Zhuang Kang

Comparative Brain Stem Lesions on MRI of Acute Disseminated Encephalomyelitis, Neuromyelitis Optica, and Multiple Sclerosis

Background Brain stem lesions are common in patients with acute disseminated encephalomyelitis (ADEM), neuromyelitis optica (NMO), and multiple sclerosis (MS). Objectives To investigate comparative brain stem lesions on magnetic resonance imaging (MRI) among adult patients with ADEM, NMO, and MS. Methods Sixty-five adult patients with ADEM (n = 17), NMO (n = 23), and MS (n = 25) who had brain stem lesions on MRI were enrolled. Morphological features of brain stem lesions among these diseases were assessed. Results Patients with ADEM had a higher frequency of midbrain lesions than did patients with NMO (94.1% vs. 17.4%, P<0.001) and MS (94.1% vs. 40.0%, P<0.001); patients with NMO had a lower frequency of pons lesions than did patients with MS (34.8% vs. 84.0%, P<0.001) and ADEM (34.8% vs. 70.6%, P = 0.025); and patients with NMO had a higher frequency of medulla oblongata lesions than did patients with ADEM (91.3% vs. 35.3%, P<0.001) and MS (91.3% vs. 36.0%, P<0.001). On the axial section of the brain stem, the majority (82.4%) of patients with ADEM showed lesions on the ventral part; the brain stem lesions in patients with NMO were typically located in the dorsal part (91.3%); and lesions in patients with MS were found in both the ventral (44.0%) and dorsal (56.0%) parts. The lesions in patients with ADEM (100%) and NMO (91.3%) had poorly defined margins, while lesions of patients with MS (76.0%) had well defined margins. Brain stem lesions in patients with ADEM were usually bilateral and symmetrical (82.4%), while lesions in patients with NMO (87.0%) and MS (92.0%) were asymmetrical or unilateral. Conclusions Brain stem lesions showed various morphological features among adult patients with ADEM, NMO, and MS. The different lesion locations may be helpful in distinguishing these diseases.

Clinical, radiographic characteristics and immunomodulating changes in neuromyelitis optica with extensive brain lesions

BackgroundNeuromyelitis optica (NMO) shows various brain magnetic resonance imaging (MRI) abnormalities with recurrent central nervous system (CNS) attacks, although predominantly affecting the spinal cord and optic nerve. However, NMO with extensive involvement of the brain has infrequently been studied. We investigated the clinical, radiographic features and immunomodulating changes of NMO patients with extensive brain lesions (EBLs) in China.MethodsNMO patients (including 16 NMO patients with EBLs and 53 NMO patients without EBLs) hospitalized during January 2006 and February 2010 were recruited and analyzed retrospectively. Data of clinical characteristics, magnetic resonance imaging (MRI) features, laboratory abnormalities, treatment details and outcomes were analyzed. All the patients received the follow-up visits for two years.ResultsEBLs in NMO were classified into four categories according to their respective MRI characteristics: 1) Tumefactive-like lesions (n=4, 25%); 2) Acute disseminated encephalomyelitis (ADEM)-like lesions (n=6, 37.5%); 3) Multiple sclerosis (MS)-like lesions (n=5, 31.25%); 4) Posterior reversible encephalopathy syndrome (PRES)-like lesions (n=1, 6.25%). NMO patients with EBLs had higher rates of encephalopathy symptoms (37.5% vs. 5.6%, p = 0.004), homonymous hemianopia (18.8% vs. 0%, p = 0.011) and AQP4 seropositivity (100% vs. 69.8%, p = 0.008) than NMO patients without EBLs (NEBLs). Immunomodulating changes (including the levels of C3, C4, ESR and CRP) were significantly higher in patients with EBLs than those without EBLs. The relapse times in EBLs during the follow-up period were more frequent than those happened in NEBLs (1.88 ± 0.30 vs. 1.23 ± 0.14, p = 0.04). The EDSS scores in EBLs patients were also much higher than those in NEBLs throughout all the whole visits of follow-up.ConclusionsThe presence of EBLs in NMO may indicate a higher diseases activity and portend a worse prognosis. CRP is a useful marker in monitoring diseases activity. Systemic inflammation may be crucial to the formation of EBLs in NMO.

