MRI White Matter Hyperintensities Research Articles

CSF1R-Related Disorder: Prevalence of CSF1R Variants and Their Clinical Significance in the UK Population.

CSF1R-related disorder (CSF1R-RD) is a devastating neurodegenerative disorder caused by variants in the colony stimulating factor-1 receptor (CSF1R) gene. CSF1R-RD leads to a variable combination of cognitive impairment, movement disorders, upper motor neuron signs, and spasticity with associated imaging abnormalities in brain white matter. Although increasingly recognized, there is evidence that it is significantly underdiagnosed or misdiagnosed, and its true prevalence is unknown. We leveraged the large data set of the UK Biobank to determine the prevalence of CSF1R mutations in the UK population and identify clinical phenotypes associated with these variants. Pathogenic and likely pathogenic CSF1R variants were identified in UK Biobank whole-exome sequencing data (N = 470,000). Medical history, including neurologic and psychiatric disease, were determined from self-reported and hospital collected codes, and the volume of MRI white matter hyperintensities were compared between variant carriers and controls. We identified 25 individuals carrying 18 unique pathogenic variants and 107 individuals carrying 44 unique likely pathogenic variants-combined prevalence 132 (∼1 in 3,500). Pathogenic CSF1R variant carriers had increased risk of psychiatric disease (OR: 5.15, p = 0.0079), depression (OR: 10.52, p = 0.0015), and Parkinson disease (OR: 19.80, p = 0.0038). Using algorithmically defined diagnosis data, pathogenic or likely pathogenic variants (the combined group) carriers were at higher risk for both dementia (OR: 2.50, p = 0.046) and vascular dementia (OR: 4.72, p = 0.032). Damaging variants in CSF1R are more common than expected in the general population and are associated with cognitive, psychiatric, and movement disorder diagnoses, which may reflect clinical manifestation of the disease. This study suggests that CSF1R-RD is either underreported, not diagnosed because of lack of genetic screening or that there is reduced penetrance.

Automated segmentation of MRI white matter hyperintensities in 8,421 patients with acute ischemic stroke.

To date, only a few small studies have attempted deep learning-based automatic segmentation of white matter hyperintensity (WMH) lesions in patients with cerebral infarction, which is complicated because stroke-related lesions can obscure WMH borders. We developed and validated deep learning algorithms to segment WMH lesions accurately in patients with cerebral infarction, using multisite datasets involving 8,421 patients with acute ischemic stroke. We included 8,421 stroke patients from 9 centers in Korea. 2D UNet and SE-Unet models were trained using 2,408 FLAIR MRI from 3 hospitals and validated using 6,013 FLAIR MRIs from 6 hospitals. WMH segmentation performance was assessed by calculating DSC, correlation coefficient, and concordance correlation coefficient compared to a human-segmented gold standard. In addition, we obtained an uncertainty index that represents overall ambiguity in the voxel classification for WMH segmentation in each patient based on the Kullback-Leibler divergence. In the training dataset, the mean age was 67.4±13.0 years and 60.4% were men. The mean (95% CI) DSCs for Unet in internal testing and external validation were respectively 0.659 (0.649-0.669) and 0.710 (0.707-0.714), which were slightly lower than the reliability between humans (DSC=0.744; 95% CI=0.738-0.751; P=.031). Compared with the Unet, the SE-Unet demonstrated better performance, achieving a mean DSC of 0.675 (0.666-0.685; P<.001) in the internal testing and 0.722 (0.719-0.726; P<.001) in the external validation; moreover, it achieved high DSC values (ranging from 0.672 to 0.744) across multiple validation datasets. We observed a significant correlation between WMH volumes that were segmented automatically and manually for the Unet (r=0.917, P<.0001) and even stronger for the SE-Unet (r=0.933, P<.0001). The SE-Unet also attained a high concordance correlation coefficient (ranging from 0.841 to 0.956) in external test datasets. In addition, the uncertainty indices in the majority of patients (86%) in the external datasets were below 0.35, with an average DSC of 0.744 in these patients. We developed and validated deep learning algorithms to segment WMH in patients with acute cerebral infarction using the largest-ever MRI datasets. In addition, we showed that the uncertainty index can be used to identify cases where automatic WMH segmentation is less accurate and requires human review. WMH = white matter hyperintensity; CNN = convolutional neural networks; SE = squeeze-and-excitation; KL = Kullback-Leibler; ReLU = rectified linear unit; LKW = last known well; mRS = modified Rankin Scale; NIHSS = National Institute of Health Stroke Scale; LAA = large artery atherosclerosis; SVO = small vessel occlusion; CE = cardioembolism.

