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ABSTRACT: BACKGROUND AND PURPOSE: To describe a patient with relapsing remitting MS who was treated with natalizumab for 36 months. First symptoms of presumptive progressive multifocal leukoencephalopathy (PML) appeared 14 weeks after her last natalizumab infusion. METHODS: Neurological examination, MRI and CSF analysis were performed. RESULTS: The lack of anti-inflammatory treatment response, clinical course, and serial MRI examinations showed lesion development typical for PML on diffusion-weighted and FLAIR MRI. CSF analysis for JC virus was tested negative twice. CONCLUSIONS: This case represents a presumptive PML after discontinuation of natalizumab treatment-similar to the definition established for PML in HIV patients.
Journal of neuroimaging: official journal of the American Society of Neuroimaging 01/2013; · 1.72 Impact Factor
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Stroke 09/2012; 43(11):e165. · 5.73 Impact Factor
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ABSTRACT: The toxic leukoencephalopathy syndrome is increasingly recognized, but rarely presents as an acute cerebrovascular syndrome. We report a 23-year-old man with sudden onset of a right hemispheric sensorimotor syndrome and final diagnosis of HIV-induced toxic leukoencephalopathy.
Case Reports in Neurology 09/2012; 4(3):231-5.
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ABSTRACT: Cerebral infarctions in the anterior cerebral artery (ACA) territory account for only up to 3-5% of strokes. Subject to the affected ACA branches, different clinical patterns can be defined. We report a case series of patients with isolated infarctions of the pericallosal (PC) artery territory. We analyzed 36 consecutive patients presenting over a 10-year period with isolated PC artery territory infarctions (15 left-sided, 19 right-sided, 2 bilateral) regarding clinical symptoms as well as MRI findings. Analysis of DWI lesion pattern showed complete PC artery infarctions in three patients. The majority of patients had partial infarctions predominantly involving either the superior frontal gyrus (n = 12), the corpus callosum (n = 1) or both (n = 20). Hemodynamic lesion patterns were found in 13 patients, while multiple cortical emboli occurred in six. Distal pathology of the ACA (n = 13) was the most frequent MRA finding. Core symptom was contralateral hemiparesis with lower limb predominance (n = 29), partly associated with early-onset spasticity. Interestingly, motor evoked potential recording was abnormal in only five patients. Further characteristic symptoms were psychomotor slowing (n = 9), often with speech disturbances such as decreased verbal fluency, and confusional state (n = 4). Visual or motor hemineglect (n = 5) as well as apraxia (n = 5) was confined to a few patients only. Pericallosal artery infarctions are a rare localization of stroke, mostly occurring as partial infarctions due to distal ACA pathology. Clinically, they are mainly characterized by hemiparesis predominately in the lower limb caused by involvement of supplementary motor cortex areas without affection of the corticospinal tract.
Journal of Neurology 11/2011; 259(5):944-51. · 3.47 Impact Factor
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ABSTRACT: Hemorrhagic transformation (HT) after acute ischemic stroke is frequently detected using magnetic resonance imaging (MRI), in particular in patients treated with tissue plasminogen activator (tPA). Knowledge about causes and early clinical consequences of HT mostly arises from computed tomography-based studies. We analyzed potential predictors and early outcome of HT after stroke detected by MRI with T(2)*-weighted gradient echo sequences (T(2)*-MRI).
122 consecutive stroke patients (mean age 65.5 years, 41% women) who underwent T(2)*-MRI within 6-60 h after stroke onset were included. 25.4% of patients were treated with tPA; the overall detection rate of HT on T(2)*-MRI was 20.5%. Potential predictors of HT, such as age, sex, blood pressure, stroke etiology, prior antithrombotic medication, neurological deficit on admission, tPA treatment, and specific MRI findings, were analyzed. In addition, we evaluated the effect of HT on early outcome: a decrease of >4 points on the National Institute of Health Stroke Scale (NIHSS) on day 5 was considered early improvement, and an increase of >4 points was considered early deterioration.
The main predictor for occurrence of HT was tPA treatment (48.4 vs. 11.1%; odds ratio 7.50; 95% confidence interval 2.9-19.7; p < 0.001). Furthermore, the development of HT was associated with a severer neurological deficit on admission (mean NIHSS score 9.9 vs. 5.9; p = 0.003), and territorial infarction (88 vs. 58.8%; p = 0.007). 19 patients (15.6%) showed early improvement which was associated with the occurrence of HT (p = 0.011) and tPA treatment (p < 0.001).
