neuroimaging findings in migraine and prognostic

NEUROIMAGING FINDINGS IN MIGRAINE AND
PROGNOSTIC IMPLICATIONS
S. Marqués Llano, H. Vidal Trueba, E. López Uzquiza, E. Torres, N. Valle, E. Marco de Lucas, Eva Ruiz.
Department of Radiology, Hospital Universitario "Marqués de Valdecilla", Santander, Cantabria, Spain.
Purpose / Aim
To analyze the clinical features of migraine, which should suggest the possibility
of associated findings in neuroimaging procedures.
To assess the role of MRI in the management of these patients.
To review the main neuroimaging findings that can be found in a patient with
migraine.
To show several examples of neuroimaging findings in migraine.
INTRODUCTION
Migraine is an extraordinarily common, chronic,
intermittently disabling, and usually inherited
neurovascular disorder.
This affects about 15% of the population. It is a primary
disorder of the brain, which is often influenced by lifestyle
and genetic factors.
The incidence of migraine peaks between 15 years and 24
years of age. The prevalence is highest among persons
between the ages of 35 and 45 years (17.6% in women
and 5.7% in men).
It is underdiagnosed (approximately half of patients),
and even when diagnosed, migraine is often undertreated.
PATHOPHYSIOLOGY
Patients with migraine typically suffer
• severe and recurrent headache
• accompanied by autonomic symptoms
• a minority experience transient neurological symptoms known as an aura.
NEUROVASCULAR THEORY
1. The aura symptoms are considered to be due to
cerebral vasoconstriction with focal cortical
spreading depression.
2. The headache phase although still poorly
understood, might be caused by subsequent
vasodilatation producing headache disorder.
Functional neuroimaging
(PET) has provided new
insights into the physiological
dysfunction that characterizes
migraine.
The unilateral, focal (occipitoparietal) oligaemia during the
aura was preceded by
hyperaemia.
CBV
CBF
36 y-o man with left sided migraine and left facial and hand
parestherias. CTPERFUSION showed slight hyperperfusion in right
CMA territory. Resolution of the clinical symptoms was observed
after 2 days with normal subsequent MR and CTP.
In migraine, perfusion may be increased
or decreased depending on the timing
of the scan relative to the symptom
onset.
The oligaemia spread
anteriorly and severe
headache occurred during
the oligaemic phase
A PET study showed a
hypothalamic activation in
association with brainstem
areas.
DIAGNOSIS
•
•
The diagnosis is generally made based on clinical criteria
Neuroimaging used in some cases to exclude secondary causes of
headache or ischemic complications. (Migraine is an independent risk factor for
ischemic stroke)
IDENTIFICATION OF PATIENTS WHO SHOULD UNDERGO AN MR EXAMINATION.
•
•
•
•
•
change in headache pattern
side-locked headaches (unilateral headaches that never change sides)
new onset of chronic daily headache.
prolonged aura
Higher possibility of ischemic complication (women with migraine with aura ,
younger than 45 years and use of estrogen containing oral contraceptives).
The International Classification of Headache Disorders
3rd edition (2013)
1.1 Migraine without aura
1.2 Migraine with aura
1.2.1 Migraine with typical aura
1.2.1.1 Typical aura with headache
1.2.1.2 Typical aura without headache
1.2.2 Migraine with brainstem aura
1.2.3 Hemiplegic migraine
1.2.3.1 Familial hemiplegic migraine (FHM)
1.2.3.1.1 Familial hemiplegic migraine type 1
1.2.3.1.2 Familial hemiplegic migraine type 2
1.2.3.1.3 Familial hemiplegic migraine type 3
1.2.3.1.4 Familial hemiplegic migraine, other loci
1.2.3.2 Sporadic hemiplegic migraine
1.2.4 Retinal migraine
1.3 Chronic migraine
1.4 Complications of migraine
1.4.1 Status migrainosus
1.4.2 Persistent aura without infarction
1.4.3 Migrainous infarction
1.4.4 Migraine aura-triggered seizure
1.5 Probable migraine
1.5.1 Probable migraine without aura
1.5.2 Probable migraine with aura
1.6 Episodic syndromes that may be associated with migraine
1.6.1 Recurrent gastrointestinal disturbance
1.6.1.1 Cyclical vomiting syndrome
1.6.1.2 Abdominal migraine
1.6.2 Benign paroxysmal vertigo
1.6.3 Benign paroxysmal torticollis
IMAGING protocol
CT
CT is of extremely low yield in patients who undergo imaging for chronic headache
without neurologic abnormality.
