Infarct-like Lesions Research Articles

Migraine-like headache in subjects with isolated Lambl’s excrescences: a case series and literature review

Aim Lambl’s excrescences are mobile, thin, fibrinous connective tissue strands typically found on left-sided cardiac values. Migraine is positively associated with structural cardiac anomalies. However, it remains unclear whether Lambl’s excrescences are associated with migraine. Methods Retrospective review of 182 inpatients with Lambl’s excrescences confirmed by transesophageal echocardiogram in Chinese PLA General Hospital since January 2010. Among them, those with isolated Lambl’s excrescences presented with migraine-like headache were included. We collected information on the demographics and clinical profiles of all participants, and performed follow-up visits. Results A total of 8 patients presented with migraine-like headache among 15 patients with isolated Lambl’s excrescences. They included 2 men and 6 women, with an average age of 44.63 ± 12.24 years. Among these patients, 3 had visual aura, and 6 manifested infarct-like lesions on magnetic resonance imaging, of which 2 developed lesions after first visit. During follow-up, 4 patients suffering from intervention for Lambl’s excrescences dramatically reduced headache recurrence compared to the other 4 patients only receiving migraine preventive medications. Conclusions This study supports the hypothesis that microemboli from isolated Lambl’s excrescences could cause migraine-like headache. And intervention for Lambl’s excrescences may be crucial for preventing headache recurrence.

Correlation between migraine and cerebral small vessel disease: A case-control study.

Microcirculatory pathology is one of the pathophysiological theories of migraine, which may present as visually subclinical lesions. Image markers of cerebral small vessel disease (CSVD) have been investigated in elderly migraineurs. However, past studies looked at only part of image features, and the conclusions may have been hindered by confounding factors. The relationship between migraine and CSVD signs needs reliable demonstrations. We conducted a case-control study by recruiting episodic young migraineurs from a tertiary headache centre, with tension-type headache (TTH) and healthy controls. Distinct image features of microvascular damage and baseline characteristics across groups were assessed, and multivariate linear regression was performed to evaluate the risk factors for image abnormalities in migraineurs. Forty-eight migraineurs, 32 TTHs and 49 healthy controls were included. The median age was 32 year-old. 58.7% of the participants were female. The Scheltens score and volume of white matter hyperintensities (WMHs) in migraineurs, and the number of Virchow-Robin spaces (VRSs) in both migraineurs and TTHs were different from those in normal controls. No lacunar infarct-like lesions (ILLs) or cerebral microbleeds (CMBs) were found. Age, education level (high level: β = -2.23, lobar WMHs), attack duration (long duration: β = 3.81, lobar WMHs) and attack frequency were independent risk factors for Scheltens score and volume of WMH in migraineurs. Migraine aura (β = -2.389), attack frequency and education level were correlated with the number of VRSs. Migraine was associated with WMHs and VRSs. Aura, attack duration, attack frequency, age and education level were risk factors for image abnormalities of CVSD in migraineurs. This study provides a novel and comprehensive landscape of CSVD MRI features in young migraineurs, and it fills the blank of CMBs and VRSs which received less attention, with more persuasive, more reliable and stronger evidence of the association between CSVD and migraine. Our results also imply some new feature of TTH and the possible pathophysiology of the migraine course as well as new clues for the early management of migraine in terms of visual brain damage.

A Study of The Cardio-Protective Effect of Pioglitazone on Isoprenaline- Induced Myocardial Infarction in Male Albino Rats

ABSTRACT Background: Isoprenaline (ISO) in large doses induces morphological and functional alterations in the heart leading to myocardial necrosis. It also produces excessive free radicals resulting from oxidative metabolism of catecholamine. There are increasing evidences that cardiotoxicity of ISO occurs because of generation of free radicals and oxidative stress. Objective: To investigate the protective effect of pioglitazone on the outcome of isoprenaline (ISO) induced myocardial infarct-like lesions in rats. Materials and methods: 50 male Wistar albino rats (150-200gm) were selected for this study. The rats were divided into five groups each consisted of 10 rats. This study was conducted at Department of Pharmacology, Faculty of Medicine, Al-Azhar University (Assiut). Results: Results showed that pretreatment with pioglitazone significantly decreased the activity of LDH, CK, TNF alpha, IL 6 and the levels of CTnI in serum of ISO-induced rats. Our results showed that pretreatment with pioglitazone significantly (p < 0.01) decreased the level of MDA compared with ISO alone-induced rats. Conclusion: Pioglitazone has a valuable protective role against myocardial infarction through its action as peroxisome proliferator activated receptor gamma (PPAR-γ) agonist.

