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.

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.

Clinical significance of centripetal propagation of vasoconstriction in patients with reversible cerebral vasoconstriction syndrome: A retrospective case-control study.

Introduction We previously reported centripetal propagation of vasoconstriction at the time of thunderclap headache remission in patients with reversible cerebral vasoconstriction syndrome. Here we examine the clinical significance of centripetal propagation of vasoconstriction. Methods Participants comprised 48 patients who underwent magnetic resonance angiography within 72 h of reversible cerebral vasoconstriction syndrome onset and within 48 h of thunderclap headache remission. Results In 24 of the 48 patients (50%), centripetal propagation of vasoconstriction occurred on magnetic resonance angiography at the time of thunderclap headache remission. The interval from first to last thunderclap headache in patients with centripetal propagation of vasoconstriction (14 ± 10 days) was significantly longer than that of patients without centripetal propagation of vasoconstriction (4 ± 2 days). In the patients with centripetal propagation of vasoconstriction at the time of thunderclap headache remission, the incidence of another cerebral lesion (38%, 9 of 24 cases) was significantly higher than in patients without centripetal propagation of vasoconstriction (0%). From findings of sequential magnetic resonance angiography before and after thunderclap headache remission, we observed tendencies in which centripetal propagation of vasoconstriction gradually progressed after the onset of reversible cerebral vasoconstriction syndrome and peaked at the time of thunderclap headache remission. The progress of centripetal propagation of vasoconstriction concluded with thunderclap headache remission. Conclusions Centripetal propagation of vasoconstriction has clinical significance as an indicator of the severity of reversible cerebral vasoconstriction syndrome. The presence of centripetal propagation of vasoconstriction is associated with an increased risk of brain lesions and a longer interval from first to last thunderclap headache. Moreover, repeat magnetic resonance angiography to assess centripetal propagation of vasoconstriction during the time from onset to thunderclap headache remission can help diagnose reversible cerebral vasoconstriction syndrome.

Usefulness of attenuated vein sign and T2*-weighted imaging for diagnosis of deep cerebral venous sign--case report.

A 45-year-old woman presented with extensive deep cerebral venous thrombosis (DCVT) identified by typical direct thrombosed sign in the internal cerebral vein, vein of Galen, and straight sinus on both computed tomography and T(2)*-weighted magnetic resonance imaging. Moreover, rare direct sign, probably of the direct lateral vein, was also obtained. Direct sign of the thrombosed vein or sinus is important for the diagnosis of DCVT. The present case indicates the usefulness of attenuated vein sign and T(2)*-weighted imaging for the diagnosis of direct thrombosed vein in patients with DCVT.

Cortical subarachnoid hemorrhage caused by cerebral venous thrombosis.

Patients with non-traumatic, non-aneurysmal, and non-perimesencephalic subarachnoid hemorrhage (SAH) tend to have clots circumscribed along the cortical convexity, a condition referred to as acute cortical SAH. Cerebral venous thrombosis (CVT) is a potential cause of cortical SAH. The study tried to establish the diagnosis and management of cortical SAH caused by CVT. Retrospective review of 145 patients with non-traumatic SAH identified 15 patients with no ruptured aneurysm. Clinical features were investigated with a specific focus on patients with SAH caused by CVT. Eight of the 15 patients had perimesencephalic SAH, and 7 had cortical SAH. SAH caused by CVT was diagnosed in 4 of the 7 patients with cortical SAH. The cortical SAH involved the unilateral convexity or sylvian cistern and spared the basal cistern on computed tomography in all 4 patients. CVT occurred in the transverse sinus and cortical vein (1 patient), insular vein (1 patient), and cortical vein (2 patients). Identification of thrombosed veins or sinuses was established directly by T(2)*-weighted and diffusion-weighted magnetic resonance (MR) imaging in the acute stage and diffusion-weighted and T(1)-weighted MR imaging in the subacute stage. All patients had cortical swelling without findings of venous hemorrhagic infarction on T(2)*-weighted MR imaging. None of the 4 patients received active treatment, and all had favorable outcomes. CVT in patients with non-traumatic cortical SAH should be first excluded as a potential hemorrhagic cause by MR imaging for thrombosed veins or sinuses before initiating antifibrinolytic therapy.

Problems with diagnosis by fluid-attenuated inversion recovery magnetic resonance imaging in patients with acute aneurysmal subarachnoid hemorrhage.