Freezing of gait in idiopathic normal pressure hydrocephalus

BackgroundReports of freezing of gait (FoG) in idiopathic normal pressure hydrocephalus (iNPH) are few and results are variable. This study’s objective was to evaluate the frequency of FoG in a large cohort of iNPH patients, identify FoG-associated factors, and assess FoG’s responsiveness to shunt surgery.MethodsVideotaped standardized gait protocols with iNPH patients pre- and post-shunt surgery (n = 139; median age 75 (71–79) years; 48 women) were evaluated for FoG episodes by two observers (Cohens kappa = 0.9, p < 0.001). FoG episodes were categorized. Mini-mental state examination (MMSE) and MRI white matter hyperintensities (WMH) assessment using the Fazekas scale were performed. CSF was analyzed for Beta-amyloid, Tau, and Phospho-tau. Patients with and without FoG were compared.ResultsTwenty-two patients (16%) displayed FoG at baseline, decreasing to seven (8%) after CSF shunt surgery (p = 0.039). The symptom was most frequently exhibited during turning (n = 16, 73%). Patients displaying FoG were older (77.5 vs. 74.6 years; p = 0.029), had a slower walking speed (0.59 vs. 0.89 m/s; p < 0.001), a lower Tinetti POMA score (6.8 vs. 10.8; p < 0.001), lower MMSE score (21.3 vs. 24.0; p = 0.031), and longer disease duration (4.2 vs. 2.3 years; p < 0.001) compared to patients not displaying FoG. WMH or CSF biomarkers did not differ between the groups.ConclusionsFoG is occurring frequently in iNPH patients and may be considered a typical feature of iNPH. FoG in iNPH was associated with higher age, longer disease duration, worse cognitive function, and a more unstable gait. Shunt surgery seems to improve the symptom.

Association of Plasma YKL-40 With MRI, CSF, and Cognitive Markers of Brain Health and Dementia.

Higher YKL-40 levels in the CSF are a known biomarker of brain inflammation. We explored the utility of plasma YKL-40 as a biomarker for accelerated brain aging and dementia risk. We performed cross-sectional and prospective analyses of 4 community-based cohorts in the United States or Europe: the Age, Gene/Environment Susceptibility-Reykjavik Study, Atherosclerosis Risk in the Communities study, Coronary Artery Risk Development in Young Adults study, and Framingham Heart Study (FHS). YKL-40 was measured from stored plasma by a single laboratory using Mesoscale Discovery with levels log transformed and standardized within each cohort. Outcomes included MRI total brain volume, hippocampal volume, and white matter hyperintensity volume (WMHV) as a percentage of intracranial volume, a general cognitive composite derived from neuropsychological testing (SD units [SDU]), and the risk of incident dementia. We sought to replicate associations with dementia in the clinic-based ACE csf cohort, which also had YKL-40 measured from the CSF. Meta-analyses of MRI outcomes included 6,558 dementia-free participants, and for analysis of cognition, 6,670. The blood draw preceded MRI/cognitive assessment by up to 10.6 years across cohorts. The mean ages ranged from 50 to 76 years, with 39%-48% male individuals. In random-effects meta-analysis of study estimates, each SDU increase in log-transformed YKL-40 levels was associated with smaller total brain volume (β = -0.33; 95% CI -0.45 to -0.22; p < 0.0001) and poorer cognition (β = -0.04; 95% CI -0.07 to -0.02; p < 0.01), following adjustments for demographic variables. YKL-40 levels did not associate with hippocampal volume or WMHV. In the FHS, each SDU increase in log YKL-40 levels was associated with a 64% increase in incident dementia risk over a median of 5.8 years of follow-up, following adjustments for demographic variables (hazard ratio 1.64; 95% CI 1.25-2.16; p < 0.001). In the ACE csf cohort, plasma and CSF YKL-40 were correlated (r = 0.31), and both were associated with conversion from mild cognitive impairment to dementia, independent of amyloid, tau, and neurodegeneration status. Higher plasma YKL-40 levels were associated with lower brain volume, poorer cognition, and incident dementia. Plasma YKL-40 may be useful for studying the association of inflammation and its treatment on dementia risk.

