preserve: how intensively should we treat blood pressure in … · estimating the degree of...

PRESERVE: How intensively should we treat bloodpressure in established cerebral small vessel disease?

Guide to assessing MRI scans

Inclusion Criteria – Clinical syndrome

Patients must have clinical evidence of cerebral small vessel disease, falling into one ofthe following categories:

a) Lacunar stroke syndrome with symptoms lasting >24 hours

b) Transient ischaemic attack lasting < 24 hours with limb weakness, hemisensory loss ordysarthria 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 ananatomically appropriate position on MRI

c) Vascular cognitive impairment with MRI showing no evidence of hippocampal atrophy

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 ofhippocampal atrophy

This document will provide guidance and examples to help with assessing these criteria.

Lacunar infarct

Leukoaraiosis

Estimating the degree ofLeukoaraiosis – 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 aroundventricles2 = 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 1987:8:421–426

Fazekas et al. Pathological correlates of incidental MRI white matter signal hyperintensities. Neurology 1993; 43:1683-1689

• 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

www.sbirc.ed.ac.uk/research/imageanalysis.html

Applying the Fazekas Scale - Examples

There are two rows of images in each slide, each showing 3 standard slices, from inferior tosuperior. The T2-weighted images are on the top row with the FLAIR images below.

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 whichan 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). Focallesions should be ignored for the purposes of rating white matter lesions.

T2 inferior T2 medial T2 superior

FLAIR inferior FLAIR medial FLAIR superior

Fazekas Scale - Examples

1

Fazekas Rating: PVH 1 / DWMH 0

Comments: This slide demonstrates the lowest level of white matter lesions.

NOT ELIGIBLE FOR PRESERVE



2



3



4


ELIGIBLE FOR PRESERVE

5



6



7



8



9

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 leftinternal capsule (arrow) which you should ignore. Note that there are alsonumerous enlarged perivascular spaces – the tiny white dots in the basal

ganglia on the T2-weighted images (circled on the right side).

10


Comments: In this case, the white matter is diffusely abnormal throughout the cerebralhemispheres. The case demonstrates the highest possible level of whitematter lesions.

11

The following slides show FLAIR images only

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

12


13


14


15


16


17


18


19

Rating Hippocampal (Medial Temporal) Atrophy

This only applies if you are entering the patient onthe basis of Vascular Cognitive impairment

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

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 approx20mm)

• starting at the anterior hippocampus (immediately posterior to the amygdala)

• 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

Width of choroidWidth of choroidfissurefissure

Width ofWidth oftemporal horntemporal horn

HippocampalHippocampalheightheight

00 NN NN NN

11 ↑↑ NN NN

22 ↑↑↑↑ ↑↑ ↓↓

33 ↑↑↑↑↑↑ ↑↑↑↑ ↓↓↓↓

44 ↑↑↑↑↑↑ ↑↑↑↑↑↑ ↓↓↓↓↓↓Scheltens, 1992

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):967-72.

Visual ratings of MTL atrophy - a visual scale

Examples

MTA 0

ELIGIBLE FORPRESERVE

A

MTA 0


B

C

MTA 0MTA 0


D

MTA 0MTA 0


A

MTA 1


B

MTA 1


C

MTA 1


D

MTA 1


A

MTA 2

NOT ELIGIBLE FORPRESERVE

B

MTA 2


C

MTA 2


D

MTA 2


A

MTA 3


B

MTA 3


C

MTA 3


D

MTA 3


A

MTA 4


B

MTA 4


C

MTA 4


D

MTA 4


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