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Durrleman C, Grevent D, Aubart M, Kossorotoff M, Roux CJ, Kaminska A, Rio M, Barcia G, Boddaert N, Munnich A, Nabbout R, Desguerre I. Clinical and radiological description of 120 pediatric stroke-like episodes. Eur J Neurol 2023; 30:2051-2061. [PMID: 37046408 DOI: 10.1111/ene.15821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/27/2023] [Accepted: 04/03/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND AND PURPOSE Stroke-like episodes (SLEs) are defined as acute onset of neurological symptoms mimicking a stroke and radiological lesions non-congruent to vascular territory. We aimed to analyze the acute clinical and radiological features of SLEs to determine their pathophysiology. METHODS We performed a monocenter retrospective analysis of 120 SLEs in 60 children over a 20-year period. Inclusion criteria were compatible clinical symptoms and stroke-like lesions on brain magnetic resonance imaging (MRI; performed for all 120 events) with focal hyperintensity on diffusion-weighted imaging in a non-vascular territory. RESULTS Three groups were identified: children with mitochondrial diseases (n = 22) involving mitochondrial DNA mutations (55%) or nuclear DNA mutations (45%); those with other metabolic diseases or epilepsy disorders (n = 22); and those in whom no etiology was found despite extensive investigations (n = 16). Age at first SLE was younger in the group with metabolic or epilepsy disorders (18 months vs. 128 months; p < 0.0001) and an infectious trigger was more frequent (69% vs. 20%; p = 0.0001). Seizures occurred in 75% of episodes, revealing 50% episodes of SLEs and mainly leading to status epilepticus (90%). Of the 120 MRI scans confirming the diagnosis, 28 were performed within a short and strict 48-h period and were further analyzed to better understand the underlying mechanisms. The scans showed primary cortical hyperintensity (n = 28/28) with decreased apparent diffusion coefficient in 52% of cases. Systematic hyperperfusion was found on spin labeling sequences when available (n = 18/18). CONCLUSION Clinical and radiological results support the existence of a vicious circle based on two main mechanisms: energy deficit and neuronal hyperexcitability at the origin of SLE.
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Affiliation(s)
- Chloe Durrleman
- Pediatric Neurology Department, Necker Enfants Malades Hospital, APHP, Université Paris Cité, Paris, France
| | - David Grevent
- Pediatric Imaging Department, Necker Enfants Malades Hospital, APHP, Université Paris Cité, Paris, France
- Lumiere Platform, Université Paris Cité, Paris, France
| | - Melodie Aubart
- Pediatric Neurology Department, Necker Enfants Malades Hospital, APHP, Université Paris Cité, Paris, France
| | - Manoelle Kossorotoff
- Pediatric Neurology Department, Necker Enfants Malades Hospital, APHP, Université Paris Cité, Paris, France
| | - Charles-Joris Roux
- Pediatric Imaging Department, Necker Enfants Malades Hospital, APHP, Université Paris Cité, Paris, France
| | - Anna Kaminska
- Neurophysiology Department, Necker Enfants Malades Hospital, APHP, Université Paris Cité, Paris, France
| | - Marlene Rio
- Genetic Department, Necker Enfants Malades Hospital, APHP, Université Paris Cité, Paris, France
| | - Giulia Barcia
- Genetic Department, Necker Enfants Malades Hospital, APHP, Université Paris Cité, Paris, France
| | - Nathalie Boddaert
- Pediatric Imaging Department, Necker Enfants Malades Hospital, APHP, Université Paris Cité, Paris, France
- Lumiere Platform, Université Paris Cité, Paris, France
| | - Arnold Munnich
- Genetic Department, Necker Enfants Malades Hospital, APHP, Université Paris Cité, Paris, France
| | - Rima Nabbout
- Pediatric Neurology Department, Necker Enfants Malades Hospital, APHP, Université Paris Cité, Paris, France
