Periventricular Deep White Matter Research Articles

MRI and proton spectroscopy in children with late infantile neuronal ceroid lipofuscinosis: Preliminary results

Aim of the study was to characterize findings on magnetic resonance imaging (MRI) and proton magnetic resonance spectroscopy ( 1 H-MRS) in children with late infantile neuronal ceroid lipofuscinosis (NCL) and the relationship between these results and duration of the disorder. Three children with late infantile NCL and six age-matched controls were examined with MRI and by localized 1 H-MRS. Voxel regions studied were periventricular frontal white matter, thalami and cerebellar deep white matter. N-acetylaspartate/creatine (NAA/Cr) and choline/creatine (Cho/Cr) ratio was calculated. MRI showed various degrees of cortical atrophy and increased periventricular white matter signal intensity on T2- and -fluid attenuated inversion recovery-weighted images. There was no significant volume loss in the brainstem. Metabolic ratio (NAA/Cr and Cho/Cr) showed progressive decrease with longer disease duration in thalamic and cerebellar voxels and exhibited a negative relationship in frontal voxels. In conclusion, the most significant changes on neuroimaging in late infantile NCL are progressive cortical and cerebellar atrophy, which are more pronounced in the cerebellum. Decreased signal intensity in the thalami may also be observed as in other forms of NCL. 1 H-MRS is the most sensitive method for measuring metabolic changes. The decreased level of NAA although

Acute disseminated encephalomyelitis: A rare central nervous system manifestation of dengue hemorrhagic fever

Acute disseminated encephalomyelitis (ADEM) is a rare central nervous system manifestation of dengue hemorrhagic fever. We report a 14-year-old male who presented to the emergency department with complaints of fever, vomiting and headache for last 6 days and altered sensorium for last 1 day. On general physical examination, he had multiple petechial spots over the trunk. In central nervous system examination child was having neck stiffness, intermittent decerebrate posturing, brisk deep tendon reflexes, hypertonia in all the limbs, bilateral plantars extensors and sluggishly reacting small pupils. His initial investigations revealed hemoglobin of 12 g/dL, total white cell count 7.500 cells/mm3, platelet count 70,000 cells /mm3, urea 59 mg/dL, creatinine 0.9 mg/dL, calcium 9.1 mg/dL, sodium 140 mEq/L, potassium 4.6 mEq/L and a positive dengue IgM (39.4 panbio units, normal < 11 panbio units) by capture enzyme-linked immunosorbent assay method (PAN BIO KIT, Australia). In view of fever, petechial spots, shock, low platelet counts and a positive dengue serology, a diagnosis of dengue hemorrhagic fever was kept. Magnetic resonance imaging report showed symmetrical hyperintensities on T2-weighted and fluid-attenuated inversion recovery images involving bilateral cerebellar hemispheres, bilateral middle cerebellar peduncles, brain stem, bilateral thalami, hypothalamus and periventricular deep and subcortical white matter, suggesting ADEM. Previously only two cases of ADEM in dengue fever have been reported.

P128 – 2769: Human Parechovirus CNS infection: A rare cause of neonatal encephalitis

Objective Human Parechoviruses (HPeV) belong to the family of Picornaviridae and can cause a variety of symptoms ranging from mild diarrhoea to sepsis, meningitis and encephalitis, particularly among young children and infants. We describe the clinical spectrum, laboratory and radiological findings of two neonates with HPeV CNS infection. Method Case reports. Results Case 1: A nine day old neonate with no preceding risk factors for infection presented with a one day history of irritability and poor feeding. He was apyrexial on presentation but deteriorated with apnoeas and encephalopathy needing intensive care support. He had normal inflammatory markers and TORCH screen. CSF examination revealed 0 WCC, normal protein, glucose with no growth on culture. MRI Brain multiple small lesions in bifrontal subcortical, deep periventricular white matter, corpus callosum with marked restricted diffusion. CSF PCR was positive for HPeV. He received I/V antibiotics/antivirals (1 week) and showed spontaneous clinical improvement with normal neurodevelopment at 6 months. Case 2: A twelve day old neonate with no preceding history of note presented with a one-day history of intermittent facial twitch and clonic jerking of upper or lower limbs. He was commenced on antibiotics and antiviral following infection screen and treated with IV phenobarbitone for focal seizures. CSF was acellular, with normal protein and glucose with no growth on culture. MRI scan showed multifocal parenchymal lesions with marked restricted diffusion in the white matter along with corpus callosum. A CSF PCR was positive for HPeV. Baby was discharged after clinical improvement. Conclusion HPeV CNS infection is a rare but emerging cause of neonatal encephalitis. Paediatricians must be aware of this disease and consider it as a part of neurotropic virus screen in neonatal sepsis. Neuroimaging may be helpful with its characteristic MRI findings.

