Silent brain infarct in migraine: Systematic review and meta-analysis.

BACKGROUND: While migraine, particularly migraine with aura, is a recognized risk factor for ischemic stroke, the association of migraine with silent brain infarction is a matter of debate, as studies on this topic have yielded conflicting results. METHODS: A systematic review of the literature was conducted of studies reporting migraine and silent brain infarction, assessed by magnetic resonance imaging, between January 1980 and April 2022, by consulting Medline and Embase databases. Studies with a control group were included in a meta-analysis of population-based studies. An exploratory meta-analysis of both population-based and clinical-based studies was further performed to test the association between migraine with aura and silent brain infarction. RESULTS: A total of 2,408 articles were identified, among which 24 were included in the systematic review and 10 in the meta-analysis. The meta-analysis of population-based studies showed no association of migraine with silent brain infarction (odds ratio (OR)=1.32 [95% CI 0.92;1.90], P=0.13) and migraine with aura with silent brain infarction (OR=1.56 [0.74;3.30], P=0.24). However, in the exploratory meta-analysis of population-based and clinical-based studies, migraine with aura was significantly associated with silent brain infarction (OR=1.91 [1.02;3.59], P=0.04) and to silent cerebellar infarcts (OR=2.57 [1.01;6.56], P=0.05). CONCLUSION: In this updated systematic review and meta-analysis of population-based studies, migraine and migraine with aura were not associated with silent brain infarction.

Large artery intracranial stenosis in young adults with ischaemic stroke.

Large artery intracranial stenosis (ICS) is a common finding in stroke patients, but is much less prevalent in Western countries than in Asia and in young adults than in the elderly. We investigated the prevalence and causes of ICS among French young adults with ischaemic stroke. Clinical and radiological data of patients aged 18-54 years treated consecutively for acute ischaemic stroke in the anterior circulation at a tertiary stroke centre were analysed retrospectively. Patients with>50% ICS were identified. ICS was evaluated using TOF-MRA, vessel wall-MRI, digital subtraction angiography and CT-angiography. A total of 316 patients were included. ICS was diagnosed in 29 patients, resulting in a prevalence of 9.2% (95% CI, 6.2 to 13.3). The leading cause of ICS was atherosclerosis (n=13), ahead of moyamoya disease (n=4), dissection (n=2), vasculitis (n=2), and reversible cerebral vasoconstriction syndrome (n=1). The cause of ICAS could not be determined in 7 patients. ICS was found in nearly one in 10 ischaemic strokes among French young adults. Atherosclerosis was the leading cause of ICS. The cause of ICS could not be determined in almost a quarter of the patients.

Should CT angiography of the supra-aortic arteries be performed systematically following attempted suicide by hanging?

PURPOSE: Characterize and determine the frequency of dissections of the supra-aortic arteries (SAA) and injuries to the cervical spine and pharyngolaryngeal cartilages viewed on CT scans after an attempted suicide by hanging. MATERIALS AND METHODS: A retrospective, single-centre study of all patients admitted for attempted suicide by hanging between January 2010 and June 2017 who received CT angiography of the SAA. Search for signs of dissection of the cervical arteries and injuries to the brain, spinal column and pharyngeal and laryngeal cartilages. The results were compared with the initial clinical severity, which was assessed indirectly by whether patients were initially admitted in an intensive care unit (ICU) or in an emergency department (ED). RESULTS: Out of 162 patients included, 4 presented with SAA dissection (2.5%), comprising 3 vertebral arteries and 1 external carotid artery. The cases in question were of 4 men, all in cardiac arrest on arrival and all were treated in ICU. Of the most serious cases, 18/72 (25%) had anoxia-related injuries and one also presented with a C2 fracture. No vascular lesions or signs of cerebral anoxia were observed in the 90 ED patients. Nevertheless, pharyngeal and laryngeal fractures were observed in both groups, with no significant difference. CONCLUSION: In our study, 2.5% of CT angiograms performed after an attempted hanging revealed SAA dissection. Crucially, only most severe patients, who have been immediately admitted to ICU suffered SAA. These results call into question the systematic indication of this exam in cases of hanging attempts.