| | - Isabelle Desguerre
- Pediatric Neurology Department, Necker Enfants Malades Hospital, APHP, Université Paris Cité, Paris, France
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Finsterer J, Aliyev R. Metabolic stroke or stroke-like lesion: Peculiarities of a phenomenon. J Neurol Sci 2020; 412:116726. [PMID: 32088469 DOI: 10.1016/j.jns.2020.116726] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/03/2020] [Accepted: 02/06/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVES One of the most frequent cerebral lesions in mitochondrial disorders(MIDs) on imaging is the stroke-like lesion(SLL) clinically manifesting as stroke-like episode (SLE, metabolic stroke). This review aims at discussing recent advances concerning the presentation, diagnosis, and treatment of SLLs. METHODS Systematic literature review using appropriate search terms. RESULTS SLLs are the hallmark of MELAS but occasionally occur in other MIDs. SLLs are best identified on multimodal, cerebral MRI. SLLs may present as uni-/multilocular, symmetric/asymmetric, cortical/subcortical, supra-/infratentorial condition, initially resembling a cytotoxic edema and later a vasogenic edema, or a variable mix between them. SLLs run through an acute and a chronic stage. The acute stage is characterised by a progressively expanding lesion over days, weeks, or months, showing up as increasing hyperintensity on T2/FLAIR, DWI, and PWI and by hyperperfusion, that does not conform to a vascular territory. ADC maps are initially hypointens to become hyperintens during the course. More rarely, a variable mixture of hyper- and hypointensities may be found. The chronic stage is characterised by hypoperfusion, gadolinium enhancement, and regression of hyperintensities to various endpoints. SLLs originate from an initial cortical lesion due to focal metabolic breakdown, which either remains stable or expands within the cortex or to subcortical areas. Some SLLs show spontaneous reversibility (fleeing cortical lesions) suggesting that neuronal/glial damage does not reach the threshold of irreversible cell death. CONCLUSIONS SLLs are a unique feature of various MIDs in particular MELAS. SLLs are dynamic and change their appearance over time. SLLs are accessible to treatment.
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Affiliation(s)
- Josef Finsterer
- Krankenanstalt Rudolfstiftung, Messerli Institute, Vienna, Austria.
| | - Rahim Aliyev
- Department of Neurology and Clinical Neurophysiology, Azerbaijan State Advanced Training Institute for Doctors named after A. Aliyev, Baku, Azerbaijan
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Voronovich ZA, Wolfe K, Foster K, Sorte D, Carlson AP. Restrictive cerebral cortical venopathy: A new clinicopathological entity. Interv Neuroradiol 2019; 25:322-329. [PMID: 31138039 DOI: 10.1177/1591019918821861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We present a case of a novel restrictive cerebral venopathy in a child, consisting of a bilateral network of small to medium cortical veins without evidence of arteriovenous shunting, absence of the deep venous system, venous ischemia, elevated intracranial pressure, and intracranial calcifications. The condition is unlike other diseases characterized by networks of small veins, including cerebral proliferative angiopathy, Sturge-Weber syndrome, or developmental venous anomaly. While this case may be the result of an anatomic variation leading to the congenital absence of or early occlusion of the deep venous system, the insidious nature over many years argues against this. The absence of large cortical veins suggests a congenital abnormality of the venous structure. The child's presentation with a seizure-like event followed by protracted hemiparesis is consistent with venous ischemia. We propose that this is likely to represent a new clinicopathological entity.