Narrative review of neuroimaging in migraine with aura.

To improve the understanding of the role and utility of various neuroimaging modalities (clinical and research) for the evaluation of migraine aura (MA) and hemiplegic migraine during the ictal and interictal phases. MA is defined by reversible neurologic symptoms and is considered a manifestation of a primary condition. As such, most patients with MA do not require imaging. However, if there are atypical features, change in symptom pattern, or it is a first-time presentation, neuroimaging may be used to evaluate for secondary conditions. Neuroimaging includes many modalities, and it is important to consider what information is being captured by these modalities (i.e., structural vs. functional). Imaging abnormalities may be noted both during (ictal) and between (interictal) MA attacks, and it is important for clinicians to be familiar with neuroimaging findings reported in migraine with aura (MWA) compared with other conditions. With the assistance of a medical librarian, we performed a review of the literature pertaining to MWA and neuroimaging in PubMed. Search terms included were magnetic resonance imaging, positron-emission tomography, single photon-emission computed tomography, functional magnetic resonance imaging, and migraine with aura. We hand-searched these references to inform our subsequent literature review. Acute MA can be associated with several unique neuroimaging findings-reversible cortical diffusion restriction, cortical venous engorgement, and a "biphasic" transition from hypoperfusion to hyperperfusion. Imaging findings during MA tend to span more than one vascular territory. Between acute attacks, neuroimaging in people with MWA can resemble migraine without aura in terms of white matter abnormalities and "infarct-like lesions." Research imaging modalities such as volumetric analysis and functional imaging have demonstrated unique findings in migraine with aura. Although migraine is a clinical diagnosis, understanding of neuroimaging findings in MWA can help clinicians interpret imaging findings and improve patient care.

Mitochondrial encephalomyopathy involves ophthalmology otorhinolaryngology neurology and their clinical features

Objective:This study aimed to provide better understanding of the otolaryngologic features, combined with ophthalmologic and neurologic characteristics in mitochondrial encephalomyopathy（MEM）, and to help ENT and auditory practitioner making correct diagnosis as well. Methods:Twenty-eight patients with MEM were enrolled between September 2001 and January 2020. Information about family histories and clinical symptoms was retrospectively analyzed. All patients underwent otorhinolaryngological, ophthalmological and neurological examinations, including: pure-tone audiometry, acoustic immittance（AI）, distortion-product otoacoustic emissions（DPOAE）, auditory brainstem response（ABR）, cochlear micropotential（CM）, speech discrimination score（SDS）, electroneurography（ENoG）, computed tomography（CT） of the temporal bone and cranial magnetic resonance weighted imaging scan（MRI）, muscle biopsy and mtDNA gene testing. Results:ENT subjective manifestations were present in 15 cases （53.6%） with sensorineural hearing loss（SNHL）, 4（14.3%） with tinnitus, 4（14.3%） with facial weakness, 3（10.7%） with dysphagia, 1（3.6%） with auditory agnosia. Ophthalmological and neurological symptoms included ptosis in 16 cases （57.1%）, exercise intolerance in 16（57.1%）, optic atrophy in 15（53.6%）, muscular atrophy in 6（21.4%）, and stroke-like episodes in 5（17.9%）. The results of objective examinations were as follows: DPOAE were not elicited in 18（64.3%） cases, ABR abnormalities in 18（64.3%） cases, hearing threshold shift in 15（53.6%） cases, AI normal and CM was not detected in all cases, SDS decreased in 6（21.4%） cases, facial ENoG abnormalities in 4（14.3%） cases, laryngeal ENoG abnormalities in 3（10.7%） cases, EMG abnormalities in 6（21.4%） cases, and ECG abnormalities in 8（28.6%） cases. Temporal CT were normal, but cranial MRI abnormalities were found in 19 cases（67.9%）, including central nerve demyelination, white matter hyperintensities, generalized cerebellar and cerebral atrophy, multiple cortical/subcortical infarct-like lesions, basal ganglia calcification. Conclusion:Multisystemic syndromes in MEM can present as a variety of otolaryngological, ophthalmological and neurological abnormalities, such as ptosis, audio-visual disturbance, exercise intolerance and stroke-like episodes etc. SNHL, tinnitus, auditory agnosia, facial weakness and dysphagia were ENT specific manifestations. SNHL in MEM is bilateral symmetrical progressive or of sudden onset since teenage. mtDNA testing may be helpful for adolescent patient whose SNHL was associated with neuromuscular symptoms. Muscle biopsy should be considered when middle-aged patients developed facial weakness and dysphagia. DPOAE and ABR are the optimal objective audiometric tests to monitor the progression of MEM associated with SNHL.

