MR imaging of Wallerian degeneration in the brainstem: temporal relationships

Degeneration of the myelin sheath and axon distal to the most proximal site of axonal interruption secondary to axonal disease has been called wallerian degeneration. On MR imaging, wallerian degeneration of the pyramidal tract can be observed as an abnormal signal intensity, showing prolonged T1 and T2 relaxation times that correspond to the corticospinal tract, with or without shrinkage of the ipsilateral cerebral peduncle and pons. Review of MR studies in 150 cases of supratentorial cerebrovascular accidents showed abnormal signal alterations in the ipsilateral brainstem in 33 of the cases. Abnormal intensity in the ipsilateral brainstem was seen as early as 5 weeks after the supratentorial ictus and was fully evident after 10 weeks in all 33 cases. Signal alterations were strongest at about 3-6 months when compared with alterations seen at 10 weeks or even 10 months after the ictus. Shrinkage of the ipsilateral brainstem appeared as early as 8 months and was demonstrated in all cases 13 months after the ictus. MR seems to be the most effective technique for early detection of wallerian degeneration and may provide insight into its pathophysiological and chemical changes.