Acute and chronic ischemia in the bilateral cerebellar border zones in patient with migraine with associated diffusion weighted imaging findings

Clin Imaging. 2020 Mar;60(1):33-37. doi: 10.1016/j.clinimag.2019.10.016. Epub 2019 Nov 28.

Abstract

We present a case of acute and chronic ischemia in the bilateral cerebellar border zones in a patient with migraine with aura. To our knowledge, this imaging presentation has not been published. The patient presented with 20 years of migraines that had worsened with developing aura prior to MRI, which showed restricted diffusion in the bilateral cerebellar border zones, consistent with acute ischemia. Additional ADC hyperintensities were demonstrated in the border zones, consistent with chronic infarcts. Follow-up CT angiogram showed no occlusion, stenosis, vasospasm, or significant atherosclerosis in the posterior circulation. Additionally, follow-up MRI performed 56 days after initial MRI showed that post-migraine ischemia can be associated with signs of microscopic damage on DWI/ADC map that are not visible with T2 weighted or FLAIR sequences. Cerebellar border zone hypoperfusion from cortical spreading depression and/or transient vasospasm is the most likely etiology due to poor collateral circulation and thus a lower ischemic threshold. Changes in physiologic response to 5-HT during migraine with aura may be responsible for these perfusional abnormalities. Some patients may be more prone due to anatomic variability of the superior cerebellar arteries (SCA) and posterior inferior cerebellar arteries (PICA). Radiologist should be aware of subtle small cerebellar zone infarcts with migraine patients when scrutinizing the posterior fossa.

Keywords: ADC; Acute ischemia; Border zone; Cerebellum; DWI; MR; Migraine; Watershed.

Publication types

  • Case Reports

MeSH terms

  • Cerebellum / abnormalities
  • Constriction, Pathologic
  • Developmental Disabilities
  • Diffusion Magnetic Resonance Imaging
  • Humans
  • Infarction
  • Magnetic Resonance Imaging / methods
  • Middle Aged
  • Migraine Disorders / diagnostic imaging*
  • Nervous System Malformations
  • Perfusion
  • Vertebral Artery

Supplementary concepts

  • Cerebellar Hypoplasia