CTP may be very useful to analyze acute attacks perfusion regional changes.
MRI
It is more sensitive than CT in the detection of an intracranial abnormality.
Protocol: T1, T2, T2*, FLAIR, Diffusion, Perfusion, MRA.
*More recently functional MRI (fMRI) is often employed due to its non invasive nature, and exploiting the
blood oxygenation level dependent (BOLD) signal and neurovascular coupling.
IMAGING FINDINGS OF MIGRAINE
a) WHITE MATTER LESIONS
•
White matter hyperintensities are more
prevalent in
– migraineurs compared to the general
population (12–47% of all patients).
– More than 60% of migraineurs with aura
– Patients with frequent attacks
•
The consequences of these lesions are unclear
even if they are by large considered clinically silent.
•
There is a correlation of the number of new lesions
with the duration of aura.
– In the majority of cases, transient hypoperfusion would not
lead to any brain tissue damage but episodes of perfusion
perturbation, if long enough, might reach the threshold for
tissue damage as suggested by experimental studies.
They are typically seen on T2 and FLAIR
MRI as multiple, small, punctuate
lesions in the deep or periventricular
white matter, as well as in the pons. This
coronal FLAIR shows a white matter
hyperintensity in left sentrum semiovale.
She had suffered a migraine attack with
transient hypoesthesia.
VASCULAR
PHENOMENA
CT study of a
patient within a
migraine attack
with prolonged
aura.
NECT is normal.
CTPerfusion showed
areas of
hypoperfusion in left
frontal and temporal
regions.
AURA
HYPOXIA
INFLAMMATORY
MEDIATORS
•
•
Consistent demonstrable changes in
brain perfusion have been reported in
migraine, especially with aura
Prevalence of white matter lesions
has been reported to be more
frequent in migraineurs with aura.
*Other larger studies did not confirm these data on WMLs difference
in migraine subtypes.
CBF
MTT
b) ISCHEMIC CORTICAL LESIONS
•
Migraine is an independent risk
factor for ischemic stroke
(but increase is very small)
•
More frequent in
– young women
– contraceptives with estrogen.
– aura
•
In acute attacks, CTP can delineate
the area of hypoperfusion
•
MRI can show an area of restricted
diffusion without MRA
32 y-o woman with lethargy, fever and right hemiparesis. Initial
NECT showed a light midline shift without focal lesions. One day
later the patient suffered clinical deterioration and was transferred to
the ICU.
Subsequently an MRI study demonstrated hyperintense left
hemispheric cortical thickening without diffusion restriction and no
enhancement. The patient had a progressive improvement and MRI
was normal again.
SEE NEXT SLIDE
T2
FLAIR
DWI
33 year-old woman treated with oral anticonceptives, migraineur since whe was 16
y-o. She suffered an acute left hand weakness during an aura episode without
headache.
MRI showed a cortico-subcortical hyper T2/FLAIR lesion with restricted diffusion
suggestive of acute ischemic infarction. MRA was normal. She had a progressive
clinical improvement despite infarction with hand movement almost complere
recovery.
•
•
MRA
•
It is still a matter of debate whether perfusion changes
observed during an aura could cause acute ischemic stroke.
Clinical differentiation between migraine aura and migrainous
infarction is difficult especially when severe headache is
absent.
Early MRI diffusion- and perfusion-weighted imaging may aid
in differentiating these entities.
c) HEMIPLEGIC MIGRAINE
•
•
•
Rare type of migraine with aura
Recurrent episodes
May present acute neurologic symptoms:
•
•
•
•
•
•
•
fever, lethargy, aphasia, confusion,
scintillating scotoma, hemianopsia,
hemisensory symptoms,
cerebellar ataxia,
epilepsy,
loss of consciousness, coma.
CT
T2
Differential diagnosis:
–
–
–
–
–
–
acute brain infarction
vasculitis
focal infections
MELAS
CADASIL
HaNDL
DWI
T1+Gd
32 y-o woman with lethargy, fever and right hemiparesis.
