Cortical Hyperperfusion on MRI Arterial Spin-Labeling during the Interictal Period of Patients with Migraine Headache.

BACKGROUND AND PURPOSE: Concentrations of calcitonin gene-related peptide, a neuropeptide and potent endogenous vasodilator, are reportedly higher in patients with migraine than in healthy subjects, both during and between migraine attacks, reflecting ongoing activation of the trigeminal nervous system. In this prospective study, we measured CBF during the interictal period of patients with migraine after considering insomnia and depression and examined the effects of ongoing activation of the trigeminal nervous system, including during the interictal period, on CBF. MATERIALS AND METHODS: In a total of 242 patient with migraine (age range, 18-75 years), CBF was measured by MR imaging arterial spin-labeling during the interictal period and was compared with results from 26 healthy volunteers younger than 45 years of age as control subjects (age range, 22-45 years). Cortical hyperperfusion was defined as identification of ≥2 cerebral cortical regions with regional CBF values at least 2 SDs above the mean regional CBF in control subjects. RESULTS: The overall frequency of cortical hyperperfusion was significantly higher in patients with migraine (115 of 242, 48%) than in control subjects (1 of 26, 4%). Multivariable analysis revealed the 18- to 40-year age group and patients with migraine without insomnia as significant positive clinical factors associated with cortical hyperperfusion. Among patients with migraine without insomnia, the frequency of cortical hyperperfusion was >92% (89 of 97). One-way ANOVA showed that in all ROIs of the cortex, regional CBF was significantly higher in patients with migraine without insomnia than in patients with migraine with insomnia or control subjects. In patients with migraine without insomnia, cortical hyperperfusion findings showed a sensitivity of 0.918 and a specificity of 0.962 for migraine in the interictal period, representing excellent accuracy. In contrast, among patients with migraine with insomnia, sensitivity was only 0.179 but specificity was 0.962. CONCLUSIONS: Patients with migraine without insomnia may have cortical hyperperfusion during the interictal period; however, the findings of the present study need to be prospectively validated on a larger scale before clinical applicability can be considered.

Ruptured aneurysm in collateral arteries with blood-flow impairment of posterior inferior cerebellar artery: a report of three cases.

Herein, we report three cases of cerebellar hemorrhage due to a ruptured small aneurysm located on a collateral artery compensating for one or more stenotic or occluded major cerebellar arteries. In each case, endovascular distant parent artery occlusion of both the collateral artery and aneurysm was performed to prevent rebleeding. A ruptured small aneurysm in a collateral artery may be observed in patients with hemorrhage in an atypical cerebellar region, especially in cases of stenosis or occlusion of the vertebral artery or posterior inferior cerebellar artery. Thus, cerebral angiography is recommended to rule out collateral artery aneurysm.

Reversible Cerebral Vasoconstriction Syndrome Patients with a History of Migraine: A Retrospective Case-control Study.

Objective We investigated the clinical characteristics of patients with reversible cerebral vasoconstrictor syndrome who had a history of migraine before the onset and considered the relationship between these two pathologies. Methods We investigated 98 patients who underwent magnetic resonance angiography within 14 days of the onset of reversible cerebral vasoconstriction syndrome at our hospital. Of these, 11 cases involved recurrences, so data from 87 patients were analyzed. Materials All consecutive patients diagnosed with reversible cerebral vasoconstrictor syndrome at our institution between October 2010 and July 2021. Results Fifty of the 87 patients (57%) had a history of migraine. A multivariate analysis revealed that the following clinical factors were significantly more frequent in patients with a history of migraine than in those without such a history: female sex; emotional situations as a trigger of the onset; presence of deep and subcortical white matter hyperintensity, absence of vasoconstriction in the M1 portion of the middle cerebral artery, and absence of other cerebral lesions on initial magnetic resonance imaging; absence of vasoconstriction of the basilar artery on follow-up magnetic resonance imaging; and progression of deep and subcortical white matter hyperintensity in the chronic stage. Conclusion Reversible cerebral vasoconstrictor syndrome patients with a history of migraine showed clinical features of migraine, including one aspect of cerebral small-vessel disease due to endothelial dysfunction, as a common causative condition.

Possibility of arterial spin labeling perfusion magnetic resonance imaging sequences with steroid therapy for Tolosa-Hunt syndrome: A case report and review of literature.

