Acta Neurol Belg DOI 10.1007/s13760-014-0355-2
NEURO-IMAGES
Transient lesion in the splenium of the corpus callosum in status migrainosus Debopam Samanta
Received: 10 August 2014 / Accepted: 25 August 2014 Ó Belgian Neurological Society 2014
A 10-year-old Caucasian boy presented to the pediatric emergency room with continuous severe bitemporal throbbing headache, photophobia, phonophobia and vomiting for 7 days. He also endorsed some intermittent right leg and foot numbness. He was diagnosed with migraine without aura 6 months back fulfilling the required criteria of the International Classification of Headache Disorders, 3rd edition. His intermittent headaches prior to this presentation were easily controlled with nonsteroidal antiinflammatory drugs. There was no history of fever, concussion or any other sick symptoms. MRI of brain revealed focal area of restricted diffusion in the splenium of the corpus callosum with corresponding T2 and flair hyperintensity (Fig. 1a, b). During further evaluation, repeat brain MRI next day showed resolution of the restricted diffusion but T2 and flair hyperintensity persisted. Laboratory tests including hemogram and basic metabolic panel including renal function and serum electrolytes were within normal limits. MR angiography of the brain, extensive stroke workup and EEG were unremarkable. The patient was treated with IV ketorolac and valproic acid with prompt resolution of headache. He was started on low dose of amitriptyline. Follow-up MRI at 3 months showed interval resolution of the long TR signal abnormality also. Followup over 3 years showed only one to two episodes of easily controllable migrainous headache each month. Transient splenial lesions (TSL) are oval homogeneous, non-hemorrhagic and non-enhancing lesions over the central part of the splenium. This entity was first described in
D. Samanta (&) Division of Child Neurology, University of Arkansas for Medical Sciences, 2010 Rebsamen Park Road, Apt #301, Little Rock, AR 72202, USA e-mail: [email protected]
1996 in association with epilepsy [1]. Afterward, reversible splenial lesion has been described with other varied etiologies, including sudden withdrawal of antiepileptic drugs,
Fig. 1 a Diffusion weighted imaging shows restricted diffusion in the splenium of the corpus callosum. b Axial T2W image shows hyperintense lesion in the splenium of the corpus callosum
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different infections, multiple sclerosis, trauma, hypoglycemia and other encephalopathic conditions. The exact mechanism of the lesion is unclear and several possible mechanisms including transient breakdown of blood–brain barrier due to focal edema, reversible demyelination or reversible extrapontine osmotic myelinolysis were proposed [2]. In our patient, the lesion may be related to the high vulnerability of the splenium of the corpus callosum to cytotoxic damage associated with cortical spreading depression as proposed by Lin et al. [3]. Awareness of these lesions is necessary for both neurologists and radiologists. Appropriate clinical decisionmaking, patient management and counseling can only be possible with the knowledge of its association with various etiologies. This case describes a benign association of TSL with status migrainosus and highlights the importance of recognition of this entity in patients with severe migraine
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attack to prevent unnecessary complementary diagnostic workup. Conflict of interest The author (Debopam Samanta) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
References 1. Chason DP, Fleckenstein JL, Ginsburg ML et al (1996) Transient splenial edema in epilepsy: MR imaging evaluation. In: Presented at the annual meeting of the American Society of Neuroradiology, June 21–27, Seattle 2. Singh P, Gogoi D, Vyas S et al (2010) Transient splenial lesion: further experience with two cases. Indian J Radiol Imaging 20(4):254–257 3. Lin FY, Yang CY (2011) Reversible splenial lesion of the corpus callosum in migraine with aura. Neurologist 17(3):157–159
NEURO-IMAGES
Transient lesion in the splenium of the corpus callosum in status migrainosus Debopam Samanta
Received: 10 August 2014 / Accepted: 25 August 2014 Ó Belgian Neurological Society 2014
A 10-year-old Caucasian boy presented to the pediatric emergency room with continuous severe bitemporal throbbing headache, photophobia, phonophobia and vomiting for 7 days. He also endorsed some intermittent right leg and foot numbness. He was diagnosed with migraine without aura 6 months back fulfilling the required criteria of the International Classification of Headache Disorders, 3rd edition. His intermittent headaches prior to this presentation were easily controlled with nonsteroidal antiinflammatory drugs. There was no history of fever, concussion or any other sick symptoms. MRI of brain revealed focal area of restricted diffusion in the splenium of the corpus callosum with corresponding T2 and flair hyperintensity (Fig. 1a, b). During further evaluation, repeat brain MRI next day showed resolution of the restricted diffusion but T2 and flair hyperintensity persisted. Laboratory tests including hemogram and basic metabolic panel including renal function and serum electrolytes were within normal limits. MR angiography of the brain, extensive stroke workup and EEG were unremarkable. The patient was treated with IV ketorolac and valproic acid with prompt resolution of headache. He was started on low dose of amitriptyline. Follow-up MRI at 3 months showed interval resolution of the long TR signal abnormality also. Followup over 3 years showed only one to two episodes of easily controllable migrainous headache each month. Transient splenial lesions (TSL) are oval homogeneous, non-hemorrhagic and non-enhancing lesions over the central part of the splenium. This entity was first described in
D. Samanta (&) Division of Child Neurology, University of Arkansas for Medical Sciences, 2010 Rebsamen Park Road, Apt #301, Little Rock, AR 72202, USA e-mail: [email protected]
1996 in association with epilepsy [1]. Afterward, reversible splenial lesion has been described with other varied etiologies, including sudden withdrawal of antiepileptic drugs,
Fig. 1 a Diffusion weighted imaging shows restricted diffusion in the splenium of the corpus callosum. b Axial T2W image shows hyperintense lesion in the splenium of the corpus callosum
123
Acta Neurol Belg
different infections, multiple sclerosis, trauma, hypoglycemia and other encephalopathic conditions. The exact mechanism of the lesion is unclear and several possible mechanisms including transient breakdown of blood–brain barrier due to focal edema, reversible demyelination or reversible extrapontine osmotic myelinolysis were proposed [2]. In our patient, the lesion may be related to the high vulnerability of the splenium of the corpus callosum to cytotoxic damage associated with cortical spreading depression as proposed by Lin et al. [3]. Awareness of these lesions is necessary for both neurologists and radiologists. Appropriate clinical decisionmaking, patient management and counseling can only be possible with the knowledge of its association with various etiologies. This case describes a benign association of TSL with status migrainosus and highlights the importance of recognition of this entity in patients with severe migraine
123
attack to prevent unnecessary complementary diagnostic workup. Conflict of interest The author (Debopam Samanta) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
References 1. Chason DP, Fleckenstein JL, Ginsburg ML et al (1996) Transient splenial edema in epilepsy: MR imaging evaluation. In: Presented at the annual meeting of the American Society of Neuroradiology, June 21–27, Seattle 2. Singh P, Gogoi D, Vyas S et al (2010) Transient splenial lesion: further experience with two cases. Indian J Radiol Imaging 20(4):254–257 3. Lin FY, Yang CY (2011) Reversible splenial lesion of the corpus callosum in migraine with aura. Neurologist 17(3):157–159
