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The Truth About T2 Hyperintense White Matter Lesions

11/8/2023

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Are T2 hyperintense white matter lesions in pediatric migraine patients cause for alarm, or could reinterpreting these bright spots on MRIs lead to a revolutionary shift in pediatric neurology?


When pediatric patients present with migraine and headaches, clinicians often recommend magnetic resonance imaging (MRI) scans to rule out more severe secondary causes, like intracranial masses or vascular anomalies. While these scans rarely show underlying issues, they often reveal incidental findings of nonspecific T2-weighted hyperintense white matter lesions, which appear as small, bright spots in brain tissue. The appearance of these bright spots often adds a layer of complexity, raising red flags, triggering additional tests, causing clinical trepidation and fueling parent anxieties. But what if these lesions aren’t connected to migraine or indicative of something sinister? The research, a collaborative effort first authored by Children’s Hospital Colorado headache fellow Elizabeth Ackley, MD, and senior authored by neuroradiologist Ilana Neuberger, MD, challenges long-standing perceptions of these lesions.

Analyzing the anomalies in pediatric migraine: the Dots and Spots study

Driven anecdotally by experience and the lack of conclusive data in the pediatric population, Dr. Ackley and her team conducted a retrospective cross-sectional study, aptly named Dots and Spots, to compare the incidence of lesions among children with migraine, other headaches and those without headaches.

“I started wondering,” Dr. Ackley recalls, “whether these bright spots on MRIs were truly indicative of a problem or just incidental findings that we’ve misunderstood.”

The research involved the careful examination of MRI scans from pediatric patients spanning various ages and backgrounds. The study utilized the International Classification of Headache Disorders Third Edition criteria for migraine and other headache disorders. While the team encountered challenges with incomplete medical records, they managed to categorize 248 patients — 144 with migraine, 42 with other primary headaches and 62 with unspecified headaches. Children with known neurological conditions were excluded to eliminate the potential of confounding variables.

In contrast to adults with migraine, who unequivocally exhibit a higher prevalence of white matter lesions compared to those without migraine, this study revealed no significant difference in the occurrence of such lesions across all groups.

“We found that 40% of all children had these spots, whether they had migraines, different kinds of headaches or no headaches at all,” Dr. Ackley says. “Neither age, gender, nor the degree of headache-associated disability had any bearing on the frequency of these lesions. We were expecting no significant differences, and that’s exactly what we found.”

While there are lingering questions about when and how white matter lesions form — and their connection to migraine in adult patients — the results could have profound implications for medical practice and policy.

Impactful insights in pediatric neurology

The study’s findings have the potential to significantly reduce the number of follow-up diagnostic tests, reducing the risks associated with additional MRI procedures and decreasing healthcare costs. By disentangling the significance of these lesions from the diagnostic process, physicians are liberated to better focus on symptomology and identifying the root cause of patients’ symptoms. At the policy level, insurance companies may find it necessary to reevaluate and potentially revise preauthorization requirements for follow-up MRIs that are based solely on the presence of white matter lesions, unless there is concern for another neurologic process. It’s important to note that white matter lesions can be hallmarks of conditions like multiple sclerosis and leukodystrophy. However, in most cases where concerns for other neurologic diseases are absent, such as in individuals experiencing headaches or those who underwent MRI post-accidents, these lesions may not hold clinical significance.  

For parents, the findings are a welcome relief. Hearing that a child has white matter lesions can send parents into a spiral of worry and worst-case scenarios. “The way that I sometimes explain these spots to patients is that they’re freckles on the brain,” Dr. Ackley says. “I might have more freckles than you, and even though it’s technically a sign of a little bit of mild injury to the skin, we don’t think of that as being anything dangerous or harmful.” By shifting the perspective about the lesions as “freckles” of the brain, parents can breathe a sigh of relief. 

Future of white matter lesion research

While there are still lingering questions, such as the influence of cardiovascular risk factors, Dr. Ackley’s Dots and Spots study serves as a compelling argument that, in most cases, these spots probably aren’t clinically significant. And while these bright spots on MRIs may no longer be perceived as harbingers of doom, they are still pieces of a larger puzzle that requires continued research to unravel the ongoing mystery of these spots.

In fact, neuroradiologists David Mirsky, MD, and Dr. Neuberger are collaborating with Dr. Ackley to lead a follow-up study aimed at understanding these lesions from a radiologic perspective.

“Their hope is to reinforce the findings of the Dots and Spots study and put to rest any remaining misconceptions about these MRI features,” Dr. Ackley explains. “The study reminds us that bright spots on an MRI may just be that — bright spots, not dark omens.”

"Neither age, gender, nor the degree of headache-associated disability had any bearing on the frequency of these lesions. We were expecting no significant differences, and that's exactly what we found."

Elizabeth Ackley, MD

In contrast to adults with migraine, who unequivocally exhibit a higher prevalence of white matter lesions compared to those without migraine, this study revealed no significant difference in the occurrence of such lesions across all groups.

“We found that 40% of all children had these spots, whether they had migraines, different kinds of headaches or no headaches at all,” Dr. Ackley says. “Neither age, gender, nor the degree of headache-associated disability had any bearing on the frequency of these lesions. We were expecting no significant differences, and that’s exactly what we found.”

While there are lingering questions about when and how white matter lesions form — and their connection to migraine in adult patients — the results could have profound implications for medical practice and policy.

Impactful insights in pediatric neurology

The study’s findings have the potential to significantly reduce the number of follow-up diagnostic tests, reducing the risks associated with additional MRI procedures and decreasing healthcare costs. By disentangling the significance of these lesions from the diagnostic process, physicians are liberated to better focus on symptomology and identifying the root cause of patients’ symptoms. At the policy level, insurance companies may find it necessary to reevaluate and potentially revise preauthorization requirements for follow-up MRIs that are based solely on the presence of white matter lesions, unless there is concern for another neurologic process. It’s important to note that white matter lesions can be hallmarks of conditions like multiple sclerosis and leukodystrophy. However, in most cases where concerns for other neurologic diseases are absent, such as in individuals experiencing headaches or those who underwent MRI post-accidents, these lesions may not hold clinical significance.  

For parents, the findings are a welcome relief. Hearing that a child has white matter lesions can send parents into a spiral of worry and worst-case scenarios. “The way that I sometimes explain these spots to patients is that they’re freckles on the brain,” Dr. Ackley says. “I might have more freckles than you, and even though it’s technically a sign of a little bit of mild injury to the skin, we don’t think of that as being anything dangerous or harmful.” By shifting the perspective about the lesions as “freckles” of the brain, parents can breathe a sigh of relief. 

Future of white matter lesion research

While there are still lingering questions, such as the influence of cardiovascular risk factors, Dr. Ackley’s Dots and Spots study serves as a compelling argument that, in most cases, these spots probably aren’t clinically significant. And while these bright spots on MRIs may no longer be perceived as harbingers of doom, they are still pieces of a larger puzzle that requires continued research to unravel the ongoing mystery of these spots.

In fact, neuroradiologists David Mirsky, MD, and Dr. Neuberger are collaborating with Dr. Ackley to lead a follow-up study aimed at understanding these lesions from a radiologic perspective.

“Their hope is to reinforce the findings of the Dots and Spots study and put to rest any remaining misconceptions about these MRI features,” Dr. Ackley explains. “The study reminds us that bright spots on an MRI may just be that — bright spots, not dark omens.”