Daily Living Activities and Cognition in Aged Patients: Effect of Acute Systemic Diseases and Stroke on Leukoaraiosis

BACKGROUND

Acute Systemic Diseases (ASD) impact on extended leukoaraiosis (ExLA) have been seldom described. We study the deterioration in daily life activities (DLA) and cognition associated with ASD events compared with the well-described impacts of stroke in patients with leukoaraiosis (L-A).

METHODS

Cross-sectional surveys of aged adults from the emergency room after an acute event of ASD or stroke, hospitalized or receiving home care, were followed for one year. From 268 initial patients 206 were included in the study, all with moderate to severe L-A (Fazekas 2 and 3). The Clinical Deterioration Rating (CDR) and the modified Rankin scale with structured interview were obtained one week previous to admission and after 3 and 12 months of evolution. Comparisons were conducted within and between groups with nonparametric techniques.

RESULTS

We formed three groups of similar age, A: Inpatients with one Stroke, B: Inpatients with one ASD, and C: Outpatients with one ASD. A sudden deterioration in Rankin was evident in Group A, while in B and C impairment was progressive. Impairment in CDR was smooth in all groups while in Rankin it was always greater than in cognition (CDR). No differences were found in the associations between groups and risk factors, hypertension being the most frequent one.

CONCLUSION

ASD in ExL-A causes a worsening of DLA and cognition similar to that observed in ExL-A with concomitant stroke indicating the need, in ageing patients, of differential diagnosis in order to achieve the best possible treatment.

Longitudinal patterns of leukoaraiosis and brain atrophy in symptomatic small vessel disease

Cerebral small vessel disease is a common condition associated with lacunar stroke, cognitive impairment and significant functional morbidity. White matter hyperintensities and brain atrophy, seen on magnetic resonance imaging, are correlated with increasing disease severity. However, how the two are related remains an open question. To better define the relationship between white matter hyperintensity growth and brain atrophy, we applied a semi-automated magnetic resonance imaging segmentation analysis pipeline to a 3-year longitudinal cohort of 99 subjects with symptomatic small vessel disease, who were followed-up for ≥1 years. Using a novel two-stage warping pipeline with tissue repair step, voxel-by-voxel rate of change maps were calculated for each tissue class (grey matter, white matter, white matter hyperintensities and lacunes) for each individual. These maps capture both the distribution of disease and spatial information showing local rates of growth and atrophy. These were analysed to answer three primary questions: first, is there a relationship between whole brain atrophy and magnetic resonance imaging markers of small vessel disease (white matter hyperintensities or lacune volume)? Second, is there regional variation within the cerebral white matter in the rate of white matter hyperintensity progression? Finally, are there regionally specific relationships between the rates of white matter hyperintensity progression and cortical grey matter atrophy? We demonstrate that the rates of white matter hyperintensity expansion and grey matter atrophy are strongly correlated (Pearson's R = -0.69, P < 1 × 10(-7)), and significant grey matter loss and whole brain atrophy occurs annually (P < 0.05). Additionally, the rate of white matter hyperintensity growth was heterogeneous, occurring more rapidly within long association fasciculi. Using voxel-based quantification (family-wise error corrected P < 0.05), we show the rate of white matter hyperintensity progression is associated with increases in cortical grey matter atrophy rates, in the medial-frontal, orbito-frontal, parietal and occipital regions. Conversely, increased rates of global grey matter atrophy are significantly associated with faster white matter hyperintensity growth in the frontal and parietal regions. Together, these results link the progression of white matter hyperintensities with increasing rates of regional grey matter atrophy, and demonstrate that grey matter atrophy is the major contributor to whole brain atrophy in symptomatic cerebral small vessel disease. These measures provide novel insights into the longitudinal pathogenesis of small vessel disease, and imply that therapies aimed at reducing progression of white matter hyperintensities via end-arteriole damage may protect against secondary brain atrophy and consequent functional morbidity.

Genetic associations of leukoaraiosis indicate pathophysiological mechanisms in white matter lesions etiology

Leukoaraiosis (LA), also called white matter lesions (WMLs) and white matter hyperintensities (WMHs), is a frequent neuroimaging finding commonly seen on magnetic resonance imaging brain scans of elderly people with prevalence ranging from 50% to 100%. Although it remains asymptomatic, LA is not considered to be benign, and it is showed to be related to a host of poor clinical outcomes and increases the risk of disability, dementia, depression, stroke, and the overall morbidity and mortality. Pathologically, LA is characterized by loss of myelin and axons, patchy demyelination, and denudation of ependyma in regions of WMH. Age and hypertension are the most importantly established risk factors for LA. However, the precise pathogenic mechanisms remain unclear. Together with the previous findings, our recent genetic results strongly supported that LA is associated with immune response and neuroinflammation. Therefore, we confidently hypothesized that LA was not only a common neuroimaging phenomenon in the elderly but also an emerging neuroinflammatory disorder in the central nervous system. This article focusing on neuroimaging classification, genetics basis, and putative molecular mechanism introduced the basic knowledge and current status of LA and put forward some of our research ideas and results from our molecular genetics research, which may pave the way for deciphering the putative pathogenic mechanism, risk factor, epigenetic index, and its application in diagnostic agents or drug target for prevention and treatment. Thus, it could provide clinicians and researchers with a specific and modern overview of LA to enable the understanding of recent progress and future directions in this illness.

Association of leukoaraiosis with stroke recurrence within 5 years after initial stroke

BACKGROUND

Leukoaraiosis (LA) is closely associated with stroke. Despite the fact that LA has consistently been shown to predict development of recurrent stroke, prior studies on the association of LA and stroke subtypes have been unsatisfactory. In this study, we sought to identify whether LA contributes to the recurrence of certain subtypes of stroke at long term.

