American Journal of Emergency Medicine xxx (2014) xxx–xxx

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American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajem

Case Report

Transient splenial diffusion-weighted image restriction mimicking stroke☆,☆☆,★

Abstract
Acute transient diffusion-weighted image (DWI) restriction of the
splenium of corpus callosum is reported in various medical conditions
(encephalopathy, hypoglycemia, in patients on antiepileptic drugs)
and in various infections. In some cases, the cause is unknown. We
report a case of a 55-year-old woman who presented with acute-onset
disorientation and ataxia, initially diagnosed as a case of stroke but
later on found to be a case of transient splenial DWI restriction due to
unknown cause. Because of a rich blood supply, stroke of the splenium
of corpus callosum occurs only rarely. Thus, other reversible causes of
splenial DWI restriction should always be excluded before diagnosing
a patient with stroke. It is crucial to identify transient splenial DWI
restriction and to rule out its reversible but critical causes, which, if
not managed quickly, may lead to irreversible brain damage.
Reversible diffusion-weighted image (DWI) restriction of the brain
is an uncommon finding usually seen in hemiplegia, migraine, seizure,
venous sinus occlusion, or splenial injury [1,2]. Acute transient DWI
restriction of the splenium of corpus callosum has been reported in
various clinical conditions like encephalopathy and hypoglycemia in
patients on antiepileptic drugs, various cerebral infections, and, in
some cases, with no apparent cause [3]. We herein report a case of a
55-year-old woman who presented with acute-onset disorientation
and ataxia along with DWI restriction of the splenium and was
initially misdiagnosed as a case of stroke, but later turned out to be a
case of transient splenial DWI restriction of unknown etiology.
A 55-years-old woman, not a known case of any chronic illness
neither on any chronic medication (including antiepileptic drugs),
presented with acute onset of inappropriate talking, slurring of
speech, and increased tendency to fall on unassisted walking. She was
first seen at a local hospital where she was diagnosed as having stroke
and referred to a higher center for further management. When
received in the emergency department of our medical college
hospital, the patient was conscious, her vitals were stable, and other
systemic examinations were unremarkable. On neurologic examination, the patient was found to be disoriented to time, place, and
person; speech was dysarthric; and all cranial nerves were normal.
Motor examination revealed normal bulk, tone, and power with brisk
reflexes in all 4 limbs and bilateral plantar extensor. There was no
neck rigidity, and Kerning sign was negative. The patient was ataxic
with swaying on either side, but other cerebellar signs were negative.

☆ Department and institution where work was preformed: Neurology Department,
SMS Medical College, Jaipur, Rajasthan, India.
☆☆ No grant was available for this case.
★ No author has any conflict of interest.

On examination, we could not find any localizing feature, so we
evaluated the patient for some possible metabolic abnormality.
However, metabolic parameters including blood sugar, serum
electrolytes, liver function tests, and renal function tests were within
normal limits. Magnetic resonance imaging (MRI) of brain revealed
DWI restriction of splenium of corpus callosum and posterior limb of
internal capsule bilaterally (Fig. A). Acute infarct was kept as a
provisional diagnosis, and conservative management was initiated.
Considering the fact that splenial DWI abnormality can also be seen in
various other clinical conditions, the patient was investigated to rule
out any other possible etiology. Urine examination, blood culture, and
cerebrospinal fluid examination were found to have normal results,
which ruled out infectious etiology.
Over the next 2 to 3 days, the patient showed significant
improvement in terms of orientation and ataxia, and by fifth day,
the patient was absolutely normal. Repeat MRI of the brain was done,
5 days after the first MRI, which showed complete resolution of the
brain lesion (Fig. B). Thus, the patient was diagnosed as having a case
of transient splenial DWI abnormality of unknown etiology and was
advised follow-up after 1 month. On follow-up after 1 month, the
patient had no residual neurologic deficit.
Clinically, splenial abnormality presents with confusion, seizures,
dysarthria, or ataxia [4]. The exact mechanism of transient splenial
abnormality on DWI is not known, but intramyelinic edema can
explain the reversibility of the lesion [5]. Splenial abnormality evident
on MRI is important to be identified because many of the causes of
splenial abnormality are completely reversible on early institution of
treatment. In addition, if it is timely identified, the patient may not be
subjected to undue investigations [4]. It is very important to rule out
metabolic abnormalities such as hypoglycemia or hyponatremia or
any infectious cause. Metabolic abnormalities must be detected at the
earliest and treated promptly, so that irreversible brain damage can be
prevented. Patients should also be investigated for any infectious
cause and, if found, should be treated accordingly [6]. Metabolic
parameters were within the reference range in our patient. Normal
findings from the cerebrospinal fluid examination, urine culture, and
blood culture ruled out any infectious etiology.
Diffusion-weighted image restriction of splenium of corpus
callosum usually makes the clinicians think of a possible infarct.
However, an infarct of corpus callosum is rare because corpus
callosum receives rich blood supply from anterior communicating,
pericallosal, and posterior pericallosal arteries. Thus, it is suggested
that other causes of DWI restriction of splenium of corpus callosum
should always be ruled out before diagnosing the patient as having
infarct of splenium of corpus callosum [7].
Acute disseminated encephalomyelitis (ADEM) is an important
differential diagnosis of transient splenial DWI restriction and should
be excluded. Patients with ADEM usually improve clinically over a few

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Please cite this article as: Bhawna S, et al, Transient splenial diffusion-weighted image restriction mimicking stroke, Am J Emerg Med (2014),
http://dx.doi.org/10.1016/j.ajem.2014.02.044

2

S. Bhawna et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx

Fig. A, MRI brain diffusion-weighted image showing diffusion restriction in splenium of corpus callosum and bilateral posterior limb of internal capsule. B, Repeat MRI brain
diffusion-weighted image (done 5 days after the first) showing resolution of the lesion.

weeks with treatment. Magnetic resonance imaging of the brain in
ADEM usually shows an asymmetric white matter abnormality, which
disappears over a period of 1 to 2 months; thus, clinical improvement
precedes the radiologic resolution of the lesion [6,8]. Acute disseminated encephalomyelitis in our patient was excluded, considering the
absence of white matter abnormality on MRI, radiologic resolution of
splenial abnormality for 5 days, and complete clinical improvement
for 4 to 5 days without any specific treatment.
Stroke of the splenium of corpus callosum occurs very rarely owing
to its rich blood supply. Thus, other reversible causes of splenial DWI
restriction should always be excluded before making a final diagnosis
of stroke of the corpus callosum. It is crucial to identify transient
splenial DWI restriction and to rule out its reversible critical causes,
which, if not managed, quickly may lead to irreversible brain damage.
Bhawna Sharma DM
Rahul Handa MD
Kadam Nagpal MD
Swayam Prakash MD
Pankaj Kumar Gupta MD
Rakesh Agrawal MD
Mahendra S. Sisodiya MD

Department of Neurology
SMS Medical College
Jaipur, Rajasthan, India
E-mail address: rahulhanda0411@gmail.com
http://dx.doi.org/10.1016/j.ajem.2014.02.044
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Please cite this article as: Bhawna S, et al, Transient splenial diffusion-weighted image restriction mimicking stroke, Am J Emerg Med (2014),
http://dx.doi.org/10.1016/j.ajem.2014.02.044