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Sanchez-Caro JM, de Lorenzo Martínez de Ubago I, de Celis Ruiz E, Arribas AB, Calviere L, Raposo N, Blancart RG, Fuentes B, Diez-Tejedor E, Rodriguez-Pardo J. Transient Focal Neurological Events in Cerebral Amyloid Angiopathy and the Long-term Risk of Intracerebral Hemorrhage and Death: A Systematic Review and Meta-analysis. JAMA Neurol 2021; 79:38-47. [PMID: 34779831 DOI: 10.1001/jamaneurol.2021.3989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Transient focal neurological episodes (TFNEs) are a frequently overlooked presentation of cerebral amyloid angiopathy (CAA), a condition with prognostic implications that are still not well described. Objective To perform a systematic review and meta-analysis to examine the factors associated with incident lobar intracerebral hemorrhage (ICH) and death in patients with CAA presenting with TFNEs. Data Sources A systematic review and individual participant meta-analysis including (1) a hospital-based cohort and (2) the results obtained from a systematic search performed in MEDLINE and Embase completed in December 2019. Study Selection Included studies were observational reports of TFNEs. Patient-level clinical, imaging, and prognostic data were required for inclusion. For aggregate data studies, patient-level data were requested. Disagreements were resolved by consensus. Data Extraction and Synthesis Data were extracted following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines by 4 independent reviewers. The quality of reports was determined based on the modified Pearson Case Report Quality Scale. Main Outcomes and Measures The clinical characteristics of TFNEs, neuroimaging features, and use of antithrombotics during follow-up were considered exposures. The predefined main outcomes were lobar ICH and risk of death during follow-up. Results Forty-two studies and 222 CAA-associated TFNE cases were included from the initial 1612 records produced by the systematic search; 26 additional patients (11 men [42.3%]; mean [SD] age, 77 [8] years) were provided by the hospital-based cohort. A total of 108 TFNEs (43.5%) consisted of motor symptoms. Convexity subarachnoid hemorrhage and cortical superficial siderosis were detected in 193 individuals (77.8%) and 156 individuals (62.9%) in the systematic search and hospital-based cohort, respectively. Follow-up duration could be obtained in 185 patients (median duration, 1 year [IQR, 0.8-2.5 years]). During follow-up, symptomatic lobar ICH occurred in 76 patients (39.4%). Motor symptoms (odds ratio, 2.08 [95% CI, 1.16-3.70]) at baseline and antithrombotic use during follow-up (odds ratio, 3.61 [95% CI, 1.67-7.84]) were associated with an increase in risk of lobar ICH. A total of 31 patients (16.5%) died during follow-up; lobar ICH during follow-up and cortical superficial siderosis were the main risk factors for death (odds ratio, 3.01 [95% CI, 1.36-6.69]; odds ratio, 3.20 [95% CI, 1.16-8.91], respectively). Conclusions and Relevance Patients presenting with CAA-associated TFNEs are at high risk of lobar ICH and death. Motor TFNEs and use of antithrombotics after a TFNE, in many cases because of misdiagnosis, are risk factors for ICH, and therefore accurate diagnosis and distinguishing this condition from transient ischemic attacks is critical.
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Affiliation(s)
- Juan María Sanchez-Caro
- Department of Neurology, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | - Iñigo de Lorenzo Martínez de Ubago
- Department of Neurology, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | - Elena de Celis Ruiz
- Department of Neurology, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | | | - Lionel Calviere
- Neurology Department, Hôpital Pierre-Paul Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Nicolas Raposo
- Neurology Department, Hôpital Pierre-Paul Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Rafael Galiano Blancart
- Department of Neurology, Doctor Peset University Hospital, University of Valencia, Valencia, Spain
| | - Blanca Fuentes
- Department of Neurology, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | - Exuperio Diez-Tejedor
- Department of Neurology, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | - Jorge Rodriguez-Pardo
- Department of Neurology, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
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Smith EE, Charidimou A, Ayata C, Werring DJ, Greenberg SM. Cerebral Amyloid Angiopathy-Related Transient Focal Neurologic Episodes. Neurology 2021; 97:231-238. [PMID: 34016709 PMCID: PMC8356377 DOI: 10.1212/wnl.0000000000012234] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 04/19/2021] [Indexed: 12/22/2022] Open
Abstract
Transient focal neurologic episodes (TFNEs) are brief disturbances in motor, somatosensory, visual, or language functions that can occur in patients with cerebral amyloid angiopathy (CAA) and may be difficult to distinguish from TIAs or other transient neurologic syndromes. They herald a high rate of future lobar intracerebral hemorrhage, making it imperative to differentiate them from TIAs to avoid potentially dangerous use of antithrombotic drugs. Cortical spreading depression or depolarization triggered by acute or chronic superficial brain bleeding, a contributor to brain injury in other neurologic diseases, may be the underlying mechanism. This review discusses diagnosis, pathophysiology, and management of CAA-related TFNEs.