METHODS

Data from the Ege Stroke Registry were examined, and 5 years follow-up data for LA and stroke recurrence were analyzed. We performed survival curves using the Kaplan-Meier method (unadjusted) and log-rank tests in patients with stroke to determine the relationship between LA and recurrent stroke by stroke subtypes within a time period of 5 years. Multivariate survival analyses were undertaken using Cox proportional hazards models to determine the prognostic value of LA, stroke subtypes, and other vascular risk factors before recurrent stroke.

RESULTS

Of 9522 patients with stroke, 1280 (26%) with LA and 901 (19%) without LA experienced a stroke recurrence within 5 years of follow-up (odds ratio, 1.53; 95% confidence interval, 1.39-1.69). After stratification by stroke subtypes, multivariable analysis revealed a significant association between LA and large artery disease (LAD; odds ratio [OR], 1.39; 95% confidence interval [CI], 1.18-1.64), small artery disease (SAD; OR, 1.57; 95% CI, 1.27-1.94), and intracerebral hemorrhage (ICH; OR, 1.88; 95% CI, 1.32-2.66), except cardioembolic stroke and "other" stroke subtypes at 5 years after stroke onset. The survival analysis showed that stroke recurrence was significantly higher in patients with severe LA compared with those with mild/moderate LA (log-rank test [Mantel-Cox], P < .001).

CONCLUSIONS

Our results showed that LA is related to the recurrent strokes in patients with stroke within 5 years after stroke, specifically to the LAD, SAD and ICH.

Phase white matter signal abnormalities in patients with clinically isolated syndrome and other neurologic disorders

BACKGROUND AND PURPOSE

Identifying MRI biomarkers that can differentiate multiple sclerosis patients from other neurological disorders is a subject of intense research. Our aim was to investigate phase WM signal abnormalities for their presence, prevalence, location, and diagnostic value among patients with clinically isolated syndrome and other neurologic disorders and age-, sex-, and group-matched healthy controls.

MATERIALS AND METHODS

Forty-eight patients with clinically isolated syndrome and 30 patients with other neurologic diseases and a healthy control group (n = 47) were included in the study. Subjects were scanned at 3T by using SWI-filtered phase and T2WI, with WM signal abnormalities ≥3 mm being classified.

RESULTS

Patients with clinically isolated syndrome had significantly more phase and T2 WM signal abnormalities than healthy controls (P < .001). Phase WM signal abnormalities were more prevalent among patients with clinically isolated syndrome compared with patients with other neurologic disorders (4:1 ratio), whereas T2 WM signal abnormalities were more ubiquitous with a 2:1 ratio. The presence of phase WM signal abnormalities was sensitive for clinically isolated syndrome (70.8%) and achieved a moderate-to-high specificity for differentiating patients with clinically isolated syndrome and healthy controls, patients with other neurologic disorders, and patients with other neurologic disorders of other autoimmune origin (specificity, 70%-76.7%). Combining the presence of ≥2 phase lesions with the McDonald 2005 and 2010 criteria for dissemination in space improved the specificity (90%), but not the accuracy, in differentiating patients with clinically isolated syndrome from those with other neurologic disorders. In subanalyses among patients with clinically isolated syndrome who converted to clinically definite multiple sclerosis versus those who did not within a 3-year follow-up period, converters had significantly more phase (P = .008) but not T2 or T1 WM signal abnormalities.

CONCLUSIONS

Phase WM signal abnormalities are prevalent among patients with clinically isolated syndrome. The presence of (multiple) phase WM signal abnormalities tended to be more predictive of conversion to clinically definite multiple sclerosis and was specific in differentiating patients with clinically isolated syndrome and other neurologic disorders, compared with T2 WM signal abnormalities; however, the accuracy remains similar to that of the current McDonald criteria.

[Risk factors and predictive factors of cognitive deterioration in patients of vascular cognitive impairment no dementia with subcortical ischemic vascular disease]

OBJECTIVE

To explore the independent risk factors and predictive factors of cognitive deterioration in patients of vascular cognitive impairment no dementia with subcortical ischemic vascular disease (VCIND-SIVD).

METHODS

The clinical and neuropsychological characteristics of 96 VCIND-SIVD patients were collected and their cognitive states re-assessed after one year. The distribution of continuous and categorical variables was examined with univariate analysis. And Logistic regression in multivariate modeling was employed to identify the risk and predictive factors of cognitive deterioration.

RESULTS

After 1-year follow-up, 8 patients dropped out, 2 died and the remainder remained. There were 48 males and 38 females with an average age of 64.3 ± 5.4 years. Among them, 17 (19.8%) deteriorated into dementia, 24 (27.9%) upgraded to normal cognition and 45 (52.3%) maintained their cognitive status. They were divided into dementia group (cognition deteriorating into dementia) and control group (elevated/sustained cognition). After univariate analysis of general information and vascular risk factors, Logistic regression demonstrated that education level (P < 0.05, OR = 0.7) was a preventive factor of dementia while age (P < 0.05, OR = 1.2), hypertension (P < 0.05, OR = 5.6) and high homocysteine (P < 0.05, OR = 4.2) were independent risk factors of dementia. After univariate analysis of neuropsychological scores, Logistic regression demonstrated that visual reproduction-immediate recall (P < 0.05, OR = 3.4), digit span forward (P < 0.05, OR = 1.2), clock drawing test (P < 0.05, OR = 6.8) and completion time of London tower (P < 0.05, OR = 5.4) were predictive factors of dementia.

CONCLUSION

VCIND-SIVD patients with low score of visual reproduction-immediate recall, digit span forward, clock drawing test and completion time of London tower should receive vigorous controls of hypertension and high homocysteine.