Initial NECT showed a light midline shift without focal
lesions. One day later the patient suffered clinical
deterioration and was transferred to the ICU.
Subsequently an MRI study demonstrated hyperintense left
hemispheric cortical thickening without diffusion
restriction and no enhancement. The patient had a
progressive improvement and MRI was normal again.
SEE NEXT SLIDE
•
•
•
When the attack is finished, the
neurologic
deficit
usually
resolves fully
Unilateral symptoms may switch
sides between attacks.
MRI:
– cortical hemispheric thickening
hyper T2
– No vascular territory
– No contrast enhancement or
diffusion restriction.
– Midline shift and sulcal
effacement
32 y-o woman with lethargy, fever and right hemiparesis.
Initial NECT showed a light midline shift without focal
lesions.
MRI study (A) demonstrated hyperintense left
hemispheric cortical swelling without diffusion
restriction and no enhancement. The patient had a
progressive improvement and MRI was normal again (B).
MRI was repeated in two new attacks with right
hemispheric (the other side) with subsequent normalization.
A. ATTACK HEMIPLEGIC MIGRAINE
B. AFTER CLINICAL NORMALIZATION
d) FUNCTIONAL IMAGING STUDIES:
ADVANCING OUR UNDERSTANDING OF THE UNDERLYING
MIGRAINE MECHANISM
•
•
•
•
The employment of functional neuroimaging gives us a way
to learn more about the complex pathophysiology of
migraine.
A recent study has shown dramatic fMRI changes in the
visual cortex of patients experiencing migraine aura.
Patients with migraine have increased contralateral primary
sensorimotor cortex activation and a shift of the center of
supplementary motor area activation, suggesting that
migraine can be associated with local functional
reorganization of the cortex outside the cephalalgic phase
of the disease.
The rostral displacement of the SMA detected in patients
with migraine might be secondary to an increased
activation of the pre-SMA in these patients.
PET
Many of the functional imaging studies in headache research have used position
emission tomography (PET). This method contains some degree of invasiveness,
with injection of a radiopharmaceutical.
Several studies showed brainstem activation during the migraine attack. The
information provided with PET cannot provide clear information about the nuclei,
but the maximum activation was around the dorsal midbrain, which contains the
dorsal raphe nucleus and periaqueductal grey matter, and the dorsolateral pons,
which contains the locus coeruleus.
In addition, the activation was seen in the anterior cingulate, posterior cingulate,
cerebellum, thalamus, insula, prefrontal cortex, and temporal lobes. It was not seen
outside the attacks.
E) SECONDARY MIGRAINES & MIMICS
MR in patients with migraine
can help to identify a treatable
lesion:
–
–
–
–
brain tumor
hydrocephalus
subdural hematoma.
Intracranial hypotension
CEREBRAL ARTERIOVENOUS
MALFORMATIONS
•
•
•
•
23 y-o woman with chronic migraine episodes without
aura. Because of an increased frequency an MRI was
performed. It showed a right frontal AVM.
•
Headache is first clinical presentation in about
14 % of patients with AVMs.
Headache associated with AVMs often shows
characteristics of migraine with and without
aura.
Angiographic characteristics of AVMs could
determine the ‘migraine-like’ features of attacks.
An occipital location may be linked with
spreading depression and could have clinical
features similar to migraine.
Prevalence of migraine-like headache as AVM
initial symptom is higher than the prevalence of
this kind of headache in the general population.
Summary
•
•
•
•
•
•
•
Migraine is an extraordinarily common, chronic, intermittently
disabling, and usually inherited neurovascular disorder, frequently
underdiagnosed.
Complex pathophysiology includes alterations in regional cerebral
perfusion (including hyper and hypoperfusion)
The diagnosis is generally made based on clinical criteria
MR should be used in some cases to exclude secondary causes of
headache or ischemic complications.
White matter FLAIR hyperintensities are more prevalent in
migraineurs, especially with aura (but without clear prognostic
correlation).
Ischemic lesions are more frequent in migraineurs, possibly related
to the hypoperfusion phase.
Hemiplegic migraine presents a typical MR imaging with nonvascular extensive cortical hyper T2 thickening.
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•
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