Association of cerebral white matter lesions with cognitive function and mood in Japanese elderly people: a population-based study.

BackgroundTo determine the relationships between regional white matter lesions (WMLs), lifestyle factors, and cognitive, motor function and mood.MethodsA comprehensive evaluation, including brain MRI, blood tests, the Unified Parkinson's Disease Rating Scale, the Mini Mental State Examination, and the Geriatric Depression Scale, was performed for people aged 65 years or older living in Ama-cho on October 1, 2009. Participants were classified by severity of periventricular hyperintensities (PVH) and deep white matter hyperintensities (DWMH) using the Fazekas score.ResultsOf 900 eligible participants, 688 (76.4%) were enrolled, including 303 men. Significant predictors of severe PVH were older age, lower low-density lipoprotein cholesterol (LDL-C) levels, elevated blood pressure (BP), cerebral infarction, and no current alcohol use. Significant predictors of severe DWMH were older age, lower 1,5-anhydroglucitol (1,5-AG) levels, elevated BP, cerebral infarction, and no current alcohol use. Higher cognitive function was associated with younger age, female sex, mild DWMH, more years of education, and higher high-density lipoprotein cholesterol levels. Depressive symptoms were associated with lower 1,5-AG levels, lower LDL-C levels, moderate to severe PVH, and no current alcohol use.ConclusionsWhite matter lesions in elderly people were related to hypertension and impaired glucose tolerance. The severity of WMLs was associated with cognitive function and mood.

Abstract W P142: White Matter Lesion Severity and Functional Recovery Following Inpatient Rehabilitation After Ischemic Stroke

Background and purpose: Functional outcome after stroke mainly depends on the stroke severity. However, extent of functional recovery varies between individual patients of same degree of disability in stroke rehabilitation. The aim of this study is to investigate the association between white matter lesion (WML) severity and the extent of functional recovery following intensive rehabilitation after ischemic stroke. Methods: The study included patients who were moved to a rehabilitation unit within 2 months after onset of ischemic stroke. Patients with diagnosed dementia or patients with cognitive decline who needed care before stroke were excluded. The degree of WMLs, the location and size of stroke lesions were assessed using brain MRI performed in an acute phase. Separate visual ratings were made for the periventricular hyperintensities and deep white matter hyperintensities on FLAIR images. Functional status was measured using the Functional Independence Measure (FIM) when a patient was moved to a rehabilitation unit and at the time of discharge. Functional recovery was quantified by the change in FIM score (FIM gain). We retrospectively investigated the association between WML severity and FIM gain. Results: A total of 292 patients (166 men and 126 women, mean age 73.3 ± 9.8 years) were included in the study. The mean time interval between stroke onset and rehabilitation start was 35.0 days and the mean length of stay in the unit was 71.6 days. FIM gain was associated with age, stroke severity, functional status before stroke, lobar stroke lesions, and both periventricular and deep white matter hyperintensity scores. Infarct size was not significantly associated with FIM gain. On the other hand, deep white matter hyperintensity score was independently associated with lower FIM gain after adjusting for age, sex, timing of rehabilitation start, length of stay, functional status before stroke, and NIHSS score on admission. Conclusion: In patients with subacute ischemic stroke, severity of cerebral WMLs is an independent factor affecting functional recovery following intensive rehabilitation.

The effects of white matter hyperintensities and amyloid deposition on Alzheimer dementia.

Background and purposeElevated levels of amyloid deposition as well as white matter damage are thought to be risk factors for Alzheimer Disease (AD). Here we examined whether qualitative ratings of white matter damage predicted cognitive impairment beyond measures of amyloid.Materials and methodsThe study examined 397 cognitively normal, 51 very mildly demented, and 11 mildly demented individuals aged 42–90 (mean 68.5). Participants obtained a T2-weighted scan as well as a positron emission tomography scan using 11[C] Pittsburgh Compound B. Periventricular white matter hyperintensities (PVWMHs) and deep white matter hyperintensities (DWMHs) were measured on each T2 scan using the Fazekas rating scale. The effects of amyloid deposition and white matter damage were assessed using logistic regressions.ResultsLevels of amyloid deposition (ps < 0.01), as well as ratings of PVWMH (p < 0.01) and DWMH (p < 0.05) discriminated between cognitively normal and demented individuals.ConclusionsThe amount of amyloid deposition and white matter damage independently predicts cognitive impairment. This suggests a diagnostic utility of qualitative white matter scales in addition to measuring amyloid levels.