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Affiliation(s)
- Eric E Smith
- From the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Canada; Hemorrhagic Stroke Research Program (A.C., S.M.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School; Stroke Service and Neurovascular Research Lab (C.A.), Department of Neurology, Massachusetts General Hospital, Boston; and Stroke Research Centre (D.J.W.), University College London Queen Square Institute of Neurology, UK.
| | - Andreas Charidimou
- From the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Canada; Hemorrhagic Stroke Research Program (A.C., S.M.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School; Stroke Service and Neurovascular Research Lab (C.A.), Department of Neurology, Massachusetts General Hospital, Boston; and Stroke Research Centre (D.J.W.), University College London Queen Square Institute of Neurology, UK
| | - Cenk Ayata
- From the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Canada; Hemorrhagic Stroke Research Program (A.C., S.M.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School; Stroke Service and Neurovascular Research Lab (C.A.), Department of Neurology, Massachusetts General Hospital, Boston; and Stroke Research Centre (D.J.W.), University College London Queen Square Institute of Neurology, UK
| | - David J Werring
- From the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Canada; Hemorrhagic Stroke Research Program (A.C., S.M.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School; Stroke Service and Neurovascular Research Lab (C.A.), Department of Neurology, Massachusetts General Hospital, Boston; and Stroke Research Centre (D.J.W.), University College London Queen Square Institute of Neurology, UK
| | - Steven M Greenberg
- From the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Canada; Hemorrhagic Stroke Research Program (A.C., S.M.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School; Stroke Service and Neurovascular Research Lab (C.A.), Department of Neurology, Massachusetts General Hospital, Boston; and Stroke Research Centre (D.J.W.), University College London Queen Square Institute of Neurology, UK
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Di Stefano V, Rispoli MG, Pellegrino N, Graziosi A, Rotondo E, Napoli C, Pietrobon D, Brighina F, Parisi P. Diagnostic and therapeutic aspects of hemiplegic migraine. J Neurol Neurosurg Psychiatry 2020; 91:764-771. [PMID: 32430436 PMCID: PMC7361005 DOI: 10.1136/jnnp-2020-322850] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 01/25/2023]
Abstract
Hemiplegic migraine (HM) is a clinically and genetically heterogeneous condition with attacks of headache and motor weakness which may be associated with impaired consciousness, cerebellar ataxia and intellectual disability. Motor symptoms usually last <72 hours and are associated with visual or sensory manifestations, speech impairment or brainstem aura. HM can occur as a sporadic HM or familiar HM with an autosomal dominant mode of inheritance. Mutations in CACNA1A, ATP1A2 and SCN1A encoding proteins involved in ion transport are implicated. The pathophysiology of HM is close to the process of typical migraine with aura, but appearing with a lower threshold and more severity. We reviewed epidemiology, clinical presentation, diagnostic assessment, differential diagnosis and treatment of HM to offer the best evidence of this rare condition. The differential diagnosis of HM is broad, including other types of migraine and any condition that can cause transitory neurological signs and symptoms. Neuroimaging, cerebrospinal fluid analysis and electroencephalography are useful, but the diagnosis is clinical with a genetic confirmation. The management relies on the control of triggering factors and even hospitalisation in case of long-lasting auras. As HM is a rare condition, there are no randomised controlled trials, but the evidence for the treatment comes from small studies.
