NORTH CAROLINA NEUROLOGICAL SOCIETY 201...AAN Sports Neurology Strategic Plan, updated 2013 1.Neurological injuries insport A. Concussion and braininjuries B. Spinal and peripheralinjuries

This continuing medical education activity is jointly provided by the North Carolina Neurological Society and

the Southern Regional Area Health Education Center

FEBRUARY 15-17, 2019 GRANDOVER RESORT, GREENSBORO, NC

SUNDAY HANDOUTS: General Session

2019ANNUAL MEETING

NORTH CAROLINA NEUROLOGICAL SOCIETY

1

Sports Concussions…& more!!

Christopher C. Giza, M.D.Pediatric Neurology and Neurosurgery

North Carolina Neuro Society March 17th, 2019Greensboro, NC

45min

A Quick Tour of Sports Neurology

Credit where credit deserved!

Basic Science FacultyDavid Hovda, Ph.D.Fernando Gomez-Pinilla, Ph.D. Tiffany Greco, Ph.D.Neil Harris, Ph.D. Dejan Markovic, Ph.D.Raman Sankar, M.D., Ph.D.

Medical Students Stephanie Pham Kwame Firempong Lilian Yousefi

Lab ManagersYan Cai, M.S.Sima Ghavim

Residents/FellowsDorothy Harris, M.D., Ph.D. Beth Nakae, M.D.Rafael Romeu-Mejia, M.D. Tara Sharma, M.D.Aliyah Snyder, Ph.D.

Clinical FacultyRobert Asarnow, Ph.D. Michelle Kraske, Ph.D. Adam Darby, M.D. Josh Goldman, M.D. Josh Kamins, M.D. Jason Lerner, M.D. Andy Madikians, M.D. Joyce Matsumoto, M.D.David McArthur, Ph.D., M.P.H. Doug Polster, Ph.D.Raj Rajaraman, M.D.

www.uclahealth.org/brainsport [email protected] Twitter: @griz1

AdminAssistants Janet KorNikol Ledesma

Funded by: NIH NS27544, NCAA, Dept of Defense, Stan & Patti Silver, UCLA BIRC, UCLA Steve Tisch BrainSPORT, Richie Fund, UCLA Easton Clinic for

Brain Health, Avanir, Neural AnalyticsAdvisor: MLS, NBA, USSoccer; Consultant: Neural

Analytics, NFL-NCP, NHLPA, LA Lakers

Program Management Constance Johnson Philip Rosenbaum

Associate Directors, BrainSPORTTalin Babikian, Ph.D. Meeryo Choe, M.D. Joshua Goldman, M.D. Mayumi Prins, Ph.D.

Graduate Student

Research Assistants Mania Alexandrian MichaelAmickAnne Brown Yena Kim Chris Sheridan

StudentHolly Kular

Alexandra Tanner

Occupational Therapist Madison Harris, O.T.D.

Post-docsEmily Dennis, Ph.D. Annie Hoffman, Ph.D. Saman Sargolzaei, Ph.D.

Sports Neurology: Areas of Focus

AAN Sports Neurology Strategic Plan, updated 2013

1.Neurological injuries in sportA. Concussion and brain injuriesB. Spinal and peripheral injuries

2.Safe participation in sports by patients with neuro conditions

3.Understanding chronic neurobehavioral sequelae of sports injury

4.Understanding the neurological benefit of exercise

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Concussion

Resources Recognize Remove Recover Return

AAN Evidence-Based Guidelines Released 3/18/13!

http://www.aan.com/concussion

Heads Up! www.cdc.gov

Berlin: Conference 2016;Consensus 2017

McCrory P et al., Concussion in Sport, (3rd ), Br J Sport Med 2017

11 “Rs”1. Recognize2. Remove3. Re-evaluate4. Rest5. Rehabilitation6. Refer7. Recovery8. Return to Sport9. Re-consider10.Residual effects & sequelae11.Risk Reduction

McCrory P et al., Concussion in Sport, (5th), Br J Sport Med 2017

3

Recognize: What is a Concussion?