Advanced multiparametric magnetic resonance imaging of multinodular and vacuolating neuronal tumor.

BACKGROUND AND PURPOSE: Multinodular and vacuolating neuronal tumor (MVNT) of the cerebrum is a rare brain lesion with suggestive imaging features. The aim of our study was to report the largest series of MVNTs so far and to evaluate the utility of advanced multiparametric magnetic resonance (MR) techniques. METHODS: This multicenter retrospective study was approved by our institutional research ethics board. From July 2014 to May 2019, two radiologists read in consensus the MR examinations of patients presenting with a lesion suggestive of an MVNT. They analyzed the lesions' MR characteristics on structural images and advanced multiparametric MR imaging. RESULTS: A total of 64 patients (29 women and 35 men, mean age 44.2 ± 15.1 years) from 25 centers were included. Lesions were all hyperintense on fluid-attenuated inversion recovery and T2-weighted imaging without post-contrast enhancement. The median relative apparent diffusion coefficient on diffusion-weighted imaging was 1.13 [interquartile range (IQR), 0.2]. Perfusion-weighted imaging showed no increase in perfusion, with a relative cerebral blood volume of 1.02 (IQR, 0.05) and a relative cerebral blood flow of 1.01 (IQR, 0.08). MR spectroscopy showed no abnormal peaks. Median follow-up was 2 (IQR, 1.2) years, without any changes in size. CONCLUSIONS: A comprehensive characterization protocol including advanced multiparametric magnetic resonance imaging sequences showed no imaging patterns suggestive of malignancy in MVNTs. It might be useful to better characterize MVNTs.

Acute ischaemic lesions are associated with cortical superficial siderosis in spontaneous intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Diffusion-weighted imaging (DWI) commonly detects acute ischaemic lesions in patients with acute intracerebral hemorrhage (ICH), especially with cerebral amyloid angiopathy (CAA). We investigated the relationship between cortical superficial siderosis (cSS), a neuroimaging marker of CAA, and DWI lesions in patients with acute ICH. METHODS: We conducted a retrospective analysis of prospectively collected data from consecutive patients with acute supratentorial ICH who underwent brain magnetic resonance imaging within 10 days after symptom onset. Magnetic resonance imaging scans were analyzed for DWI lesions, cSS and other markers for small-vessel disease. Univariate and multivariate analyses were performed to assess the association between cSS and DWI lesions. RESULTS: Among 246 ICH survivors (mean age 71.4 ± 12.6 years) who were enrolled, 126 had lobar ICH and 120 had deep ICH. Overall, DWI lesions were observed in 38 (15.4%) patients and were more common in patients with lobar ICH than deep ICH (22.2% vs. 8.3%; P = 0.003). In multivariate logistic regression analysis, the extent of white matter hyperintensities [odds ratio (OR), 1.29; 95% confidence interval (CI), 1.05-1.58; P = 0.02] and cSS severity (focal cSS: OR, 3.54; 95% CI, 1.28-9.84; disseminated cSS: OR, 4.41; 95% CI, 1.78-10.97; P = 0.001) were independently associated with the presence of DWI lesions. CONCLUSIONS: Diffusion-weighted imaging lesions are more frequently observed in patients with acute lobar ICH than in those with deep ICH. cSS severity and white matter hyperintensity extent are independent predictors for the presence of DWI lesions, suggesting that CAA may be involved in the pathogenesis of DWI lesions associated with acute ICH.

Cortical superficial siderosis and acute convexity subarachnoid hemorrhage in cerebral amyloid angiopathy.