The effect of Phosphodiesterase type 5 inhibitor, Sildenafil and vitamin E on Isoprenaline induced Myocardial Infarction in male Rats.

Background and Aim: Despite great efforts during the last decades, acute myocardial infarction (MI) contributes to significant mortality statistics with growing yearly prevalence. The cardioprotective effect of the phosphodiesterase5-inhibitor, Sildenafil (Sil) against MI and its complications stills a matter of debate and controversy. So, we aimed to investigate the impact of Sil pretreatment on the outcome of isoprenaline (ISO)-induced infarct-like lesions and comparing it to that of vitamin E (Vit.E). Methods: 5 groups of rats were conducted; Control and ISO-injected group (75mg/kg; i.p) to induce infarct-like lesion in addition to 3 groups that were pretreated with either oral Sil (10mg/kg/day) and/or oral Vit.E (100IU/kg/day) for 3 weeks before injection of ISO. Results: the preconditioning with Sil or Vit.E significantly ameliorated ECG alterations, decreased serum levels of the cardiac enzyme CK-MB, and reduced cardiac injury score with no evident necrotic changes on histopathological examination that were observed in the ISO-induced MI. These changes were accompanied by significant increases in the cardiac SOD content and decreases in MDA content in addition to reduced immunohistochemical expression of transforming growth factor β (TGFβ) that plays an outstanding role in post-infarct remodeling. Conclusion: Sil and/or Vit.E exerted a prophylactic effect against MI and post-infarct remodeling, at least in part, through preserving the cardiac redox balance and antifibrotic effect by lowering TGFβ.

Structural and Functional Brain Changes in Migraine.

Migraine is a prevalent primary headache disorder and is usually considered as benign. However, structural and functional changes in the brain of individuals with migraine have been reported. High frequency of white matter abnormalities, silent infarct-like lesions, and volumetric changes in both gray and white matter in individuals with migraine compared to controls have been demonstrated. Functional magnetic resonance imaging (MRI) studies found altered connectivity in both the interictal and ictal phase of migraine. MR spectroscopy and positron emission tomography studies suggest abnormal energy metabolism and mitochondrial dysfunction, as well as other metabolic changes in individuals with migraine. In this review, we provide a brief overview of neuroimaging studies that have helped us to characterize some of these changes and discuss their limitations, including small sample sizes and poorly defined control groups. A better understanding of alterations in the brains of patients with migraine could help not only in the diagnosis but may potentially lead to the optimization of a targeted anti-migraine therapy.

Nocturnal Hypertension Associated with Stroke and Silent Cerebral Infarcts in Children with Sickle Cell Disease

Background: Strokes and silent cerebral infarcts (SCIs) lead to significant morbidity and mortality in children with sickle cell disease (SCD). Discovering modifiable risk factors is paramount to decreasing the incidence and progression of these devastating cerebrovascular outcomes. Higher systolic blood pressures have previously been shown to increase risk for stroke and SCIs however patients with SCD often have lower clinic blood pressures than the general population. 24 hour ambulatory blood pressure monitoring (ABPM) allows for more robust examination of blood pressure values. Previous studies have investigated associations with abnormal ABPM parameters and end-organ dysfunction, mainly SCD nephropathy. Associations with cerebrovascular events have not yet been investigated. This study aimed to determine if there is an association between blood pressure abnormalities on ABPM with stroke and silent cerebral infarcts. Methods: A cross-sectional study was performed. Children with SCD were enrolled and completed a 24-hour ABPM. Of this cohort, children with HbSS or HbSβ0 with a documented MRI brain within a year of the ABPM were included in the analysis. SCIs were defined as discrete, infarct-like T2 hyperintense lesions measuring at least 3mm in diameter on two orthogonal imaging sequences. Bivariate analyses were performed to identify the association between ambulatory blood pressure parameters with cerebrovascular outcomes specifically SCI or history of stroke. Results: A final cohort of 42 children with a median age of 13 years (10, 17) was included in the analysis. Seven (17%) had a history of stroke, 7 (17%) had documented SCIs, and the remaining 28 (67%) had no history of stroke or SCIs. Masked hypertension was seen in 5% of subjects and nocturnal hypertension was seen in 25%. Abnormal overnight dipping noted in 85% of subjects. The presence of nocturnal hypertension was significantly higher in the SCI/stroke group (55% vs 12%, p = 0.01). Sensitivity analyses were performed to determine if blood pressure abnormalities continued to show an association with cerebrovascular findings when stroke patients were removed. Nocturnal hypertension remained significantly associated with the presence of SCIs (p = 0.006). The median systolic load (percentage of blood pressures above the 95th percentile on ABPM), while below the cutoff for hypertension in both cohorts, was higher in the stroke/SCI group (18.6) compared to the group without SCIs or stroke (6.1), but did not meet statistical significance (p = 0.07). Conclusions: This study reveals an association between nocturnal hypertension and a higher prevalence of SCI and stroke in children with SCD. Our findings also confirm the high prevalence of nocturnal hypertension and impairment of nocturnal dipping seen in this population. Adequately powered, prospective cohorts of ABPM in SCD patients are needed to further evaluate causation between nocturnal hypertension and cerebrovascular outcomes. Disclosures No relevant conflicts of interest to declare.