Post‐mortem MRI white matter hyperintensities are associated with cortical astrocytopathy and water channel expression in the oldest‐old

AbstractBackgroundCerebrovascular small vessel disease, a common cause of cognitive impairment in older individuals, is characterized by the presence of MRI white matter hyperintensities (WMH). Our previous MRI‐targeted histopathological studies have found WMHs and the surrounding NAWM penumbra to be associated with glial markers. This study aims to assess the relationship between cortical markers of glial dysfunction and post‐mortem (PM) MRI WMH.MethodLeft brain hemispheres were obtained from 45 Oregon Alzheimer’s Disease Research Center subjects &gt;/ = 80 years of age without significant AD pathology. Intact and sliced hemispheres were scanned at 7T MRI. MRI scans were used to target histological sampling. Slides were stained for glial fibrillary acid protein (GFAP), ionized calcium binding adapter molecule‐1 (IBA1), aquaporin‐1 (AQP1), aquaporin‐4 (AQP4), vimentin and amyloid‐beta (ABETA). Slides were co‐registered to MRI. Tissue masks were hand‐drawn to delineate white matter and cortex. Cortical ROIs were quantified for mean pixel value (AQP1, AQP4, GFAP, and Vimentin) or area coverage (IBA1, ABETA). Cassettes with no local WMH were compared with those in the top third of slide WMH coverage (187 cassettes). Global WMH burden was dichotomized at the mean. Linear mixed‐effects models regressed stain quantification on local WMH (in slide) and global WMH burden, with a random effect for staining batch (levels = 4). The final model controlled for age at death and ABETA expression within a slide. Interactions between local and global WMH were included where appropriate.ResultHigh local WMH burden was associated with greater cortical vimentin (p = 0.036), GFAP (p = 0.066), and AQP4 (p = 0.004), while high global WMH burden was associated with greater IBA1 (p = 0.034) and AQP1 (p = 0.071). An interaction was identified between local and global WMH burden for AQP1 (p&lt;0.10), such that in subjects with high global WMH burden, high local WMH burden was associated with higher AQP1. Greater local cortical ABETA was associated with cortical AQP1 (p = 0.004) expression.ConclusionIn oldest‐old individuals without significant AD pathology, high local and global PM‐MRI WMH burden is associated with cortical astrocytopathy, including increased water channel expression and inflammation. Findings implicate WMH as a state marker of widespread cortical pathology that may confer increased vulnerability to cognitive decline with advanced age.

Examining Complex Relationships among Cerebrovascular, β‐Amyloid, Tau and Cognitive Measures in a Cognitively Unimpaired Late‐Middle Aged Sample