“A Brain Movement Injury”

• A biological process affecting the brain induced by physical forces

Biomechanical event

Symptoms start quickly

Neurological symptoms but not only rarely unconsciousness

Gets better with time if you don’t get hit again

Symptoms not caused by something elseMcCrory P et al., Concussion in Sport, (5th), Br J Sport Med 2017

Recognize, Remove, Re-evaluate

STEP 1:Recognize:

Suspect Concussion?

Yes / No?

Concussion not suspected

Concussion suspected

STEP 2:Remove & EvaluateMechanism Symptoms

SCAT5ChildSCAT5

Concussion diagnosed

ImpactEvent

Concussion not diagnosed or unsure

STEP 3:Re-

evaluate

Recognize & Remove• NO SINGLE test to diagnose concussion• Using SCAT5 - test conditions are important

• Quiet conditions• Minimum 10 minutes

• Helmet/impact sensors not for diagnosis

• Video may help?

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80

70

60

50

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>7 days

1-7 days

<1 day

Remove: Avoid Repeat Concussion

Athletes with prior concussions are more likely to get another concussion & may take longer to recover.

Guskiewicz et al., JAMA 2003

% o

f co

ncu

sse

da

thle

tes

1 2

# of concussions

Days to recovery

Of in-season repeat concussions, 11/12 (92%) occurred within 10 days of initial concussion

Remove: Avoid Prolonged Recovery & Musculoskeletal Injury

Eisenberg et al., Pediatrics 2013

LEx injury #

Total # % of total

mTBI 15 87 17%

No mTBI 17 182 9%

Total 32 269 12%

Brooks MA et al., AJSM 2016 McPherson AL, et al., AJSM 2018

Recovery time and risk of musculoskeletal injury may be related to prior concussion(s)

Re-evaluate• May occur during/after game, in emergency

room or in clinic

1. Comprehensive history2. Physical examination3. Symptoms4. Cognition5. Gait & Balance6. Visual & Ocular7. Determine need for CT?

5

Re-evaluate• May occur during/after game, in emergency

room or in clinic

1. Neuropsychological testing – useful in assessment & recovery

2. Computerized cognitive testing – optional

RESEARCH ONLY1. Fluid biomarkers?2. Advanced neuroimaging?3. Genetic testing?

Remove, Rest

Athletes with delayed removal from play after concussion take longer to recover.

Eblin et al., Pediatrics 2016Asken et al. AJSM 2018

Asken et al. J Athl Training 2016

Rest: But Not Too Long

Strict rest took longer than usual care for recovery. Grool, et al., JAMA 2016

Prospective; n=3063; age=5-17.99y

Higher activity had less persistent symptoms than

no activity

%PPCS @ 4 wks

Early Activity <7d 28.7%

No Activity <7d 40.1%

Thomas DG, et al, Pediatrics 2015

For review, see Kerrigan & Giza, Childs Nerv System, 2017

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Rehabilitation

Leddy JJ, et al., Clin J Sport Med 2010

Gagnon I, et al., Scand J Med Sci Sport 2015

Giza CC, et al., JAMA Neurol 2018

• Activity drives neuroplasticity and enhances brain performance

• Activity is good for the recovering brain• Active exercise improves symptoms• Athletes may improve more rapidly• Exercise tolerance improves with training

ReferFor Persistent Symptoms

• Assessment for Comorbidities

• Multidisciplinary subspecialty evaluation can be beneficial

• Individualized treatment plan

OTHER TREATMENT OPTIONS1. Controlled subsymptom

threshold exercise2. Physical therapy, with

vestibular component3. Cognitive behavioral therapy4. Pharmacotherapy for

comorbid conditions

Recovery: Prolonged SymptomsPrior concussion

Prior headaches

HeadacheFogginess

Younger age

On-field AMS

Learning disability /

ADHD

Dizziness

Giza, Kutcher, et al., Neurol 2013

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Return to SportAthletes should NOT return to play the same day of injury

“Return to Play” only after “Return to Learn” starts

(physical and mental rest)

24-48 hours for high school and younger

McCrory, et.al. Br J Sports Med, 2013, 2017

(add balance, running, balance)

1. Symptom-limited rest

2. Light aerobic exercise

3. Sport-specific exercise

(add aerobic, stationary bike, swim)