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Affiliation(s)
- Zoya A Voronovich
- 1 Department of Neurosurgery, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Kathy Wolfe
- 2 Department of Neurology, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Kimberly Foster
- 1 Department of Neurosurgery, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Danielle Sorte
- 1 Department of Neurosurgery, University of New Mexico Health Sciences Center, Albuquerque, USA.,3 Department of Radiology, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Andrew P Carlson
- 1 Department of Neurosurgery, University of New Mexico Health Sciences Center, Albuquerque, USA
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Abstract
OBJECTIVES Because the central nervous system (CNS) is the second most frequently affected organ in mitochondrial disorders (MIDs) and since paediatric MIDs are increasingly recognised, it is important to know about the morphological CNS abnormalities on imaging in these patients. This review aims at summarising and discussing current knowledge and recent advances concerning CNS imaging abnormalities in paediatric MIDs. METHODS A systematic literature review was conducted. RESULTS The most relevant CNS abnormalities in paediatric MIDs on imaging include white and grey matter lesions, stroke-like lesions as the morphological equivalent of stroke-like episodes, cerebral atrophy, calcifications, optic atrophy, and lactacidosis. Because these CNS lesions may be seen with or without clinical manifestations, it is important to screen all MID patients for cerebral involvement. Some of these lesions may remain unchanged for years whereas others may be dynamic, either in the sense of progression or regression. Typical dynamic lesions are stroke-like lesions and grey matter lesions. Clinically relevant imaging techniques for visualisation of CNS abnormalities in paediatric MIDs are computed tomography, magnetic resonance (MR) imaging, MR spectroscopy, single-photon emission computed tomography, positron-emission tomography, and angiography. CONCLUSIONS CNS imaging in paediatric MIDs is important for diagnosing and monitoring CNS involvement. It also contributes to the understanding of the underlying pathomechanisms that lead to CNS involvement in MIDs.
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Affiliation(s)
| | - Sinda Zarrouk-Mahjoub
- University of Tunis, El Manar and Genomics Platform, Pasteur Institute of Tunis, Tunisia
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Mack HG, Milea D, Thyagarajan D, Fagan X. Transient bilateral optic disc oedema in mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS). Can J Ophthalmol 2018; 53:e208-e211. [DOI: 10.1016/j.jcjo.2017.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/10/2017] [Accepted: 11/20/2017] [Indexed: 11/16/2022]
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Magnetic resonance imaging of arterial stroke mimics: a pictorial review. Insights Imaging 2018; 9:815-831. [PMID: 29934921 PMCID: PMC6206386 DOI: 10.1007/s13244-018-0637-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/23/2018] [Accepted: 05/14/2018] [Indexed: 12/18/2022] Open
Abstract
Acute ischaemic stroke represents the most common cause of new sudden neurological deficit, but other diseases mimicking stroke happen in about one-third of the cases. Magnetic resonance imaging (MRI) is the best technique to identify those 'stroke mimics'. In this article, we propose a diagnostic approach of those stroke mimics on MRI according to an algorithm based on diffusion-weighted imaging (DWI), which can be abnormal or normal, followed by the results of other common additional MRI sequences, such as T2 with gradient recalled echo weighted imaging (T2-GRE) and fluid-attenuated inversion recovery (FLAIR). Analysis of the signal intensity of the parenchyma, the intracranial arteries and, overall, of the veins, is crucial on T2-GRE, while anatomic distribution of the parenchymal lesions is essential on FLAIR. Among stroke mimics with abnormal DWI, T2-GRE demonstrates obvious abnormalities in case of intracerebral haemorrhage or cerebral amyloid angiopathy, but this sequence also allows to propose alternative diagnoses when DWI is negative, such as in migraine aura or headaches with associated neurological deficits and lymphocytosis (HaNDL), in which cortical venous prominence is observed at the acute phase on T2-GRE. FLAIR is also of major interest when DWI is positive by better showing evocative distribution of cerebral lesions in case of seizure (involving the hippocampus, pulvinar and cortex), hypoglycaemia (bilateral lesions in the posterior limb of the internal capsules, corona radiata, striata or splenium of the corpus callosum) or in posterior reversible encephalopathy syndrome (PRES). Other real stroke mimics such as mitochondrial myopathy, encephalopathy, lactic acidosis, stroke-like episodes (MELAS), Susac's syndrome, brain tumour, demyelinating diseases and herpes simplex encephalitis are also included in our detailed and practical algorithm. KEY POINTS: • About 30% of sudden neurological deficits are due to non-ischaemic causes. • MRI is the best technique to identify stroke mimics. • Our practical illustrated algorithm based on DWI helps to recognise stroke mimics.
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Response regarding involvement of the cerebral veins in MELAS syndrome. Neuroradiology 2017; 59:947-949. [DOI: 10.1007/s00234-017-1902-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 08/01/2017] [Indexed: 10/19/2022]
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