AbstractBackgroundRecent research linking vascular risk with promotion of tau pathology in the inferior temporal cortex (ITC) suggests a potential mechanism connecting cerebrovascular risk to AD pathology and cognitive decline among cognitively unimpaired (CU) individuals (Yau et al, 2022).We used MRI White Matter Hyperintensity (WMH), a neuroimaging marker of chronic cerebral small‐vessel disease/cerebrovascular disease, to further elucidate longitudinal relationships between cerebrovascular risk, PET AD pathological burden, and cognition.MethodWe examined baseline CU late middle‐aged adults from the University of Wisconsin’s Alzheimer’s disease research cohorts. β‐Amyloid burden was measured with 11C‐Pittsburgh compound B (“PiB”; DVR derived from a 0‐70 min dynamic PET scan; PET A+ threshold∼1.16 DVR/∼CL 17). Cerebrovascular risk was quantified using WMH volumes (T2‐FLAIR images; SPM Lesion Segmentation Tool). Tau burden was measured with florquinitau PET (MK6240 SUVR from 70‐90 min post‐injection). Tau outcomes included bilateral volume‐weighted averages for ITC, Medial temporal lobe (MTL) and Meta‐temporal (MTC) composites. Biomarker values were z‐transformed relative to CU/PET A‐ values. Random intercept models examined interactive effects of baseline WMH and Aβ levels on longitudinal tau (covarying baseline tau age, sex, APOE ε4 count). We modeled time two ways: years since baseline PiB (TimePiB1; replicating Yau, et al models); and, in parallel models, amyloid duration (years) at tau scans was substituted for years since PiB1 in the A+ subset (TimePiB1/PiB+). We also used LME to examine Aβ, WMH, and time interactions in longitudinal cognition (PACC3 and Digit Symbol Substitution).ResultThe mean(SD) tau baseline age was 67.9(6.8) years (sample details in Table1). The most parsimonious models using TimePiB1 included WMH*Aβ*Time for ITC and MTC and WMH*Aβ for MTL. Patterns showed a synergistic effect of WMH and Aβ on tau accumulation that was attenuated using TimePiB1/PiB+ where the most parsimonious models included Aβ_status*TimePiB1/PiB+ (ITC, MTC) or WMH*Aβ_status*TimePiB1/PiB+ (MTL; Figure1). AICc model fits were substantially better using TimePiB1/PiB+. Both Aβ and WMH contributed to cognitive trajectories (Figure2).ConclusionAlthough cerebrovascular risk’s apparent contribution to tau accumulation varied depending on how time was modeled, results suggest that cerebrovascular risk may complement imaging biomarkers in assessing risk of tau accumulation and cognitive decline in preclinical Alzheimer disease.

Later life Body composition and Alzheimer’s disease

AbstractBackgroundMid‐life obesity is linked with increased risk for late‐life dementia, however relationships between later‐life body composition and dementia are less clear.MethodUsing a combined cohort from two major observational studies (AIBL and ADNI) and categorising Body Mass Index (BMI) according to WHO criteria, we computed multivariable linear mixed‐effects models to determine association between BMI category and outcomes: brain beta‐amyloid PET quantification (centiloid); MRI (global, hippocampal and white matter hyperintensity volume); and cognition (PACC [preclinical Alzheimer cognitive composite], composite scores for attention, executive function and episodic memory). All models were adjusted by covariables age, gender, education, APOE ε4, and study (AIBL/ADNI).ResultsThe cohort included 4,668 observations from 2,828 individuals (49.4% male, mean age 73.8 years, 38.2% APOE ε4 carriage, 61.8% normal cognition [NC], 25.6% Mild Cognitive Impairment [MCI], 12.6% dementia due to Alzheimer’s disease). The average BMI was 26.8 kg/m2 (0.6% underweight, 37.7% normal‐range, 41.7% overweight, 20.0% obese [BMI &lt;18, 18‐25, 25‐30 and &gt;30 kg/m2, respectively]).Relative to normal‐range BMI, those with overweight‐or‐obese range BMI had a significant negative association with PET centiloid level, beta = ‐0.150 (0.037 se) and ‐0.309 (0.042), respectively (i.e. greater BMI had lower amyloid level). This remained significant for obese‐range BMI in fully‐adjusted models when restricted to only NC participants. Also, obesity was associated with greater hippocampal volume, beta = 0.192 (0.046), but this was not significant when restricted to NC only. Associations with total grey matter/cortical volume and white matter hyperintensities were not significant. Obese‐range BMI was associated with stronger performance on attention and episodic memory composites, but not for PACC and executive function. For NC‐only, there was only significant negative association between obesity and attention performance. In multivariate analyses, neither obesity category nor BMI were associated with longitudinal change in cognitive scores.ConclusionPresence of obesity in later life was associated with lower brain amyloid levels and less hippocampal atrophy in a mixed cohort including older adults with dementia, mild cognitive impairment and normal cognition. While mid‐life obesity is associated greater risk for AD, later life associations appear influenced by weight loss with emerging dementia.

