Deep white matter pathologic features in watershed regions: A novel pattern of central nervous system involvement in MELAS

Liana G. Apostolova, Matthew White, Steven A. Moore, Patricia H. Davis

Research output: Contribution to journalArticle

29 Scopus citations


Background: Myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome typically manifests in adults younger than 40 years with encephalopathy, stroke-like episodes, and lactic acidosis. Magnetic resonance imaging (MRI) abnormalities typically involve the cortical gray and the adjacent subcortical white matter. Objective: To describe a 58-year-old woman diagnosed with MELAS who was initially seen with acute myopathy, cardiac ischemia, psychosis, and MRI changes in a watershed distribution. Results: Initial MRI of the brain showed the characteristic parieto-occipital gray matter lesions involving the adjacent white matter. Follow-up MRI revealed striking deep white matter involvement in a watershed distribution. A cerebral angiogram and thorough hypercoagulable workup results were normal. Electromyography showed acute denervation and myopathy. A muscle biopsy specimen revealed ragged red and cytochrome-c oxidase-negative fibers. Mitochondrial DNA analysis revealed an A3243G mutation. Conclusions: Myopathy, encephalopathy, lactic acidosis, and stroke-like episodes should be considered in older patients with myopathy, cardiomyopathy, encephalopathy, and unaccountable MRI findings. Watershed pathologic features are a rare pattern of cerebral involvement in MELAS.

Original languageEnglish (US)
Pages (from-to)1154-1156
Number of pages3
JournalArchives of Neurology
Issue number7
StatePublished - Jul 1 2005


ASJC Scopus subject areas

  • Arts and Humanities (miscellaneous)
  • Clinical Neurology

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