HT is a frequent finding on T(2)*-MRI in patients with acute ischemic stroke associated with tPA treatment, territorial infarction and severer neurological deficits on admission. However, HT does not cause clinical deterioration; it is rather related to a favorable early outcome likely reflecting early recanalization and better reperfusion in these patients.
Cerebrovascular Diseases 09/2011; 32(4):334-41. · 2.72 Impact Factor
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ABSTRACT: We analyzed the phenomenon of transient regional diffusion-weighted MRI (DWI) hyperintensity in a series of status epilepticus (SE) patients with respect to seizure type, epileptogenic lesions and EEG findings. A prospective series of 54 patients (30 men, 24 women, mean age 61.5 years) admitted with SE was analyzed with regard to clinical semiology, EEG and MRI findings including DWI and EEG recordings in the acute peri-ictal phase. DWI abnormalities occurred most frequently in patients with complex-partial SE (27/50%) and generalized SE (18/33.3%). Forty patients (74.1%) had symptomatic, 13/24.1% cryptogenic and 1/1.9% idiopathic epilepsies. On DWI, the hippocampus was affected in 37/68.5% cases, often in combination with other brain areas (15/40.5%), in particular the pulvinar was affected in 14/25.9% patients. Bilateral DWI changes were found in 8/14.8% patients. No correlation with a specific seizure type was observed. In 21/38.9%, DWI changes were ipsilateral to the epileptogenic brain lesion (p<0.001) and in 5/9.3% contralateral, whereas in the majority of patients, either bilateral changes or no specific epileptogenic lesion were found. EEG abnormalities correlated with lateralization of DWI abnormalities in 44/81.5% (p<0.001). The most common localization of DWI abnormalities associated with ictal activity was the hippocampus and the pulvinar. Combined DWI-MRI and EEG analysis provides clues to seizure localization and propagation, as well as to identify brain structures affected by continuous or frequent ictal activity. This large series of patients with different features (SE type and cause, various epileptogenic lesions) demonstrates the heterogeneity of the phenomenon of peri-ictal DWI changes.
Epilepsy research 07/2011; 97(1-2):45-51. · 2.48 Impact Factor
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ABSTRACT: Recovery from stroke is presumed to be a function of a widespread cerebral network. Chronic white matter lesions (WML) have been proposed to be a predictor of poor outcome after acute stroke. We tested the hypothesis that the extent of WML has an effect on functional recovery in acute pontine stroke by disrupting the integrity of the supratentorial cerebral network.
Seventeen patients with acute unilateral pontine stroke who had received a standardized stroke workup and additional diffusion tensor imaging (DTI) were studied. After grading the extent of WML according to the Fazekas scale and semiautomated lesion volume calculation, we compared patients with acute pontine infarction and advanced WML to those with absent or minimal WML regarding baseline characteristics, stroke subtype and clinical outcome. In addition, we used tract-based spatial statistics for voxel-wise analysis of the DTI-derived parameter fractional anisotropy in the white matter tracts.
The volume of WML ranged between 0.1 and 42.1 cm³ (mean = 15.9) and was graded as follows: 0 in 5.9%, 1 in 35.3%, 2 in 41.2% and 3 in 17.6%. Both patients with Fazekas grades 2-3 (p = 0.014) as well as those with larger WML volumes (p = 0.037) had severer functional deficits at the 3-month follow-up. White matter tracts displaying a significant decrease in fractional anisotropy values were the corpus callosum, the anterior thalamic radiation and the inferior fronto-occipital fasciculus.
Chronic WML contribute to a less favorable clinical outcome after pontine stroke depending on (1) the extent of pre-existing WML and (2) the degree of disruption of cerebral connectivity as indicated by reduced tissue integrity in the white matter not affected by WML as detected by DTI and tract-based spatial statistics.
Cerebrovascular Diseases 03/2011; 31(5):499-505. · 2.72 Impact Factor
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ABSTRACT: OPINION STATEMENT: For some time, posterior circulation stroke has been neglected in diagnostic and therapeutic studies for various reasons, such as minor incidence compared to anterior circulation stroke or anatomical and vascular characteristics. This changed at least partly when the New England Medical Center (NEMC) Posterior Circulation Registry was initiated, and now the number of publications concerning posterior circulation stroke is continuously increasing. Whether the differences outweigh the similarities between posterior and anterior circulation stroke remains open to debate, but both are the subject of intensive investigations. In this article, we review the most recent literature on different MRI techniques, such as diffusion-weighted and diffusion tensor imaging (DWI and DTI), perfusion-weighted imaging (PWI), vascular imaging, and susceptibility weighted imaging (SWI), in posterior circulation stroke and discuss their diagnostic and prognostic impact as well as general implications for acute treatment.