[Benign paroxysmal positional vertigo in a female with arterial hypertension and meningioma]

Diagnosis of benign paroxysmal positional vertigo (BPPV) often causes difficulties, in particular, in elderly people with concomitant diseases. The article presents a case of a 77 year-old woman with BPPV. A patient's complaint on vertigo was mistakenly diagnosed as brain ischemia because the patient had long suffered from uncontrolled arterial hypertension. MRI-study revealed leucoaraiosis and one lacuna as well as a meningioma which was mistakenly linked to vertigo. The diagnosis of BPPV, use of Epley maneuver with the following vestibular exercises resulted in complete stopping of vertigo. Effective treatment of arterial hypertension with the normalization of arterial pressure, use of aspirin and statins reduced the risk of stroke. Exclusion of BPPV is needed in all cases of vertigo with unclear etiology.

[Leukoaraiosis as a cause of non-arteritic anterior ischemic optic neuropathy--a case report]

The paper presents the case of a 61-year-old man with specific symptoms of non-arteritic anterior ischemic optic neuropathy. The head computed tomographyscans revealed multiple leukoaraiotic lesions. Leukoaraiosis is a disease affecting small cerebral vessels. Its pathogenesis is associated with a chronic inflammatory process and ischemic vascular endothelial dysfunction which reduce the cerebral blood flow. It cannot be ruled out that this process, alongside with Horton disease, hypertension, diabetes and atherosclerosis, may also be involved in the pathogenesis of non-arteritic anterior ischemic optic neuropathy. leukoaraiosis, non-arteritic anterior ischemic optic neuropathy.

Brain iron deposition in white matter hyperintensities: a 3-T MRI study

Iron accumulation has been implicated in the pathogenesis of demyelinating diseases. Therefore, we hypothesized that abnormal high cerebral iron deposition may be involved in the development of white matter hyperintensities (WMHs). We used R2* relaxometry to assess whether iron levels in different brain regions correlate with the severity of WMHs. This technique has been recently validated in a postmortem study to demonstrate in vivo brain iron accumulation in a quantitative manner. Fifty-two consecutive WMH patients and 30 healthy controls with 3-T magnetic resonance imaging (MRI) were reviewed in this study. We measured WMH volume (as a marker of the severity of WMHs) on MRI, and the transverse relaxation rate R2*, as an estimate of iron content in seven brain regions. We found that R2* in globus pallidus was associated with WMH volume after adjusting for sociodemographic variables (partial correlation coefficient = 0.521, P < 0.001) and in a multivariate analysis adjusted for common vascular risk factors (partial correlation coefficient = 0.572, P = 0.033). Regional R2* in globus pallidus was also significantly higher in WMHs than in controls (P = 0.042). Iron content in globus pallidus, as assessed by R2* relaxometry, is independently linked to the severity of WMHs in our cohort of patients, suggesting that iron deposition in the brain may play a role in the pathogenesis of WMHs. This may provide prognostic information on patients with WMHs and may have implications for therapeutic interventions in WMHs.

Leukoaraiosis and increased cerebral susceptibility to ischemia: lack of confounding by carotid disease

BACKGROUND

Leukoaraiosis is associated with an increased risk of stroke, but the underlying mechanism remains uncertain, as do the associations with other risk factors, such as carotid disease. We aimed to determine the role of carotid disease and of other clinical variables in the development of leukoaraiosis and to define their contributions to the associated increased risk of stroke.

METHODS AND RESULTS

We prospectively studied a large cohort of consecutive patients with transient ischemic attack (TIA) and minor stroke who attended a TIA clinic between 2002 and 2009. Detailed clinical data were obtained, and patients underwent magnetic resonance brain and vascular imaging. We assessed the severity of leukoaraiosis with use of the ARWMC (Age Related White Matter Changes) score: 671 patients (374 [56%] men; mean [SD] age 71 [11] years) were studied, of whom 415 (62%) had leukoaraiosis. In a multivariate analysis, leukoaraiosis was associated with increasing age (P<0.0001) and hypertension (P=0.01), as well as the presence of acute (P<0.0001) and chronic (P=0.014) infarction on magnetic resonance imaging. In the univariate analysis, a current and past diagnosis of stroke versus TIA also showed a strong association. Carotid disease was not associated with leukoaraiosis, even in the presence of a flow-limiting (>70%) stenosis or occlusion, and the risk factor profiles for leukoaraiosis and carotid disease differed.

CONCLUSIONS

The association with more severe ischemic events (stroke versus TIA) and infarction on imaging is consistent with leukoaraiosis being a marker of increased cerebral susceptibility to ischemia. In contrast, the presence, severity of, and risk factors for atheromatous disease showed no association with leukoaraiosis, suggesting that these are two unrelated disease processes.

Differential risk factors for lacunar stroke depending on the MRI (white and red) subtypes of microangiopathy

Background

Leukoaraiosis and cerebral microbleeds (CMB), which represent cerebral microangiopathy, commonly coexist in patients with acute lacunar stroke. Since they may have different impacts on stroke prognosis and treatment, it is important to know the factors associated with leukoaraiosis-predominant vs. CMB-predominant microangiopathies.

Methods

We prospectively recruited 226 patients with acute lacunar infarction and divided them into four groups according to the Fazekas’ score and the presence of CMB: mild, red (predominant CMB), white (predominant leukoaraiosis) and severe microangiopathy groups. For comparison, we also evaluated 50 patients with intracerebral hemorrhage (ICH). We evaluated the clinical and laboratory findings of microangiopathy subtypes in patients with acute lacunar stroke and then compared them with those of primary ICH.

