subcortical lesion-classification-presentation-2011-10-10
TRANSCRIPT
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A Consensus Meeting
for The Definitions of Subcortical
lesions, Lacunes, Microbleeds, and Subcortical
White Matter Change
Jei Kim, MD
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M/71, 2011. 1. 28
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M/71, 2011. 1. 28
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M/71, 2011. 1. 28
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Subcortical lesions
4. Microbleeds
3. Subcortical white matter changes
1. Perivascular spaces (etat crible)
2. Lacunes
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Perivascular spaces (etat
crible)
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1) Histopathologic definition (ref. 1)
1. Perivascular spaces (etat
crible)
: the dilatation of perivascular spaces around
cerebral arterioles in the brain of elderly patients
(Virchow-Robin space)
2) MRI definition (ref. 1)
: the punctiform dilatations of the perivascular
spaces often seen by brain MRI in the white
matter and in the basal ganglia
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1. Perivascular spaces (etat
crible)2) MRI definition: the punctiform dilatations of the perivascular spaces
often seen by brain MRI in the white matter and
in the basal ganglia
: On T2WI – high intensity,
same as the intensity of CSF
: On FLAIR – dark (low), same as the intensity of CSF
: On T1WI – dark (low), same as the intensity of CSF
http://www.radiologyassistant.nl/en/4556dea65db62
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M/80, 2011. 10. 13
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Lacune
s
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2. Lacunes
1) Histopathologic definition
: a small, cystic cavity of the brain substance that
usually results from an ischemic infarction in the
territory of a penetrating arteriole (ref. 1)
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2. Lacunes
2) Vascular pathology of lacunes (ref. 13)
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3) Perforating arteries
(1) Anterior perforating arteries
(2) Posterior perforating arteries
(3) Arterial supply of the brainstem
2. Lacunes
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(1) Anterior perforating arteries
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A. Perforating branches arising from ACA
and the recurrent artery of Heubner
(1) Anterior perforating arteries
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B. Perforating branches arising from MCA
a. Perforating branches arising from MCA
(1) Anterior perforating arteries
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b. Percentage of perforating arteries arising
from MCA trunk and its branches
(1) Anterior perforating arteries
B. Perforating branches arising from MCA
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c. Origin of perforating arteries arising
from MCA trunk and its branches
(1) Anterior perforating arteries
B. Perforating branches arising from MCA
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d. Number of perforating arteries arising
from different distances from the origin of MCA
(1) Anterior perforating arteries
B. Perforating branches arising from MCA
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e. Branching characteristics of 508 perforating arteries
arising from common stems of MCA
(1) Anterior perforating arteries
B. Perforating branches arising from MCA
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(2) Posterior perforating arteries
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(3) Arterial supply of the brainstem
A. Perforating arteries of the midbrain
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B. Perforating arteries of the pons
(3) Arterial supply of the brainstem
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C. Perforating arteries of the midbrain
(3) Arterial supply of the brainstem
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Schematic diagram of origin of deep
perforating branches from a parent artery
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4) Pathogenic implications of microcirculation
1) Stenosis or complete occlusion by atherosclerosis
2) Stenosis or occlusion of ostium of a branch point
3) Atherosclerotic narrowing of a parent artery
4) Proximal thrombus or embolus in atherosclerotic
artery
(1) Perforating arteries
(2) Cortical branches
2. Lacunes
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4) Pathogenic implications of microcirculation
A. Stenosis or complete occlusion by atherosclerosis
(1) Perforating arteries
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B. Stenosis or occlusion of ostium of a branch point
4) Pathogenic implications of microcirculation
(1) Perforating arteries