How Imaging Can Help Us Better Understand the Migraine-Stroke Connection.

Migraine and stroke are among the most prevalent and disabling neurological diseases. Epidemiologic studies showed that there is an association between migraine and stroke. Migraineurs, especially those with aura, are more likely to develop subclinical infarct-like lesions in the brain and are at risk for cryptogenic or cardioembolic stroke. Migrainous headache can be found at the onset of acute ischemic stroke in some patients, and in rare instances, an infarction can be directly attributed to a prolonged migraine aura, ie, migrainous infarction. Importantly, recent studies suggest that in the event of cerebral artery occlusion, even a history of migraine is sufficient to accelerate infarct progression and worsen outcomes. The mechanisms underlying the migraine-stroke connection are multifactorial, with genetic predisposition, aura-related electrophysiological mechanisms (cortical spreading depolarization), and cerebral microembolism being the most convincing ones at this point. Here, we provide a comprehensive overview on recent imaging studies that have helped us better understand the complex association between migraine and stroke.

Diagnostic Significance of Hyperintense Lesion in the Pons on Brain Magnetic Resonance Imaging in Patients with Intravascular Lymphoma

Introduction: Neurological symptoms related to the involvement of the central nervous system (CNS) have been commonly observed at diagnosis and at relapse in intravascular large B-cell lymphoma (IVLBCL). Although various patterns of abnormal findings on brain magnetic resonance imaging (MRI) in patients with IVLBCL have been reported, most of them were from case reports or small case series of selected patients.Hence, we aimed to investigate the prevalence and clinical value of abnormal findings detected using brain MRI in patients with IVLBCL regarding diagnosis and prognosis.Methods: A total of 33 consecutive patients diagnosed with IVLBCL who underwent treatment at Kameda Medical Center between 1998 and 2017 were available for data of routine pretreatment brain MRI.The diagnosis of IVLBCL was pathologically made by an expert hematopathologist (KT) in all patients. Brain MRI was performed as previously reported, and the abnormalities were classified into the following 4patterns by 2 neuroradiologists in consensus (Figure 1): (A) hyperintense lesion in the pons on T2-weighted imaging (T2WI), (B) nonspecific white matter lesions, (C) infarct-like lesions, and (D) meningeal thickening and/or enhancement. We subsequently identified 77 consecutive patients (52 patients at initial presentation and 25 patients at relapse) with pathologically diagnosed diffuse large B-cell lymphoma (DLBCL) without IVLBCL and 41 patients who received random-skin biopsy on the suspicion of IVLBCL but were found to be negative, as control groups for the presence or absence of hyperintense lesions in the pons.Results: Pretreatment brain MRI revealed abnormal findings in 29 (87.9%) patients. Hyperintense lesions in the pons on T2WI was the most common abnormal finding and was detected in 19 (65.5%) patients. Among them, 10 (52.6%) patients did not have impaired consciousness (Figure 2). Among the 7 patients in whom hyperintense lesions in the pons on T2WI was the sole abnormality, 5 patients (71.4%) did not have impaired consciousness. Infarct-like lesions were detected in 8 (27.6%) patients, and impaired consciousness was more frequent in patients with this pattern than in those without (87.5% vs. 28.0%; P=0.005). Nonspecific white matter lesions and meningeal thickening and/or enhancement were detected in 14 (48.3%) and 4 (13.8%) patients, respectively. No significant difference in overall survival (OS) was detected between patients with and without hyperintense lesions in the pons on T2WI (Figure 3). Patients with nonspecific white matter lesions had relatively shorter OS than those without the finding, although the difference was not statistically significant (median OS, 19.8 months vs. not achieved; P=0.057). Infarct-like lesions were associated with unfavorable survival (median OS, 12.5 months vs. not achieved; P=0.030). Follow-up brain MRI revealed improvements in abnormal findings in most of the patients who responded to chemotherapy (Figure 4). Furthermore, postmortem examinations revealed pathological changes in the brain related to the lymphoma lesions, indicating that these MRI findings might represent these lesions of the brain. Next, we reviewed findings on brain MRI in 77 control patients with DLBCL without IVLBCL. Among them, 16 (20.8%) patients had concomitant CNS involvement of lymphoma. No patients harbored hyperintense lesions in the pons, in contrast with the patients with IVLBCL (P<0.001). This finding was detected in no patient also among those who received random-skin biopsy on the suspicion of IVLBCL but were found to be negative (P<0.001).Conclusions: Our findings revealed that most patients with IVLBCL presented abnormal findings on pretreatment brain MRI, even if they exhibited no neurological symptoms. In particular, hyperintense lesions in the pons on T2WI were frequently observed in patients with IVLBCL, irrespective of the presence or absence of impaired consciousness, and were highly specific in IVLBCL compared to those in control groups, suggesting that this pattern may be pathognomonic and valuable for the timely diagnosis of IVLBCL. Improvements in all types of abnormal findings on follow-up brain MRI indicated that these findings might reflect structural changes associated with IVLBCL and might be useful for confirmation of the therapeutic effect. Further longitudinal studies are required to validate our findings and determine their clinical implications. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Episodic Migraine and White Matter Hyperintensities: Association of Pain Lateralization.