Cognitive and affective functions in diabetic patients associated with diabetes-related factors, white matter abnormality and aging.

Diabetes mellitus (DM) is associated with a decline in cognitive and affective functions. In all, 182 outpatients with DM were investigated for associations of cognitive and affective functions with diabetes-related factors and cerebral white matter abnormalities. In addition, the difference in cognitive decline of age-matched late elderly normal subjects and DM patients was investigated. The present study revealed that cognitive and affective functions declined in some DM patients. Furthermore, the decline in these functions was unrelated to fasting blood sugar level but was related to glycosylated hemoglobin (HbA1c) and insulin resistance. Poor HbA1c control was associated with a significant decline in the 'calculation' subscale and insulin resistance for 'naming', 'read list of letters' and 'delayed recall' Montreal Cognitive Assessment (MoCA) subscale scores. Magnetic resonance imaging scans showed that both periventricular hyperintensity (PVH) and deep white matter hyperintensity were associated with Mini Mental State Examination (MMSE) and MoCA scores, but only PVH was related to homeostasis model assessment of insulin resistance scores. Compared with age-matched late elderly normal subjects, 'orientation to time' and 'registration' MMSE subscales declined in late elderly DM patients. These results suggest that cognitive and affective decline in DM patients was mostly related to glucose control and insulin resistance, whilst amongst late elderly subjects the impairment of 'attention' and 'orientation' were characteristic features of DM patients.

Multiple sclerosis patients lacking oligoclonal bands in the cerebrospinal fluid have less global and regional brain atrophy

To investigate whether multiple sclerosis (MS) patients with and without cerebrospinal fluid (CSF) oligoclonal immunoglobulin G bands (OCB) differ in brain atrophy. Twenty-eight OCB-negative and thirty-five OCB-positive patients were included. Larger volumes of total CSF and white matter (WM) lesions; smaller gray matter (GM) volume in the basal ganglia, diencephalon, cerebellum, and hippocampus; and smaller WM volume in corpus callosum, periventricular-deep WM, brainstem, and cerebellum, were observed in OCB-positives. OCB-negative patients, known to differ genetically from OCB-positives, are characterized by less global and regional brain atrophy. This finding supports the notion that OCB-negative MS patients may represent a clinically relevant MS subgroup.

Cerebral Microbleeds Are Associated with Deep White Matter Hyperintensities, but Only in Hypertensive Patients

Cerebral microbleeds (CMBs) and white matter hyperintensities (WMH) are the most common manifestations of small vessel disease, and often co-occur in patients with cerebral vascular disease. Hypertension is widely accepted as a risk factor for both CMBs and WMH. However, the effect of hypertension on the association between CMBs and WMH remains unclear. We hypothesized that the relationship between CMBs and WMH is determined by hypertension. One hundred forty-eight patients with acute cerebrovascular disease who were admitted to PLA general hospital in Beijing, China from February 2010 to May 2011 were recruited in this study. CMBs on T2*-weighted angiography (SWAN) were assessed using the Brain Observer Microbleed Rating Scale criteria. The severity of the WMH was separately assessed as either peri-ventricular hyperintensities (PVH) or deep white matter hyperintensities (DWMH). The association among CMBs and the severity of WMH, and hypertension were determined. CMBs were found in 65 (43.9%) patients. The frequency of CMBs was related to the severity of DWMH and PVH. CMBs were more frequently observed in patients with hypertension compared to patients without hypertension (51.3% vs. 20.0%, p = 0.001). Hypertension was an independent risk factor for CMBs (odds ratio 5.239, p = 0.001) and DWMH (odds ratio 2.373, p = 0.040). Furthermore, the relationship between the presence of CMBs and the severity of DWMH was only found in patients with hypertension (r = 0.298, p<0.01). However, CMBs were associated with PVH independently of hypertension. This study demonstrated that hypertension determined the association between CMBs and DWMH.