4. Non-contact training drills (add thinking, resistance training)

(after medical clearance)5. Full contact training

6. Return to competition (game play)

Reconsider: Return to School

REST

• 1-2 days• Limited/ no

work

BEGINNING RECOVERY

• Start cognitive effort• Partial return to

school• Monitor symptoms

GRADUAL ACTIVITY

• Increase cognitive effort

• Return to school• Monitor symptoms• May start non-contact

risk exercise

RETURN TO NORMALCY

• Return to normal school

• Monitor symptoms• Begin/ continue

return to play progression

Modified From: McCrory P et al., Concussion in Sport, (5th), Br J Sport Med 2017

Davis G et al., Concussion in Sport, (5th), Br J Sport Med 2017

Risk Reduction1. Pre-participation sports neurology evaluation2. Prevention

a) Helmet use in snowboarding/skiing is supportedb) Mouthguards NOT proven to reduce concussion (but use for teeth)c) Disallowing body checking in <13y youth hockey is supportedd) Stricter rules for high elbows in pro soccer is supportede) Need more investigation:

i. Limited contact in youth American football – maybeii. Fair play rules in hockey, tackle practice in football & rugby –

maybe3. Knowledge translation

McCrory P et al., Concussion in Sport, (5th), Br J Sport Med 2017 Emery CA et al., Concussion in Sport, (5th), Br J Sport Med 2017

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Spinal Neurotrauma in Sport

Adapted from Brian Hainline

1.Catastrophic Cervical Spine Injury

• Axial loading is mechanism for catastrophic C spine injuries

• Results from head-down tackling and spearing

• These injuries largely mitigated through proper rules enforcement and training

Spinal Neurotrauma in Sport

Adapted from Brian Hainline

2. Cervical Cord Neurapraxia• Sudden neck extension with uni- or bilateral upper extremity

symptoms

• C3-7 diameter <13mm

• Torg ratio: midsagittal spinal canal diameter to vertebral body diameter

• Torg ratio <0.7 predictor of functional stenosis

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Peripheral Neurotrauma in Sport

Adapted from Aleksander Beric

1. Upper extremityA. Stinger/Burner – football, etc. Shoulder/arm pain w/ brief

weakness. Likely neurapraxia.

B. Brachial plexopathy – football, hockey, snowboarding, etc. Usually upper trunk

C. Axillary neuropathy – baseball, football, hockey, martial arts, etc. Associated with anterior shoulder dislocations

D. Ulnar neuropathy – baseball pitching, weightlifting, cycling, martial arts. Elbow most common, then wrist

E. Median neuropathy & CTS – cycling, weightlifting, golf

Peripheral Neurotrauma in Sport

Adapted from Aleksander Beric

2. Lower extremityA. Lateral femoral cutaneous neuropathy (meralgia paresthetica) –

running, gymnastics, backpacking

B. Peroneal neuropathies – soccer, football, martial arts, surfing. Traction or blow at knee. For superficial or deep branch –exertional compartment syndrome.

C. Tibial nerve (tarsal tunnel syndrome) – mountain climbing, running, ballet







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Sports Participation: Headaches1.Headaches & migraines

A. No evidence-based guidelinesi. Headache common in athletes – maybe more so?

B. Exertional headaches & migrainesi. Triggered by exertion, increase HR & BPii. Warm up, good hydration, gradual conditioning

C. Cervical & musculoskeletal painsD. Occipital neuralgiaE. Post-concussion headaches

i. The complicating factor for the athlete with headaches…how to determine the presence of a concussion?

Sports Participation: Seizures2. Epilepsy

A. No evidence-based guidelinesB. Timing of seizures

i. Frequency of seizuresii. Nocturnal vs diurnaliii. Triggers?

C. Safety issuesi. Injury potential

a. Catastrophic: rockclimbing, cycling, autoracing, etc.b. Serious: football, hockey, etc.c. Low: tennis, golf, running, etc.

ii. Medical team aware and with treatment planiii. Risk of trauma-induced seizure?

