Nonspecific White Matter Hyperintensities Research Articles

Case Report of Anti-DPPX Encephalitis: Diagnostic Challenges in Hematologic-Oncologic Comorbidities (P5-5.024)

<h3>Objective:</h3> Describe a case of anti-dipeptidyl-peptidase-like protein-6 (DPPX) encephalitis with attention to hematologic-oncologic comorbidities. <h3>Background:</h3> Anti-DPPX encephalitis is a rare autoimmune encephalitis with prodromal features of weight loss and gastrointestinal symptoms, followed by cognitive impairment and central nervous system hyperexcitability. Due to atypical and variable presentation, diagnosis is frequently delayed. Autoimmune encephalitis is associated with malignancies, and three cases of anti-DPPX encephalitis have been linked to hematologic malignancies. <h3>Design/Methods:</h3> Consent was obtained from patient’s wife. PubMed and Ovid databases were searched using terms (“DPPX” and “lymphoma”) as well as “DPPX”. <h3>Results:</h3> A 54-year-old male presented with two months of metallic taste and unintentional weight loss followed by confusion, memory impairment, hallucinations, and sleep disturbances. Neurologic exam was significant for encephalopathy, ataxia, and stimulus-induced myoclonus. Initial workup revealed mildly elevated protein in cerebrospinal fluid but no pleocytosis, MRI brain with nonspecific white matter hyperintensities, and electroencephalogram without epileptiform activity. Initial basic chemistries were within normal limits, and no vitamin deficiencies were identified. Intravenous methylprednisolone (1000 mg) was initiated for suspected autoimmune encephalitis. After anti-DPPX antibody returned positive, he received additional first- and second-line treatment with intravenous immunoglobulins, plasmapheresis and rituximab with modest improvements in encephalopathy and myoclonus. The patient had a history of monoclonal gammopathy of undetermined significance (MGUS) and tobacco use. He underwent serum protein electrophoresis, confirming IgM MGUS with low to intermediate risk of malignant transformation. However, peripheral flow cytometry revealed an indeterminate kappa monotypic restricted B cell population (CD19 positive, CD5 and CD10 negative) without corresponding findings in the CSF or lymphadenopathy. In discussion with hematology-oncology, the B cell population was favored to be reactive to the anti-DPPX encephalitis, rather than a primary malignant hematologic condition. Other malignancy screening was performed and negative. <h3>Conclusions:</h3> This case highlights the challenges of determining association of anti-DPPX encephalitis with hematologic malignancy and importance of interdisciplinary collaboration. <b>Disclosure:</b> Dr. Fisher has nothing to disclose. Dr. Misiolek has nothing to disclose. Dr. Buckley has nothing to disclose.

Pathologically- confirmed Osmotic Demyelination in the Case of Clinically and Radiographically Progressive Encephalopathy due to Liver Disease and Malnutrition. (P4-4.007)

<h3>Objective:</h3> To report a case of osmotic demyelination syndrome (ODS) in a patient with alcoholic liver cirrhosis and normal sodium levels. <h3>Background:</h3> Correction of hyponatremia and chronic alcoholism have been identified as the most frequent conditions associated with osmotic demyelination syndrome (ODS). <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A 77 year old female with a history of gastric bypass surgery complicated by copper deficiency, and alcoholic liver cirrhosis was hospitalized for failure to thrive and encephalopathy. Initial MRI brain showed non-specific white matter hyperintensities. Mental status continued to worsen despite treatment with IV thiamine, copper (low 41 mcg/dL, normal 80–155), and antibiotics for presumed peritonitis. Repeat MRI brain showed T2 signal abnormality within the central pons and midbrain with sparing of the anterior pontine periphery. Serum sodium on presentation was 138 mEq/L (normal 135–145) and fluctuated during hospitalization between 133–150. She subsequently developed hypoxemic respiratory failure requiring intubation and kidney failure requiring hemodialysis. Despite all aggressive measures she remained severely encephalopathic with repeat MRI brain revealing new confluent large areas of T2 hyperintensity in the centrum semiovale and corona radiata. T2 hyperintensity in the midbrain and central pons remained unchanged. The family declined lumbar puncture and pursued comfort measures. Autopsy was performed which revealed extensive demyelination in the midbrain tegmentum with relative preservation of axons; capillary and arterial cerebral amyloid angiopathy most prominent in the cerebellar leptomeninges, extending into the cerebellar cortex; and moderate Alzheimer’s type 2 astrocytosis in the basal ganglia consistent with prior history of hepatic encephalopathy. <h3>Conclusions:</h3> Our patient was diagnosed with toxic-metabolic, hepatic encephalopathy and had progressive radiological findings suggestive of ODS. Demyelination was confirmed on autopsy with copathology including cerebral amyloid angiopathy and findings of hepatic encephalopathy. ODS must be considered with progressive MRI findings in the setting of encephalopathy with liver disease and malnutrition despite absence of significant serum sodium fluctuations. <b>Disclosure:</b> Dr. Hanson has nothing to disclose. Dr. Bronstein has nothing to disclose. Dr. Fong has nothing to disclose. Dr. Ashikian has nothing to disclose.