BACKGROUND AND PURPOSE: Acute convexity subarachnoid hemorrhage (cSAH) and cortical superficial siderosis (cSS) are neuroimaging markers of cerebral amyloid angiopathy (CAA) that may arise through similar mechanisms. The prevalence of cSS in patients with CAA presenting with acute cSAH versus lobar intracerebral hemorrhage (ICH) was compared and the physiopathology of cSS was explored by examining neuroimaging associations. METHODS: Data from 116 consecutive patients with probable CAA (mean age, 77.4 ± 7.3 years) presenting with acute cSAH (n = 45) or acute lobar ICH (n = 71) were retrospectively analyzed. Magnetic resonance imaging scans were analyzed for cSS and other imaging markers. The two groups' clinical and imaging data were compared and the associations between cSAH and cSS were explored. RESULTS: Patients with cSAH presented mostly with transient focal neurological episodes. The prevalence of cSS was higher amongst cSAH patients than amongst ICH patients (88.9% vs. 57.7%; P < 0.001). In multivariable logistic regression analysis, focal [odds ratio (OR) 6.73; 95% confidence interval (CI) 1.75-25.81; P = 0.005] and disseminated (OR 11.68; 95% CI 3.55-38.35; P < 0.001) cSS were independently associated with acute cSAH, whereas older age (OR 0.93; 95% CI 0.87-0.99; P = 0.025) and chronic lobar ICH count (OR 0.45; 95% CI 0.25-0.80; P = 0.007) were associated with acute lobar ICH. CONCLUSIONS: Amongst patients with CAA, cSS is independently associated with acute cSAH. These findings suggest that cSAH may be involved in the pathogenesis of the cSS observed in CAA. Longitudinal studies are warranted to assess this potential causal relationship.

Main inherited neurodegenerative cerebellar ataxias, how to recognize them using magnetic resonance imaging?

Ataxia is a neurodegenerative disease resulting from brainstem, cerebellar, and/or spinocerebellar tracts impairments. Symptoms onset could vary widely from childhood to late-adulthood. Autosomal cerebellar ataxias are considered as one of the most complex group in neurogenetics. In addition to their genetic heterogeneity, there is an important phenotypic variability in the expression of cerebellar impairment, complicating the genetic mutation research. A pattern recognition approach using brain MRI measures of atrophy, hyperintensities and iron-induced hypointensity of the dentate nuclei, could be therefore helpful in guiding genetic research. This review will discuss a pattern recognition approach that, associated with the age at disease onset, and clinical manifestations, may help neuroradiologists differentiate the most frequent profiles of ataxia.

Intractable epistaxis: which arteries are responsible? An angiographic study.

PURPOSE: Epistaxis constitutes a significant proportion of the Otolaryngologist's emergency workload. Optimal management differs in relation to the anatomic origin of the bleeding. The outcome of our study was to determine which artery(ies) could be considered as the cause of severe bleeding in the context of severe epistaxis. METHODS: Fifty-five procedures of embolization preceded by angiography were reviewed. Medical records of interventionally treated patients were analysed for demographics, medical history, risk factors and clinical data. Angiographic findings were also assessed for active contrast extravasation (blush), vascular abnormality and embolised artery. RESULTS: Previous angiography showed an active contrast extravasation in only 20 procedures. The most common bleeding source was the sphenopalatine artery (SPA) followed by anterior ethmoïdal artery (AEA) and facial artery. Majority of multiple or bilateral extravasations occured in patients with systemic factors. CONCLUSIONS: A better understanding of the potential bleeding source might help and limit the risk of treatment failures. Our study confirms that the SPA is the most common cause of severe bleeding. We also emphasise the role of the AEA not only in traumatic context. Others arteries are rarely involved except in patients with comorbidities or frequent recurrences.

[Facial linear scleroderma associated with neurological abnormalities relating to microangiopathy]. / Sclérodermie linéaire de la face associée à des anomalies neurologiques par microangiopathie.

