Carla Uggetti

Migraine with aura and white matter lesions: an MRI study

Several studies report the presence of white matter lesions on brain magnetic resonance imaging in patients with migraine. The aim of our study was to detect the entity of white matter T2-hyperintensities in 90 high selected patients affected by migraine with aura, compared to a group of 90 healthy controls. We found no significant difference of incidence of white matter alterations comparing these two groups.

Migraine with aura white matter lesions: preliminary data on clinical aspects

A few clinic-based magnetic resonance imaging studies report an increased risk of signal abnormalities in migraineurs brain’s white matter, especially in migraine with aura subjects. A vascular genesis has been hypnotized and migraine with aura was considered an independent risk factor for stroke. Available data of magnetic resonance imaging alterations are often nonspecific and sometimes controversial. The aim of our study is to investigate migraine with aura patients with standardized brain magnetic resonance imaging to detect and to quantify the presence of white matter lesions and to analyze their relation with clinical data. We report preliminary data about first 90 subjects. We did not recognize any clinical aspect in close relationship with these alterations. The only clinical feature that seems to play a role in the presence of alterations is the age, and only in migraineurs women.

Headache in the emergency department: the role of imaging

Headache is a common problem in medical practice and can be the presenting feature of both benign and serious conditions. The International Classification of Headache Disorders divides all headache entities into primary and secondary. Primary headaches are those where there is no underlying cause identifiable and where the diagnosis is made through detailed history and pattern recognition. Secondary headaches are those where the headache is a symptom of an underlying cause that is identifiable on examination or investigation. Primary headaches are the most frequent type (approximately 90%), while secondary headaches account for 10% of all. By definition, primary headaches such as migraine, tension-type headache, or cluster headache have no underlying secondary cause [1]. Alarm signs and symptoms (red flags) that should be raise the suspicion of an underlying life-threatening condition are as follows:

Parry–Romberg syndrome: conventional and advanced MRI follow-up in a boy:

We studied a 9-year-old boy, affected with the Parry–Romberg syndrome, during a period of 32 months, by means of clinical evaluations and neuroradiological magnetic resonance imaging. Over this time we observed a clinical progression of the cutaneous disease without a simultaneous progression of the neurological alterations. Conventional and advanced magnetic resonance imaging techniques showed white matter alterations which proved to be stable during the follow-up.

Moyamoya disease: A rare case with an unusual presentation

Dear Editor, We would like to draw the attention of readers of the Neuroradiology Journal to an unusual presentation of moyamoya disease (MMD) in a 56-year-old Caucasian male who suffered from sudden onset of inferior right facial drop and dizziness, while no other clinical manifestations involving the central nervous system were noted. An onset of MMD symptoms is typically linked with ischemic or hemorrhagic

Magnetic resonance imaging in central nervous system vasculitis in a patient affected by crioglobulin-negative hepatitis C virus infection: A likely correlation

A 56-year-old man with behavioural disorders and facial-brachio-crural right hemiparesis presented with a brain lesion studied with computed tomography, magnetic resonance imaging and brain biopsy, leading to the diagnosis of cerebral vasculitis. Hepatitis C virus (HCV) infection in a phase of activity, without cryoglobulins, was also detected. Brain biopsy, laboratory analysis and response to a specific therapy supported the diagnosis of central nervous system vasculitis that was HCV related.

Brain MRI in patients affected by migraine with aura: is there any cortical lesion?

Migraine with typical aura (MWA), a common disorder affecting about 4–5% of the general population, consists of transient neurological dysfunction episodes usually followed by headache. Aura attacks clinically present initially as visual disturbances (90% of cases) that can be followed in a subgroup of patients, by somatosensory symptoms (about 10% of cases), reflecting a pathophysiological process that begins in the visual cortex and, in some patients, spreads from there to the parietal lobe and to the frontal lobe raising in this case speech alterations. It has been widely hypothesized that an underlying mechanism in migraine aura could be the cortical spreading depression (CSD), a slowly propagated (3 mm/min) wave of depolarization followed by suppression of brain activity. However, it is unknown why such cortical disturbances episodically occur in migraine patients. In addition, the longterm consequences of repeated migraine auras to the cerebral structure and function are still matter of study, although the condition is generally self-limiting and not associated with cognitive decline. MRI is a diagnostic tool often used in patients with MWA in order to exclude other underlying diseases. However, until today, no brain imaging abnormalities have been surely associated with migraine and no pathognomonic lesions have been recognized yet. The most common abnormalities described in literature are white matter T2 hyperintensities (WMH) [1, 2]. The relation between these white matter abnormalities and migraine is still not clear. Considering the physiopathology of MWA, attention should be focused on the cerebral cortex. Many studies support the relationship between CSD and aura phase inmigraine, while the relation between this phenomenon and migraine headache is still controversial. The latter being most probably due, according to some authors, to neuroplastic changes in cortical and subcortical structures of the trigeminal somatosensory system because of repetitive migraine attacks. A few studies in literature reported increased cortical thickness of visual and somatosensory areas in migraine patients compared to healthy controls. Other authors found out that cortical thickness and surface area were increased in regions involved in executive functions and visual motion processing, while were reduced in regions subserving pain processing, being all these abnormalities related to the presence of aura and WMHs. Moreover, in some studies, no differences in cortical thickness were found between migraine patients and healthy controls, nor any cortical abnormality. It is still not clear whether these changes, when present, indicate either an increased neuronal density that would render the tissue more susceptible to CSD or an altered structure, such as reactive gliosis, resulting frommultiple CSD episodes. Considering a possible role of cortical abnormalities in the physiopathologic process of migraine with aura, we decided to investigate if any cortical lesions such as reactive gliosis are detectable through MR imaging (without specific postprocessing software) in these patients. In a prospective longitudinal study made in our institution, 100 patients were recruited (from December 2015 to December 2017), all of them clinically diagnosed with * Carla Uggetti carla.uggetti@asst–santipaolocarlo.it