352. Seronegative Relapse of Brucellosis in the Central Nervous System

BackgroundBrucellosis is the most common zoonotic infection in the world. High risk areas include the Mediterranean Basin, Eastern Europe and the Middle East. Clinical presentation is quite heterogenous.CNS involvement (neurobrucellosis) varies widely, from 0,5 to 25%. This reflects a high prevalence in endemic areas and the lack of established criteria for a diagnosis. We present a patient with a seronegative relapse of brucellosis, confined in the CNS, identified by Brucella IgG ELISA and 16S rRNA sequencing.MethodsCase ReportResultsA 60-year-old man, farmer, with a history of systematic brucellosis two years before admission, presented with high fever, headache and agitation. A serum agglutination test and anti-Brucella IgG ELISA were negative at baseline. Spinal tap revealed lymphocytosis and low glucose. CSF culture was negative. The patient received ceftriaxone, ampicillin and acyclovir with an initial remission. A week later the patient’s symptoms relapsed. Administration of ceftriaxone and acyclovir was reinitiated with clinical improvement, however, lymphocytic meningitis persisted even after 15 days of treatment.Brain MRI demonstrated nonspecific white matter hyperintensities and severe meningitis as identified by contrast-enhanced 3D Flair MRI. CSF oligoclonal bands showed intrathecal immunoglobin synthesis. CSF agglutination tests and CSF IgG ELISA were positive for Brucella. Though CSF PCR for Brucella was negative, 16S rRNA sequencing revealed the presence of Brucella spp. Patient was treated with ceftriaxone and dexamethasone and despite an initial worsening of neurological symptoms of tremor, loss of balance, hearing loss and diplopia, a clinical remission was achieved after a month and a laboratory remission after eight months of treatment.Brain MRI: 3D Flair Sequence with Contrast Enhancement Table. CSF Parameters ConclusionNeurobrucellosis presents with a variety of clinical symptoms and it should always be considered in neurological patients in highly endemic areas. Establishing a diagnosis is challenging. In our patient, CSF oligoclonal bands and the agglutination test in the CSF helped in achieving a diagnosis, suggesting their possible role in the diagnostic criteria. Although still under debate, the use of corticosteroids in our patient as well as the prolonged use of ceftriaxone in the therapeutic regime were crucial.Disclosures All Authors: No reported disclosures

Incidental Brain MRI Findings in Children: A Systematic Review and Meta-Analysis.

The detection of incidental findings on children's brain MR imaging poses various practical issues because the life-long implications of such findings may be profound. Our aim was to assess the prevalence and characteristics of incidental brain MR imaging findings in children. Electronic databases (PubMed, EMBASE, and Cochrane) were searched for articles published between 1985 to July 2018, with the following search terms: "incidental," "findings," "brain," "MR imaging." Inclusion criteria were the following: 1) patients younger than 21 years of age, 2) healthy children without any clinical condition, 3) MR images obtained with at least a 1.5T magnet, 4) original articles, and 5) a methodologic quality score of ≥10. Two observers independently extracted data and assessed data quality and validity. The number and type of incidental findings were pooled. Heterogeneity was assessed using the Cochran Q statistic and the I2 statistic. Seven studies were included, reporting 5938 children (mean age, 11.3 ± 2.8 years). Incidental findings were present in 16.4% (99% CI, 9.8-26.2; Q = 117.5, I2= 94.9%) of healthy children, intracranial cysts being the most frequent (10.2%, 99% CI, 3.1-28.5; Q = 306.4, I2 = 98.0%). Nonspecific white matter hyperintensities were reported in 1.9% (99% CI, 0.2-16.8; Q = 73.6, I2 = 94.6%), Chiari 1 malformation was found in 0.8% (99% CI, 0.5-1.3; Q = 7.6, I2 = 60.5%), and intracranial neoplasms were reported in 0.2% (99% CI, 0.1-0.6; Q = 3.4, I2 = 12.3%). In total, the prevalence of incidental findings needing follow-up was 2.6% (99% CI, 0.5-11.7; Q = 131.2, I2 = 95.4%). Incidental findings needing specific treatment were brain tumors (0.2%) and cavernomas (0.2%). Limitations were no age stratification or ethnicity data and variation in the design of included studies. The prevalence of incidental findings is much more frequent in children than previously reported in adults, but clinically meaningfull incidental findings were present in <1 in 38 children.

