The hemorrhage exclusion sign can be a useful MRI finding following prostate biopsy.
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Pathology
The normal prostate produces high concentrations of citrate, which among other properties, acts as an anticoagulant 1. As tumor cells are dysfunctional, they will produce lower levels of citrate than the surrounding normal prostate and should bleed less.
Radiographic features
MRI
Post-biopsy hemorrhage is detectable on multiparametric prostate MRI, particularly in the peripheral zone 2, as hyperintense areas on T1W sequences, due to the paramagnetic effect of methemoglobin.
The abnormal prostate tissue will appear darker on T1W (with corresponding low T2W signal and diffusion restriction) and will be outlined by the hemorrhage in the adjacent normal prostate, hence can help identify or delineate lesions 1,2.
Treatment and prognosis
Alone, the positive predictive value (PPV) of this hemorrhage exclusion sign is about 50%, but with consideration of other features on other sequences, this can approach 95% for prostate cancer 3. This can be especially useful in the post-biopsy state, where post-biopsy changes are considered to reduce the diagnostic yield of MRI.
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