Tract-Specific Fractional Anisotropy Predicts Cognitive Outcome in a Community Sample of Middle-Aged Participants with White Matter Lesions

Cerebral white matter lesions (WMLs) have been consistently related to cognitive dysfunction but the role of white matter (WM) damage in cognitive impairment is not fully determined. Diffusion tensor imaging is a promising tool to explain impaired cognition related to WMLs. We investigated the separate association of high-grade periventricular hyperintensities (PVHs) and deep white matter hyperintensities (DWMHs) with fractional anisotropy (FA) in middle-aged individuals. We also assessed the predictive value to cognition of FA within specific WM tracts associated with high-grade WMLs. One hundred participants from the Barcelona-AsIA Neuropsychology Study were divided into groups based on low- and high-grade WMLs. Voxel-by-voxel FA were compared between groups, with separate analyses for high-grade PVHs and DWMHs. The mean FA within areas showing differences between groups was extracted in each tract for linear regression analyses. Participants with high-grade PVHs and participants with high-grade DWMHs showed lower FA in different areas of specific tracts. Areas showing decreased FA in high-grade DWMHs predicted lower cognition, whereas areas with decreased FA in high-grade PVHs did not. The predictive value to cognition of specific WM tracts supports the involvement of cortico-subcortical circuits in cognitive deficits only in DWMHs.

Abstract W P364: Relationships Between Endothelial Function, Biological Markers and Cerebral Small Vessel Diseasein Patients with Chronic Cerebrovascular Disease and Comorbidity

Background and Purpose: Pathogenesis of white matter lesions is thought to be associated with endothelial dysfunction and inflammation. Ultrasound assessment of brachial artery flow mediated dilation (FMD) as a noninvasive and useful method has been recently used as an index of endothelium-dependent vasodilation. The aim of this study was to investigate the associations between endothelial function which was evaluated by FMD and the severity of white matter lesions in patients with chronic cerebrovascular disease and comorbidity. Additionally, we evaluated association between FMD and the number of circulating progenitor cells. Methods: Patients with cerebrovascular diseases history and other untypical neurological problems were enrolled in this study (n=63; 39 male, 69.8±10.0 years). Patients were classified according to periventricular hyperintensities (PVH) and deep white matter hyperintensities (DWMH) scores by fluid-attenuate inversion recovery image of magnetic resonance images (Fazekas gradings). Endothelial dysfunction was defined as a FMD≤4.5%. The numbers of CD34+/CD133+ cells defined as circulating progenitor cells were evaluated by flow cytometry. Results: The patients with endothelial dysfunction (n=39, 61.9%) were older (72.4±7.6 vs. 65.5±11.8, P=0.007), more frequently male (74.4% vs. 41.7%, P=0.016) and more frequently had hypertension (89.7% vs. 37.5%, P&lt;0.001) than the patients without. FMD was negatively correlated with age, the severity of PVH and the severity of DWMH (R 2 =0.120, p=0.006, R 2 =0.280, p&lt;0.001 and R 2 =0.234, p&lt;0.001, respectively). In addition, FMD was positively correlated with the number of circulating progenitor cell (R 2 =0.078, p=0.034). After multivariate analysis with age, sex, presence of stroke and comorbidities, endothelial dysfunction was independently associated with the severity of PVH (standardized partial regression coefficient [β] 0.703, p=0.002), as well as DWMH (β 0.589, p=0.042). Conclusion: Endothelial dysfunction which was evaluated by FMD might be predictive for the grade of cerebral small vessel disease.

Magnetic Resonance Imaging Findings of Pediatric Neurobrucellosis

Brucellosis is an endemic disease often observed in the Mediterranean and Middle East regions. Systemic brucellosis is the most frequent clinical form of this infection; however, hematogenic spread may result in the focal form of the disease. Neurobrucellosis is a rare disease seen in 0, 5-25 % of the adults with systemic brucellosis. 0,8 % of the children affected by systemic brucellosis are reported to have neurological complications. A 16 year old female applied with the complaints of headache, vomiting, bilateral hip and knee pain, and inability to walk. Physical and laboratory examination, brain computed tomography (CT) brain and cervical spinal MRI were carried out as well as the magnetic resonance spectroscopy (MRS) of the lesion areas in the brain. On MRI hydrocephaly in 3rd, 4th and lateral ventricles, atrophic dilatation in bilateral hemispheric cortical sulcuses were seen. On T2W and FLAIR images, hyperintense focal nodular lesions not accompanied by pathological contrast enhancement were detected on parietal subcortical white matter and the periventricular deep white matter. Dural thickening and contrast enhancement on the bilateral parietal region were observed. On cervical spinal MRI, leptomeningeal enhancing was at the level of C1-C7. On MRS applied to lesions in brain (TE 136 and 31 ms), lactate peak at 1.3 ppm was observed. In the differential diagnosis of central nervous system diseases in children living in endemic regions, neurobrucellosis should be kept in mind, though observed rarely. In these cases, the neurological system involvement that cannot be demonstrated via CT, can be shown with MRI effectively.