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Affiliation(s)
- Vincenzo Di Stefano
- Department of Biomedicine, Neuroscience and Advanced Diagnostic (BIND), University of Palermo, Palermo, Sicilia, Italy
| | - Marianna Gabriella Rispoli
- Department of Neuroscience Imaging and Clinical Sciences, 'G. d'Annunzio' University, Universita degli Studi Gabriele d'Annunzio Chieti e Pescara, Chieti Scalo, Chieti, Italy
| | - Noemi Pellegrino
- Pediatrics, University Gabriele d'Annunzio of Chieti Pescara Department of Medicine and Aging Science, Chieti, Abruzzo, Italy
| | - Alessandro Graziosi
- Pediatrics, University Gabriele d'Annunzio of Chieti Pescara Department of Medicine and Aging Science, Chieti, Abruzzo, Italy
| | - Eleonora Rotondo
- Pediatrics, University Gabriele d'Annunzio of Chieti Pescara Department of Medicine and Aging Science, Chieti, Abruzzo, Italy
| | - Christian Napoli
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Roma, Lazio, Italy
| | - Daniela Pietrobon
- Department of Biomedical Sciences & Padova Neuroscience Center, University of Padova, Padova, Italy.,CNR Neuroscience Institute, Padova, Italy
| | - Filippo Brighina
- Department of Biomedicine, Neuroscience and Advanced Diagnostic (BIND), University of Palermo, Palermo, Sicilia, Italy
| | - Pasquale Parisi
- Dipartimento di Neuroscienze Salute Mentale e Organi di Senso (NESMOS), University of Rome La Sapienza Faculty of Medicine and Psychology, Roma, Lazio, Italy
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Koemans EA, Voigt S, Rasing I, van Etten ES, van Zwet EW, van Walderveen MAA, Wermer MJH, Terwindt GM. Migraine With Aura as Early Disease Marker in Hereditary Dutch-Type Cerebral Amyloid Angiopathy. Stroke 2020; 51:1094-1099. [PMID: 32114932 DOI: 10.1161/strokeaha.119.028170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background and Purpose- To determine whether migraine, which has often been described as an inaugural manifestation in monogenic cerebrovascular syndromes, is associated with cerebral amyloid pathology, we assessed migraine and its correlation with magnetic resonance imaging markers in Hereditary Dutch-Type Cerebral Amyloid Angiopathy (D-CAA or Hereditary Cerebral Hemorrhage With Amyloidosis-Dutch type). Methods- All D-CAA mutation carriers who visited our clinic between 2012 and 2018 were included. Migraine was diagnosed by an interview and classified according to the International Classification of Headache Disorders. Magnetic resonance imaging scans were scored for intracerebral hemorrhage (ICH) location(s) and presence of cortical superficial siderosis. Kaplan Meier survival analysis was used for age of ICH onset in carriers with and without migraine. Correlation with ICH location(s) and cortical superficial siderosis were calculated with Poisson regression analysis adjusted for confounders. Results- We included 86 D-CAA mutation carriers (57% women, mean age 57 years), 48 (56%) suffered from migraine, all with aura. Prevalence was higher than expected compared with the general population (women, P<0.05; men, P<0.001). Migraine was the inaugural symptom in 77% and an isolated symptom in 35% of the carriers. Carriers with and without migraine did not differ for age of first ICH, cortical superficial siderosis prevalence, or occipital ICH. Time between migraine onset and first ICH was 8.5 years. Aura attacks lasting ≥60 minutes signaled acute ICH in 55%. Conclusions- Migraine with aura is an important, often inaugural, symptom in D-CAA. Aura attacks lasting ≥60 minutes may signal acute ICH in D-CAA. Migraine with aura may be regarded as an early marker of disease in hereditary CAA preceding the occurrence of symptomatic ICH by several years.