Migraine pathophysiology involves a neuronal mechanism that is closely associated with the neuronal activation of peripheral trigeminal nociceptive pathways. It also involves a vascular mechanism that is supported by studies concerning the presence of migraine with aura in various vascular diseases. Migraine is associated with silent infarct-like lesions and white matter hyperintensities (WMHs) that can be encountered during magnetic resonance imaging. In this study, we aimed to demonstrate the migraine-WMH link based on pain lateralization. We recruited 628 episodic migraine patients and examined their cranial magnetic resonance images regarding the presence of deep, subcortical, and periventricular WMHs. We sought to identify an association between lesion occurrence and pain side. We found that the patients had more deep/subcortical hyperintensities in the cerebral hemisphere that was ipsilateral to the pain side (ƙ = 0.421). Periventricular hyperintensities were not associated with the pain side (P = 0.768). Based on our study results, we concluded that pain in episodic migraine is associated with the occurrence of WMHs in the cerebral hemispheres.

Mitochondrial dysfunction and cerebral metabolic abnormalities in patients with mitochondrial encephalomyopathy subtypes: Evidence from proton MR spectroscopy and muscle biopsy.

Accumulated evidence indicates that cerebral metabolic features, evaluated by proton magnetic resonance spectroscopy (1 H-MRS), are sensitive to early mitochondrion dysfunction associated with mitochondrial encephalomyopathy (ME). The metabolite ratios of lactate (lac)/Cr, N-acetyl aspartate (NAA)/creatine (Cr), total choline (tCho)/Cr, and myoinositol (mI)/Cr are measured in the infarct-like lesions by 1 H-MRS and may reveal metabolic changes associated with ME. However, the application of this molecular imaging technique in the investigation of the pathology of ME subtypes is unknown. In this study, cerebral metabolic features of pathologically diagnosed ME cases, that is, 19 mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS); nine chronic progressive external ophthalmoplegia (CPEO); and 23 healthy controls, were investigated using 1 H-MRS. Receiver operating characteristics (ROC) analysis was used to evaluate the diagnostic power of the cerebral metabolites. Histochemical evaluation was carried out on muscle tissues derived from biopsy to assess the abnormal mitochondrial proliferation. The association between cerebral metabolic and mitochondrial cytopathy was examined by correlation analysis. Patients with MELAS or CPEO exhibited a significantly higher Lac/Cr ratio and a lower NAA/Cr ratio compared with controls. The ROC curve of Lac/Cr ratio indicated prominent discrimination between MELAS or CPEO and healthy control subjects, whereas the NAA/Cr ratio may present diagnostic power in the distinction of MELAS from CPEO. Lower NAA/Cr ratio was associated with higher Lac/Cr in MELAS, but not in CPEO. Furthermore, higher ragged-red fibers (RRFs) percentages were associated with elevated Lac/Cr and reduced NAA/Cr ratios, notably in MELAS. This association was not noted in the case of mI/Cr ratio. Mitochondrial cytopathy (lactic acidosis and RRFs on muscle biopsy) was associated with neuronal viability but not glial proliferation, notably in MELAS. Mitochondrial neuronopathy and neuronal vulnerability are considered significant causes in the pathogenesis of MELAS, particularly with regard to stroke-like episodes.

