Kevin King MD UT Southwestern Medical Center Division of ...
Kevin King MD UT Southwestern Medical Center Division of ...
Kevin King MD UT Southwestern Medical Center Division of ...
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<strong>Kevin</strong> <strong>King</strong> <strong>MD</strong><br />
<strong>UT</strong> <strong>Southwestern</strong> <strong>Medical</strong> <strong>Center</strong><br />
<strong>Division</strong> <strong>of</strong> Neuroradiology<br />
NIH CTSA Clinical Scholar
Normal Impairment<br />
WMH
White Matter Hyperintensities are biomarkers <strong>of</strong><br />
preventable cerebral microvascular disease & predict risk<br />
for cognitive and motor impairment, stroke and death<br />
Debette S, Markus HS. The clinical importance <strong>of</strong> white matter hyperintensities on brain magnetic resonance<br />
imaging: Systematic review and meta-analysis. BMJ. 2010.341:c3666
Vascular pathology is likely involved in a majority <strong>of</strong><br />
clinically significant cases <strong>of</strong> dementia, lowering the<br />
threshold for development <strong>of</strong> Alzheimers Dementia<br />
Black, S., F. Gao, and J. Bilbao, Understanding white matter disease: imaging-pathological correlations in vascular<br />
cognitive impairment. Stroke, 2009. 40(3 Suppl): p. S48-52.
Normal Impairment
Without an accepted grading system, the near ubiquity <strong>of</strong><br />
WMH in older populations causes the finding to be<br />
ignored by most clinicians and is a source <strong>of</strong> unnecessary<br />
concern for many patients.
Fazekas<br />
An Ideal Clinical Screening Scale:<br />
Benefits:<br />
Simple: Easy to incorporate into practise<br />
Predictive <strong>of</strong> clinical outcomes<br />
Areas <strong>of</strong> concern:<br />
Rating <strong>of</strong> Deep vs. Periventricular<br />
Reproducibility
Original Fazekas WMH Scale<br />
Grade Descriptor Deep WMH Periventricular WMH<br />
0 Absent None None<br />
1 Mild Punctate Pencil Thin Lining<br />
2 Moderate Near Confluent Smooth Halo<br />
3 Severe Confluent Irregular band extending<br />
into the deep white matter<br />
Fazekas F, et al. MR signal abnormalities at 1.5 t in alzheimer's dementia and normal aging. Am. J. Roentgenol.<br />
1987;149:351-356
Fazekas outcome correlations<br />
equivalento to volumetry and<br />
more complex scales<br />
Scale Gait (SPPB) Cognition (MMSE)<br />
Fazekas- Gouw* -0.19 -0.13<br />
Scheltens -0.21 -0.13<br />
Volumetry -0.22 -0.10<br />
* included objective measurement criteria:<br />
mild 2cm.<br />
Gouw AA, et al. LADIS Study Group. Simple versus complex assessment <strong>of</strong> white matter hyperintensities in relation<br />
to physical performance and cognition: the LADIS study. J Neurol. 2006 Sep;253(9):1189-96. Sep 22.
Research insights on rating<br />
Periventricular Vs. Deep
Irregular Periventricular WMH<br />
demonstrated = pathologic changes<br />
as Severe Deep WMH<br />
Fazekas, et al. revision<br />
Grade Descriptor Deep WMH Periventricular WMH<br />
0 Absent Absent Absent<br />
1 Mild Punctate Pencil Thin Lining<br />
2 Moderate Near Confluent Smooth Halo<br />
3 Severe Confluent DWMH equivalent to Irregular PVWMH<br />
Fazekas F, et al. Pathologic correlates <strong>of</strong> incidental mri white matter signal hyperintensities. Neurology. 1993;43:1683-<br />
1689.
Periventricular & Deep WMH<br />
3D analysis by De Carli et al suggested identification <strong>of</strong><br />
periventricular vs. deep in 2D axial images is arbitrary-<br />
on sagittal and coronal ‘deep’ lesions <strong>of</strong>ten contact the<br />
ventricle<br />
C. DeCarli, et al. Anatomical Mapping <strong>of</strong> White Matter Hyperintensities (WMH): Exploring the Relationships<br />
Between Periventricular WMH, Deep WMH, and Total WMH Burden. Stroke, January 1, 2005; 36(1): 50 - 55.
Periventricular & Deep WMH<br />
Spatial analysis failed to identify distinct<br />
populations with Deep versus Periventricular<br />
disease.<br />
PVWMH and DWMH correlate highly with each<br />
other and with total WMH burden<br />
C. DeCarli, et al. Anatomical Mapping <strong>of</strong> White Matter Hyperintensities (WMH): Exploring the Relationships<br />
Between Periventricular WMH, Deep WMH, and Total WMH Burden. Stroke, January 1, 2005; 36(1): 50 - 55.
Questioned Reproducibility<br />
Inter-rater reliability for Fazekas<br />
Variable among studies ranging from poor to excellent,<br />
kappa <strong>of</strong> .43 to .78<br />
May be higher in studies with more advanced WMH due<br />
to a ceiling effect<br />
? Increased by objective criteria such as in Gouw: not<br />
assessed for inter-rater reliability<br />
Scheltens, P., et al., White matter changes on CT and MRI: an overview <strong>of</strong> visual rating scales. European<br />
Task Force on Age-Related White Matter Changes. Eur Neurol, 1998. 39(2): p. 80-9.
