Hemorrhage exclusion sign (prostate)

The hemorrhage exclusion sign can be a useful MRI finding following prostate biopsy.

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.

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.

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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Article information

rID: 50638
Section: Signs, Approach
Tag: cases
Synonyms or Alternate Spellings:
  • MRI exclusion sign
  • hemorrhage exclusion sign

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Cases and figures

  • Case 1: T1w signal drop out in left posterior peripheral zone
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  • Case 1: reduced T1w, low T2w and restricted diffusion in post-biopsy prostate cancer
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