Cortical laminar necrosis related to migrainous cerebral infarction

Ultrafast power Doppler imaging for ischemic encephalopathy: A case report

BACKGROUND

Severely elevated intracranial pressure due to various reasons, such as decreased cerebral perfusion, can lead to devastating neurological outcomes, such as brain herniation. Decompression craniectomy is a life-saving procedure that is commonly performed for such a critical situation, but the changes in cerebral microvessels after brain herniation and decompression are unclear. Ultrafast power Doppler imaging (uPDI) is a new microvascular imaging technology that utilizes high frame rate plane/diverging wave transmission and advanced clutter filters. uPDI significantly improves Doppler sensitivity and can detect microvessels, which are usually invisible using traditional ultrasound Doppler imaging.

CASE SUMMARY

In this report, uPDI was used for the first time to observe the brain blood flow of a hypoperfusion area in a 4-year-old girl who underwent decompression craniectomy due to refractory intracranial hypertension (ICP) after malignant brain tumor surgery. B-mode imaging was used to verify the increased densities of the cerebral cortex and basal ganglia that were observed by computed tomography.

CONCLUSION

uPDI showed the local blood supplies and anatomical structures of the patient after decompressive craniectomy. uPDI is potentially a more intuitive and noninvasive method for evaluating the effects of severe ICP on cerebral microvessels.

Diagnosis of Migrainous Infarction: A Case Report and Analysis of Previously Published Cases

Migrainous infarction (MI) is a rare disorder. The precise diagnostic criteria for this diagnosis have been available in the International Classification of Headache Disorders (ICHD) since 1988, but many cases do not fulfil these criteria. This paper describes a good example of MI and analyzes previously published case reports. We report a very special case of MI in an 18-year-old woman who had a recurrent episode of migraine with a similar aura with numbness of the right arm and speech disturbances which had an unusually long duration (>120 min). On admission to the headache centre "Europe-Asia", she complained of slowness of speech and problems with choice of words. An MRI showed acute lacunar infarcts in the left parietal subcortical area. Ischemic infarcts were localized in a relevant area on the left side and the aura symptoms were right-sided. The patient, therefore, fulfilled the ICHD-3 diagnostic criteria for "Migrainous infarction". An analysis of 35 previously published articles with case reports about MI showed that 22 did not meet the diagnostic criteria of the ICHD for migrainous infarction. Using all this, we developed diagnostic recommendations for migrainous infarction which can help to improve the quality of diagnosis when used together with the diagnostic criteria of the ICHD for migrainous infarction.

Migrainous Infarction And Cerebral Vasospasm: Case Report And Literature Review

Migrainous infarction (MI) is a rare complication of migraines that accounts for 0.5-1.5% of all ischemic strokes. Although the pathogenesis of MI is still debated, cortical spreading depression and the consequent biochemical cascade and hemodynamic changes are presumed to play an important role. Here we describe a case of MI and systematically review the literature on the complex and possibly bidirectional relationship between migraine and stroke. A 44-year-old female with history of migraine with visual aura presented at the Emergency Department due to a sudden onset of left limb paresis and hypoesthesia. Brain magnetic resonance imaging revealed right fronto-parietal ischemic stroke. Two days after hospitalization, the patient experienced a prolonged visual aura and showed ultrasound evidence of intracranial artery vasospasm. To date, there have been 33 published articles on a total 119 patients with MI, although intracranial vasospasm has rarely been reported. Sustained hyperexcitability of cortical neurons, impairment of γ-aminobutyric acid inhibitory circuitry, altered serotonergic transmission, release of vasoconstrictive molecules, and cerebral blood flow changes have been proposed as pathogenic mechanisms of MI. The present case provides insight into the pathophysiological link between stroke and migraine, thus aiding clinicians in therapeutic decision-making although additional studies are needed to clarify the clinical, neuroradiological, and ultrasound findings that link MI and stroke-related migraine.

Advanced magnetic resonance imaging of cortical laminar necrosis in patients with stroke

PURPOSE

The aim of this study was to assess the novel advanced magnetic resonance imaging findings of acute stage cortical laminar necrosis developing after complicated cardiovascular or abdominal surgery.