Results

The risk factor profile was different among the groups. Patients with acute lacunar infarct but mild microangiopathy were younger, predominantly male, less hypertensive, and more frequently had smoking and heavy alcohol habits than other groups. The risk factor profile of red microangiopathy was similar to that of ICH but differed from that of white microangiopathy. The subjects in the white microangiopathy group were older and more frequently had diabetes than those in the red microangiopathy or ICH group. After adjustments for other factors, age [odds ratio (OR) 1.13; 95% confidence interval (CI) 1.08–1.18; p<0.001] and diabetes (OR 2.28; 95% CI 1.02–5.13; p = 0.045) were independently associated with white microangiopathy, and age (OR 1.05; 95% CI 1.01–1.08; p = 0.010) was independent predictor for red microangiopathy compared to mild microangiopathy.

Conclusion

Patients with acute lacunar infarction have a different risk factor profile depending on microangiopathic findings. Our results indicate that diabetes may be an one of determinants of white (leukoaraiosis-predominant) microangiopathy, whereas smoking and alcohol habits in relatively young people may be a determinants of mild microangiopahic changes in patients with lacunar infarction.

[Study on syndrome factors of leukoaraiosis patients with mild cognitive impairment]

OBJECTIVE

To explore the syndrome factors of leukoaraiosis patients with mild cognitive impairment (LACI), thus providing evidence for syndrome typing.

METHODS

The prospective schedule was adopted including 103 LACI patients (as the LACI group) and 100 leukoaraiosis patients without mild cognitive impairment (as the control group). Syndrome factors were extracted from the patients' symptoms with frequency statistics and factor analysis.

RESULTS

Fifteen common factors were extracted from the LACI group, and 12 common factors from the control group. After analyzed the distribution of syndrome factors in the LACI group, the most common factors were ranked as follows: yang deficiency (33.98%), phlegm (22.33%), yin deficiency (19.42%), qi deficiency (10.68%), fire (9.71%), blood deficiency and blood stasis (3.88%). As for the control group, the most common factors were ranked as follows: yang deficiency (31.00%), qi deficiency (27.00%), yin deficiency and fire (24.00%), blood deficiency and blood stasis (12.00%), phlegm and yang deficiency and blood deficiency (6.00%).

CONCLUSIONS

The main syndrome factors of LACI were yang deficiency, phlegm, yin deficiency, and fire. The secondary syndrome factors were qi deficiency, blood deficiency, and blood stasis. It was mainly involved with Shen and Pi, with secondary organs as Gan and Xin. Deficiency syndrome is its pathogenesis. Phlegm and fire, and other pathological factors are essential for its development and aggravation, with more syndrome factors accompanied in complex condition.

White matter hyperintensities: age appropriate or risk indicator?

White matter hypertensity (WMH) is a term frequently seen in the MRI reports of insurance applicants. Its significance is often uncertain. There are different patterns and extent of WMH of variable clinical significance can be identified. Pathological correlates are varied with most pointing toward WMH as a reflection of small vessel ischemic burden. The predominant clinical associations are with stroke, cognitive impairment, dementia, general disability and death. This review examines the relationship of white matter hyperintensities to client morbidity, disability and mortality from an insurance medicine perspective.

Selective reduction of blood flow to white matter during hypercapnia corresponds with leukoaraiosis

BACKGROUND AND PURPOSE

Age-related white matter disease (leukoaraiosis) clusters in bands in the centrum semiovale, about the occipital and frontal horns of the lateral ventricles, in the corpus callosum, and internal capsule. Cerebrovascular anatomy suggests that some of these locations represent border zones between arterial supply territories. We hypothesized that there are zones of reduced cerebrovascular reserve (susceptible to selective reductions in blood flow, ie, steal phenomenon) in the white matter of young, healthy subjects, the physiological correlate of these anatomically defined border zones. Furthermore, we hypothesized that these zones spatially correspond with the regions where the elderly develop leukoaraiosis.

METHODS

Twenty-eight healthy volunteers underwent functional MR mapping of the cerebrovascular response to hypercapnia. We studied 18 subjects by blood oxygen level-dependent MRI and 10 subjects by arterial spin labeling MRI. We controlled both end-tidal pCO(2) and pO(2). All functional data was registered in Montreal Neurological Institute space and generated composite blood oxygen level-dependent MR and arterial spin labeling MR maps of cerebrovascular reserve. We compared these maps with frequency maps of leukoaraiosis published previously.

RESULTS

Composite maps demonstrated significant (90% CI excluding the value zero) steal phenomenon in the white matter. This steal was induced by relatively small changes in end-tidal pCO(2). It occurred precisely in those locations where elderly patients develop leukoaraiosis.

CONCLUSIONS

This steal phenomenon likely represents the physiological correlate of the previously anatomically defined internal border zones. Spatial concordance with white matter changes in the elderly raises the possibility that this steal phenomenon may have a pathogenetic role.

Whole-brain histogram and voxel-based analyses of diffusion tensor imaging in patients with leukoaraiosis: correlation with motor and cognitive impairment

BACKGROUND AND PURPOSE

Cerebral white matter changes, termed leukoaraiosis (LA), appearing as areas of increased signal intensity in T2-weighted MR images, are common in elderly subjects, but the possible correlation of LA with cognitive or motor deficit has not been established. We hypothesized that histogram and voxel-based analyses of whole-brain mean diffusivity (MD) and fractional anisotropy (FA) maps calculated from diffusion tensor imaging (DTI) could be more sensitive tools than visual scales to investigate the clinical correlates of LA.

