PRESERVE: How intensively should we treat blood pressure in established cerebral small vessel disease? Guide to assessing MRI scans

Transcription

1 PRESERVE: How intensively should we treat blood pressure in established cerebral small vessel disease? Guide to assessing MRI scans

2 Inclusion Criteria Clinical syndrome Patients must have clinical evidence of cerebral small vessel disease, falling into one of the following categories: a) Lacunar stroke syndrome with symptoms lasting >24 hours b) Transient ischaemic attack lasting < 24 hours with limb weakness, hemisensory loss or dysarthria AND with MR DWI imaging performed acutely showing lacunar infarction, or if MRI is not performed acutely (>2 weeks after TIA) with a lacunar infarction in an anatomically appropriate position on MRI c) Vascular cognitive impairment with MRI showing no evidence of hippocampal atrophy

3 Inclusion Criteria MRI As well as having an appropriate clinical lacunar syndrome patients must have: MRI evidence of lacunar infarct(s) (<=1.5cm vascular diameter) AND Confluent leukoaraiosis (defined on Fazekas scale as >=grade 2) Patients entered with Vascular Cognitive Impairment must show no evidence of hippocampal atrophy This document will provide guidance and examples to help with assessing these criteria.

4 Lacunar infarct Leukoaraiosis

5 Estimating the degree of Leukoaraiosis Fazekas Scale The Fazekas Scale is a simple visual rating scale used to rate the degree of leukoaraiosis (white matter hyperintensity) It rates periventricular and deep white-matter hyperintensities (PVH and DWMH) on a four point scale. PVH and DWMH are considered separately and rated from 0-3 To be eligible for PRESERVE, a patient must have a score of at least 2 for either PVH or DWMH PVH 0 = absent 1 = caps or pencil-thin lining around ventricles 2 = smooth halo around ventricles (6-10mm regular margins) 3 = irregular halo > 10mm DWMH 0 = absent 1 = multiple focal lesions (>5) 2 = early confluent disease 3 = confluent disease Fazekas et al. MR signal abnormalities at 1.5T in Alzheimer s disease and normal aging. AJNR 1987:8: Fazekas et al. Pathological correlates of incidental MRI white matter signal hyperintensities. Neurology 1993; 43:

6 Applying the Fazekas Scale - Examples The following slides show standard slices from MRI scans which have been chosen to represent a range of white matter abnormalities. Some of the Fazekas scale examples have been taken from the following useful resource: 20 standard MR scans with validated ratings on several white matter rating scales Authors: Prof. Joanna Wardlaw & Dr. Karen Ferguson, University of Edinburgh

7 Fazekas Scale - Examples There are two rows of images in each slide, each showing 3 standard slices, from inferior to superior. The T2-weighted images are on the top row with the FLAIR images below. T2 inferior T2 medial T2 superior FLAIR inferior FLAIR medial FLAIR superior The consensus expert ratings for each scale are shown below the images. WMH can be assessed on either T2 or FLAIR images. They are easier to assess on FLAIR, in which an inversion recovery sequence suppresses signal from free water (for example in the ventricles). Note that some of the cases have also have a focal lesion, which are pointed out (see arrows). Focal lesions should be ignored for the purposes of rating white matter lesions.

8 1 Fazekas Rating: PVH 1 / DWMH 0 Comments: This slide demonstrates the lowest level of white matter lesions. NOT ELIGIBLE FOR PRESERVE

9 2 Fazekas Rating: PVH 1 / DWMH 1 NOT ELIGIBLE FOR PRESERVE

10 3 Fazekas Rating: PVH 1 / DWMH 1 NOT ELIGIBLE FOR PRESERVE

11 4 Fazekas Rating: PVH 1 / DWMH 1 NOT ELIGIBLE FOR PRESERVE

12 5 Fazekas Rating: PVH 2 / DWMH 1 ELIGIBLE FOR PRESERVE

13 6 Fazekas Rating: PVH 2 / DWMH 2 ELIGIBLE FOR PRESERVE

14 7 Fazekas Rating: PVH 3 / DWMH 2 ELIGIBLE FOR PRESERVE

15 8 Fazekas Rating: PVH 3 / DWMH 3 ELIGIBLE FOR PRESERVE

16 9 Fazekas Rating: PVH 3 / DWMH 3 ELIGIBLE FOR PRESERVE

17 10 Fazekas Rating: PVH 3 / DWMH 3 ELIGIBLE FOR PRESERVE Comments: This case has a focal lesion; a lacunar infarct in the posterior limb of the left internal capsule (arrow) which you should ignore. Note that there are also numerous enlarged perivascular spaces the tiny white dots in the basal ganglia on the T2-weighted images (circled on the right side).