EFFECTS OF CEREBROVASCULAR INFARCT BURDEN ON COGNITIVE DECLINE IN THE PRESENCE OF DEMENTIA AND DEATH: ACCOUNTING FOR POTENTIALLY INFORMATIVE DROPOUT USING COMPETING RISK SHARED PARAMETER MODELS: THE ARIC STUDY

Large biases may occur in cognitive decline studies due to informative dropout, where participants with the worst cognitive decline also have more missing outcomes due to competing dementia/death/other events. Shared parameter models (SPM) jointly estimate longitudinal submodels with event submodels through a set of “shared parameters” (latent/random effects) to address this selection bias. We compare cerebrovascular infarct relationships with cognitive decline using SPM versus standard models in the Atherosclerosis Risk in Communities (ARIC) study. Infarct burden was assessed using 1.5T MRI in 1,835 stroke-free participants of the ARIC study (V3:1993–1995; mean age 62.8, range 51–73 years; 60% women) and categorized as no-burden (no infarct like lesions (ILL)<3mm nor any infarcts>3mm, n=1580), small-burden (ILL<3mm only, n=48), large-burden (infarcts≥3 mm only, n=174), and double-burden (co-existingILL<3mm plus infarcts≥3 mm (n=30)). Global cognition z-scores over 20 years were available in up to five visits; dementia and death events were available via cohort surveillance. Random-slope linear mixed models (LMM) estimated associations of infarct burden with 10-year cognitive decline under inherent missing at random (MAR) assumptions. SPM approaches used this LMM submodel alongside cause-specific Weibull survival submodels for dementia and death events, sharing the random intercepts and slopes between the longitudinal and event submodels under missing not at random (MNAR) assumptions. The double-burden group experienced triple the dementia (Cox-PHM HR=2.8, [1.5, 5.2]) and double the death rates (HR=2.3, [1.4, 3.7]) compared to the no-burden group. LMM gave 10-year cognitive change estimates for the double-burden group which were counterintuitively positive (change=+0.10 SD) and statistically supported as better (p<0.001) than the no-burden group (change= -0.32 SD). Conversely, SPM gave 10-year cognitive change estimates for the double-burden group which were modestly negative (change=-0.05 SD) and non-supported (p=0.220) as being different from the no-burden group (change=-0.34 SD). SPM estimates of informative relationships connecting the longitudinal (cognitive decline) submodel with the survival submodels (dementia and death) were highly supported (p<0.0001 for both). Including informative competing events such as dementia and deaths in studies of cognitive decline can improve estimates and understanding of the interplay between cognitive decline and cause-specific dropout mechanisms.

Persistent lesion hyperintensity on brain diffusion-weighted MRI is an early sign of intravascular lymphoma

A 63-year-old man presented with right-sided hemianopia and unsteady gait. Brain MRI revealed multiple hyperintense infarct-like lesions on diffusion-weighted images (DWI). Hyperintensity persisted in some of these lesions even after...

New daily persistent headache: A lack of an association with white matter abnormalities on neuroimaging.