MATERIALS AND METHODS

Thirty-six patients of the Leukoaraiosis and Disability Study were evaluated with fluid-attenuated inversion recovery for LA extension, T1-weighted images for volume, and DTI for MD and FA. The extent of LA was rated visually. The normalized total, gray, and white matter brain volumes were computed, as well as the 25th percentile, 50th percentile, kurtosis, and skewness of the MD and FA maps of the whole brain. Finally, voxel-based analysis on the maps of gray and white matter volume, MD, and FA was performed with SPM2 software. Correlation analyses between visual or computerized data and motor or neuropsychologic scale scores were performed using the Spearman rank test and the SPM2 software.

RESULTS

The visual score correlated with some MD and FA histogram metrics (P<.01). However, only the 25th and 50th percentiles, kurtosis, and skewness of the MD and FA histograms correlated with motor or neuropsychologic deficits. Voxel-based analysis revealed a correlation (P<.05 corrected for multiple comparisons) between a large cluster of increased MD in the corpus callosum and pericallosal white matter and motor deficit.

CONCLUSIONS

These results are consistent with the hypothesis that histogram and voxel-based analyses of the whole-brain MD and FA maps are more sensitive tools than the visual evaluation for clinical correlation in patients with LA.

Comparison of the Alzheimer's Disease Assessment Scale Cognitive Subscale and the Vascular Dementia Assessment Scale in differentiating elderly individuals with different degrees of white matter changes. The LADIS Study

BACKGROUND/AIMS

The Alzheimer's Disease Assessment Scale cognitive subscale (ADAS-cog) is a widely used rating instrument. The Vascular Dementia Assessment Scale cognitive subscale (VADAS-cog) includes additional tests reflecting mental speed and executive functions. The objective of this study was to compare the results of the two scales among subjects with various degrees of white matter hyperintensities (WMHs).

METHODS

In the multicentre, multinational Leukoaraiosis and Disability in the Elderly (LADIS) study, 616 non-disabled subjects between the ages of 65 and 84 were examined using MRI, the ADAS-cog and VADAS-cog. The WMH rating from the MRI divided the patients into groups of mild (n = 280), moderate (n = 187) and severe (n = 149) degrees of change.

RESULTS

Covariance analysis controlling for the effect of age and education revealed that the ADAS-cog differentiated only the mild and severe WMH groups, while the differences between all three groups were highly significant with the VADAS-cog.

CONCLUSIONS

The VADAS-cog significantly differentiated between all the white matter groups. In comparison, the ADAS-cog differentiated only severe changes. Accordingly, the VADAS-cog may be a more sensitive endpoint in studies of patients with white matter load and vascular burden of the brain.

White matter changes and late-life depressive symptoms: longitudinal study

BACKGROUND

Evidence from cross-sectional studies suggests a link between cerebral age-related white matter changes and depressive symptoms in older people, although the temporal association remains unclear.

AIMS

To investigate age-related white matter changes on magnetic resonance imaging (MRI) as an independent predictor of depressive symptoms at 1 year after controlling for known confounders.

METHOD

In a pan-European multicentre study of 639 older adults without significant disability, MRI white matter changes and demographic and clinical variables, including cognitive scores, quality of life, disability and depressive symptoms, were assessed at baseline. Clinical assessments were repeated at 1 year.

RESULTS

Using logistic regression analysis, severity of white matter changes was shown to independently and significantly predict depressive symptoms at 1 year after controlling for baseline depressive symptoms, quality of life and worsening disability (P<0.01).

CONCLUSIONS

White matter changes pre-date and are associated with the development of depressive symptoms. This has implications for treatment and prevention of depression in later life.

Treatment of Leukoaraiosis: A Futuristic View

Leukoaraiosis (LA or white matter changes of the brain) is a common finding on brain imaging studies in the elderly people. LA predisposes to dementia, ischemic stroke, intracerebral hemorrhage, and cognitive decline as well as associates with a significant increase in falls and gait disorders. As population ages, the incidence of LA increases and is becoming a major global health problem. Therefore, strategies for its prevention and management are urgently needed. This review includes basic knowledge on the pathophysiology, patterns of clinical presentation, risk factors, and imaging findings of LA. The very last and the most comprehensive part of this review discusses potential therapeutic approaches of the future.

Significant association between leukoaraiosis and metabolic syndrome in healthy subjects

OBJECTIVE

To investigate the relationship between leukoaraiosis (LA), which has been considered as an intermediate substitute of ischemic brain damages, and metabolic syndrome (MetS), which attracts attention as a risk factor for cerebrovascular diseases, in healthy subjects derived from various age groups.

METHODS

We studied 1,030 healthy persons at ages between 28 and 78 years (mean, 52.7 years) with no history of stroke who visited a health care facility for routine health checkups. MetS was defined using the criteria of the National Cholesterol Education Program Adult Treatment Panel III. LA was assessed using the rating scale of the Atherosclerosis Risk in Communities study on MRI. Logistic regression analysis was performed to examine associations between LA and MetS.

RESULTS

A total of 296 (28.8%) subjects had LA on MRI. MetS was significantly associated with the presence of LA (adjusted OR, 3.33; 95% CI, 2.30, 4.84). The association was constant across grades of LA; the adjusted OR was 3.41 (95% CI, 2.30, 5.06) for minimal LA and 3.07 (95% CI, 1.75, 5.38) for LA combining mild, moderate, and severe grades. As for MetS components, elevated blood pressure (adjusted OR, 2.16; 95% CI, 1.57, 2.99), impaired fasting glucose (adjusted OR, 1.64; 95% CI, 1.13, 2.39), and hypertriglyceridemia (adjusted OR, 1.56; 95% CI, 1.08, 2.28) were independently associated with all grades of LA.