Gouw Modification <strong>of</strong> Fazekas<br />
Gouw et al. revision<br />
Grade Descriptor Deep WMH Periventricular WMH<br />
0 Absent Absent Not explicitly described.<br />
1 Mild Single lesions < 10mm<br />
Grouped ≤ 20mm<br />
2 Moderate Single lesions 10-20mm<br />
Grouped >20mm<br />
3 Severe Single/ Confluent lesions<br />
>20mm<br />
Gouw AA, et al. Simple versus complex assessment <strong>of</strong> white matter hyperintensities in relation to physical<br />
performance and cognition: The ladis study. J Neurol. 2006;253:1189-1196
Proposed Clinical Scale<br />
Grade Descriptor Deep WMH Periventricular WMH*<br />
0 Absent All foci
Evaluation <strong>of</strong> New Method<br />
Subset <strong>of</strong> the Dallas Heart Study,<br />
a multi-ethnic community based study<br />
Age 50.7+9.7<br />
Hispanic 15%<br />
NonHisp Black 44%<br />
NonHisp<br />
White 38%<br />
Other Race 2%<br />
Female 52%
3T Images,<br />
Achieva Philips <strong>Medical</strong> Systems<br />
FLAIR<br />
3D MP RAGE
Initial Evaluation<br />
Test set <strong>of</strong> 52 studies demonstrating a range <strong>of</strong> WMH<br />
volumes independently read by two reviewers<br />
Evaluation <strong>of</strong> discordant reads demonstrated poor<br />
agreement in categorization <strong>of</strong> small hyperintense foci<br />
Revision<br />
Established 3mm size threshold, reviewed 40 random<br />
studies<br />
Agreement for grading <strong>of</strong> no versus mild disease was<br />
72.4% (kappa 0.44 SE 0.17) without the threshold<br />
compared with 89.2% with the rule (kappa 0.76 SE 0.11)<br />
with p= 0.055.
Overall Reproducibility<br />
For initial test group enriched for large WMH volumes<br />
Agreement <strong>of</strong> 67% (kappa=0.71) n=52<br />
For random community sample with overall small<br />
WMH volumes (with 3mm threshold)<br />
Agreement <strong>of</strong> 87.5% (kappa = 0.76) n=40
Comparison with WMH Volumes<br />
WMH scores from 559 participants showed<br />
significant correlation with automated<br />
volumes (spearman rho 0.57, p
Conclusion<br />
We report the development <strong>of</strong> a visual WMH scoring<br />
system suited for use in clinical practice.<br />
Grade<br />
0<br />
Descriptor<br />
Absent<br />
Deep WMH<br />
All foci
DHS Brain Study Group<br />
Ronald M. Peshock <strong>MD</strong> 1,2<br />
Keith M. Hulsey MS 1<br />
Lea Alhilali <strong>MD</strong> 3<br />
Roderick W. McColl PhD 1<br />
Myron Weiner 4<br />
Anthony R. Whittemore <strong>MD</strong> PhD 1<br />
Departments <strong>of</strong> 1 Radiology, 2 Internal Medicine, and 4 Neurology<br />
The University <strong>of</strong> Texas <strong>Southwestern</strong> <strong>Medical</strong> <strong>Center</strong><br />
Department <strong>of</strong> 3 Radiology<br />
University <strong>of</strong> Pittsburgh <strong>Medical</strong> <strong>Center</strong>
Regular progression <strong>of</strong> WMH<br />
Magnetic resonance abnormalities and cardiovascular disease in older adults. The Cardiovascular Health Study.<br />
Manolio TA, Bryan RN, et al. Stroke. 1994 Feb;25(2):318-27.
Age Related White Matter Changes<br />
Score: A variant <strong>of</strong> Fazekas<br />
Grade Descriptor<br />
0 No lesions (including symmetrical, well-defined caps or bands)<br />
1 Focal lesions, ≥5 mm<br />
2 Beginning confluence <strong>of</strong> lesions<br />
3 Diffuse involvement <strong>of</strong> the entire region<br />
• Frontal, Parieto-Occipital, Temporal, Infratentorial & Basal Ganglia scored<br />
separately for each hemisphere<br />
• Periventricular and Deep scored Jointly<br />
ARWMC Scale: A new rating scale for age-related white matter changes applicable to MRI and CT. Stroke<br />
2001;32:1318–1322. Wahlund LO, Barkh<strong>of</strong> F, Fazekas F, Scheltens P. et al on behalf <strong>of</strong> the European Task Force on Age-<br />
Related White Matter Changes
Fazekas has good correlation with<br />
WMH volumetry<br />
Scale<br />
Agreement with<br />
Volumetry<br />
(Kendall W)<br />
Fazekas- Schmidt* 0.57<br />
Scheltens 0.48<br />
Manolio 0.37<br />
* included category for number <strong>of</strong> lesions with 0 for no lesions, 1 for 1 to 4<br />
lesions, 2 for 5 to 9 lesions, and 3 for >9 lesions.<br />
Kapeller Pet al. Visual rating <strong>of</strong> age-related white matter changes on magnetic resonance imaging: scale comparison,<br />
interrater agreement, and correlations with quantitative measurements. Stroke. 2003 Feb;34(2):441-5.
Among the Many Systems developed:<br />
Which to choose?<br />
Mäntylä R, et al.Variable agreement between visual rating scales for white matter hyperintensities on MRI. Stroke.<br />
1997 Aug;28(8):1614-23.