MATERIALS AND METHODS

This institutional review board-approved study included patients with postoperative stroke due to cortical laminar necrosis imaged with magnetic resonance in the acute stage. Brain magnetic resonance imaging examinations were obtained on a 3T magnetic resonance scanner within 48 hours of the neurological symptoms, including diffusion-weighted images (b value, 1000 s/mm²) and arterial spin labelling using a pseudo-continuous arterial spin labelling method in four patients. Conventional and advanced magnetic resonance images were analysed to assess the imaging features in acute stage cortical laminar necrosis.

RESULTS

The final population consisted of 14 patients (seven men and seven women, mean age 61 years, range 32-79 years) diagnosed with stroke and acute phase cortical laminar necrosis. All the patients presented with cortical lesions showing restricted diffusion on diffusion-weighted images and hypointensity on the apparent diffusion coefficient map. Cortical hyperintensity on T2-weighted or fluid-attenuated inversion recovery images was found in three (21%) and six (43%) patients, respectively. Reduced perfusion was noted in three out of four patients imaged with arterial spin labelling, while in one case no corresponding perfusion abnormality was noted on the arterial spin labelling maps. Arterial spin labelling abnormalities were much more extensive than diffusion restriction in two patients, and they were associated with a poor outcome.

CONCLUSION

Cortical hyperintense abnormalities on diffusion-weighted imaging may be the only sign of developing cortical laminar necrosis injury. The acquisition of arterial spin labelling helps to identify perfusion alterations and the extension of the ischaemic injury.

Cortical Laminar Necrosis as a Presenting Manifestation of Migraine in an Apparently Normal Patient: A Rare Case Report

We present a 27-year-old female, a known case of classical migraine headache, who had a severe episode of migraine with visual aura attack which continued late into night. The next morning, she had persistent headache and developed abrupt onset of dysarthria and right hemiparesthesias. She attributed symptoms to her long-lasting headache problem and hence did not seek medical help for the next 2 weeks. The symptoms persisted despite her headache subsiding over the next 36 hours. Her condition worsened 2 weeks later during another such episode of headache. This time she developed right hemiparesis, right hemihypoesthesia, and brief and autolimited left-clonic facial movements. Extensive neurological workup done to rule out other known causes of cerebral infarct with cortical laminar necrosis (CLN) was unrevealing. Magnetic resonance imaging of the brain showed left frontoparietal T2-/T1-/fluid-attenuated inversion recovery hyperintensity without diffusion restriction in diffusion-weighted imaging and subtle blooming in gradient recalled-echo and was radiologically compatible with cortical laminar necrosis. The patient improved with antiplatelets, antimigraine prophylaxis, and stroke rehabilitation therapy. Our present case is a unique one where CLN can be associated with cerebral ischemic infarct due to migrainous etiology.

Migrainous Infarction And Cerebral Vasospasm: Case Report And Literature Review

Migrainous infarction (MI) is a rare complication of migraines that accounts for 0.5-1.5% of all ischemic strokes. Although the pathogenesis of MI is still debated, cortical spreading depression and the consequent biochemical cascade and hemodynamic changes are presumed to play an important role. Here we describe a case of MI and systematically review the literature on the complex and possibly bidirectional relationship between migraine and stroke. A 44-year-old female with history of migraine with visual aura presented at the Emergency Department due to a sudden onset of left limb paresis and hypoesthesia. Brain magnetic resonance imaging revealed right fronto-parietal ischemic stroke. Two days after hospitalization, the patient experienced a prolonged visual aura and showed ultrasound evidence of intracranial artery vasospasm. To date, there have been 33 published articles on a total 119 patients with MI, although intracranial vasospasm has rarely been reported. Sustained hyperexcitability of cortical neurons, impairment of γ-aminobutyric acid inhibitory circuitry, altered serotonergic transmission, release of vasoconstrictive molecules, and cerebral blood flow changes have been proposed as pathogenic mechanisms of MI. The present case provides insight into the pathophysiological link between stroke and migraine, thus aiding clinicians in therapeutic decision-making although additional studies are needed to clarify the clinical, neuroradiological, and ultrasound findings that link MI and stroke-related migraine.