CONCLUSIONS

Metabolic syndrome (MetS) was significantly associated with every grade of leukoaraiosis (LA), including the minimal LA. Impaired fasting glucose and hypertriglyceridemia were associated with LA independently of elevated blood pressure. MetS can play an important role in identifying healthy subjects who have an increased risk of LA.

Cerebral volume measurements and subcortical white matter lesions and short-term treatment response in late life depression

BACKGROUND

Late life depression is associated with volumetric reductions of gray matter and increased prevalence of subcortical white matter lesions. Previous studies have shown a poorer treatment outcome in those with more severe structural brain abnormalities. In this study, quantitative and semi-quantitative magnetic resonance imaging (MRI) measures were studied in relation to response to a 12-week controlled antidepressant monotherapy trial.

METHODS

MRI (1.5 T) brain scans of 42 elderly inpatients with major depression, of which 23 were non-responder to a controlled 12-week antidepressant monotherapy trial, were acquired. In addition, clinical outcome was assessed after a one year period. Measures were volumes of global cerebral and subcortical structures.

RESULTS

After controlling for confounding, no differences were found between non-responders and responders after 12 weeks and after one year in volumes of cerebral gray and white matter, orbitofrontal cortex, hippocampus and white matter lesions.

CONCLUSIONS

Structural brain measures associated with late life depression may not be related to short-term treatment response.

Chronic ischemic cerebral white matter disease is a risk factor for nonfocal neurologic injury after total aortic arch replacement

OBJECTIVE

Leukoaraiosis (chronic ischemic white matter changes) on preoperative brain magnetic resonance imaging is common in patients having aortic arch surgery. This study sought to determine whether it is associated with adverse neurologic outcome in the postoperative period.

METHODS

Data were collected from a retrospective chart review of 142 patients in whom total aortic arch replacement was planned at the Cleveland Clinic between April 2000 and December 2004. All patients had preoperative brain magnetic resonance imaging evaluation. Leukoaraiosis severity was rated semiquantitatively using the Schelten's scale. Postoperative neurologic injuries were investigated by clinical examination and appropriate neuroimaging. They were stratified as type 1 (focal ischemic stroke) and type 2 (nonfocal neurocognitive changes, generalized seizures) injuries.

RESULTS

The following were independent predictors of type 1 neurologic injury: age (odds ratio 1.06 [1.01-1.13], P = .02) and moderate to severe aortic atheroma (odds ratio 4.4 [1.4-9.7], P = .012). Total white matter scores (odds ratio 1.16 [1.06-1.27], P = .002) and higher preoperative hemoglobin A1c levels (odds ratio 1.8 [1.00-3.50], P = .05) were significantly associated with type 2 neurologic injuries. Survival was 96%, and 4.2% had persistent focal neurologic deficits at the time of hospital discharge.

CONCLUSIONS

Leukoaraiosis is a significant independent predictor of nonfocal postoperative neurologic morbidity following aortic arch replacement surgery. Preoperative evaluation with magnetic resonance imaging allows identification of a patient subgroup at risk and implementation of strategies aimed at improving neurologic outcome.

Association Between Leukoaraiosis and Saccadic Oscillation

OBJECTIVE

To use an audiovestibular test battery to evaluate patients with leukoaraiosis in order to investigate the relationship between vertigo and dizziness and leukoaraiosis.

DESIGN

Retrospective study.

SETTING

Tertiary university hospital. Patients A total of 18 elderly patients with vertigo and dizziness and with leukoaraiosis confirmed by magnetic resonance imaging (hereafter, leukoaraiosis group), and another 18 age- and sex-matched patients with vertigo and dizziness but without leukoaraiosis (hereafter, nonleukoaraiosis group) were enrolled in this study.

MAIN OUTCOME MEASURES

Each patient underwent a battery of audiovestibular tests, including audiometry and electronystagmography (ENG).

RESULTS

In the leukoaraiosis group, ENG examination showed slow pursuit movements in 72% of patients, slowing of saccadic eye movements in 28%, abnormal optokinetic nystagmus test results in 44%, and canal paresis or caloric areflexia in 56% of cases. Compared with the nonleukoaraiosis group, 50%, 17%, 44%, and 61% of cases exhibited nonsignificant differences in slow pursuit movements, slowing of saccadic eye movements, abnormal optokinetic nystagmus test results, and abnormal caloric test results, respectively. However, saccadic oscillation had an occurrence rate of 72% in the leukoaraiosis group in contrast with a 22% rate in the nonleukoaraiosis group, revealing a significant statistical difference.

CONCLUSIONS

Saccadic oscillations in the ENG examination indicated leukoaraiosis on the magnetic resonance imaging scan, with a sensitivity of 72% and a specificity of 78%. We therefore recommend using ENG examination to screen elderly individuals with leukoaraiosis.

Associations between findings on cranial magnetic resonance imaging and retinal photography in the elderly: the Cardiovascular Health Study

Associations between findings on cranial magnetic resonance imaging (MRI) and retinal photographs have been described mostly in middle-aged people. In the Cardiovascular Health Study, 1,717 elderly participants underwent MRI and retinal photography between 1991 and 1999. Associations were sought between MRI findings and four findings of retinal microvascular disease: retinopathy, focal arteriolar narrowing, arteriovenous nicking, and the arteriovenous ratio--the last based upon semiautomated measurements of arterioles and venules. After controlling for age and gender, the authors found associations between MRI findings and the smaller arteriovenous ratio (per standard deviation decrease): prevalent infarcts (odds ratio = 1.18, 95% confidence interval: 1.05, 1.34; p = 0.007), white matter grade (regression coefficient, 0.093; p = 0.011), incident infarct (odds ratio = 1.26, 95% confidence interval: 1.09, 1.46; p = 0.002), and worsening white matter grade (odds ratio = 1.12, 95% confidence interval: 0.98, 1.29; p = 0.09). Arteriovenous nicking was also associated with prevalent (odds ratio = 1.84, 95% confidence interval: 1.23, 2.76; p = 0.003) and incident (odds ratio = 1.84, 95% confidence interval: 1.15, 2.94; p = 0.011) infarcts. Adjustment for hypertension and diabetes had minimal effect. Evidence of small vessel disease in the retina increases the likelihood of finding it in the brain. Associations were less prominent in this elderly population than have been described in middle-aged people.