Clinical and Radiological Localization of Language Dysfunctions in Acute Ischemic Stroke

Objective: To study the effect of cerebral ischemic vascular insult on the localization of language areas as regard to automatic speech, initiation, and mutism. Materials and Methods: Seventy ischemic stroke patients were selected within the first 48 h of the onset of stroke with left hemispheric stroke with aphasia. Inclusion criteria: any age above seven years, both sexes, first ever clinical stroke, admitted within the first 2 days of stroke insult. Patients underwent careful history taking, neurological examination, routine laboratory investigations, echo cardiography, and carotid duplex and language assessments. Results: Automatic speech disorders were mainly seen along left insular, left supramarginal and left frontal inferior orbital lesions. Initiation difficulty is seen mainly along as left insular, left temporal superior and left periventricular lesions. Mutism is seen along left external capsule, left internal capsule, left pallidum, left frontal inferior orbital and left inferior trigone lesions. Conclusions: Deep periventricular white matter and insular area in the dominant hemisphere play an important role in many language tasks. Thus aphasia is not a mere cortical function.

Hemiplegic migraine: An atypical presentation of Moyamoya disease.

Sir, Migraine is a common disorder causing attacks of disabling headaches that can be accompanied by an aura in a third of patients. Few patients having motor weakness during the aura qualify for hemiplegic migraine.[1] This can occur as a sporadic or familial disorder; the latter type is characterized by affection of one first or second degree relative, and then known as familial hemiplegic migraine.[2] Moyamoya disease is a progressive cerebrovascular occlusive disease identified by stenosis of distal internal carotid arteries (ICA) and their branches. Dilation of small cerebral vessels in an attempt to compensate for the decreased blood flow in the anterior circulation produces the characteristic “puff of smoke” appearance on angiography.[3] Headache is one of the common presentations of moyamoya disease in children.[4] Pathophysiological mechanisms for headache remain unclear, but presumed to be closely related to the intracranial oligemic state, as reflected by the disappearance of headache after the improvement of cerebral bold flow augmentation surgery, that is, vascular anastomosis.[5] Familial hemiplegic migraine could be a rare presentation of moyamoya disease. We describe a case of moyamoya disease presented as familial hemiplegic migraine. An 11-year-old girl presented to the pain clinic with periodic throbbing pain over right forehead associated with complete hemiparesis of left half of the body since last 2 years. Frequency of headache was 1-2 times/month with intermittent symptom free periods up to 3 months. Headache was not related to any particular time of the day and any precipitating, aggravating or relieving factors were absent. Initially, her complaints began with nausea, circumoral paresthesia and paresthesia of the left half of the body lasting for 20-30 min. Initial aura symptoms were followed by pain and hemiparesis for 4-10 h with spontaneous and complete recovery thereafter. She was treated for migraine without any effect. There were no past histories of head injury, seizures, involuntary movements, developmental delay, central nervous system infections, or other significant medical illness. On examination, she was afebrile, with normal vitals, pupils were equal (7 mm) and reactive to light, cranial nerve examination was normal and disc margins were sharp on fundoscopy. Tone, power, and reflexes were within normal ranges; bilaterally in both the extremities. Patient's elder sister (15-year-old) had similar symptoms but never underwent treatment. Magnetic resonance imaging brain showed bilateral periventricular deep white matter ischemia with mild cortical atrophy. Cerebral angiography revealed the occlusion of supra-clinoid segments of ICA bilaterally with evidences of moyamoya vessels [Figure 1]. Pial to pial collateral circulation from bilateral posterior cerebral artery to anterior cerebral artery and middle cerebral artery noted through pericallosal collateral vessels [Figure 1]. Considering moyamoya disease is the primary pathology responsible for the headache patient was referred for neurosurgical management. Figure 1 (a) Digital subtraction angiography image showing pial collaterals. (b) Choroidal to choroidal pial collaterals (c) Moyamoya vessels This particular case report and the review of the existing literatures suggest that pediatric patients presenting with migraineous or cluster headache refractory to prophylactic and abortive medical therapies should be evaluated further with cerebral angiography. If moyamoya disease is responsible, an early revascularization procedure will alter the prognosis and life expectancy in such patients.