Prevalence of Potentially Clinically Significant Magnetic Resonance Imaging Findings in Athletes with and without Sport-Related Concussion.

Previous studies have shown that mild traumatic brain injury (mTBI) can cause abnormalities in clinically relevant magnetic resonance imaging (MRI) sequences. No large-scale study, however, has prospectively assessed this in athletes with sport-related concussion (SRC). The aim of the current study was to characterize and compare the prevalence of acute, trauma-related MRI findings and clinically significant, non-specific MRI findings in athletes with and without SRC. College and high-school athletes were prospectively enrolled and participated in scanning sessions between January 2015 through August 2017. Concussed contact sport athletes (n = 138; 14 female [F]; 19.5 ± 1.6 years) completed up to four scanning sessions after SRC. Non-concussed contact (n = 135; 15 F; 19.7 ± 1.6) and non-contact athletes (n = 96; 15 F; 20.0 ± 1.7) completed similar scanning sessions and served as controls. Board-certified neuroradiologists, blinded to SRC status, reviewed T1-weighted and T2-weighted fluid-attenuated inversion recovery and T2*-weighted and T2-weighted images for acute (i.e., injury-related) or non-acute findings that prompted recommendation for clinical follow-up. Concussed athletes were more likely to have MRI findings relative to contact (30.4% vs. 15.6%; odds ratio [OR] = 2.32; p = 0.01) and non-contact control athletes (19.8%; OR = 2.11; p = 0.04). Female athletes were more likely to have MRI findings than males (43.2% vs. 19.4%; OR = 2.62; p = 0.01). One athlete with SRC had an acute, injury-related finding; group differences were largely driven by increased rate of non-specific white matter hyperintensities in concussed athletes. This prospective, large-scale study demonstrates that <1% of SRCs are associated with acute injury findings on qualitative structural MRI, providing empirical support for clinical guidelines that do not recommend use of MRI after SRC.

Neuropsychiatric features of the coexistence of epilepsy and psychogenic nonepileptic seizures

ObjectiveTo investigate demographic, epidemiologic and psychiatric features suggestive of the coexistence epilepsy (ES) and psychogenic nonepileptic seizures (PNES) that may contribute to precocious suspicion of the association. MethodsIn this exploratory study, all patients older than 16 years admitted to prolonged video-electroencephalogram monitoring were evaluated about demographic, epileptological and psychiatric features. Detailed psychiatric assessment using M.I.N.I.-plus 5.0, Beck Anxiety Inventory, Beck Depression Inventory and the Childhood Trauma Questionnaire (CTQ) was performed. Data were collected previous to the final diagnosis and patients with ES-only, PNES-only or coexistence of ES/PNES were compared. ResultsOf 122 patients admitted to epilepsy monitoring unit, 86 patients were included and 25 (29%) had PNES. Twelve (14%) had PNES-only, 13 (15%) had ES/PNES and the remaining 61 (71%) had only ES. A coexistence of ES and PNES was associated with clinical report of more than one seizure type (p˂0.001), nonspecific white matter hyperintensities on MRI (p < .001) and a past of psychotic disorder (p = .005). In addition, these patients had significantly more emotional abuse and neglect (p < .002 and 0.001, respectively). Somatization (including conversion disorder) was the most common diagnosis in patients with PNES- only (83%) and co-existing of PNES and ES (69.2%), differentiating both from ES-only patients (p < .001). ConclusionThe high prevalence of this coexistence ES/PNES in this study reinforces a need to properly investigate PNES, especially in patients with confirmed ES who become refractory to medical treatment with antiepileptic drugs. The neuropsychiatric assessment may help to diagnostic suspicion and in the planning of therapeutic interventions.