Small artery dementia in Japan: radiological differences between CADASIL, leukoaraiosis and Binswanger's disease

CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) is a hereditary small artery disease which is phenotypically similar to Binswanger's disease (BD), a nonhereditary form of small artery disease. Recent studies have indicated that lesions in the temporopolar, medial frontopolar areas and external capsule are frequently seen in Caucasian patients with CADASIL. However, it remains unclear whether magnetic resonance (MR) imaging findings are helpful in diagnosing small artery disease outside countries with Caucasian populations, since CADASIL is rare despite the high prevalence of small artery disease in Japan. We examined 58 patients with small artery disease, all of whom were devoid of major vessel occlusion or severe stenosis. These patients included 7 patients from 3 families with CADASIL, 27 nondemented patients with extensive leukoaraiosis (LA) and 24 patients with BD. On T(2)-weighted MR images, hyperintensities in the temporopolar areas were observed in all 7 patients with CADASIL, whereas these lesions were observed in only 1 subject from each of the nondemented LA and BD groups. Hyperintensities in the medial frontopolar areas were seen in 4 of the 7 patients with CADASIL (57%) and in 14 of the 24 patients with BD (58%), and were more frequent than in the nondemented LA group (4 of the 27 patients; 15%). In contrast, hyperintensities in the external capsule were frequently observed in all groups. Therefore, temporopolar lesions can also serve as diagnostic markers for CADASIL in non-Caucasian patients.

Executive dysfunction in hyperhomocystinemia responds to homocysteine-lowering treatment

An elevated serum homocysteine level is a risk factor for the development of cognitive impairment. Reported is a late-onset case of hyperhomocystinemia due to a vitamin B12 metabolic deficit (cobalamin C) with cognitive impairment, primarily in frontal/executive function. After homocysteine-lowering therapy, the patient's functional and neuropsychological status improved in conjunction with a decrease in leukoariosis on his MRI scan. These findings suggest that homocysteine-related cognitive impairment may be partially reversible.

Cerebral white matter hyperintense lesions are associated with unstable carotid plaques

OBJECTIVES

The aim of this study was to determine whether unstable carotid plaques, a known risk factor for cerebral emboli, are associated with cerebral white matter lesions.

METHODS

Seventy-one symptomatic patients undergoing magnetic resonance imaging prior to carotid endarterectomy for high grade carotid stenosis were included in this study. The number and volume of white matter hyperintense lesions (WMHL) on fluid attenuated inversion recovery brain scans were compared according to the morphology of carotid plaque based upon the American Heart Association (AHA) histological classification.

RESULTS

Of the 57 patients who had good quality brain scans and non-fragmented carotid plaques, 15 plaques were defined as stable (type V) and 42 as unstable (type VI). After adjustment for the major risk factors affecting WMHL, unstable carotid plaques were found to be associated with more WMHL in the ipsilateral cerebral hemisphere than stable plaques (transformed means 2.50+/-1.2 vs. 1.53+/-1.1, p=0.016), however, there was only a trend towards larger WMHL volumes (p=0.079).

CONCLUSIONS

The observed association between unstable carotid plaques and the number of white matter lesions suggest that thromboembolic plaque activity may contribute to the development of leukoaraiosis, in particular smaller individual lesions. Larger studies are warranted to confirm this finding and explore the potential clinical impact for selecting candidates for carotid endarterectomy.

White matter lesions, cognition, and recurrent hemorrhage in lobar intracerebral hemorrhage

BACKGROUND

Accumulating evidence suggests that white matter lesions are associated with vascular cognitive impairment. The authors investigated the relationships between white matter lesions, cognitive impairment, and risk of recurrent hemorrhage in a prospectively identified cohort of patients with lobar intracerebral hemorrhage (ICH).

METHODS

The authors collected clinical and genetic information on 182 consecutive patients age > or = 55 who had CT scan at admission for lobar ICH. White matter disease was graded on CT in all subjects and on MRI in a subset of 82 patients. All scans were interpreted blinded to clinical information. Survivors were followed for recurrent ICH by telephone interview.

RESULTS

White matter damage was common (present on CT in 77%) and severe (advanced CT grade in 32%). White matter damage was correlated with the total number of hemorrhages on gradient-echo MRI and with risk of recurrent ICH. Subjects with cognitive impairment prior to their index ICH were more likely to have severe white matter damage on CT (OR 3.6, 95% CI 1.6 to 8.1, p = 0.003) and more likely to have advanced periventricular hyperintensities on MRI. The relationships between white matter damage and cognitive impairment were similar in the subset of 88 subjects meeting criteria for probable or definite cerebral amyloid angiopathy and remained independent after adjustment for age, cortical atrophy, and APOE genotype.

CONCLUSIONS

White matter damage in lobar ICH is common and is associated with cognitive impairment. These data support the possibility that an underlying vasculopathy in lobar ICH patients, possibly cerebral amyloid angiopathy, can cause clinically important vascular dysfunction.

