Radiographic Features of “Stroke-Like Episodes”

The stroke-like episodes seen in MELAS are ischemic events resulting in cerebral injury. The pattern of involvement
can be demonstrated using diffusion-weighted (DWI) sequences on magnetic resonance imaging (MRI) (Fig. 8.1).
There are asym- metric lesions of the occipital and parietal lobes that mimic ischemia, except they usually do not respect
vascular territories and are often restricted to the cortex with relative sparing of deep white matter [9, 10]. There is a
characteristic fluctuation of lesions [19] with repeated imaging over time. MR angiography (MRA) is typically normal.
In a review of 31 angiograms in MELAS patients, 11 were abnormal [10]. The most common abnormalities were
increased caliber of arteries or veins, or a cap- illary blush, seen in six subjects. In two patients, there were abnormalities
of major vessels [10]. The abnormalities were nonspecific and unlikely secondary to athero- sclerosis. More recent
studies suggest that there is vasodilatation of cerebral arteries early on in stroke–like episodes as evidenced by changes in
computer tomography angiography and MRA [20]. Another study revealed hyperperfusion on arterial spin labeling
perfusion MRI even before changes were seen on routine MRI [21]. Finally, quantitative measurements of cerebral
extraction fraction using MRI shows reduced utilization of oxygen in stroke-