Thalamic diffusion differences related to cognitive function in white matter lesions

Cerebral white matter lesions (WMLs) are related to cognitive deficits, probably due to a disruption of frontal–subcortical circuits. We explored thalamic diffusion differences related to white matter lesions (WMLs) and their association with cognitive function in middle-aged individuals. Ninety-six participants from the Barcelona-AsIA Neuropsychology Study were included. Participants were classified into groups based on low grade and high grade of periventricular hyperintensities (PVHs) and deep white matter hyperintensities (DWMHs). Tract-Based Spatial Statistics was used to study thalamic diffusion differences between groups. Mean fractional anisotropy (FA) values in significant areas were calculated for each subject and correlated with cognitive performance. Participants with high-grade PVHs and DWMHs showed lower FA thalamic values compared to those with low-grade PVHs and DWMHs, respectively. Decreased FA thalamic values in high-grade DWMHs, but not high-grade PVH, were related to lower levels of performance in psychomotor speed, verbal fluency, and visuospatial skills. Thalamic diffusion differences are related to lower cognitive function only in participants with high-grade DWMHs. These results support the hypothesis that fronto–subcortical disruption is associated with cognitive function only in DWMHs.

Pacientes con enfermedad de Parkinson avanzada con y sin congelación de la marcha. Análisis comparativo de lesiones vasculares en resonancia magnética cerebral

IntroductionFreezing of gait (FOG) is one of the most disabling and enigmatic symptoms in Parkinson's disease. Vascular lesions, observed in magnetic resonance imaging (MRI) scans, may produce or exacerbate this symptom. Patients and methodsThe study includes 22 patients with Parkinson's disease subjects, 12 with freezing of gait and 10 without. All patients underwent an MRI scan and any vascular lesions were analysed using the modified Fazekas scale. ResultsPatients with FOG scored higher on the modified Fazekas scale than the rest of the group. Although the two groups contained the same percentage of patients with vascular lesions (50% in both groups), lesion load was higher in the group of patients with FOG. Vascular lesions in the periventricular area and deep white matter seem to be the most involved in the development of FOG. DiscussionVascular lesions may contribute to the onset or worsening of FOG in patients with PD. This study suggests that cerebral vascular disease should be considered in patients with FOG.

Demographics and risk factors for recurrent ischemic stroke in Aegean part of Turkey

WCN 2013 No: 361 Topic: 3 — Stroke Demographics and risk factors for recurrent ischemic stroke in Aegean part of Turkey Y. Secil, Y. Ciftci, Y. Beckmann. Neurology, Izmir Katip Celebi University, Ataturk Education and Research Hospital, Izmir, Turkey Background: Recurrent stroke is defined as a new cerebrovascular event which occurs after the stabilization of the previous stroke. Recurrence of stroke increases likelihood of disability–mortality associated with stroke. Systematic evaluation of stroke cases can help to reduce the risk of recurrence. Objective: In order to predict ischemic strokes which carry the risk of recurrence, our study aimed to compare data related to risk factors, stroke type, etiology and disability–mortality rates associated with stroke. Material and method: Our study including patients with recurrent ischemic stroke admitted to our hospital Neurology department between February 2010 and June 2011. Information about previous strokes and demographics were recorded. Risk factors were classified. Disability–mortality rates and secondary prevention treatment at recurrent stroke onset were evaluated. Results: 151 patients with recurrent ischemic stroke were included in our study. The mean age was 71.35 ± 12.06. The most frequent risk factors were hypertension, hyperlipidemia, coronary artery disease and atrial fibrillation. The most frequent recurrence etiology was cardiac embolic events. 53.2% of patients were receiving antiplatelet, 10.4% of patients were receiving anticoagulation therapy. 26.5% of patients died. The mean of modified Rankin score of patients was significantly higher at the recurrent ischemic stroke than the previous ischemic stroke. Conclusion:Knowing the etiological factor can help to predict recurrence of stroke and prevent death. Effective treatment ofmodifiable risk factors in recurrent stroke groups is very important in primary and secondary stroke prevention. Recurrent stroke prevention is very important in prognosis, disability and financial basis all around the world. doi:10.1016/j.jns.2013.07.676 Abstract — WCN 2013 No: 292 Topic: 3 — Stroke Clinicoradiological localization of language dysfunctions in acute ischemic brain attack WCN 2013 No: 292 Topic: 3 — Stroke Clinicoradiological localization of language dysfunctions in acute ischemic brain attack M.H. Ibrahim. Neurology, GMC & GMU University, Ajman, United Arab Emirates Objective: The aim of the study was to study the effect of cerebral ischemic vascular insult on the localization of language areas as regard automatic speech, initiation and mutism. Materials and methods: Seventy ischemic stroke patients selected within the first 48 h of the onset of stroke with left hemispheric stroke with aphasia. Inclusion criteria: At any age above seven years, both sexes, first ever clinical stroke, admittedwithin the first 2 days of stroke insult. Patients underwent careful history taking, neurological examination, routine laboratory investigations, echocardiography, carotid duplex and language assessments. Results: Automatic speech disorders were seen in (76%) patients and their MRI lesion distribution showed lesions within the deep periventricular white matter and anterior Perisylvian regions and other areas. Initial difficulty was with lesions in deep periventricular white matter, and other areas. Mutism significantly correlated with lesions in temporal mid-area, external capsule and other areas. Conclusions: Deep periventricular white matter and insular area in the dominant hemisphere play an important role in many language tasks. Thus aphasia is not a mere cortical function. doi:10.1016/j.jns.2013.07.677 Abstract — WCN 2013 No: 388 Topic: 3 — Stroke How accurate are clinicians when estimating stroke outcomes? Results from the Jurassic randomized study WCN 2013 No: 388 Topic: 3 — Stroke How accurate are clinicians when estimating stroke outcomes? Results from the Jurassic randomized study G. Saposnik, R. Cote, R. Raptis, M. Mamdani, K. Thorpe, J. Fang, D. Redelmeier, L.B. Goldstein JURASSIC Study Group University of Toronto, Toronto, Canada; McGill University, Montreal, Canada; St Michael's Hospital, Toronto ON, Canada; Institute for Clinical Evaluative Sciences (ICES), Toronto ON, Canada; DukeUniversity, Durham

