making such medical treatment available,
or providing it, does not imply that such injury is the fault of the investigator(s). I also
understand that by my participation in this study I am not waiving any of my legal rights. I
understand that in the case of any problem I can contact Dr.Ramesh.V.Mankare, of the Dept
of Radio-Diagnosis or any member of the Institutional Ethical Review Board, AMC Bijapur.
Date: ---------------------
Signature: ---------------------
Witness: -------------------
Name: ----------------------
Physician’s Statement:
I have carefully explained the nature, demands and foreseeable risks of the above studies to
the patient.
Date: --------------------
Signature: ---------------------
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ANNEXURE – VIII
LIST OF REFERENCES :
1. Maas LC, Mukherjee P. Diffusion MRI: Overview and clinical applications in
neuroradiology. Applied Radiology. 2005;34:44–60.
2. Förster A, Ottomeyer C, Wolf ME, Kern R, Griebe M et al. (2010) Dynamic
susceptibility contrast perfusion MRI identifies persistent vessel pathology in acute
pontine stroke. Cerebrovasc Dis 29: 389-394.10.1159/000286341 PubMed:
20173322.
3. Restrepo L, Jacobs MA, Barker PB, Beauchamp NJ, Skolasky RL et al. (2005)
Etiology of perfusion-diffusion magnetic resonance imaging mismatch patterns. J
Neuroimaging 15: 254-260. PubMed: 15951408.
4. Mascalchi M, Filippi M, Floris R, Fonda C, Gasparotti R, Villari N. Diffusion MR
imaging:clinical applications. Radiol Med 2005 march;109(3):155-197.
5. Weidauer S, Nichtweiss M, Zanella FE, Lanfermann H (2004) Assessment of
paramedian thalamic infarcts: MR imaging, clinical features and prognosis. Eur
Radiol 14: 1615-1626 PubMed: 15106015.
6. Steven W, Jochen G, Bettina S, Piotr W, Robert RE. acute human stroke studied by
whole brain echo planar diffusion-weighted magnetic resonance imaging. Annals of
neurology 2004;37(2):231-241.
7. Bamford J, Sandercock P, Dennis M, Burn J, Warlow C (1991) Classification and
natural history of clinically identifiable subtypes of cerebral infarction. Lancet 337:
1521-1526
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8. Ronald LW, Robert AZ, Robert C, John H. Quantitative apparent diffusion coefficient
measurements in term neonates for early detection of hypoxic-ischemic brain injury:
initial experience. Radiology 2001;218:825-833.
9. Paciaroni M, Caso V, Agnelli G. The concept of ischemic penumbra in acute stroke
and therapeutic opportunities. Eur Neurol. 2009;61(6):321-30. doi:
10.1159/000210544.
10. Manish Prasad, Shanawaz Hussain, Daniele Connolly, and Santosh Mordekar
“Reversible” stroke like episodes with bilateral diffusion restriction brain magnetic
resonance imaging changes J Pediatr Neurosci. 2013 May-Aug; 8(2): 173–175.
11. Tadeusz WS, Philippe D, Robert RL, Christo C, Katrijn LV, Alex M
et al. Differential diagnosis of bright lesions on diffusion-weighted MR images.
Radiographics 2003;23.
12. Daniel LAC, Smith JK, Mauricio C. Differentiation of toxoplasmosis and lymphomas
in AIDS patients by using apparent diffusion coefficients. AJNR 2003 april;24:633637.
13. Ronald LW, Robert AZ, Robert C, John H. Quantitative apparent diffusion coefficient
measurements in term neonates for early detection of hypoxic-ischemic brain injury:
initial experience. Radiology 2001;218:825-833.
14. Maeda M, Kawamura Y, Tamagawa Y, et al. Intravoxel incoherent motion (IVIM)
MRI in intracranial, extra-axial tumors and cysts. J Comput Assist Tomogr 1992;
16:514-518.
15. de Margerie-Mellon C, Turc G, (2013) Can DWI-ASPECTS Substitute for Lesion
Volume in Acute Stroke? PubMed:24092549
16. Wey HY, Desai VR, Duong TQ. (2013) A review of current imaging methods used in
stroke research. PubMed:24070268
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17. Volkher Engelbrecht, MD , Axel Scherer, MD, Margarethe Rassek, PhD,Hans J
Witsack, PhD ,Ulrich Mo¨dder, MD(2002) Diffusion-weighted MRImaging in the
Brain in Children. Radiology 2002; 222:410–418
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PROFORMA
Name:
Age:
IP/OP No:
Date:
Sex:
Clinical history:
Past/Personal history:
EXAMINATION:
1. General examination:
2. Systemic examination:
3. Local examination
INVESTIGATIONS:
CLINICAL DIAGNOSIS :
CT SCAN / X-RAY :
DW MRI FINDINGS :
ADC VALUES :
ADVmin−ADVmax(10-3mm2 /sec)
LESION
NORMAL WHITE MATTER
DW MRI DIAGNOSIS:
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ADV average (10-3mm2/sec)