Hemoglobin A1C is independently associated with severity and prognosis of brainstem infarctions

OBJECTIVE To assess the association of Hemoglobin A1C (HbA1c) with acute brainstem infarctions (BSIs) and to determine whether HbA1c is an independent risk factor in BSIs patients. METHODS 96 only BSIs patients were categorized into four groups according to HbA1c as <6%, ≥ 6% but <7%, ≥ 7% but <8%, or ≥ 8%, respectively. The association of the four HbA1c groups with diffusion-weighted imaging (DWI) infarct volumes (DIV), National Institutes of Health Stroke Scale (NIHSS), and follow-up modified Rankin Scale (FmRS) scores were analyzed. Patients also were categorized into two groups according to HbA1c<6% or ≥ 6%. Logistic regression analyses were performed to determine independent risk factors. RESULTS There was a significant correlation between HbA1c and DIV (Spearman ρ=0.339, P=0.001), NIHSS scores (ρ=0.292, P=0.004) and FmRS scores (ρ=0.315, P=0.002). The incidence of pons infarction was highest in BSIs and patients with HbA1c ≥ 6% showed significantly more frequent isolated pontine infarction. Logistic regression analyses showed that only HbA1c was independently associated with larger DIV (P=0.025) and FmRS scores (P=0.026). CONCLUSIONS These results suggest that elevated HbA1c level may be a potential serologic marker in the evaluation of the severity and prognosis of acute BSIs. There is an urgent need to study control of diabetes mellitus (DM) before and after BSIs.

Comparison of clinical characteristics between neuromyelitis optica spectrum disorders with and without spinal cord atrophy.

BackgroundSpinal cord lesions is one of the predominant characteristics in patients with neuromyelitis optica spectrum disorders (NMOSD). Interestingly, mounting evidence indicates that spinal cord atrophy (SCA) is one of common clinical features in multiple sclerosis (MS) patients, and correlates closely with the neurological disability. However, Clinical studies related to the SCA aspects of NMOSD are still scarce.MethodsWe retrospectively analyzed 185 patients with NMOSD, including 23 patients with SCA and 162 patients without SCA. Data were collected regarding clinical characteristics, laboratory tests, and magnetic resonance imaging findings.Results12.4% of patients had SCA in NMOSD. Patients with SCA had a longer disease duration and higher EDSS at clinical onset and last visit. More importantly, SCA patients were more prone to reach disability milestones (EDSS ≥ 6.0). Bowel or bladder dysfunction, movement disorders, and sensory disturbances symptoms were more common in patients with SCA. ESR and CRP were significantly higher in patients with SCA than those without SCA. Patients with SCA were more frequently complicated with cervical cord lesions. However, the ARR, progression index, seropositive rate of NMO-IgG and OCB were similar in the two groups. Futhermore, LETM did not differ significantly between patients with SCA and without SCA in NMOSD patients.ConclusionsPatients with SCA might have longer disease duration, more severe clinical disability, and more frequently complicated with cervical spinal cord lesions. SCA might be predictive of the more severe neurologic dysfunction and worse prognosis in NMOSD. Inflammation contributes to the development of SCA in NMOSD.

Risk factors, topographic patterns and mechanism analysis of intracranial atherosclerotic stenosis ischemic stroke.

Background: The association between topographic patterns, risk factors and stroke mechanisms of ICAS in first-ever stroke remains unknown. Methods: A large sample sized retrospective study was performed on first-ever ICAS ischemic stroke using DWI and MRA. Results: Hypertension (60.92%), cigarette smoking (26.82%), MCA (76.65%) and multiple vessels (65.37%) stenosis, were the major factors favoring different mechanisms. Subcortical lesions were the most occurring topographic patterns (41.4%). The common mechanism was LBO (66.3%). Statistical analysis showed a significant relationship between lesion patterns and mechanisms (r = 0.384, P = 0.001). Single mechanism had the higher apoB/apoAI ratio (P = 0.005) and levels of plasma apoB (P = 0.007) compared with multiple mechanisms. The anterior circulation stroke were more multiple mechanisms as compared to the posterior circulation stroke (P = 0.001). LBO was more prevalent in posterior circulation stroke than in anterior circulation stroke (P = 0.001). Conclusions: The topographic patterns of ischemic lesions is helpful in early identification of different mechanisms of ICAS. Monitoring apoB and apoB/apoA1 may help to predict the mechanism of stroke with ICAS. The prevalence of mechanisms differ between anterior and posterior circulation stroke with ICAS.