Migraine with aura and white matter lesions: new evidences

Headache is one of most frequent disorders to require a medical counseling. Among primary headaches, migraines are very frequent: approximately 12% of the population of Bindustrialized^ countries are migraineurs, whom 70–75% Bwithout aura^ (MO) type and about one third Bwith aura^ (MA) type. In young adult, the prevalence seems double to overall population. According to WHO reports, migraine is one of 20 most disabling chronic diseases, and disability of migraine may worse with the discomfort of aura phenomenon. In recent years, several reports showed that the presence of aura in migraine patients seems to increase the risk of ischemic vascular brain alterations. Despite the fact that migraine is essentially a clinical-anamnestic diagnosis, based on the classification criteria listed in the classifications published by the Ad Hoc Committee of HIS since 1988, most of migraine patients, especially the ones who have experienced the aura phenomenon, undergo a magnetic resonance imaging (MRI) examination. This increasing widespread use of MRI disclosed the presence of alterations in white substance (white matter lesions (WML)) whose significant is still not clear. Recently, clinicbased and population-based studies confirmed the association between migraine (especially with aura) and MRI abnormalities. However, in the literature, there is no univocal interpretation regarding these findings. Vascular hypothesis seems to be the more probable, so that some authors consider MA as a risk factor for ischemic stroke. Different reasons make comparison between the different data of the literature very difficult. MRI data on structural brain abnormalities are often nonspecific and sometimes controversial. Different definitions of white matter lesions, such as gliosis area, hyperintense lesions, demyelination, and silent infarct-like lesions (ILLs), were considered. Migraine diagnosis is another topic: ICHD criteria are not always completely respected. The concept of Bmigraineur^ subject is generally considered and a clear distinction between migraine subtypes is sometimes difficult or impossible. In many studies, participant selection is often too heterogeneous or not representative, especially concerning sex—in some of them, there are only females—and age, with range generally too wide, up to 60 years and sometimes even beyond. Furthermore, different studies are based on the same cohort. Migraine-related variables, i.e., years from onset of the aura, attack frequency, duration and type of the aura, and common cardiovascular risk factor (smoke, oral contraceptives, hypertension, lipid profile, and BMI), are not always completely and well reported, especially in people where the presence of WML is more likely. Given this scenario of uncertainty and the need for a longitudinal study to investigate the possible role of WML in migraine with aura, we decided to study a homogeneous group of relatively young migraine patients with aura. We performed a magnetic resonance imaging (MRI) study for all patients according to a standard protocol aimed at highlighting any white matter lesions. Protocol study, approved by the institute ethics committee, started in December 2014. We recruited subjects through all consecutive patients referred to the Headache Centre of San Carlo Borromeo Hospital—ASST Santi Paolo e Carlo Milano—who received a diagnosis of migraine with aura. The patient enrollment phase was conducted in collaboration with the Headache Center of Neurological Institute BCarlo Besta^ of Milan. Inclusion criteria were diagnosis based on the ICHD3beta criteria, age between 16 and 50 years, and at least one episode per year of migraine with aura in the last 3 years. At the recruitment, all subjects underwent a face-to-face interview * Alberto Galli alberto.galli@asst–santipaolocarlo.it

Bilateral transfer phenomenon: A functional magnetic resonance imaging pilot study of healthy subjects.

Background The bilateral transfer of a motor skill is a physiological phenomenon: the development of a motor skill with one hand can trigger the development of the same ability of the other hand. Objective The purpose of this study was to verify whether bilateral transfer is associated with a specific brain activation pattern using functional magnetic resonance imaging (fMRI). Methods The motor task was implemented as the execution of the Nine Hole Peg Test. Fifteen healthy subjects (10 right-handers and five left-handers) underwent two identical fMRI runs performing the motor task with the non-dominant hand. Between the first and the second run, each subject was intensively trained for five minutes to perform the same motor task with the dominant hand. Results Comparing the two functional scans across the pool of subjects, a change of the motor activation pattern was observed. In particular, we observed, in the second run, a change in the activation pattern both in the cerebellum and in the cerebral cortex. We found activations in cortical areas involved in somatosensory integration, areas involved in procedural memory. Conclusions Our study shows, in a small group of healthy subjects, the modification of the fMRI activation pathway of a motor task performed by the non-dominant hand after intensive exercise performing the same task with the dominant hand.

La sindrome di Aicardi-Goutières: Descrizione neuroradiologica di undici nuovi casi

We describe the clinical and neuroradiological features of eleven patients with Aicardi-Goutières syndrome, a rare and severe progressive encephalopathy with onset in the first year of life. The syndrome is autosomal recessive with varying clinical presentation and course. Our patients were studied by CT and MR imaging and findings were in agreement with literature reports. Calcification of the basal nuclei was found in 100% of cases and six patients presented a progressive increase in the number and size of the calcifications which were bilateral and largely symmetrical. White matter changes were seen in 76% of cases without a specific pattern of distribution. Early neuroradiological diagnosis of suspect Aicardi-Goutières syndrome is established by ruling out other pathological processes and the site and features of the calcifications rather than the white matter changes is important to then search for typical CSF changes.