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Affiliation(s)
- Emma A Koemans
- From the Department of Neurology (E.A.K., S.V., I.R., E.S.v.E., M.J.H.W., G.M.T.), Leiden University Medical Center, the Netherlands
| | - Sabine Voigt
- From the Department of Neurology (E.A.K., S.V., I.R., E.S.v.E., M.J.H.W., G.M.T.), Leiden University Medical Center, the Netherlands
| | - Ingeborg Rasing
- From the Department of Neurology (E.A.K., S.V., I.R., E.S.v.E., M.J.H.W., G.M.T.), Leiden University Medical Center, the Netherlands
| | - Ellis S van Etten
- From the Department of Neurology (E.A.K., S.V., I.R., E.S.v.E., M.J.H.W., G.M.T.), Leiden University Medical Center, the Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences (E.W.v.Z.), Leiden University Medical Center, the Netherlands
| | | | - Marieke J H Wermer
- From the Department of Neurology (E.A.K., S.V., I.R., E.S.v.E., M.J.H.W., G.M.T.), Leiden University Medical Center, the Netherlands
| | - Gisela M Terwindt
- From the Department of Neurology (E.A.K., S.V., I.R., E.S.v.E., M.J.H.W., G.M.T.), Leiden University Medical Center, the Netherlands
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The frequency of central nervous system complications in the Cypriot cohort of ATTRV30M neuropathy transplanted patients. Neurol Sci 2020; 41:1163-1170. [PMID: 31897943 DOI: 10.1007/s10072-019-04176-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 11/25/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Hereditary transthyretin amyloidosis (ATTR) is a hereditary, sensorimotor and autonomic neuropathy caused by deposits of mutated transthyretin (TTR). The commonest TTR mutation is V30M (ATTRV30M) with patients usually living for about 10 years after disease onset. Liver transplantation (LT) until recently was considered the standard treatment. OBJECTIVE AND METHODS This study aims to assess the frequency of CNS complications in post-LT patients from the Cypriot cohort. Epidemiological data were collected for all genetically confirmed ATTRV30M neuropathy patients diagnosed at CING since 1992, and CNS-associated symptoms were assessed and evaluated by two neurology specialists. RESULTS Out of the 48 transplanted patients, 10 (20.8%) presented with a CNS complication. All patients had ocular involvement, mainly glaucoma (7/10). Eight presented with transient focal neurological episodes (TFNEs), with expressive dysphasia being reported by four of them. The mean time of TFNE-emergence was 16.6 years after the LT. Three died from cerebral hemorrhage. CONCLUSIONS CNS complications in post-LT ATTRV30M patients are not rare and usually manifest themselves at a time that surpasses the mean time the patients would have survived without a LT. CNS involvement is associated with increased mortality, due to cerebral hemorrhage.
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Jansson PS, Kosowsky JM, Faust JS, Wilcox SR, Wittels KA. A Woman With Metamorphopsia and Visual Hallucinations. J Emerg Med 2020; 58:113-116. [PMID: 31708321 DOI: 10.1016/j.jemermed.2019.09.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/13/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Paul S Jansson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joshua M Kosowsky
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeremy S Faust
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan R Wilcox
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kathleen A Wittels
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Vales-Montero M, García-Pastor A, Iglesias-Mohedano AM, Esteban-de Antonio E, Salgado-Cámara P, García-Domínguez JM, Vázquez-Alén P, Díaz-Otero F, Fernández-Bullido Y, Gil-Núñez A. Cerebral amyloid angiopathy-related transient focal neurological episodes: A transient ischemic attack mimic with an increased risk of intracranial hemorrhage. J Neurol Sci 2019; 406:116452. [PMID: 31525529 DOI: 10.1016/j.jns.2019.116452] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 08/05/2019] [Accepted: 09/06/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Transient focal neurological episodes (TFNEs) are a recently recognized clinical presentation of cerebral amyloid angiopathy (CAA). Our aim was to describe the clinical and radiological features of a series of patients with AS. METHODS We included 11 patients presenting with recurrent transient focal neurological symptoms and radiological features related to CAA. RESULTS Mean age was 76,6 and 5 patients were women. All patients reported transient, stereotyped, and recurrent episodes (6 patients had >10 episodes). Gradual spread of the symptoms was recorded in 9 patients. Initially, 3 patients were misdiagnosed as having recurrent transient ischemic attack (TIA), 6 as having seizures, and 2 as having both. Two patients were prescribed antiplatelet therapy. A cerebral MRI with T2* gradient-recalled echo sequence revealed cortical superficial siderosis (cSS) in 5 patients, cortical microbleeds in 1 patient, and both features in 5 cases. After a median follow-up of 36 months, intracranial hemorrhage (ICH) was recorded in 4 patients. All 4 had cSS in the previous cerebral MRI, and 1 was on antiplatelet therapy. CONCLUSION CAA-related TFNEs are an underdiagnosed entity, often mimicking TIA, seizures, or migraine aura. This misdiagnosis can lead to the prescription of antiplatelet or anticoagulant therapy, which increases the risk of ICH. Our results suggest that cSS might be a radiological marker that is closely related to an increased risk of bleeding. A T2* gradient-recalled echo MRI should be performed in elderly patients with transient focal neurological symptoms suggestive of CAA.