D. Medication compliancei. Monitor for medication SEs – drowsiness, ataxia, nystagmusii. Compliance essential to maximize sport safety

Sports Participation: Other3. Multiple sclerosis

A. Advantages of exercise & fitness balanced with risksB. Heat sensitivityC. Limitations based upon individual impairments – visual,

strength, coordination, speed, balance

4. Neuromuscular / neurodegenerativeA. Advantages balanced with risksB. Limitations based upon individual impairmentsC. Periodic reassessments to monitor for progressive deficits

5. Arachnoid cystsA. Congenital – what is long-term risk?B. Case reports of hemorrhage into cysts – should

collision/contact sports be discouraged

6. Post-neurosurgical?

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Chronic DysfunctionPost-concussionsyndrome (PCS)

Chronic Traumatic Encephalopathy

(CTE)

Persistent post-concussive symptoms (PPCS)

Initial TBI LOC, PTA, altered mentation, post-traumatic seizures

Repetitive mTBI/blast injuries

Diagnosed concussion +/- LOC, PTA, etc

Onset of symptoms

Unspecified to within 4 weeks of TBI event

Months to years after exposure to repeat impacts

Concussion sx <24-48 hrs; PPCS>3-6 weeks

Symptoms 3/8 from headache, dizziness, fatigue, irritability, problems with sleep, concentration, memory or stress/emotions

Broad range of symptoms: cognitive dysfunction, emotional, motor impairment

Multiple symptoms from 21-22 item validated checklists

Duration Unspecified to a minimum of3 months

Unspecified tominimum of 2 years

Symptoms lasting longer thanexpected (>3-6 weeks)

Other terminology

Neurocognitive disorder, mild

Dementia pugilistica, “punch-drunk”

PPCS

Diagnostic criteria

Nonspecific, see above Phosphorylated-tau on brain autopsy

Specific for each symptom complex

Treatment Unspecified, rest, waiting None Diagnosis specific

Implication No specific intervention, chronic disability

Progressive neuro-degeneration & death

Treatment focused on each diagnosis

PPCS Diagnostic Approach1. Neuropsychological evaluation - ADHD, anxiety, depression, learning

problems, MCI2. MRI (include SWI) – usually normal – evidence of prior TBI, chronic

SDH, ventriculomegaly, atrophy, low pressure headache3. Sleep study – sleep issues frequently comorbid4. Cervical/musculoskeletal examination – cervicogenic headache, occipital

neuralgia, dizziness5. Autonomic testing/orthostatics – dysautonomia, POTS6. Vestibular/oculomotor testing – BPPV, vestibular dz, migraine7. Laboratory/blood tests – endocrine, metabolic, vascular8. Other – deconditioning, migraine, other chronic pain

Not all chronic problems are “PCS” or CTE!

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Post-Concussion Symptom PieDeconditioning• Aerobic exercise• Nutrition• Hydration

Sleep disturbance• Sleep hygiene• Melatonin• Sleep study?

Headache• Abortive meds• Preventive meds• PT/cervical• Injections• Avoid med overuse

Anxiety/Depression• Neuropsych

assessment• Psychotherapy• CBT• Medications

Dizziness• Vestibular tx• Hydration• Autonomic eval• Migraine

Cognitive• Neuropsych assessment/premorbid• Treat comorbidities• CBT• Medications

Long-term studies of contact sports risk

CTE autopsy studies Living patient studies

Design Retrospective Prospective

Outcome measure

Autopsy neuropathology

Neurocognitive testingor clinical diagnosis ofneurodegenerative dz

N 274 3756

Level of play Mostly professional High school

Bias? Ascertainment, recall Attrition

Control group? No Yes

Main Finding 201/274 (73.4%) had No cognitive impairmentCTE pathology or neurodegeneration

30-50 ys after HScompared to controls

Mez 2017; Hazrati 2013;Bieniek 2015

Deshpande 2017, Savica2012; Janssen 2017







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Benefits of Exercise

Larson EB et al, Ann Int Med 2006

Lautenschlager NT, et al, JAMA 2008

Hillman CH et al, Nature Neurosci 2008

Improve cardiovascular fitness

Improve cerebral blood flow Increase neurotrophins

(plasticity) Increase endorphins (pain

relief) Increase mood/well being Decrease anxiety Improve sleep Enhance / preserve

cognition / attention

Cardiovascular Health:modifiable factors improve brain health

Samieri et al., JAMA 2018

7 cardiovascular health metrics: nonsmoking, exercise, healthy diet, BMI<25, cholesterol <200 mg/dL, BP < 120/80, fasting glucose <100 mg/dL