Risk Factors and Clinical Manifestations of Juxtacortical Small Lesions: A Neuroimaging Study

Background and objective White matter hyperintensities can be easily identified by brain imaging. Juxtacortical small lesion (JCSL) is a special type of white matter lesion, defined as no greater than 5 mm in diameter and adjacent to the cerebral cortex in location. We notice lately that JCSLs alone may be associated to various neurological symptoms. Here, we design the present study to determine the risk factors for JCSLs and their clinical manifestations in patients in our neurology clinic. Methods 206 participants suffered from neurological disorders and completed magnetic resonance imaging (MRI) examinations were divided into two groups: patients with JCSLs and patients without lesions on MRI. Meanwhile, 129 age- and sex-matched healthy volunteers were also recruited. Laboratory examinations and the phenotypes and distributions of the symptoms of the three groups were compared. Results The serum levels of apoB and homocysteine (HCY) were independently related to the appearance of JCSLs and HCY level was also associated with the number of JCSLs. Patients with JCSLs might present with headache, insomnia, and/or anxiety/depression, which were related with the anatomical locations of the lesions. Conclusion These data suggest that JCSLs are symptomatic and might in result fromarteriole atherosclerosis, which should raise our attention.

A Madras Motor Neuron Disease Patient With Cerebellar Atrophy: A New Clinical Feature

A 34-year-old Chinese Han female complaining of general muscle weakness and wasting for 9 years. She was admitted for aggravation of her symptoms caused by respiratory distress. She also suffered from bulbar palsy. She had no hearing loss, visual problems, or cerebellar signs. Her parents had a consanguineous marriage, though there was no family history of these symptoms. Pure tone audiometric findings demonstrated no definite abnormality. Electromyography demonstrated neurogenic damage. Brain magnetic resonance imaging revealed cerebellar atrophy, dominantly in anterior lobe. Gene sequencing of whole gene exomes was negative. She was finally diagnosed with Madras motor neuron disease (MMND), a rare subtype of motor neuron disease. No definite therapy was available for MMND, and she died of respiratory tract infection 1 year later. Previous studies have shown that cerebellar signs are positive in 17.2% patients of MMND, but no case with cerebellar atrophy has been reported before. Thus, here we describe cerebellar atrophy as a new clinical feature of MMND.

Different Mechanisms of Two Subtypes of Perforating Artery Infarct in the Middle Cerebral Artery Territory: A High-Resolution Magnetic Resonance Imaging Study

Purpose: Perforating Artery Infarcts (PAIs) can be divided into two subtypes based on their etiologies: branch Atheromatous Disease (BAD) and Lacunar Infarct (LI). Recent studies have shown that while both subtypes can be caused by large artery lesions, the different mechanisms that underlie their development are not clear. This study was designed to use High-Resolution Magnetic Resonance Imaging (HRMRI) to explore the differences that contribute to the occurrence of these two subtypes in large artery lesions in the anterior circulation. Methods: Fifty patients with an acute PAI in the anterior circulation were enrolled (32 BAD and 18 LI patients). The ipsilateral middle cerebral artery (MCA) was scanned with HRMRI to analyze the atherosclerosis plaques. Artery remodeling and plaque characteristics of MCA lesions were compared between the two subtypes. Results: The rate of MCA lesions was significantly higher in BAD and substantially lower in LI (P = 0.033). LAs for the lumen areas in Bad, they were smaller than LI (P < 0.001), Additionally, the plaque area (P = 0.001) and plaque burden (P < 0.001) were superior in the BAD group. Most BAD patients displayed non-positive remodeling, while the great majority of LI patients showed positive remodeling (P < 0.001). Conclusion: In the anterior circulation, a considerable amount of BAD and LI share similarities with atherosclerotic plaques in large arteries. BAD patients mainly showed relatively large and stable atherosclerotic plaques in large arteries, while LI patients mainly exhibited relatively small and unstable atherosclerotic plaques. Clinical Trial Registration: This clinical trial is a retrospective study and therefore does not require registration.