Diffusion-weighted imaging findings differ between stroke attributable to spontaneous cervical artery dissection and patent foramen ovale

Background and purpose:  Spontaneous cervical arterial dissection and patent foramen ovale (PFO) are important causes of stroke in younger patients. We tested whether characteristics of cerebral ischaemia visible on diffusion-weighted imaging (DWI) aid in differentiating between these two aetiologies. Methods:  Diffusion-weighted imaging was performed after a median of 2 days [interquartile range (IQR) 1–3 days] in 94 consecutive patients with an acute ischaemic stroke caused either by carotid or vertebral artery dissection (n = 33) or PFO (n = 61). We compared number, size, location and predefined patterns of DWI lesions between both aetiologies. Results:  Ninety-three out of 94 patients had acute DWI lesions and were included in the analysis. Multiple DWI lesions occurred more frequently in patients with dissection (23/33, 70%) than in those with PFO (26/60, 43%, P = 0.02). Lesions were larger in the dissection group [median diameter of largest lesion, 50 mm (IQR 19–68 mm)] than in the PFO group [23 (9–48) mm; P = 0.02]. The distribution of lesion patterns differed between the two aetiologies (P < 0.001): single, non-territorial infarcts were more frequent in PFO (25/60, 42%) than in dissection (2/33, 6%); large territorial infarcts with or without additional smaller lesions in the same territory occurred in 20/33 (61%) patients with dissection and in 16/60 (27%) patients with PFO. Conclusions:  Diffusion-weighted imaging characteristics differ between PFO and dissection, suggesting differences in the pathogenesis of brain infarction between these aetiologies. A single non-territorial infarct seems to favour PFO as stroke aetiology. Whether this or other features are distinctive enough to diagnose PFO or dissection in individual patients requires further testing.