Routine addition of diffusion-weighted imaging to pediatric brain imaging with acute presentation: An initial experience

Context: A number of disorders affecting the pediatric brain pose a diagnostic challenge. Magnetic resonance imaging (MRI) is widely accepted as a sensitive technique for the diagnosis of ischemia, encephalitis, and leukodystrophies. Conventional MR sequences used in routine practice include T1-weighted (T1-W), T2-weighted, and fluid-attenuation inversion recovery (FLAIR) sequences. However usually, the presentation in small children is confusing and presents a diagnostic challenge even after the use of these various MR sequences requiring repeated MRI examinations. Detecting pathological changes occurring at microenvironment level is vital for early diagnosis, effective treatment, and obviating the need of repeated MRI. Aims: The purpose of our study was to assess the additional role of diffusion-weighted imaging (DWI) in better detection of these various pathologies of brain. Settings and Design: This was a prospective study. Subjects and Methods: Thirty children of ages ranging from neonate to 12 years of age with various complaints of central nervous system involvement were evaluated with MRI brain within 72 h of initial clinical presentation. T1 and T2 spin-echo sequences FLAIR and postcontrast T1-W imaging were done. DWI was performed with echoplanar imaging using depth-resolved surface coil spectroscopy sequence. The lesions were evaluated on DWI and conventional sequences. The final diagnosis was established on the basis of clinical evaluation, electroencephalographic findings, imaging, cerebrospinal fluid analysis, serologic tests, and fatty acid evaluation in plasma assay. Statistical Analysis Used: This was a descriptive study. Results: The patients were divided into three groups. Group A included patients in whom DWI detected more lesions or showed a greater extent of lesions on apparent diffusion coefficient (ADC) map than conventional MRI. This group had 11 cases including 7 cases of ischemic encephalopathy, one case of adrenoleukodystrophy (ADL) showing increased extent of lesion with restricted diffusion at the advancing edge and 3 cases of viral encephalitis. In Group B, 12 cases had similar results in both DWI and conventional MRI imaging. Of these, 7 cases with no specific diagnosis and subsequent spontaneous recovery showed no lesion on both conventional and DWI; 5 cases showed equal extent and number of lesions on DWI; 1 case was diagnosed as ADL, 2 as viral encephalitis, and 2 as ischemic encephalopathy on final workup. In Group C, T2 and FLAIR showed more lesions than DWI and had 7 cases. 5 had normal ADC maps but 1–2 small hyperintense lesions on T2 and FLAIR imaging, while the remaining two diagnosed with ischemic encephalopathy had hyperintense areas on T2 and FLAIR sequences with associated ventricular enlargement and cortical atrophy while DWI revealed them to be T2 shine through areas with increased ADC value focally. The 5 cases with hyperintensity on T2 and FLAIR, but normal ADC maps were labeled as nonspecific white matter hyperintensities. These children showed neither any progress of lesion nor any further clinical symptoms during the duration of study. Conclusions: We concluded that DWI was more sensitive than the other MR sequences in detecting early pathological changes even in cases of viral encephalitis and leukodystrophy apart from ischemia. It was also helpful in delineating the area more accurately at the microscopic level. We were also able to rule out actual pathology from nonspecific hyperintensities on T2 and FLAIR in some cases on DWI.

Different types of white matter hyperintensities in CADASIL: Insights from 7-Tesla MRI

In Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL), by contrast to sporadic cerebral small vessel disease related to age and hypertension, white matter hyperintensities (WMH) are frequently observed in the white matter of anterior temporal poles, external capsules, and superior frontal regions. Whether these WMH (specific WMH) differ from those observed in other white matter areas (nonspecific WMH) remains unknown. Twenty patients were scanned to compare specific and nonspecific WMH using high-resolution images and analyses of relaxation times (T1R: longitudinal relaxation time and T2*R: effective transversal relaxation time). Specific WMH were characterized by significantly longer T1R and T2*R (T1R: 2309 ± 120 ms versus 2145 ± 138 ms; T2*R: 40 ± 5 ms versus 35 ± 5 ms, p < 0.001). These results were not explained by the presence of dilated perivascular spaces found in the close vicinity of specific WMH. They were not either explained by the normal regional variability of T1R and T2*R in the white matter nor by systematic imaging artifacts as shown by the study of 17 age- and sex-matched healthy controls. Our results suggest large differences in water content between specific and nonspecific WMH in CADASIL, supporting that mechanisms underlying WMH may differ according to their location.