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Affiliation(s)
- Marta Vales-Montero
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Andrés García-Pastor
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain.
| | - Ana María Iglesias-Mohedano
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Ester Esteban-de Antonio
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Paula Salgado-Cámara
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - José Manuel García-Domínguez
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Pilar Vázquez-Alén
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Fernando Díaz-Otero
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Yolanda Fernández-Bullido
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Antonio Gil-Núñez
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
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Lesion location and cognitive impact of cerebral small vessel disease. Clin Sci (Lond) 2017; 131:715-728. [PMID: 28385827 DOI: 10.1042/cs20160452] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 01/17/2017] [Accepted: 01/20/2017] [Indexed: 01/20/2023]
Abstract
Cerebral small vessel disease (SVD) is an important cause of cognitive impairment. Important MRI manifestations of SVD include white matter hyperintensities (WMH) and lacunes. This narrative review addresses the role of anatomical lesion location in the impact of SVD on cognition, integrating findings from early autopsy studies with emerging findings from recent studies with advanced image analysis techniques. Early autopsy and imaging studies of small case series indicate that single lacunar infarcts in, for example the thalamus, caudate nucleus or internal capsule can cause marked cognitive impairment. However, the findings of such case studies may not be generalizable. Emerging location-based image analysis approaches are now being applied to large cohorts. Recent studies show that WMH burden in strategic white matter tracts, such as the forceps minor or anterior thalamic radiation (ATR), is more relevant in explaining variance in cognitive functioning than global WMH volume. These findings suggest that the future diagnostic work-up of memory clinic patients could potentially be improved by shifting from a global assessment of WMH and lacune burden towards a quantitative assessment of lesion volumes within strategic brain regions. In this review, a summary of currently known strategic regions for SVD-related cognitive impairment is provided, highlighting recent technical developments in SVD research. The potential and challenges of location-based approaches for diagnostic purposes in clinical practice are discussed, along with their potential prognostic and therapeutic applications.
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Abstract
PURPOSE OF REVIEW This article is a practical guide to identifying uncommon causes of stroke and offers guidance for evaluation and management, even when large controlled trials are lacking in these rarer forms of stroke. RECENT FINDINGS Fabry disease causes early-onset stroke, particularly of the vertebrobasilar system; enzyme replacement therapy should be considered in affected patients. Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), often misdiagnosed as multiple sclerosis, causes migraines, early-onset lacunar strokes, and dementia. Moyamoya disease can cause either ischemic or hemorrhagic stroke; revascularization is recommended in some patients. Cerebral amyloid angiopathy causes both microhemorrhages and macrohemorrhages, resulting in typical stroke symptoms and progressive dementia. Pregnancy raises the risk of both ischemic and hemorrhagic stroke, particularly in women with preeclampsia/eclampsia. Pregnant women are also at risk for posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome, and cerebral venous sinus thrombosis. Experts recommend that pregnant women with acute ischemic stroke not be systematically denied the potential benefits of IV recombinant tissue plasminogen activator. SUMMARY Neurologists should become familiar with these uncommon causes of stroke to provide future risk assessment and family counseling and to implement appropriate treatment plans to prevent recurrence.
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