>65y

Healthiest tertile: -20% WM lesions,+11% vessel density, +3% caliber

Williamson W, et al., JAMA 2018

8 modifiable cardiovascular risk factors: BMI<25, fitness/activity, alcohol <8/wk, nonsmoking >6m, BP < 130/80, exercise DBP <90, cholesterol <200 mg/dL, fasting glucose <100 mg/dL

18-40y

Sum Up1. Sports Concussions are a major public health problem with

several good evidence-based clinical guidelines.2. Acute sport-concussion management includes removal from

risk, avoid premature return, reassurance, symptom control.3. Return to non-risky activities should be quick, guided by

symptoms, and avoiding prolonged inactivity.4. Don’t overlook spinal and peripheral nerve injuries.5. Patients with neurological conditions may want to and

should be permitted to [safely] participate in sport.6. Patients with chronic potential sequelae of sports

concussion should undergo appropriate diagnostic workup and treatment.

7. General physical fitness is a strong influence on optimal brain fitness.

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It’s Just a Game

1

Problem Solving with MRI: Some Pearls and Pitfalls

Carol P. Geer, MD

Associate Professor, Neuroradiology

Wake Forest University

1

Objectives

• Review pearls and pitfalls in the MRI work up of some common neurologic symptoms

• Discuss applications of perfusion and susceptibility weighted imaging in the work up of neurologic diseases

2

Disclosures

• Nothing to disclose except I was formerly a neurosurgeon in private practice

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2

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Let’s start with some pitfalls….

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goodmenproject.com

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3

Case

• 45 yo male presents with trigeminal neuralgia

• Brain MRI with and without contrast interpreted as normal

• Treated with medical management

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T2 8

4 months later….

• Patient complaining of worsening face pain

• Seems “atypical”

• Referred to neurosurgeon for further treatment

• Undergoes Microvascular Decompression (MVD)

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5 months later….

• No improvement in symptoms

• Repeat brain MRI interpreted as normal

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T1

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T1 post contrast fat saturated12

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Diagnosis?

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Perineural Spread of Squamous Cell Carcinoma

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Initial Brain MRI

T1 post contrast, fat sat

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Trigeminal Nerve

https://my.statdx.com 17

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T1 post contrast, fat saturated 21

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Pearls

• Beware of “atypical” trigeminal neuralgia

• Follow the Trigeminal Nerve all the way from the brainstem into the face (remember pterygopalatine fossa)

• T1 fat saturated post contrast sequence can be helpful to follow the trigeminal nerve at the skull base (takes longer to acquire)

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Pearls: Other Causes of CN V pain

• Perineural spread of head and neck cancer

• IgG4 related disease involving the cavernous sinus

• Meningioma of cavernous sinus

• Schwannoma

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Case

• 58 yo male presents with progressive lower extremity weakness and numbness over four months

• Lumbar spine MRI: L4-5 degenerative disc disease with disc bulging

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T2

T2, fat sat

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Referred to orthopedic surgery

• Underwent L4-5 laminectomy

• Symptoms in both legs continued to progress

• Referred to neurologist who ordered a thoracic spine MRI

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T2

T2, fat sat

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T2

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T1

T1 post contrast, fat sat

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Differential for hyperintense T2 thoracic cord signal

• Trauma

• Demyelinating disease

• Cord infarct

• Tumor

• Myelitis (transverse myelitis or infectious)

• Dural arteriovenous fistula (dural avf)

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Spinal Dural AVF Suspected

• Obtained brain MRI to evaluate for demyelinating disease (which was normal)

• No enlargement of the cord—tumor unlikely

• Duration of symptoms unlikely for myelitis

• Referred for spinal angiogram to evaluate for dural AVF

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Case Continued….

• Spinal angiogram interpreted as normal

• Referred back to neurology for further work up

• Extensive work up negative

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What to do now???

• Refer back for repeat spinal angiogram

• Neuro interventionalist is not happy!!!!!!!!!