BACKGROUND: The diagnostic criteria for Tolosa-Hunt syndrome (THS) were updated in 2013 in the 3rd Edition of the International Classification of Headache Disorders. It is now possible to diagnose THS based on the presence of granulomatous inflammation demonstrated on magnetic resonance imaging (MRI) without confirmation by biopsy. No previous study has reported the use of arterial spin labeling (ASL) perfusion MRI for diagnosing THS. Here, we report a case of THS in which ASL was used in the initial identification and to monitor therapeutic response following steroid therapy. CASE DESCRIPTION: An 86-year-old man was complaining chiefly of the left orbital pain, as well as occipital pain, nausea, epiphora, and diplopia. Neurologically, his eye movements showed left adduction disorder and palsy of the right cranial nerve III. Magnetic resonance angiography revealed no abnormality in the left internal carotid artery. Contrast-enhanced MRI showed a region of slightly high signal in the left cavernous sinus. ASL was obtained using pCASL (TR/TE, 9000/98. 48 ms; postlabeling delay: 1525 ms; axial plane) revealed hyperperfusion from the intercavernous sinus to the vicinity of the left cavernous sinus due to a local increase in cerebral blood flow. The symptoms disappeared on day 62 of the treatment and he was in complete remission. Follow-up ASL was performed every other month showed reduced perfusion as the symptoms improved and confirmed the absence of a tumor over the follow-up period. CONCLUSION: This simple technique will play an important role in confirming no recurrence after steroid therapy treatment.

Hyperintense posterior cerebral artery sign in patients with reversible cerebral vasoconstriction syndrome.

BACKGROUND: This study investigated hyperintense vessel signs (HVS) on fluid-attenuated inversion recovery imaging in the P1-2 portions of posterior cerebral arteries (PCAs) as a "hyperintense PCA sign" and HVS of cortical arteries. We retrospectively examined whether these signs would be useful in diagnosing reversible cerebral vasoconstriction syndrome (RCVS) in the acute phase. METHODS: Eighty patients with RCVS who underwent initial magnetic resonance imaging (MRI) within 7 days of onset were included in this study. HVS and related clinical factors were examined. RESULTS: On initial MRI of RCVS patients, hyperintense PCA sign and HVS of cortical arteries were seen in 21 cases (26%) and 38 cases (48%), respectively. In patients showing hyperintense PCA sign, vasoconstriction of the A2-3 portion was a significant clinical factor. Conversely, vasoconstriction of the M1 and P1 portions and the presence of white matter hyperintensity on initial and chronic-stage MRI were significantly associated with the presence of HVS in cortical arteries. CONCLUSION: Because rich collateral flow exists around PCAs, the frequency of hyperintense PCA sign is not high. However, hyperintense PCA sign findings in patients with suspected RCVS offer credible evidence of extreme flow decreases due to vasoconstriction in peripheral PCAs and other arteries associated with the collateral circulation of PCAs. Conversely, HVS in cortical arteries tend to reflect slow antegrade circulation due to vasoconstriction of peripheral vessel and major trunks. Both signs appear useful for auxiliary diagnosis of acute-phase RCVS.

Differentiation between ICA and ECA Feeder Distributions in Meningioma Using MR Perfusion Original Image.

OBJECTIVE: Preoperative information regarding tumor feeder distribution is important in meningioma surgery. We aimed to examine the relationship between the contrast-enhancement pattern in meningioma on magnetic resonance (MR) perfusion images and the feeder pattern. METHODS: The subjects were 21 patients diagnosed with meningioma who underwent MR perfusion imaging between 2017 and 2020. RESULTS: The distribution of feeders from the internal carotid artery (ICA) system or external carotid artery (ECA) system within the tumor based on angiograms was compared with that in areas of enhancement on original MR perfusion images in seven of 21 patients who underwent cerebral angiography. The aspect ratios of tumors, which was defined as the ratio of the area of contrast enhancement to the length of the enhanced area in contact with the tumor margin on the early-phase MR perfusion images, supplied by the ICA (pial feeder pattern) and ECA (dural feeder pattern) systems were 0.12 ± 0.11 and 7.21 ± 4.99 (mean ± standard deviation), respectively (p < 0.0001). MR perfusion imaging in all 21 patients revealed higher frequency of the pial feeder pattern in patients with peritumoral edema (p = 0.0009). CONCLUSION: The distribution of pial and dural feeders within a meningioma could be distinguished by the aspect ratio based on original MR perfusion images.

Simple Identification of Cerebrospinal Fluid Turbulent Motion Using a Dynamic Improved Motion-sensitized Driven-equilibrium Steady-state Free Precession Method Applied to Various Types of Cerebrospinal Fluid Motion Disturbance.