To provide results from the largest study of new daily persistent headache patients to date and specifically evaluate if patients with primary new daily persistent headache develop white matter abnormalities or infarct-like lesions on neuroimaging. Retrospective analysis of patient medical records utilizing an electronic medical record system. All patients were seen at a headache specialty clinic by a single headache neurologist and diagnosed with primary new daily persistent headache during the time period of January 2009 to January 2013. Altogether, 97 patients were diagnosed with primary new daily persistent headache (65 women and 32 men). The mean average age of onset was slightly younger in women than men: 32.4 years vs. 35.8 years. In total, 84 of the 97 new daily persistent headache patients had no white matter abnormalities or infarct-like lesions on magnetic resonance imaging with a gender distribution of 56 women and 28 men. The mean age of onset of this white matter negative subgroup was 31.1 years. Of these individuals, 36% had cardiovascular/cerebrovascular risk factors and 44% had a history of migraine. Only 13 new daily persistent headache patients (nine women, four men) demonstrated white matter abnormalities on magnetic resonance imaging. None had infarct-like lesions. The mean age of onset of this white matter positive subgroup was 54.2 years, significantly older than the white matter negative population (p < .05). All new daily persistent headache patients in the white matter positive subgroup had cardiovascular/cerebrovascular risk factors and dual risk factors were noted in seven of 13 patients. Only 23% had a migraine history. Almost 40% of the patients in the white matter negative group were imaged 3 years after headache onset and at least six patients were imaged at least 9 years or more after onset of new daily persistent headache. Triggering events in both white matter lesion positive and negative populations were typical of the new daily persistent headache population as a whole and not specific to the presence or absence of brain imaging lesions except for a post-surgery trigger, which was significantly more likely to occur in the white matter positive group. Migraine associated symptoms occurred in 77% of the white matter negative subgroup compared with 46% of the white matter positive subgroup, which was a significant difference. White matter abnormalities and infarct-like lesions do not appear to occur in primary new daily persistent headache patients. Only new daily persistent headache patients with risk factors (cardiovascular/cerebrovascular or migraine) developed white matter abnormalities on brain magnetic resonance imaging. No patient with new daily persistent headache developed infarct-like lesions. New daily persistent headache triggering events (outside of possibly post-surgery) or the presence of migrainous symptoms did not appear to enhance the development of white matter abnormalities.

Overweight and Obesity in Midlife and Brain Structure and Dementia 26 Years Later: The AGES-Reykjavik Study.

High adiposity in midlife might increase risk for late-life brain pathology, including dementia. Using data from the prospective Age, Gene/Environment Susceptibility-Reykjavik Study of men and women (born 1907-1935), we studied the associations of overweight and obesity at midlife (mean age, 50 (standard deviation, 4.7) years) with 1.5-T brain magnetic resonance imaging measures of infarct-like brain lesions, cerebral microbleeds, total brain volume, and white matter lesions volume, as well as dementia, in late life (mean age, 76 (standard deviation, 5.2) years). We used linear and Poisson models to estimate associations in 3,864 persons after adjustment for sociodemographic, health, and lifestyle characteristics. In midlife, the prevalence of overweight was 39% and that of obesity was 8%. After a mean follow-up of 26.2 (standard deviation, 4.9) years, midlife overweight and obesity were not associated with infarct-like brain lesions (relative risk (RR) = 0.82, 95% confidence interval (CI): 0.61, 1.10), cerebral microbleeds (RR = 0.69, 95% CI: 0.37, 1.32), total brain volume (β = 0.05, 95% CI: -0.34, 0.45), white matter lesions volume (β = -0.10, 95% CI: -0.20, 0.01), or dementia (RR = 0.91, 95% CI: 0.49, 1.72) compared with normal weight. These findings do not support the hypothesis that high body mass index in midlife modulates the risk for dementia.

Migraine and the risk for stroke and cardiovascular disease.

Numerous data have pointed to an association between migraine and cardiovascular diseases. The majority of the available data have indicated that migraine with aura can be considered a risk factor for ischemic stroke, whereas migraine without aura cannot be reliably considered as such. High frequency of attacks and a recent onset of migraine have been related to an increased ischemic stroke risk. In addition, in young subjects with ischemic stroke migraine with aura represents an independent risk factor of overall recurrent vascular events and of recurrent ischemic stroke. Also the risk of transient ischemic attack seems to be increased in migraineurs, although this issue has not been extensively investigated. Several studies have also addressed the possible association between migraine and hemorrhagic stroke. Although the results of these individual studies were conflicting, their meta-analysis showed that migraine is associated with a 1.5-fold increase in the risk of hemorrhagic stroke (including intracerebral and subarachnoid hemorrhage). Some studies have identified migraine also as a possible risk factor for cardiac vascular events while others have yielded negative results. A meta-analysis did not show an increased risk of myocardial infarction in subjects with any migraine vs no migraine but subsequently, data has pointed to an association between any migraine with cardiac ischemic disease. Migraine has also been associated by some studies with vascular mortality and with vascular diseases in regions other than the brain and the heart. Several studies have also indicated that compared with nonmigraineurs, migraineurs have a higher burden of asymptomatic white matter brain lesions and, according to some studies, also infarct-like lesions at brain magnetic resonance. The mechanisms underlying the relationship between migraine and cardiovascular disease are still unclear. The possible explanation may rely on a peculiar vascular vulnerability of migraineurs that may contribute to the pathogenesis of migraine and, in the presence of some other unknown factors may also contribute, over time, to the development of cardiovascular disease. At the moment, there are no reliable features that may indicate which subjects, across the overall migraine population, will develop vascular events and so far, no drugs are recommended for the vascular prevention in migraineurs unless other clear indications are present. In general, the acute treatment and the secondary prevention measures of a patient with stroke who has a history of migraine do not differ from that of other stroke patients. There is currently no direct evidence to support that a migraine prophylactic treatment will reduce future stroke risk in secondary prevention.