Current Treatment Options in Cardiovascular Medicine 02/2011; 13(3):268-77.
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Martin Griebe,
Alex Förster,
Michèle Wessa,
Christina Rossmanith,
Hansjörg Bäzner,
Tamara Sauer,
Kathrin Zohsel,
Christian Blahak,
Andrea V King,
Julia Linke,
Michael G Hennerici,
Achim Gass, Kristina Szabo
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ABSTRACT: Age-related white matter changes (ARWMC) appear to correspond to a continuum from normal functioning to clinically overt neurological syndromes. Disturbance of the structural integrity of cerebral fibre tracts-the so-called cerebral network-by ARWMC might be one explanation for this development. From 3 T magnetic resonance imaging (MRI) data of 34 healthy elderly subjects (60-82 years) we calculated the lesion volume of ARWMC and the area of the corpus callosum (CC). Gait, balance and cognition were assessed. We compared these findings in those with mild (n = 22) and advanced (n = 12) ARWMC and performed tract-based spatial statistics (TBSS) to analyze white matter structural integrity. In subjects with advanced ARWMC, TBSS showed a significant decrease of fractional anisotropy (FA) in several large tracts of the white matter including the CC; total CC, CC2 and CC5 areas were significantly smaller. Despite these morphological changes, tests of gait, balance and cognition as measured by the Mini-Mental State Examination (MMSE) were in the normal range for both groups; only the Montreal Cognitive Assessment (MoCA) detected executive and language dysfunction in those with advanced ARWMC. Loss of tissue integrity and atrophy of the CC secondary to spatially remote lesions in the peri- and paraventricular white matter in ARWMC appear to be already detectable in healthy elderly individuals.
Journal of Neurology 02/2011; 258(8):1451-9. · 3.47 Impact Factor
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Journal of the American Geriatrics Society 01/2011; 59(1):178-80. · 3.74 Impact Factor
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Journal of neurology, neurosurgery, and psychiatry 07/2010; 81(7):822-3. · 4.87 Impact Factor
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Cerebrovascular Diseases 03/2010; 29(6):518-22. · 2.72 Impact Factor
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ABSTRACT: In large territorial stroke of the anterior and the posterior circulation, the extent of affected tissue can be characterized by the demonstration of vessel occlusion on MR angiography (MRA), while the extent of hypoperfusion can be shown on dynamic susceptibility contrast perfusion-weighted MRI (PWI). The ability of MRA and conventional MRI sequences to demonstrate branches of the basilar artery (BA) is very limited. This study analyzes the value of the combined use of diffusion-weighted MRI (DWI), MRA and PWI in acute pontine stroke.
A series of 24 consecutive patients with acute pontine stroke received an extensive MRI stroke workup including DWI, PWI and MRA.
In 11/24 patients visual analysis of PWI demonstrated persisting hypoperfusion, and in 1/24 patients indication of hyperperfusion was found. Vessel abnormalities were seen in 19/24 patients (15/24 hypoplastic vertebral artery, 9/24 stenosis or occlusion of the BA, 1/20 ectatic BA). Persistent pontine hypoperfusion was more frequently associated with BA pathology (9/11 vs. 1/13, p = 0.001), large-vessel disease (8/11 vs. 1/13; p = 0.001) and a more pronounced clinical deficit (NIHSS score on day 1: 7 vs. 3, p = 0.01).
In pontine ischemia areas of hypoperfusion can be identified due to the strong contrast induced by ischemia on PWI and can be easily related to DWI lesion size. This is of use particularly as small vessels are frequently missed by MRA and occlusion of the BA can be better characterized with the help of PWI.
Cerebrovascular Diseases 02/2010; 29(4):389-94. · 2.72 Impact Factor
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ABSTRACT: Patients with cardioembolic ischemic stroke from nonvalvular atrial fibrillation (NVAF) are candidates for long-term anticoagulation. This study examines the prevalence of cerebral microbleeds (MBs) in stroke patients with NVAF.
A total of 132 consecutive ischemic stroke patients with NVAF admitted to our Stroke Unit were recruited if complete magnetic resonance (MR) imaging studies including T2* imaging had been performed within less than 72 hours. National Institutes of Health Stroke Scale scores were documented and cerebrovascular risk factors were monitored.