Teaching Neuro Images : Cerebral white matter involvement in a patient with Vogt-Koyanagi-Harada syndrome

A 27-year-old man presented with decreased vision bilaterally. Ophthalmologic examination revealed panuveitis with bilateral serous retinal detachments (figure 1) characteristic of Vogt-Koyanagi-Harada (VKH) syndrome. Analysis of CSF revealed mild pleocytosis. No oligoclonal bands were detected. On MRI, there was bilateral abnormal thickening of the choroid with retinal detachment (figure 2, A and B), with hyperintense lesion on fluid-attenuated inversion recovery (FLAIR) image in the periventricular deep white matter (figure 2C). VKH syndrome is one of the causes of uveo-meningeal syndromes. Differential diagnosis of VKH syndrome includes Wegener granulomatosis, sarcoidosis, and Behçet disease.(1) The main disorders showing association with hyperintense plaques on deep white matter FLAIR images are inflammatory, metabolic, vascular, degenerative, autoimmune, and demyelinating diseases. MRI is a helpful tool in diagnosing VKH syndrome; in addition to the typical bilateral ocular findings, scattered periventricular white matter lesions on FLAIR are also described.(2.)

Abstract TP181: Serum Eiocosapentaenoic Acids Is Protective Against White Matter Lesions

[Introduction] White matter hyperintensities (WMH) are considered manifestation of arteriosclerotic small vessel disease and WMH burden increases risk of ischemic stroke and cognitive decline. There are only a few evidences concerning the relationship between polyunsaturated fatty acids (PUFA) and WMH. The present study was designed to elucidate the association between WMH and PUFA profile including eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and arachidonic acid (AA) in patients with Alzheimer’s disease (AD). [Methods] The present study was based on 119 patients who were diagnosed as having a probable AD according to the NINCDS-ADRDA criteria. Their mean age was 78.3 years old. All subjects underwent neuropsychological evaluation including mini mental state exam (MMSE) and 1.5-Tesla MRI. Fasting blood samples were also collected for the PUFA measurements. We measured the ratio of serum EPA, DHA and AA concentration to the total PUFA concentration. The WMH were evaluated on T2-weight images and classified into periventricular hyperintensity (PVH) and deep white matter hyperintensity (DWMH). The severity of WMH was graded 5 categories. We investigated the relationship between WMH and PUFA profiles. [Results] The EPA ratio correlated negatively with both PVH (rs=-0.2036, p=0.0264) and DWMH grade (rs=-0.3155, p=0.0005). It remained still significant after adjustment for age, sex, statins use, antithrombotics use, mean blood pressure and presence of hypertension (standardized partial regression coefficient(β)=-0.2516, p=0.0122 for PVH, β=-0.3598, p=0.0001 for DWMH). Neither DHA nor AA ratio correlated with DWMH or PVH grade. The EPA ratio but not DHA or AA ratio correlated positively with total MMSE score (rs=0.2310, p=0.0115). [Conclusions] Our data revealed that the serum EPA was protective against WMH as well as cognitive decline in AD patients. Pathophysiology underlying WMH is complex and the possible mechanisms involved in the pathogenesis of WMH encompass incomplete brain ischemia, increased permeability of blood-brain barrier, and inflammation responses. The relationship between serum EPA and WMH can be partly explained by those anti-ischemic and anti-arteriosclerotic effects of EPA.