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C. Atherosclerotic narrowing of a parent artery
4) Pathogenic implications of microcirculation
(1) Perforating arteries
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D. Proximal thrombus or embolus in atherosclerotic
artery
4) Pathogenic implications of microcirculation
(1) Perforating arteries
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(2) Cortical branches
4) Pathogenic implications of microcirculation
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5) MRI definition
2. Lacunes
(ref. 2)
: small hyperintense lesions on T2WI (ref. 2)
: corresponding distinctive low intensity area on T1WI
: Maximum size of lacune (ref. 4)
- with a diameter of 5-10 mm
: On CT (ref. 4)
- areas of more or less complete focal tissue destruction
- clearly defined borders with marked central
hypodensity on CT
: On MRI (ref. 4)
- low intensity on T1WI, proton-density and FLAIR scans
- high intensity on T2WI
-> isointense to CSF
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5) MRI definition
2. Lacunes
(ref. 17)
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2. Lacunes
1) Histopathologic definition
: a small, cystic cavity of the brain substance that
usually results from an ischemic infarction in the
territory of a penetrating arteriole (ref. 1)
: defined as cavitated microinfarcts or encephalomalacic
lesions, 2 mm or smaller in greatest dimension, not
identifiable with certainty on gross inspection of the
brain or non-cavitated microinfarcts, focal gliotic areas
without a cystic cavity (ref. 3)
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M/80, 2011. 10. 13
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6) Grading of lacunes
2. Lacunes
(ref. 2)
(1) Absent
(2) Mild – 1-3
(3) Moderate – 4-10
(4) Severe - >10
7) Locations of lacunes (ref. 2)
(1) Cortico-subcortical
(2) Basal ganglia
(3) Thalamus
(4) Brain stem
(5) Cerebellum
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Subcortical white matter change
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3. Subcortical white matter change
1) Definition of Binswanger‟s disease (1894)
: pronounced atrophy of the white matter, either confined
to one or more gyri of the brain or in several sections
of the hemisphere
: in the most severe cases the entire white matter
of a cerebral lobe appears to have completely wasted away
: a severe atheromatosis of the arteries of the brain is always
present in these cases
: extensive atrophic degeneration or fatty degeneration
of the small arterial and venous vessels
: partial thickening of the inner and middle vascular
membranes
: the lumen is correspondingly narrowed
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3. Subcortical white matter change
: loss of density of the periventricular white matter
observed by CT of the brain
: the white matter changes commonly observed in the
elderly by MRI of the brain
2) Definition of leukoaraiosis (Hachinski et al., 1987)
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3. Subcortical white matter change
3) Mechanisms hypothesized to be involved
in the pathogenesis of white matter change (ref. 14)
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4) Small vessel changes related to white matter changes
(ref. 14)
3. Subcortical white matter change
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3. Subcortical white matter change
5) Evolution of white matter lesions (ref. 16)
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3. Subcortical white matter change
6) Definition of „Periventricular‟ and „Deep white matter‟
change (ref.5)
(1) Periventricular
- Start directly at the ventricular border
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3. Subcortical white matter change
6) Definition of „Periventricular‟ and „Deep white matter‟
change (ref.5)
(2) Both periventricular and deep white matter
- If the periventricular abnormalities extend > 1 cm
into the adjacent white matter
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6) Definition of „Periventricular‟ and „Deep white matter‟
change (ref.5)
3. Subcortical white matter change
(3) Selective deep white matter lesion
- usually characterized by a rim of normal-appearing
tissue which separates them from the periventricular
region
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3. Subcortical white matter change
6) Definition of „Periventricular‟ and „Deep white matter‟
change (ref.5)
(4) Basal ganglia hypodensities on CT or hyperintensity on MRI
(M/82)
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6) Definition of „Periventricular‟ and „Deep white matter‟
change (ref.24)
3. Subcortical white matter change
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3. Subcortical white matter change
6) Definition of „Periventricular‟ and „Deep white matter‟
change – (1) (ref.5)
(1) Periventricular hyperintensity