Among 132 patients (mean age 74.1±9.8 years), only 9 (6.8%) had MBs (mean number 6.2) as detected on T2* MR images. No statistically significant differences between patients without versus with MBs were observed regarding arterial hypertension, diabetes, hyperlipidemia, and coronary heart disease. However, small vessel disease (SVD) was significantly more frequent in patients with MBs than without MBs (44.4% vs. 12.2%; P<.05) and significantly more patients with MBs experienced repeated strokes (44.4% vs. 14.6%; P<.05).
In contrast to studies reflecting a high incidence of MBs in stroke patients of various subtypes, MBs occurred less frequently in patients with cardioembolic acute ischemic stroke associated with NVAF. In patients with severe SVD or repeated cerebrovascular events, special caution should be taken regarding oral anticoagulation.
Journal of neuroimaging: official journal of the American Society of Neuroimaging 11/2009; 21(2):103-7. · 1.72 Impact Factor
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Journal of Neurology 06/2009; 256(10):1753-5. · 3.47 Impact Factor
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ABSTRACT: Reports of ischemic stroke affecting the hippocampus are rare. In this study we used diffusion-weighted MRI (DWI) to characterize patients with posterior circulation stroke involving the hippocampus.
Fifty-seven consecutive acute stroke patients with hippocampal infarct (HI) on DWI were analyzed with regard to clinical features and ischemic lesion patterns. The last 20 of these underwent additional neuropsychological testing of short-term, working, and episodic long-term memory.
We found unilateral HI in 54 and bilateral HI in 3 patients. Visual analysis identified 4 patterns of DWI lesion affecting (1) the complete hippocampus (15/60), (2) the lateral (19/60) or (3) dorsal (22/60) parts of the hippocampal body and tail, and (4) circumscribed lesions in the lateral hippocampus (4/60), corresponding well to hippocampal vascular anatomy. In all cases DWI showed further ischemic lesions in the posterior circulation. Symptoms from lesions outside the hippocampus were the common leading clinical signs. Whereas mnestic deficits were prominent in only 11/57 patients, neuropsychological examination in 20 patients showed deficits of verbal episodic long-term memory in left and of nonverbal episodic long-term memory in right HI.
Several phenotypic lesion patterns can be distinguished in HI that usually occur as part of multifocal PCA ischemia. A careful neuropsychological examination is necessary to detect resulting memory deficits.
Stroke 05/2009; 40(6):2042-5. · 5.73 Impact Factor
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ABSTRACT: Differences between women and men in relation to stroke are increasingly being recognized.
From July 2004 until June 2007, 237 acute ischemic stroke (AIS) patients were treated with recombinant tissue plasminogen activator (rtPA) within 3 hours after onset of symptoms in our stroke unit. Baseline characteristics, etiology, CT/MRI stroke patterns, clinical outcome, and complications of women were compared to those of men.
Of 237 AIS patients (mean age 70.7 years), 111 (46.8%) were women and 126 (53.2%) were men. Women were older (P=0.001), but history of hyperlipidemia (P=0.03), smoking (P=0.03), and coronary heart disease (P<0.001) was less frequent than in men. Internal carotid artery disease occurred more often in men (P=0.02), whereas atrial fibrillation was observed more often in women (P=0.002). In men borderzone/small embolic and lacunar stroke was found more frequently (39.7 versus 27.2%), whereas women showed a higher percentage of large territorial stroke (72.8 versus 60.3%, P=0.09). Baseline National Institute of Health Stroke Scale scores (12.5 versus 11.3), NIHSS score at discharge (11.0 versus 9.5), 3-month-outcome modified Rankin Scale score, thrombolysis-related (17.1% versus 13.5%) or independent complications (32.4% versus 30.2%), and mortality after 3 months (13.5% versus 9.5%) were similar.
Differences of stroke lesion patterns in genders are paralleled by differences in etiology and risk factor profiles (women, cardioembolism; men, large and small vessel disease). Baseline characteristics, rates of rtPA-related and independent complications, as well as clinical outcomes were not different between women and men with AIS.
Stroke 05/2009; 40(7):2428-32. · 5.73 Impact Factor
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Journal of Neurology 04/2009; 256(7):1166-8. · 3.47 Impact Factor
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Cerebrovascular Diseases 03/2009; 27(3):307-8. · 2.72 Impact Factor
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European Neurology 07/2008; 60(2):92-4. · 1.81 Impact Factor
