Page 34 - Migraine, the heart and the brain

Chapter 2
location was evaluated by normalizing the individual MRI scans with segmented lesions to standard Montreal Neurological Institute–space, and projecting the lesions (weighted for group size) of all participants per diagnostic group in a transparent 3-dimensional map (glass brain).
Infratentorial hyperintensities were hyperintense on T2- and proton-density- weighted and not hypointense on fluid attenuated inversion recovery images. Presence and progression of lesions was assesed by 1 rater, who was blinded to diagnosis by comparing baseline and follow-up scans side by side. Reproducibility data (random, n = 40 [14%]; baseline, K = 0.908; P = .09 and follow-up, K = 1.000; P < .001). Lesion progression was de ned as an increase in size, number, or both (FIGURE 1).
Infarctlike lesions were nonmass parenchymal defects with a vascular distribution, isointense to cerebrospinal fluid signal on all sequences, and, when supratentorial, surrounded by a hyperintense rim on FLAIR images.4 Virchow-Robin spaces were excluded based on typical location, shape, and absence of a hyperintense rim. In the basal ganglia, only parenchymal defects larger than 3 mm in diameter were considered in order to exclude nonspeci c lesions. Location and vascular territory of new and preexisting infarcts were read by 2 neuroradiologists, who were blinded to diagnosis (K= 0.87, P <.001). All sequences of baseline and follow- up scans were presented side by side (angulation corrected and position linked). A third senior neuroradiologist made the nal diagnosis in the 9 cases in which the 2 raters disagreed. An exploratory outcome measure of this study was the changes in cognition related to white matter hyperintensities at baseline and at follow-up. Similarly, the change in cognition between baseline and follow-up was evaluated as function of baseline and follow-up lesion volume as well as lesion volume change. For each participant, normalized test scores (Z scores of separate tests in domains of memory, executive function, attention, visuospatial ability, and speed) were summed to achieve a total composite cognitive score for each time point. Change in raw test scores (follow-up minus baseline) were normalized by Z scores. The tests, evaluating cognitive performance in the domains of memory, concentration, and attention, executive functioning, psychomotor, and processing speed, organization, ne motor skills, fluid intelligence, and visuospatial skills, consisted of the 15-word Verbal Learning Test15; abbreviated Stroop test,16 consisting of 3 subtasks; Verbal Fluency17 which is a modi ed version of the Symbol Digit Modalities Test18; and the Purdue pegboard test.19 In follow-up investigation, the Block Design Test from the Wechsler Adult Intelligence Scale III test battery20 was added. Further details on cognition testing are provided in eTable 3 (available at http://www.jama.com).
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