[Clinico-pathology and differential diagnosis of Binswanger's disease]

Pathologically, Binswanger's disease is subcortical periventricular leucoencephalopathy sparing the U fibers. Clinically it is characterised by executive dysfunction, gait problems, urinary incontinence, pseudobulbar palsy, mood disturbances and dementia. The pathomechanism of Binswanger's disease is unclear. It is hypothesized that it results from an ischemic-hypoxic injury of the periventricular white matter, which, in turn, can be caused by a sclerotic elongation of the medullary arteries, widening of the perivascular spaces or decreased brain perfusion due to hypotension or heart disease. The symptoms of Binswanger's disease frequently overlap with those of normal pressure hydrocephalus, vascular parkinsonism and Alzheimer's disease. A diagnostic criterion of Binswanger's disease is radiologically demonstrated leukoaraiosis, which, on the other hand, is not equivalent with Binswanger's disease. A good clinical response after lumbar puncture or shunt implantation might lead to confusion with normal pressure hydrocephalus, which further complicates the clinical diagnosis. It is likely that among the above mentioned disorders there are a number of transitional forms and overlaps, which might be explained by the common pathomechanism of disturbance in cerebrospinal fluid circulation.

[Distribution of ischemic leukoaraiosis in MRI: a difference from white matter lesions in CADASIL]

Previously, the distribution of white matter lesions in CADASIL has been reported to be distinct from those in patients with ischemic leukoaraiosis and Binswanger's disease. In earlier European studies, diagnostic significance of white matter lesions in the temporopolar region (Tp), medial frontopolar region (Fp) and external capsule (EC) was stressed in diagnosing CADASIL. More recently, however, high sensitivity and specificity of Tp lesions have been demonstrated. In Japan, prevalence of CADASIL is lower, and those of ischemic leukoaraiosis and Binswanger's disease, likely related to small artery disease, are much higher than in Caucasian countries. Therefore, we examined the frequencies of CADASIL-associated lesions in 17 non-demented patients with ischemic leukoaraiosis and 20 patients with Binswanger's disease. The Binswanger's disease group showed a significantly lower scores for Hasegawa Dementia Rating Scale Revised (HDSR) and a higher prevalence of hypertension, compared to the ischemic leukoaraiosis group. There was only 1 patient with Tp lesions in each group, while Fp lesions were found in 12 % and 50% in the ischemic leukoaraiosis group and Binswanger's disease group, respectively, and EC lesions in 59% and 80%. These results indicated that Tp lesions were useful diagnostic marker in diagnosing CADASIL, whereas Fp and EC lesions were non-specifically observed.

Incidence, manifestations, and predictors of worsening white matter on serial cranial magnetic resonance imaging in the elderly: the Cardiovascular Health Study

BACKGROUND AND PURPOSE

Magnetic resonance imaging (MRI) scans in the elderly commonly show white matter findings that may raise concerns. We sought to document incidence, manifestations, and predictors of worsening white matter grade on serial imaging.

METHODS

The Cardiovascular Health Study is a population-based, longitudinal study of 5888 people aged 65 years and older, of whom 1919 have had extensive initial and follow-up evaluations, including 2 MRI scans separated by 5 years. Scans were read without clinical information in standard side-by-side fashion to determine worsening white matter grade.

RESULTS

Worsening was evident in 538 participants (28%), mostly (85%) by 1 grade. Although similar at initial scan, participants with worsening white matter grade, compared with those without, experienced greater decline on modified Mini-Mental State examination and Digit-Symbol Substitution test (both P< or =0.001) after controlling for potential confounding factors, including occurrence of transient ischemic attack or stroke between scans. Independent predictors of worsening white matter grade included cigarette smoking before initial scan and infarct on initial scan. Otherwise, predictors differed according to white matter grade on initial scan. For low initial grade, increased age, increased diastolic blood pressure, increased high-density lipoprotein cholesterol, and decreased low-density lipoprotein cholesterol were associated with increased risk of worsening. For high initial grade, any cardiovascular disease and low ankle-arm index were associated with decreased risk of worsening, whereas use of diuretics and statins were associated with increased risk.

CONCLUSIONS

Worsening white matter grade on serial MRI scans in elderly is common, is associated with cognitive decline, and has complex relations with cardiovascular risk factors.

Different progression rates for deep white matter hyperintensities in elderly men and women

The authors investigated the progression of white matter hyperintensities (WMHs) in a large population of elderly men and women. After 3 years of follow-up, women had accumulated approximately twice as much deep WMH (DWMH) as men. The progression of periventricular WMH was the same for men and women. Gender differences may affect the pathogenesis of DWMH, which in turn may result in different clinical consequences in women.

Appearance of leukoaraiosis may be attenuated with compression by a chronic subdural hematoma

INTRODUCTION/OBJECTIVE

Various pathological changes have been attributed to leukoaraiosis. Some investigators have suggested that increase in interstitial water may partly contribute to leukoaraiosis. We hypothesized that leukoaraiosis may be attenuated by compression to the cerebral hemisphere if interstitial water may partly contribute to leukoaraiosis. We retrospectively reviewed patients with unilateral chronic subdural hematomas (CSDHs) to investigate the difference in appearance of leukoaraiosis between both cerebral hemispheres.

METHODS AND MATERIAL

Leukoaraiosis on T2-weighted magnetic resonance (MR) images at the levels of the centrum semiovale and those of the frontal horns of both cerebral hemispheres in five contiguous patients with unilateral CSDHs were scored. The difference in the leukoaraiosis scores on the ipsilateral side and contralateral side of the CSDH was analyzed.

RESULTS

Leukoaraiosis was less prominent on the ipsilateral side of the CSDHs than on the contralateral side of the CSDHs, both at the level of the centrum semiovale (P=0.02) and that of the frontal horns (P=0.03).

DISCUSSION AND CONCLUSION

Our results support the theories that interstitial water may partly contribute to the appearance of leukoaraiosis on MR images.