The motion of cerebrospinal fluid (CSF) within the subarachnoid space and ventricles is greatly modulated when propagating synchronously with the cardiac pulse and respiratory cycle and path through the nerves, blood vessels, and arachnoid trabeculae. Water molecule movement that propagates between two spaces via a stoma, foramen, or duct presents increased acceleration when passing through a narrow area and can exhibit "turbulence." Recently, neurosurgeons have started to perform fenestration procedures using neuroendoscopy to treat hydrocephalus and cystic lesions. As part of the postoperative evaluation, a noninvasive diagnostic technique to visualize the water molecules at the fenestrated site is necessary. Because turbulence is observed at this fenestrated site, an imaging technique appropriate for observing this turbulence is essential. We therefore investigated the usefulness of a dynamic improved motion-sensitized driven-equilibrium steady-state free precession (Dynamic iMSDE SSFP) sequence of magnetic resonance imaging that is superior for ascertaining turbulent motions in healthy volunteers and patients. Images of Dynamic iMSDE SSFP from volunteers revealed that CSF motion at the ventral surface of the brainstem and the third ventricle is augmented and turbulent. Moreover, our findings confirmed that this technique is useful for evaluating treatments that utilize neuroendoscopy. As a result, Dynamic iMSDE SSFP, a simple sequence for visualizing CSF motion, entails a short imaging time, can extensively visualize CSF motion, does not require additional processes such as labeling or trigger setting, and is anticipated to have wide-ranging clinical applications in the future.

Neuroendoscopic Evacuation for Spontaneous Cerebellar Hemorrhage Is a Safe and Secure Approach and May Become a Mainstream Technique.

Patients with spontaneous cerebellar hemorrhage present with rapidly deteriorating neurological symptoms due to a hematoma-induced mass effect in the brainstem. We compared the standard surgical approach of a suboccipital craniectomy with neuroendoscopic surgery for treating spontaneous cerebellar hemorrhage. We performed a retrospective analysis of 41 patients indicated for surgery to treat spontaneous cerebellar hemorrhage. At our hospital, craniectomy was performed until 2010, and neuroendoscopic surgery was performed thereafter when a qualified surgeon was available. Duration of surgery and intraoperative blood loss were lower in the neuroendoscopic surgery group. The extent of hematoma removal and the percentage of patients requiring shunting were similar between groups. The mass effect was resolved in all patients in both groups, and no substantial re-bleeding was observed in either group. The outcomes at discharge were comparable between the two groups. Our surgeons used the supine lateral position, which involves fewer burdens to the patient than the prone position. Selection of the site of the burr hole is important to avoid the midline and to avoid the area exactly above the transverse and sigmoid sinus. Our results suggest that minimally invasive neuroendoscopic surgery is safe and superior to craniectomy due to shortened duration of surgery and decreased intraoperative bleeding.

Effects of Pre-Existing Comorbidities on Outcomes in Patients with Chronic Subdural Hematoma.

OBJECTIVE: The number of patients with chronic subdural hematoma (CSDH) showing comorbidities and/or impaired activities of daily living (ADL) before the onset of CSDH has increased with the recent aging of society. The purposes of this study were to evaluate ADL worsening by comparing premorbid ADL and ADL at discharge and to investigate the effects of pre-existing comorbidity-related clinical factors on the outcomes. METHODS: A total of 570 patients with CSDH admitted from 2006 to 2016 were studied retrospectively. Clinical factors, including pre-existing comorbidities, related to outcomes were identified by multivariate analysis. A variation of the modified Rankin Scale (mRS) using 5 united categories of mRS scores 0/1, 2, 3/4, 5, and dead was used for evaluation of ADL. RESULTS: Of 570 patients, 390 (68.4%) had pre-existing comorbidities and 120 (21.1%) showed premorbid impaired ADL (mRS scores 2 and worse). Considering pre-existing impaired ADL, ADL deteriorated after CSDH in 92 patients (16.1%), whereas ADL impairment at discharge was found in 173 patients (30.4%). Comorbidities related to ADL deterioration on multivariate analysis were hemodialysis and chronic heart failure. Antithrombotic use for cardiovascular diseases was a predictor of acute-on-chronic subdural hematoma, which was the sole common predictor for ADL deterioration and the occurrence of surgical complications. CONCLUSIONS: In patients with CSDH, pre-existing comorbidity-linked factors related to outcomes were hemodialysis, chronic heart failure, and antithrombotic use. Patients with acute-on-chronic subdural hematoma with these factors should be regarded as a high-risk group.