The diagnostic efficacy of fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging and computed tomography (CT) for acute subarachnoid hemorrhage (SAH) were compared and the problems with diagnosis were investigated in 81 patients with aneurysmal SAH within 24 hours after onset who underwent FLAIR imaging and CT on admission. The number of hematomas in the cisterns and ventricles were evaluated by clot scores. In addition, the frequency of undetected hematomas was calculated for the cisterns and ventricles. Clot scores were significantly higher for FLAIR imaging than for CT in the lateral sylvian, quadrigeminal, and convexity cisterns. On the other hand, clot scores were significantly higher for CT than for FLAIR imaging in the interhemispheric and medial sylvian cisterns. The overall frequency of undetected SAH was 2% for FLAIR imaging and 14% for CT. With the exception of the interhemispheric and medial sylvian cisterns, the frequency of undetected SAH was higher for CT than for FLAIR imaging. In this study, FLAIR imaging was more sensitive than CT for the detection of acute SAH within 24 hours after onset. However, the diagnostic efficacy of FLAIR imaging was reduced in comparatively tight cisterns.

Clinical implications of subarachnoid clots detected by diffusion-weighted imaging in the acute stage of aneurysm rupture.

Diffusion-weighted magnetic resonance (MR) imaging findings of 72 patients with subarachnoid hemorrhage (SAH) in the acute stage were investigated to determine the clinical implications of subarachnoid clots detected by diffusion-weighted MR imaging on admission. Correlations between SAH detected by diffusion-weighted MR imaging and clinical factors were analyzed retrospectively. Diffusion-weighted MR imaging detected SAH in 34 of the 72 patients on admission. Thirty-three of 46 patients classified as Fisher group 3 had SAH detected by diffusion-weighted MR imaging. SAH detected by diffusion-weighted MR imaging on admission was significantly associated with both SAH imaging score and chronic hydrocephalus. SAH was detected by diffusion-weighted MR imaging on admission in patients who had dense clots. Detection of SAH by diffusion-weighted MR imaging was correlated with pathological conditions associated with the volume of subarachnoid clot, such as chronic hydrocephalus.

Early infarction detected by diffusion-weighted imaging in patients with subarachnoid hemorrhage.

PURPOSE: Early infarction that occurs at the time of initial subarachnoid hemorrhage (SAH) due to rupture of an aneurysm is a poorly understood phenomenon. We investigate the frequency of early infarction using diffusion-weighted images (DWI) at the time of admission. We then discuss the pathogenesis of infarction. MATERIALS AND METHODS: This study included 85 SAH patients who underwent serial DWI on admission. Early infarction detected by DWI and clinical features were investigated retrospectively. RESULTS: The overall incidence of DWI-detected early infarction at the time of SAH onset was 8% (7 of 85 cases). In all seven patients, early infarctions were asymptomatic on admission. Types of early infarction seen on DWI included infarcts occurring in the territory of the vessel harboring a ruptured aneurysm (solitary, three cases) and infarcts occurring outside the territory of the vessel (multiple, two cases; solitary, two cases). Six of seven patients eventually developed delayed ischemic neurological deficit (DIND) and computed tomography (CT)-detected and DWI-detected delayed extensive infarction. Four of seven patients with early infarction had an unfavorable outcome. The occurrence of DWI-detected early infarction on admission was significantly correlated with delayed angiographic vasospasm, DIND, CT-detected delayed infarction, DWI-detected delayed infarction, and unfavorable outcome. CONCLUSIONS: In the present study, DWI-detected early infarction at the time of SAH onset was correlated with the occurrence of delayed extensive ischemic lesions. We believe that performing DWI at the time of admission is useful for evaluating the primary ischemic insult, which might play an important role in the pathogenesis of early brain injury and delayed vasospasm-related complications.

Organized chronic subdural haematoma with a thick calcified inner membrane successfully treated by surgery: a case report.

The optimal surgical procedure for patients with calcified and organized chronic subdural haematoma (CSDH), or "armoured brain", has not been established because it is difficult to obtain good re-expansion of the brain after surgery. We present herein the case of a 32-year-old woman with huge calcified CSDH manifesting as refractory headache, periods of unconsciousness, and unsteady gait who obtained favourable results after craniotomy. Thinning of the thick calcified inner membrane using high-speed air drilling was performed after removal of the organized CSDH. The patient obtained good re-expansion after surgery. This observation illustrates that it is possible to perform such a surgery even on a huge calcified CSDH.