0 = absence
1 = “caps” or pencil-thin lining
2 = smooth “halo”
3 = irregular PVH extending into the deep white matter
(2) Deep white matter hyperintense signal
0 = absence
1 = punctuate foci
2 = beginning confluence of foci
3 = large confluent areas
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3. Subcortical white matter change
7) Definition of „Periventricular‟ and „Deep white matter‟ –(3)
(ref. 6)
(1) White matter lesions
0 = no lesions
(including symmetrical, well-defined caps or bands)
1 = Focal lesions
2 = Beginning confluence of lesions
3 = Diffuse involvement of the entire region,
with or without involvement of U fibers
(2) Basal ganglia lesions
0 = No lesions
1 = 1 focal lesion (≥ 5 mm)
2 = > 1 focal lesion
3 = Confluent lesions
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3. Subcortical white matter change
7) Definition of „Periventricular‟ and „Deep white matter‟ –(3)
(ref. 6)
1. Score of 1
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3. Subcortical white matter change
7) Definition of „Periventricular‟ and „Deep white matter‟ –(3)
(ref. 6)
2. Score of 2
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3. Subcortical white matter change
7) Definition of „Periventricular‟ and „Deep white matter‟ –(3)
(ref. 6)
3. Score of 3
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1 = Focal lesions
(1) White matter lesions
3. Subcortical white matter change
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(1) White matter lesions
2 = Beginning confluence of lesions
3. Subcortical white matter change
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(1) White matter lesions
3 = Diffuse involvement of the entire region,
with or without involvement of U fibers
(M/75)
3. Subcortical white matter change
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(1) White matter lesions
3 = Diffuse involvement of the entire region,
with or without involvement of U fibers
(M/60)
3. Subcortical white matter change
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(2) Basal ganglia lesions
1 = 1 focal lesion (≥ 5 mm)
3. Subcortical white matter change
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(2) Basal ganglia lesions
2 = > 1 focal lesion
3. Subcortical white matter change
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(2) Basal ganglia lesions
3 = Confluent lesions
3. Subcortical white matter change
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Microbleeds
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4. Microbleeds
1) Histopathologic and MRI definition
: paramagnetic material which produces local susceptibility
gradients and thereby causes a faster decay of transverse
magnetization on gradient-echo acquisition (ref. 18)
: remnants of even minor blood leakage through
damaged vessel walls
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4. Microbleeds
1) Histopathologic definition
: Postmortem gradient-echo-T2*-weighted MRI and
histopathologic finding (ref. 19)
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4. Microbleeds
Figure 1. Grading of CAA severity in single
brain samples (ref. 27)
0: No cerebral vessels showed immunopositivity
for beta amyloid
1+: Amyloid is restricted to a rim around smooth
muscle fibers in the media of occasional
normal vessels
2+: The media is thicker than normal and
circumferentially replaced by amyloid
in a few vessels
3+: Widespread medial thickening and
circumferential amyloid deposition
with a small halo of immunoreactivity
in the surrounding parenchyma
: A focus of wall leakage as evidenced
by fresh hemorrhage or hemosiderin-laden
macrophages, or occlusion, or recanalization
2) Severity of amyloid angiopathy (ref. 27)
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4. Microbleeds
3) MRI definition of microbleed (ref. 2, 19, 20, 21)
(1) Homogeneous round signal loss lesion with a
diameter of up to 5 mm (or <10 mm)
on gradient echo image
(2)Distinct from
a. Vascular flow voids on subarachnoid space
b. Leptomeningeal hemasiderosis
c. Non-hemorrhagic subcortical mineralization
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• Non-hemorrhagic subcortical mineralization (ref. 26)
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• Non-hemorrhagic subcortical mineralization
(M/80)
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• Leptomeningeal hemasiderosis
1. Superficial cortical hemosidersosis (ref. 25)
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• Leptomeningeal hemasiderosis
2. Subarachnoid hemosidersosis (ref. 25)
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• Leptomeningeal hemasiderosis
3. Schematic drawing illustrating subarachnoid hemosiderosis
and superficial corical hemosidersosi (ref. 25)
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4. Microbleeds
3) MRI definition of microbleed (ref. 20)
• In CAA Pt. • In CADASIL
Pt.
• In H/T Pt.