BACKGROUND: Linear scleroderma is a fibrotic disease affecting the skin and sometimes the deeper tissues. We describe a case of scleroderma associated with neurological anomalies not previously reported in the literature. PATIENTS AND METHODS: A 16-year-old male patient presented in 2009 for hemifacial linear scleroderma. Treatment with methotrexate for 14 months resulted in stabilization of the disease. In 2013, we noted worsening of the patient's skin lesions as well as homolateral ptosis. Head MRI revealed unilateral hemispherical signal abnormalities with T2 hypersignal in the basal gangliaand punctate foci of T2* hyposignal corresponding to microbleeds. In 2014 and 2015, the patient presented three brief episodes of right hemicorpus paresthesia (with temporary aphasia followed by headache during the first episode). The head MRI showed worsening of the anomalies, suggesting progressing cerebral microangiopathy. DISCUSSION: Clinicians may not always be familiar with the neurological abnormalities associated with localized facial scleroderma even if such abnormalities are not uncommon (their exact prevalence is unknown). Clinical signs vary but, in most cases, the radiological features are calcifications and hyperintense foci of white matter lesions in T2. As far as we are aware, there have been no reports to date of microbleeding as observed in our patient. The worsening with time of these neurological anomalies of unknown origin does not appear to be correlated with the dermatological lesions. It is important for dermatologists be aware of these complications of facial linear scleroderma.

Peripheral late reactivation of a previously typical monofocal Baló's concentric sclerosis lesion.

We report a 41-year-old woman with rapidly progressive left hemiparesis, revealing an inflammatory reactivation of a previously known parietal Baló's concentric sclerosis lesion. The first attack occurred five years before. After a slow recovery following high-dose steroid infusions the patient stabilized. Because of recurrent ataxia and left hemiparesis a new magnetic resonance imaging was performed showing an extension of the initial lesion with a peripheral gadolinium enhancement on T1-weighted images. Such a reactivation pattern of an isolated Baló's concentric sclerosis lesion, occurring some years later, is described for the first time.

Imaging in Erdheim-Chester disease: classic features and new insights.

Erdheim-Chester disease is a rare non-Langerhans cell histiocytosis. Osseous involvement is the most frequent feature with bilateral and symmetric osteosclerotic changes in long bone diaphyseal and metaphyseal regions, classically sparing epiphyses. 99mTc scintigraphy shows bilateral and symmetrical metaphysal and diaphyseal increased uptake in almost all the patients, even asymptomatic. Other classical features on CT-scan, very evocative of Erdheim-Chester disease, must be recognised: e.g. 'coated' aorta, 'hairy kidney' patterns. New imaging techniques such as MRI have led to a better description of cardiac and central nervous system involvements. Pachymeningitis and right atrium wall infiltration are new evocative images of this disease. Fluorodeoxyglucose Positron Emission Tomography in the diagnosis or prognosis assessment is still discussed. The objective of this review is to discuss the place of each imaging technique in Erdheim-Chester disease in 2013.

Transcranial color-coded sonography to predict recurrent transient ischaemic attack/stroke.

BACKGROUND AND PURPOSE: Patients with transient ischaemic attack (TIA) with a high risk of imminent stroke can be identified with the ABCD(2) score and findings on MRI and CT angiography. The predictive value of transcranial color-coded sonography (TCCS) has not been evaluated in this setting. METHODS: A retrospective analysis was conducted of patients consecutively treated for TIA or minor stroke in a TIA clinic within 24 h of symptom onset. Agreement between TCCS and MRI three-dimensional time-of-flight images for the diagnosis of proximal (internal carotid artery, vertebral artery, basilar artery, circle of Willis and main stem of the middle cerebral artery) >50% stenosis or occlusion of the intracranial symptomatic artery was evaluated. The sensitivity, specificity, predictive values and likelihood ratio of TCCS for predicting recurrent TIA/stroke at 7 days were calculated. RESULTS: Of 159 patients with a TIA or minor stroke within the last 24 h, 142 had a readable acoustic temporal bone window (89.3%). TCCS and MRI were performed within 4 h of each other in 116 patients. MRI showed a symptomatic proximal intracranial steno-occlusive lesion in six patients. Agreement between MRI and TCCS was perfect (κ coefficient = 1). Recurrent TIA/stroke occurred in 10 patients (eight TIA and two minor strokes). All recurrences occurred within 24 h of symptom onset. A symptomatic proximal intracranial steno-occlusive lesion was found on TCCS in 4/10 patients with recurrence and 3/132 patients without recurrence [sensitivity 40%; specificity 97.7%; likelihood ratio 18.1; odds ratio (95% CI) adjusted for ABCD(2) score 31.5 (4.5-218.6)]. CONCLUSION: Our study shows that TCCS can be used to guide triage of patients with TIA.