Long-Term Follow-Up in Children With Focal Cortical Dysplasia IIId for Early Brain Injuries, Including Neuropathological Findings

BACKGROUND

Early cerebral injury has a close relationship with epilepsy and focal cortical dysplasia Ⅲd. We investigated children with focal cortical dysplasia Ⅲd who underwent surgery for epilepsy.

METHODS

We selected 49 patients from among 260 pediatric patients who had undergone epilepsy surgery, analyzing their clinical materials and pathology data. The selected patients had been followed for more than two years.

RESULTS

The 49 patients were divided into seven groups based on different early brain injuries. There was a significant difference (P < 0.05) between Engel class I ratio of cerebral hemorrhage group (84.6%) and that of central nervous system infection group (42.1%) in two to eight years follow-up. The patients with prior cerebral hemorrhage had a wider scope (P < 0.05) of brain damage than those in the brain infection and febrile convulsion groups. Secondary polymicrogyria commonly existed. Neuron islands were located adjacent to polymicrogyria in cerebral hemorrhage and brain trauma patients, and missing neuronal laminations beside the polymicrogyria was noted in others.

CONCLUSIONS

In children with focal cortical dysplasia Ⅲd, individuals with cerebral hemorrhage within the perinatal period exhibited a wider range of brain lesions, while the postoperative follow-up outcome was better. Secondary polymicrogyria existed along with focal cortical dysplasia Ⅲd and is related to the developmental lesion. The processes of secondary polymicrogyria caused by different early brain injuries might be different.

Cortical laminar necrosis in a case of migrainous cerebral infarction

We report a 27-year-old woman, a known case of classical migraine headache, on oral contraceptive pills. She had a severe episode of migraine with visual aura attack, which continued late into the night. The next early morning, her headache persisted and she developed abrupt onset of dysarthria, right hemiparaesthesias. She attributed symptoms to her long-standing headache problem, and hence did not seek medical help for the next two weeks. The symptoms persisted despite her headache subsiding over the next 24 hours. She worsened 2 weeks later during another such episode of headache. This time, she developed right hemiparesis. The patient was admitted with provisional diagnosis of stroke. MRI of the brain showed left temporoparietal lesion and was radiologically compatible with cortical laminar necrosis.Extensive work-up was done to rule out other causes of young stroke. The patient improved with antiplatelets, antimigraine prophylaxis and stroke rehabilitation therapy.

A distinct clinicopathological variant of focal cortical dysplasia IIId characterized by loss of layer 4 in the occipital lobe in 12 children with remote hypoxic-ischemic injury

OBJECTIVE

In 2011, the International League Against Epilepsy (ILAE) proposed a consensus classification system of focal cortical dysplasia (FCD) to distinguish clinicopathological subtypes, for example, "isolated" FCD type Ia-c and IIa-b, versus "associated" FCD type IIIa-d. The histopathological differentiation of FCD type I and III variants remains, however, a challenging issue in everyday practice. We present a unique histopathological pattern in patients with difficult-to-diagnose FCD, which highlights this dilemma, but also helps to refine the current ILAE classification scheme of FCD.

METHODS

We present a retrospective series of 11 male and one female patient with early onset pharmacoresistant epilepsy of the posterior quadrant (mean age at seizure onset = 4.6 years). All surgical specimens were reviewed. Clinical histories were retrieved and extracted from archival patient files.

RESULTS

Microscopic inspection revealed abnormalities in cortical architecture with complete loss of layer 4 in all surgical samples of the occipital lobe, as confirmed by semiquantitative measurements (p < 0.01). Clinical history reported early transient hypoxic condition in nine patients (75%). Magnetic resonance imaging (MRI) revealed abnormal signals in the occipital lobe in all patients, and signal changes suggestive of subcortical encephalomalacia were found in seven patients. Surgical treatment achieved favorable seizure control (Engel class I and II) in seven patients with an available follow-up period of 6.1 years.

SIGNIFICANCE

Prominent disorganization of cortical layering and lack of any other microscopically visible principle lesion in the surgical specimen would result in this neuropathological pattern hitherto being classified as FCD ILAE type Ib. However, perinatal hypoxia with distinctive MRI changes suggested primarily a hypoxemic lesion and acquired pathomechanism of neuronal cell loss in the occipital lobe of our patient series. We propose, therefore, classifying this distinctive clinicopathological pattern as a separate variant of FCD ILAE type IIId.