18 11 Fazekas Rating: PVH 3 / DWMH 3 ELIGIBLE FOR PRESERVE Comments: In this case, the white matter is diffusely abnormal throughout the cerebral hemispheres. The case demonstrates the highest possible level of white matter lesions.

19 The following slides show FLAIR images only

20 12 Fazekas Rating: PVH 0 / DWMH 0 NOT ELIGIBLE FOR PRESERVE

21 13 Fazekas Rating: PVH 0 / DWMH 0 NOT ELIGIBLE FOR PRESERVE

22 14 Fazekas Rating: PVH 1 / DWMH 0 NOT ELIGIBLE FOR PRESERVE

23 15 Fazekas Rating: PVH 2 / DWMH 1 ELIGIBLE FOR PRESERVE

24 16 Fazekas Rating: PVH 3 / DWMH 2 ELIGIBLE FOR PRESERVE

25 17 Fazekas Rating: PVH 2 / DWMH 2 ELIGIBLE FOR PRESERVE

26 18 Fazekas Rating: PVH 2 / DWMH 3 ELIGIBLE FOR PRESERVE

27 19 Fazekas Rating: PVH 3 / DWMH 3 ELIGIBLE FOR PRESERVE

28 Rating Hippocampal (Medial Temporal) Atrophy This only applies if you are entering the patient on the basis of Vascular Cognitive impairment

29 Why do we want to do this? When patients are entered on the basis of vascular cognitive impairment (VCI) we are trying to exclude patients with Alzheimer s disease, rather than VCI, as a cause for their cognitive impairment A hallmark of Alzheimer s is hippocampal atrophy

30 PRESERVE Rating Hippocampal (Medial Temporal) Atrophy Rate on both left and right sides Use coronal T1 weighted MR and look through a number of slices (covering approx 20mm) starting at the anterior hippocampus (immediately posterior to the amygdala)

31 Visual ratings of MTL atrophy - a visual scale Width of choroid fissure Width of temporal horn Hippocampal height 0 N N N 1 N N Scheltens, 1992 To be eligible for PRESERVE the patient must have a score of 0 or 1 on both sides If the score is above 2 on either the left or right side they are not eligible Scheltens P, Leys D, Barkhof F, Huglo D, Weinstein HC, Vermersch P, et al. Atrophy of medial temporal lobes on MRI in "probable" Alzheimer's disease and normal ageing: diagnostic value and neuropsychological correlates. Journal of Neurology, Neurosurgery & Psychiatry. 1992;55(10):

32 Examples

33 A MTA 0 ELIGIBLE FOR PRESERVE

34 B MTA 0 ELIGIBLE FOR PRESERVE

35 C MTA 0 ELIGIBLE FOR PRESERVE

36 D MTA 0 ELIGIBLE FOR PRESERVE

37 A MTA 1 ELIGIBLE FOR PRESERVE

38 B MTA 1 ELIGIBLE FOR PRESERVE

39 C MTA 1 ELIGIBLE FOR PRESERVE

40 D MTA 1 ELIGIBLE FOR PRESERVE

41 A MTA 2 NOT ELIGIBLE FOR PRESERVE

42 B MTA 2 NOT ELIGIBLE FOR PRESERVE

43 C MTA 2 NOT ELIGIBLE FOR PRESERVE

44 D MTA 2 NOT ELIGIBLE FOR PRESERVE

45 A MTA 3 NOT ELIGIBLE FOR PRESERVE

46 B MTA 3 NOT ELIGIBLE FOR PRESERVE

47 C MTA 3 NOT ELIGIBLE FOR PRESERVE

48 D MTA 3 NOT ELIGIBLE FOR PRESERVE

49 A MTA 4 NOT ELIGIBLE FOR PRESERVE

50 B MTA 4 NOT ELIGIBLE FOR PRESERVE

51 C MTA 4 NOT ELIGIBLE FOR PRESERVE

52 D MTA 4 NOT ELIGIBLE FOR PRESERVE