Migraine and structural abnormalities in the brain.

The aim is to provide an overview of recent studies of structural brain abnormalities in migraine and to discuss the potential clinical significance of their findings. Brain structure continues to be a topic of extensive research in migraine. Despite advances in neuroimaging techniques, it is not yet clear if migraine is associated with grey matter changes. Recent large population-based studies sustain the notion of increased prevalence of white matter abnormalities in migraine, and possibly of silent infarct-like lesions. The clinical relevance of this association is not clear. Structural changes are not related to cognitive decline, but a link to an increased risk of stroke, especially in patients with aura, cannot be ruled out. Migraine may be a risk factor for structural changes in the brain. It is not yet clear how factors such as migraine sub-type, attack frequency, and sex affects this association. Additional longitudinal studies are needed to address these issues. Brain structure changes in migraine could potentially serve as disease biomarkers or as a mean of identifying sub-groups of patients with specific therapeutic needs and prognoses.

Diagnostic value of brain biopsy in intravascular large B-cell lymphoma mimickingprogressive multifocal leukoencephalopathy: Case report

We report a 68-years-old woman with systemic sclerosis and interstitial pneumonia (IP). She had developed subacute progressively encephalopathy and dementia while treated with oral cyclophosphamide and prednisolone. She admitted to our hospital because of syncope. Laboratory tests indicated slight elevated cerebrospinal fluid protein, and levels of serum C-reactive protein (CRP), levels of soluble IL-2 receptor was normal. But, magnetic resonance imaging (MRI) of the brain showed multiple infarct-like lesions mainly in the white matter, which mimics progressive multiple leukoencephalopathy (PML). Twenty days after admission, the retested MRI of the brain disclosed initial lesions progressively enlarged and numbers of the lesions were increased. The polymerase chain reaction (PCR) for JC virus of cerebrospinal fluid was negative. To make diagnosis, brain biopsy was performed. Microscopic examination revealed that small vessels were filled with lymphoma cells (CD20+, CD79+, CD3-), and intravascular lymphoma (IVL) was diagnosed. She treated with regimens of R-CHOP. After chemotherapy her consciousness and dementia were gradually improved. IVL of central nerve system (CNS) is a rare disease, and its common symptoms are ischemia, infarction and dementia. Diagnosis of IVL of CNS is difficult when the lesion mimics PML, and patient with similar laboratory examinations and radiographic findings of PML should undergo brain biopsy detected malignant cell in small vessels, which is a value of diagnosis.

Chronic migraine does not increase posterior circulation territory (PCT) infarct-like lesions

Two population-based studies have found an increased prevalence of posterior circulation territory (PCT) infarct-like lesions in migraine, which seemed to increase with attack frequency. ObjectiveTo determine whether chronic migraine (CM) patients are at increased risk of PCT infarct-like lesions. MethodsWe prospectively obtained brain MRIs from adult women fulfilling CM criteria. To keep radiologists blinded we also obtained brain MRIs in 15 episodic migraine (EM) patients. MRIs were acquired on a 1.5T unit. Protocol included whole brain weighted images in sagittal T1 (5mm slices), axial FLAIR T2 (3mm) and combined proton density and T2 fast spin echo (3mm). Two independent neuroradiologists carefully analyzed all the images. ResultsOne hundred women with CM participated. Their ages ranged from 18 to 68years (mean 43.7) and the length of CM ranged from 0.5 to 38years (mean 9.8). Sixty-three patients (63%) had at least one vascular risk factor. Thirty-three met analgesic overuse criteria. Fifty-one had a history of migraine with aura attacks, though aura frequency was below one per month in all patients except one. Eleven were not on preventatives. We found PCT infarct-like lesions in only 6 CM patients aged 42–64years (mean age 54years) who had at least two vascular risk factors. ConclusionsAs frequency of PCT infarct-like lesions in our CM patients was in the low range than that found for EM in general population studies, we conclude that frequency of migraine attacks itself is not a factor increasing PCT infarct-like lesion risk.