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4. Microbleeds
3) MRI definition of microbleed (ref. 21)
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4. Microbleeds
4) Degree of severity of microbleeds (ref. 2)
(1) Absent
(2) Mild – total number of MBs, 1-5
(3) Moderate – total number of MBs, 6-15
(4) Severe – total number of MBs, >15
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4. Microbleeds
5) The locations of the microbleeds and lacunes (ref. 2)
(1) Cortico-subcortical
(2) Basal ganglia
(3) Thalamus
(4) Brain stem
(5) Cerebellum
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Evaluation of the vessel stenosis
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1) Significant stenosis - >50%
2) No significant stenosis - <50%
Definition of coronary artery stenosis (ref. 8)
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The degrees of stenoocclusive disease (ref. 7)
1) Normal – 0% - 29% diameter stenosis
2) Mildly stenotic – 30% - 49%
3) Moderately stenotic – 50% - 79%
4) Severely stenotic – 80%- 99%
5) Occluded
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Regional location of stenosis (ref. 9)
: Schematic representation of 11 arterial segments studied
by transcranial Doppler and duplex ultrasound
MCA – 1 and 2
ACA – 3 and 4
PCA – 5 and 6
Siphon ICA – 7 and 8
Extracranial ICA - 9 and 10
Vertebrobasilar artery – 11
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Measuement of vessel stenosis (ref. 10)
1. Equation for measuring intracranial arterial stenosis
: Percent stenosis = [(1-(Dstenosis/Dnormal))] x 100
• Dstenosis: the diameter of the artery at the site of the
most severe degree of stenosis
• Dnormal: the diameter of the proximal normal artery
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Measuement of vessel stenosis (ref. 10)
2. Criteria for normal proximal artery
1) For the MCA, intracranial VA, and BA
(1) First choice
- the diameter of the proximal part of the artery
at its widest , non-tortuous, normal segment was
chosen
(2) Second choice
- if the proximal artery was diseased
-> the diameter of the distal portion of the artery
at its widest, parallel
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Measuement of vessel stenosis (ref. 10)
2. Criteria for normal proximal artery
(3) Third choice
A. If the entire intracranial artery was diseased
-> the most distal, parallel, non-tortous normal
segment of the feeding artery
B. If the entire middle cerebral artery was diseased
-> measured at the most distal, parallel segement
of the supraaclinoid carotid artery
C. If the entire intracranial vertebral artery was diseased
-> measured at the most distal, parallel,
non-tortous normal segment of the extracranial
vertebral artery
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Measuement of vessel stenosis (ref. 10)
2. Criteria for normal proximal artery
2) For the ICA
(1) First choice
: The precavernous, cavernous, and postcavernous
stenoses of ICA
-> measured at the widest, non-tortous, normal
portion of the petrous carotid artery that had
parallel margins
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Measuement of vessel stenosis (ref. 10)
2. Criteria for normal proximal artery
2) For the ICA
(2) Second choice
- If the entire petrous carotid was diseased
-> the most distal, parallel part of the extracranial
internal carotid artery was substituted
- If tandem intracranial lesions were present
-> percent stenosis of both sites was measured
and the more severe stenosis was selected
- When a “gap sign” was present
-- the lumen of the vessel could not be visualized
at the site of severe stenosis
-- could not be measured
-- defined as 99% luminal stenosis
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1. Equation for measuring intracranial arterial stenosis
Measuement of vessel stenosis (ref. 10)
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2. Equation for measuring extracranial arterial stenosis
Measuement of vessel stenosis
1) Severity of intracranial stenosis (ref. 11, 12)
(1) Mild - <30%
(2) Moderate – 30% - 69%
(3) Severe – 70% - 99%
- in case of segmental signal void
-> the stenosis was graded as severe (>70%)
(4) Occluded
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2. Equation for measuring extracranial arterial stenosis
Measuement of vessel stenosis
2) Measurement of the carotid artery stenosis (ref. 12)
(1) NASCET
: (1-md/C)x100%
(2) ECST
: (1-md/B)x100%
(3) CC
: (1-md/A)x100%