Letter to the Editor Involvement of the corpus callosum splenium in a case with SSPE: magnetic resonance spectroscopy findings

Subacute sclerosing panencephalitis (SSPE) is a fatal, incurable, inflammatory, and neurodegenerative disease. The parieto-occipital lobes are the most frequently and severely affected. The basal ganglia, cerebellum, spinal cord and corpus callosum are less frequently involved [1–4]. Because magnetic resonance spectroscopy (MRS) provides information regarding in vivo brain metabolism and neuronal function, it is a promising method that may illustrate the pathophysiological features of SSPE [5–8]. To our knowledge, this is the first report of MRS findings of corpus callosum in a case with SSPE. A 15-year-old, previously healthy boy was hospitalized because of 4-week history of muscle weakness, impaired vision, and gait imbalance. He had not been vaccinated. A neurological examination revealed symmetric muscular weakness, ataxia, sequential slow movement, decreased motor activity and deep tendon reflexes, and negative Babinski reflex. He had exhibited myoclonic jerks, intellectual deterioration and behavioral changes. The characteristic burst suppression pattern was seen on EEG. Cerebrospinal fluid investigation revealed oligoclonal IgG bands and elevated titers of the measles antibody. He was diagnosed as clinical stage II according to the Jabbour classification. Magnetic resonance imaging (MRI) demonstrated diffuse hyperintensity in the cortical gray and subcortical, deep and periventricular white matter of the parieto-occipital region with mass effect observed as sulcal effacement and hyperintensity in the splenium of the corpus callosum on T2 and FLAIR weighted images. MRS was performed (TE: 135 ms). Voxels were placed in the right parietooccipital region and splenium of the corpus callosum. MR spectrum obtained from right parietooccipital subcortical and deep white matter and splenium of the corpus callosum showed a significant decrease in N-acetylaspartate (NAA)/creatine (Cr) and increase in the ratio of choline (Cho)/Cr. Additionally, there were also inverted prominent lactate peaks (Figures 1 and ​and22). Figure 1 Sagittal T2-weighted images show widespread hyperintensities in cortical-subcortical and deep periventricular white matter of right parietooccipital region and in splenium of corpus callosum Figure 2 Multivoxel MRS (TE: 135 ms) obtained from splenium of corpus callosum reveal prominent decreased NAA/Cr, increased Cho/Cr and presence of lactate at 1.33 ppm (inverted double) Subacute sclerosing panencephalitis is persistent and chronic encephalitis secondary to measles virus infection that causes widespread demyelination of the central nervous system. Since clinical profiles of the disease lead to various presentations, early diagnosis and true clinical staging are not always easy. Usually, MRI findings and the clinical stage of SSPE are not correlated. It is not possible to define these findings as improvement or progression based on the MRI findings alone. Despite the progress of SSPE, improvement of MRI findings may be seen [2–5]. It has been reported that histopathological examinations show evidence of neuronal loss, astrogliosis, demyelination, and infiltration of inflammatory cells [5]. Magnetic resonance spectroscopy can provide information on neuronal and axonal viability, cellular energetics, and membrane status. In our case, MRS showed significantly decreased NAA/Cr ratios in the right parietooccipital subcortical white matter and splenium of the corpus callosum. The MR spectrum of the corpus callosal splenial lesion revealed increased Cho/Cr and presence of lactate. These findings might indicate neuronal loss, demyelination, active inflammation and/or anaerobic metabolism. Magnetic resonance spectroscopy findings were consistent with stage III SSPE [5]. Although to date SSPE is not completely curable, with early diagnosis it is possible to slow the progression of the disease. Although MRS is not specific or diagnostic, it can show metabolic changes in the early-late stage [7]. For this reason, MRS may be useful to reveal the extent and progression of SSPE.