Migraine with aura and silent brain infarcts lack of mediation of patent foramen ovale.

BACKGROUND AND PURPOSE: Population-based studies have shown a heightened prevalence of clinically silent brain infarcts in subjects who have migraine with aura (MA). We sought to determine whether this association could be confirmed in young patients with cryptogenic ischemic stroke, and explored the role of patent foramen ovale (PFO) as a potential underlying mechanism. METHODS: Patients were selected from a registry of young patients consecutively treated for ischemic stroke in a tertiary university hospital among those without definite cause of stroke. Patients with PFO were matched for age and gender with patients with normal atrial septum. Migraine and MA were evaluated after patient selection and matching. Silent brain infarcts were independently evaluated on MRI. RESULTS: We included 100 patients [60 men; mean age (SD), 44.8 years (8.3)], 50 patients with PFO. We found silent brain infarcts in 36 patients and MA in 13 patients. MA was more frequent in patients with silent brain infarcts than in patients without silent brain infarcts (25.0% vs. 6.3%; OR, 5; 95% CI, 1.4-17.6; P = 0.01). Traditional cardiovascular risk factors were not associated with silent brain infarcts. PFO was neither associated with MA (OR, 1.7; 95% CI, 0.5-5.3) nor silent brain infarcts (OR, 0.7; 95% CI, 0.3-1.5). The association of MA with silent brain infarcts was not altered after adjustment for PFO. CONCLUSION: Findings suggest that silent brain infarcts in young patients with cryptogenic stroke is associated with MA. We found no evidence for a mediating effect of PFO on this association.

Cortical subarachnoid haemorrhage in the elderly: a recurrent event probably related to cerebral amyloid angiopathy.

OBJECTIVE: Isolated, non-traumatic, cortical subarachnoid haemorrhage (cSAH) is a rare type of cerebrovascular disease caused by various disorders. In a few cases, especially in the elderly, no apparent cause can be identified. We report a case series of patients without apparent cause of cSAH. We aimed to determine whether cerebral amyloid angiopathy (CAA) could be a common cause of cSAH. METHODS: We retrospectively analysed clinical and radiological data of consecutive patients admitted to a tertiary stroke unit with cSAH. All patients had brain MRI as a part of their initial evaluation and a repeat examination during follow-up. RESULTS: Amongst 25 patients with cSAH, 10 patients had no apparent cause of cSAH (six men and four women; mean age ± SD: 73.8 ± 8.5 years). All patients with no apparent cause presented with single or recurrent focal transient neurological symptoms of short duration. Only one patient experienced headache. cSAH was limited to one or two sulci, mostly the central sulcus. MRI showed the evidence of prior asymptomatic bleeding in 9/10 patients: cortical hemosiderosis (9/10), lobar intracerebral haemorrhage (ICH) (6/10) and cortical microbleeds (9/10). Eight of ten patients met the Boston criteria for probable CAA and 2/10 for possible CAA. During follow-up, three patients had recurrent bleeding: cSAH (2) and lobar ICH (1). CONCLUSIONS: Our findings suggest that CAA could be a common cause of cSAH in the elderly with a fairly uniform clinical presentation. In addition to prior cortical bleeding (ICH, MBs), most patients from the present series had evidence of focal cortical hemosiderosis likely corresponding with prior unrecognized cSAH and suggesting that cSAH was a recurrent event.

[Iatrogenic venous cerebral air embolism without pulmonary manifestation: A retrograde mechanism?]. / Embolie gazeuse cérébrale iatrogène d'origine veineuse sans signe respiratoire : un mécanisme rétrograde ?