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MRA or CTA of the spine to help guide repeat spinal angiogram

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Repeat Spinal Angiogram

• Small, slow flow dural av fistula

• Fistula closed with surgery

• Patients symptoms have stabilized

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Pitfalls

• Don’t forget to look at the conus on a lumbar spine MRI

• Don’t forget to include spinal dural avf in differential for hyperintense T2 signal in the spinal cord

• Sometimes you can’t take “no” for an answer– spinal angiograms are very difficult cases and small dural avf’s can be missed

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scienceabc.com

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Pearls

• Offer spinal MRA or CTA to help localize a possible target on repeat spinal angiograms

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Case

• 48 yo female on dialysis with headaches and vertigo

• Head CT: subacute to chronic cerebellar hematoma

• Brain MRI: subacute to chronic cerebellar hematoma

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Case Continued…

• Patient transferred with these reports

• Patient getting hemodialysis MWF

• No fevers or leukocytosis

• Mild headache and vertigo

• Repeat Brain MRI

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T2 T1

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Diffusion weighted imaging (DWI)

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Case continued….

• Patient underwent chest/abdomen/pelvic CT: negative (R/O metastatic disease as cause of cerebellar disease in differential)

• Neurosurgery consulted for subacute hematoma (elected to follow due to stable neuro exam)

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Case Continued….

• Repeat brain MRI due to worsening headache and now some confusion

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Brain MRI without contrast

• No contrast given due to renal failure in dialysis patient and risk of Nephrogenic Systemic Fibrosis (NSF)

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T2 T1

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T2 T1

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T2 T1

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Susceptibility weighted imaging (SWI)

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DWI ADC

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All prior imaging reviewed

• Due to restricted diffusion, cerebellar abscess was suggested

• Neurosurgery was re-consulted and urged to biopsy

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Diagnosis

• Cerebellar abscess

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Imaging Findings Of Cerebral Abscess

• Peripheral enhancement

• *Central restricted diffusion*

• Low T2 signal rim

• Surrounding edema

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T2SWI

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T1 T1 post contrast

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DWI ADC

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Abscess• Polymicrobial

– Bacterial (strep, staph, anaerobes)• Begins as cerebritis• Elevated ESR• Treatment

– Drainage– Antibiotics with anaerobe coverage– If <2.5 cm, can consider antibiotics alone

• Ventriculitis can be fatal• LP contraindicated

– Often pathogen can’t be determined by CSF

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Causes of abscess

• Direct spread of infection– Sinusitis, mastoiditis, teeth via valveless

emissary veins

– Penetrating trauma

• Hematogenous spread of infection– Pulmonary infection, endocarditis, UTI, right

to left shunts

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22

Pitfalls

• Influenced by prior history and imaging diagnosis

• Atypical presentation of abscess

• Follow the “signal” rules– Restrict Diffusion on DWI

• Abscess

• Acute ischemia

• Cellular tumors (lymphoma, medulloblastoma)

• Epidermoid cyst

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Age of Blood Products on MRI

• Acute: iso/T1, dark/T2

• Early Subacute (72 hours): bright/T1, dark/T2

• Later Subacute (one week to several weeks): bright T1/bright T2

• Chronic (weeks): dark/T1, dark/T2

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Subacute hematomas (greater than one week)

• Hyperintense on T1 and T2

• Can restrict diffusion (unfortunate pitfall)

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T2 T1

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Case

• 60 yo male presents with tinnitus

• Neck MRA with and without contrast ordered

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2D Time of Flight 69

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Neck MRA with contrast

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Diagnosis

• Dural Arteriovenous Fistula involving the transverse/sigmoid sinuses

• Imaging findings:– Arterial signal in the left sigmoid sinus

– Arterial opacification of left internal jugular vein on post contrast neck MRA

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Pearls

• MRA is a great initial screening study for dural avf/avm

• Better to order BOTH brain and neck MRA

• Neck MRA should be with and withoutcontrast

• Brain MRA: do not need contrast

• Catheter directed angiogram for confirmation and characterization of AV Fistula

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Companion Case

• 72 yo female presents with left orbital chemosis and new left CN VI palsy

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3D Time of flight MRA without contrast

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Orbit CT with contrast78

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Case

• 17 yo female presents with headache and new onset right sided weakness

• Head CT and CTA: normal

• Brain MRI ordered

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DWIADC

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Susceptibility Weighted Imaging (SWI)

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• Compounds that are paramagnetic, diamagnetic, and ferromagnetic distort the local magnetic field and alter the phase of the tissue which results in loss of signal

84

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Dark on SWI

• Deoxyhemoglobin– Acute thrombus

– Veins

• Ferritin

• Hemosiderin

• Calcification

• Iron deposition

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SWI

• SWI can demonstrate hypointense cortical veins due to relatively increased deoxyhemoglobin in the draining veins within an acutely ischemic region.