Quantitative microstructural deficits in chronic phase of stroke with small volume infarcts: A diffusion tensor 3-D tractographic analysis

BackgroundNon-infarct zone white matter wallerian degeneration is well-documented in large volume territorial infarctions. However to what extent these abnormalities exist in small volume infarction is not known, particularly since routine T2/FLAIR MR images show minimal changes in such cases. We therefore utilized DTI based quantitative 3D tractography for quantitative assessment of white matter integrity in chronic phase of small volume anterior circulation infarcts. MethodsEleven chronic stroke subjects with small anterior circulation large vessel infarcts (≤10cm3 volume of primary infarct) were compared with 8 age matched controls. These infarcts had negligible to mild gliosis and encephalomalacia in the primary infarct territory without obvious wallerian degeneration on conventional MRI. Quantitative Diffusion Tensor 3-D tractography was performed for CST, genu and splenium of corpus callosum. Tract based Trace and fractional anisotropy (FA) were compared with age matched controls. ResultsOn univariate analysis, Chronic stroke subjects had significant elevation in Trace measurement in genu of corpus callosum (GCC), ipsilesional and contralesional CST, (p<0.05), compared to controls. After adjusting for smoking, hypertension (HTN) and non-specific white matter hyperintensities, (WMHs), there was significant elevation in trace within the ipsilesional CST (p=0.05). Contralesional CST FA correlated significantly with walking speed, r=0.67, p=0.03. ConclusionsStroke subjects with small volume infarcts demonstrate significant quantitative microstructural white matter abnormalities in chronic phase, which are otherwise subthreshold for detection on routine imaging. Ability to quantify these changes provides an important marker for assessing non-infarct zone neuroaxonal integrity in the chronic phase even in the setting of small infarction.

Subacute sclerosing panencephalitis presenting with hypersexual behavior.

Sir, Subacute sclerosing panencephalitis (SSPE) is a rare progressive demyelinating disease of the central nervous system associated with a chronic infection of brain tissue with measles virus. The disease is commonly seen in children and young adults. It is characterized by progressive intellectual deterioration, focal and/or generalized seizures, myoclonus, ataxia, and visual disturbances.[1] The presentation varies according to the age of the patient, and the diagnosis is often delayed in adults due to the atypical presentation. The hypersexual disorder is classically defined in persons aged above 18 years and is characterized by the recurrent and intense sexual urge irrespective of the situation persisting beyond 6 months.[2] The disease is usually associated with significant psychiatric ailments and also with central nervous disorders such as stroke, brain injury, and medications. SSPE presenting with hypersexual behavior is uncommon and is rarely reported in the literature. We retrospectively reviewed the data pertaining to four patients of SSPE treated at our hospital between 2012 and 2014. The diagnosis of SSPE is based on the Dyken's criteria.[3] SSPE is diagnosed, if the patient meets any three of the following five criteria: (a) Progressive intellectual deterioration with signs of myoclonus; (b) characteristic electroencephalographic (EEG) pattern; (c) elevated cerebrospinal fluid (CSF) globulin levels; (d) elevated CSF measles antibody titers; and (e) brain biopsy suggestive of measles. The demographic profile and investigation findings of all the patients are summarized in the Table 1.Table 1: Clinical details of all the four patientsBriefly, all our patients are young adults of both sexes and hail from poor socioeconomic strata of the society. All the patients presented with classical behavioral abnormalities, scholastic regression, and a couple of them presented with the hypersexual syndrome. All the patients showed a characteristic EEG pattern of periodic lateralized epileptiform discharge sequences neuroimaging revealed nonspecific white matter hyperintensities in few patients. The paired serum and CSF samples for measles ELISA IgG were positive in all the patients confirming the diagnosis of SSPE. The patients were treated with intrathecal interferon, Isoprinosine, and antipsychotic drugs including risperidone. Sodium valproate was used to control the myoclonus and seizure activity. One patient had a persistent worsening illness with recurrent seizures and succumbed to his illness at the end of 1-year of observation. Behavioral abnormalities improved in the remaining three patients, and they are under regular follow-up. In India, SSPE is still a common neurodegenerative disorder despite an increase in the measles vaccination. The diagnosis and treatment are usually delayed due to the varying presentation of the disease. Our data revealed that three patients were receiving psychiatric treatment for more than a year prior to the proper diagnosis. Poor scholastic performance and cognitive regression are important clues to the underlying diagnosis of SSPE and EEG is often diagnostic in these cases.[4] The clinical presentation of adult onset differs from childhood onset as, personality changes and ophthalmic manifestations are common presenting features and survival with treatment have been better in certain series.[5] Our data had patients from the second and third decades of life, and none of the patients had ophthalmic manifestations. Hypersexual behavior leads to social stigma and is often underreported by the patients. The same has been linked with a variety of neuropsychiatric disorders including obsessive-compulsive disorder, bipolar disorder, drugs such as dopaminergic agonists and other disorders including stroke and brain injury. The prevalence of SSPE is common among lower socioeconomic strata, large family size, and rural areas due to overcrowding. The measles virus is transmitted by respiratory secretions via aerosol exposure and also through direct contact with larger droplets.[1] A variety of metabolic disorders leads to dementia in young including Wilson's disease, hypothyroidism, B12 deficiency, etc. Our patients were investigated for these conditions and the negative screen resulted in the psychiatric diagnosis. It is essential for all the practitioners to look for myoclonus and also investigate for the rare causes of dementia such as SSPE and prion diseases. The therapy of SSPE involves the use of isoprinosine and an immunomodulator like interferon. The response to therapy depends on the clinical stage of SSPE at which the treatment was started. SSPE staging is done as per the modified Jabbour's classification and patients with stage 1 disease respond remarkably to the therapy whereas, stage 2 disease progresses invariably resulting in fatal outcomes in 2–5 years. To conclude, SSPE is a devastating disorder of public health importance in the developing countries. A high index of suspicion for SSPE is required during the evaluation of young adults with myoclonus, behavioral changes, and scholastic regression. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Brain Magnetic Resonance Imaging in Asthmatics