INTRODUCTION: Air embolism is a rare complication of various invasive medical procedures. Venous cerebral air embolism is usually the consequence of paradoxical embolism. We report a case of isolated cerebral air embolism resulting from a non-paradoxical mechanism. CASE REPORT: A few minutes after his central venous catheter had been accidentally disconnected, a 63-year-old man developed left-sided rhythmic jerking movements followed by left hemiplegia. There were no associated cardiologic or pulmonary signs. Brain CT showed air bubbles in the right frontal cortical sulci. The brain MRI DWI and FLAIR sequences showed a high intensity right frontal cortical lesion without reduction in ADC. Transesophageal echocardiogram did not find a patent foramen ovale. CONCLUSIONS: In this case of venous cerebral air embolism, the lack of any cardiopulmonary manifestation, the lack of a patent foramen ovale and the neuroradiological findings are not in favor of the hypothesis of paradoxical embolism. The hypothesis of retrograde venous cerebral air embolism is discussed.

[Interest of MR perfusion and MR spectroscopy for the diagnostic of atypical cerebral toxoplasmosis]. / Apport de l'IRM de perfusion et de la spectroscopie dans le diagnostic de toxoplasmose cérébrale atypique.

We report an atypical case of cerebral toxoplasmosis (CT) in a 70-year-old woman with a history of breast cancer. Contrast-enhanced computed tomography revealed a single ring-enhancing lesion in the pons with perifocal oedema and mass effect. Toxoplasma encephalitis was suggested by means of diffusion weighted imaging, MR perfusion and MR spectroscopy, leading to the discovery of HIV infection. The patient was put on antitoxoplasma therapy. Subsequent clinical and radiological improvements confirmed the diagnosis.

[Central nervous system involvement in systemic diseases: Spectrum of MRI findings]. / Imagerie des atteintes intracrâniennes au cours des maladies systémiques.

Central nervous system (CNS) involvement in systemic disease (SD) is unusual. MRI features of such lesions are unfamiliar to most radiologists. The diagnosis of SD is still based on clinical features and laboratory findings but some characteristic MRI findings exist for each SD: micronodular leptomeningeal enhancement in sarcoidosis, diffuse or focal pachymeningeal involvement in Wegener disease, dentate nuclei and brain stem lesions in Langerhans cell histiocytosis, meningeal masses, dentate nuclei lesions and periarterial infiltration in Erdheim-Chester disease, meningeal masses in Rosai-Dorfman disease, veinular pontic lesions and cerebral vein thrombosis in Behçet, supratentorial microvascular lesions in lupus and antiphospholipid and Gougerot-Sjögren syndrome. In this work, we explain, describe and illustrate the most characteristic MRI findings for each disease.

Standard Diffusion-Weighted Imaging in the Brain Can Detect Cervical Internal Carotid Artery Dissections.

BACKGROUND AND PURPOSE: The ICA is the most common site of cervical artery dissection. Prompt and reliable identification of the mural hematoma is warranted when a dissection is clinically suspected. The purpose of this study was to assess to capacity of a standard DWI sequence acquired routinely on the brain to detect dissecting hematoma related to cervical ICA dissections. MATERIALS AND METHODS: This was a retrospective study of a cohort of 110 patients younger than 55 years of age (40 women; mean age, 46.79 years) admitted at the acute phase of a neurologic deficit, headache, or neck pain and investigated by at least a standard 3T diffusion-weighted sequence of the brain. Among them were 50 patients (14 women; mean age, 46.72 years) with subsequently confirmed ICA dissection. In the whole anonymized cohort, both a senior and junior radiologist separately assessed, on the DWI sequences only, the presence of a crescent-shaped or circular hypersignal projecting on the subpetrosal segment of the ICA arteries, assuming that it would correspond to a mural hematoma related to an ICA dissection. RESULTS: The senior radiologist found 46 subpetrosal hyperintensities in 43/50 patients with ICA dissection and none in patients without dissection (sensitivity, 86%; specificity, 100%). The junior radiologist found 48 subpetrosal hyperintensities in 45/50 patients with dissection and none in patients without dissection (sensitivity, 90%; specificity, 100%). CONCLUSIONS: In our cohort, a standard DWI sequence performed on the brain at the acute phase of a stroke or for a clinical suspicion of dissection detected nearly 90% of cervical ICA dissections.