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Diagnosis?

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Complex Migraine

• SWI may demonstrate prominently hypointense cortical veins within the affected cerebral hemisphere, suggesting relatively increased deoxyhemoglobin in the draining veins within an area of acute ischemia presumably secondary to vasospasm associated with a migraine

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SWI Clinical Applications

• Stroke

• Traumatic Brain Injury (DAI)

• Amyloid Angiopathy– Cortex and subcortical white matter

• Neurodegenerative Diseases– Iron deposition

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Complex Migraine Imaging

• Normal

• Asymmetric hypointense cortical veins on SWI in the affected hemisphere

• Increased perfusion in the involved region of brain

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MRI Perfusion Techniques

• Performed without IV contrast: Arterial Spin Labelled Imaging

• Performed with IV contrast: Dynamic Susceptibility Contrast Imaging (DSC)

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Normal PASL CBF map

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GBM

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Case

• 32 yo female status post resection of left frontal Glioblastoma

• Status post radiation therapy 9 months prior and currently on Temazolamidetherapy

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Case Cont.

• Path proven radiation necrosis

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Case

• 55 yo female presents following sudden onset severe headache and left sided weakness and numbness

• History of migraines

• Head CT and CTA normal

• Brain MRI normal with no restricted diffusion

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Migraine

Jeffrey M. Pollock, Andrew R. Deibler, Jonathan H. Burdette, Robert A. Kraft, Huan Tan, Andrew B. Evans, Joseph A. Maldjian. Arterial Spin Labeled MRI in Migraine Evaluation. Accepted by AJNR, Sept. 29, 2008: 1494-97

6 days later

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Pearls

• Susceptibility Weighted Imaging (SWI) can be helpful in work up of complex migraine

• Cerebral Perfusion imaging can also be helpful in work up of complex migraine

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Case

• 56 yo female presents with headaches

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Capillary Telangiectasia

• Dilated capillaries with normal brain in between

• Congenital or Acquired (s/p XRT)

• Can be associated with other vascular lesions such as cavernous malformations

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Capillary Telangiectasia

• Common Locations

• Pons

• Cerebellum

• Medulla

• Spinal Cord

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Capillary Telangiectasia Imaging

• T1 and T2 often normal

• May see faint high T2 signal

• Susceptibility on gradient

• **Faint, poorly-delineated blush s/p contrast

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Pitfall

• Reporting benign lesions as aggressive pathology

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Pearl

• If you are not sure, short term follow up MRI is often a good solution

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Case

• 61 yo male presents with sudden onset left sided weakness

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Further evaluation with CTA head and neck

• CTA neck: prominent noncalcifiedatherosclerotic plaque at the right carotid bifurcation with 50% stenosis

• CTA Head: normal

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Working Diagnosis

• Hemorrhagic conversion of ischemic infarct

• MRI ordered for further evaluation

• Planning enrollment in Catch study

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T2 T1

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SWI

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T1 T1 post contrast

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T1 post contrast

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MRI Findings

• Enhancement along periphery of hemorrhage suggestive of vascular enhancement

• Increased signal in superior sagittal sinus on ASL perfusion imaging

• Catheter angiogram recommended to evaluate for dural AVM/AVF

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Diagnosis

• Parenchymal hemorrhage associated with a dural arteriovenous fistula involving the sagittal sinus

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Pearls

• Arterial intensity contrast enhancement associated with an acute intraparenchymalspontaneous hemorrhage should raise concern for possible underlying vascular malformation

• Increased perfusion in a dural venous sinus also suggestive of AV fistula

• Catheter directed angiogram for further evaluation

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Remember…..

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tonejonez.com

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espn.co.uk

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Documents

NORTH CAROLINA NEUROLOGICAL SOCIETY 201...AAN Sports Neurology Strategic Plan, updated 2013 1.Neurological injuries insport A. Concussion and braininjuries B. Spinal and peripheralinjuries