RATIONALE: There are no published data on magnetic resonance imaging (MRI) of the brain in asthmatics. We report brain MRI findings performed as part of a pre-specified safety evaluation in subjects aged 19 to 47 years from 2 clinical trials involving mild to moderate asthmatics. METHODS: A neuroradiologist performed a blinded review of brain MRI scans performed at baseline and repeated after 4 weeks in both studies. The combined data were compared with literature reports for cohorts of similar age, with other diseases. RESULTS: Fourteen brain MRI abnormalities were noted in 13 of 21 (62%) subjects. Non-specific deep white matter hyperintensities (24%), perivascular space (20%), and abnormal anatomic findings (14%) were noted either at baseline or follow-up. Thirty-eight percent of subjects had a normal study. A recent report found that nonspecific white matter hyperintensities were also seen in 34% of healthy subjects aged 44-48 years. A comparison between normal controls and neuropsychiatric patients reported rates of 31% and 43% in patients and normal controls respectively, for subjects aged 18-50 years. These results suggest that incidental brain MRI findings are relatively common in healthy individuals and in patients with various diseases. CONCLUSIONS: The high rate of incidental brain MRI findings observed in our study and our literature review suggests that brain MRI may not be an appropriate screening tool to evaluate potential neurologic toxicity in asymptomatic study subjects during clinical trials. If brain MRI is employed, baseline studies are required.

Diffusion Tensor Imaging and Fiber Tractography in Parry-Romberg Syndrome

We report a case of Parry-Romberg syndrome in a 32-year-old woman presenting with intermittent headache and mild sensory disturbance. MR imaging revealed minimal asymmetric atrophy of the right hemisphere with a few nonspecific white matter hyperintensities. Diffusion tensor imaging and fiber tractography, however, demonstrated clear fiber derangement, especially in the sensory tract of the right cerebral white matter.

Migraine and white matter hyperintensities

Patients with migraine are at increased risk for white matter hyperintensities detected on magnetic resonance imaging. The presence of nonspecific white matter hyperintensities may cause uncertainty for physicians and anxiety for patients. The pathophysiology and long-term consequences of these lesions are unknown. Occasionally, white matter lesions in a migraineur may indicate an underlying disease such as cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), mitochondrial encephalopathy with lactic acidosis and stroke-like episodes (MELAS), or central nervous system vasculitis. The ability to distinguish between nonspecific and disease-specific patterns of white matter hyperintensities in migraine sufferers is important for the practicing clinician.