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Stroke

Ischemic change in white matter - is it a TIA

09/28/2007

Question:

I am a 59 year old female. I have low blood pressure [95/60], low cholesterol with low LDL, and am at my ideal weight and i exercise regularly and eat low fat foods. I have coagulation issues [Factor V with Leiden, Lupus AnticoagulantAntibody] and am on coumadin; i have had radioiodine for Graves and take Levoxly, and I apparently have "mild quiescent lupus" per my labs- with no symptoms [i go back and forth with positive and negative ANA tests .... (1:320 in 2004; 1:2560 in September 2005);negative 2006; positive 2007 1:160; negative July 2007 o Anti cardio lipin antibody o Lupus anticoagulant antibody o antiphospholipid antibody o Low C-3 (April 2004 = 70 September 2005 =91) o Low Protein C o Low white blood count 2.8 usually; 2.4 July 07

I resolved a five month bout of Vertigo episodes recently by doing the Epley Maneuvers, per my ENT. I went ahead though last week with the MRI he had ordered prior to the resolution of the Vertigo. There were some abnormal non-specific findings that might indicate small TIA`s. I am scheduled for a Doppler this week of my Carotid Artery.

Can you explain further what is being told to me in this MRI result that i just read today. Thank you so much.

Examination: MRI Brain with and without contrast. History: Dizziness and visual disturbance [OK NOW THO....] Findings: There is no evidence of intracranial hemorrhage, mass-effect, midline shirt, or infarct. [I checked that definition – infarct: An area of tissue that undergoes necrosis as a result of obstruction of local blood supply, as by a thrombus or embolus.] The sulci and ventricles are normal in size. There are no extra-axial collections. There is scattered patchy and more focal areas of increased T2/FLAIR signal within the subcortical and periventricular white matter. These are nonspecific and may be related to mild microvascular white matter ischemic change. [I checked the meaing of ischemic - Ischemia is an insufficient supply of blood to an organ, usually due to a blocked artery]. There is no evidence of abnormal signal within the corpus callosum.

The flow-voids through the skull base are preserved. The orbits are normal in appearance. The para nasal sinuses are clear.

Impression: Nonspecific T2/FLAIR signal hyperintensities which most likely reflect mild microvascular ischemic change. Other less likely considerations in the appropriate clinical setting would include infectious / inflammatory processes, migraine headaches, or demyelination. [I checked on what demyelination means and it relates to the description of the disease MS. Demyelinate means, β€œTo destroy or remove the myelin sheath of (a nerve fiber), as through disease.”]

Answer:

Non-specific white matter changes is a very common finding in the MRI scan. Also, very frequently patients are referred to the stroke Neurologist based on this finding. The most common cause is hypertension. Other etiologies include migraine, inflammatory process (Lupus, multiple sclerosis etc.), and stroke. You have risk factors for stroke (Hypercoagulable state and positive ANA and ? lupus).

You have been adequately treated with Coumadin for hypercoagulable state (Factor V mutation and low protein C). You, also, have been adequately followed for Positive ANA and ? Lupus.

I am glad a carotid duplex is being ordered to complete the stroke work up.

I noticed that your blood pressure is low and this must be addressed. Low blood pressure can decrease the blood flow to the brain. Hence, potentially can cause these white matter changes.

For more information:

Go to the Stroke health topic, where you can:

Response by:

Yousef  Mohammad, MD, MSc Yousef Mohammad, MD, MSc
Assistant Professor
Director, Stroke Fellowship Program
College of Medicine
The Ohio State University