MRI white matter hyperintensities and neuropsychological performance in a clinical sample

Objective White-matter hyperintensities (WMH) are commonly observed on MRI of non-demented patients. Findings are mixed regarding their association with neuropsychological test performance. The purpose of this study is to investigate the association of white-matter hyperintensities on routine clinical MRI and neuropsychological test performance in non-demented outpatients. Method Two groups were selected based on MRI results: (1) normal (n = 62, M age = 50.21, M edu = 14.89) and (2) WMH without other MRI abnormality (n = 56, M age = 55.43, M edu = 14.04). Neuropsychological tests assessed five cognitive domains for which index scores were calculated and categorized in the following clinical ranges: well below average, below average, low average, average, and above average. Results Likelihood ratios comparing base rates for the WMH and normal groups across these clinical ranges revealed significant base rate differences only for attention/processing speed (Lχ2 = 16.47, df = 4, p < .01), with more WMH patients in the below average range and fewer above average. Odds ratios were calculated using two z-score cutoffs: −1.67 and −1.00. While patients with WMH were significantly more likely to have an index z-score ≤ −1.00 on attention/processing speed tests (OR = 3.62, 95% CI: 1.08–12.19) and an executive function test of reasoning (OR = 4.63, 95% CI: 1.18–18.19), there was no difference in the likelihood the groups would have a z-score ≤ −1.67 in any cognitive domain. Conclusions Taken together, these findings indicate that among referred outpatients without dementia, WMH on routine clinical MRI are associated with relatively mild decreased attention and processing speed.

Mismatch of MRI White Matter Hyperintensities and Gait Function in Patients With Cerebral Small Vessel Disease.

Cerebral small vessel disease (CSVD) is closely related to gait disorders. Previous studies have found a negative correlation between the severity of MRI white matter hyperintensities (WMH) and gait speed. However, not every individual with WMH experiences a gait disorder. To investigate the mechanisms underlying the mismatch between the severity of MRI WMH and gait impairment, in particular in subjects with severe WMH (Fazekas 3, scale 0-3) resulting from vascular disease. Cohort. 54 subjects with severe WMH and gait disorder (WMH-GD; 29 males) and 114 subjects with severe WMH with no gait disorder (WMH-nGD; 60 males). 3T/diffusion tensor imaging (DTI), and T1-weighted, T2-weighted, FLAIR, DWI, SWI. Trace-based spatial statistics analysis (TBSS) approach (fractional anisotropy, FA; mean diffusivity; radial diffusivity; axial diffusivity); Cognitive assessment; Conventional MRI markers of CSVD (WMH, enlarged perivascular spaces, lacunae, and cerebral microbleeds); Gait parameters (gait speed; cadence; stride length; gait cycle duration; step duration; time-up-and-go test, TUG). Gait disorder was defined as a TUG time exceeding 12 sec. The t-tests, Mann-Whitney U tests, Chi-square tests, and partial correlation analysis (Pearson or Spearman) were used. P < 0.05 with threshold-free cluster enhancement corrected was considered statistically significant for TBSS. After adjusting for age, sex, height, and other conventional MRI markers of CSVD, the WMH-nGD group showed significantly decreased FA values in the corpus callosum, bilateral superior longitudinal fasciculus, left corona radiata, and left posterior thalamic radiation. There was a significant association between FA values and TUG time, gait speed, and stride length in multiple WM tracts, independent of other conventional CSVD markers. This study provides evidence for microstructural damage of specific fibers in WMH-GD subjects compared to WMH-nGD subjects. This may explain the mismatch between WMH and gait impairment in subjects with severe WMH. 1 TECHNICAL EFFICACY: Stage 3.

Free water diffusion MRI and executive function with a speed component in healthy aging

Extracellular free water (FW) increases are suggested to better provide pathophysiological information in brain aging than conventional biomarkers such as fractional anisotropy. The aim of the present study was to determine the relationship between conventional biomarkers, FW in white matter hyperintensities (WMH), FW in normal appearing white matter (NAWM) and in white matter tracts and executive functions (EF) with a speed component in elderly persons.We examined 226 healthy elderly participants (median age 69.83 years, IQR: 56.99–74.42) who underwent brain MRI and neuropsychological examination. FW in WMH and in NAWM as well as FW corrected diffusion metrics and measures derived from conventional MRI (white matter hyperintensities, brain volume, lacunes) were used in partial correlation (adjusted for age) to assess their correlation with EF with a speed component. Random forest analysis was used to assess the relative importance of these variables as determinants. Lastly, linear regression analyses of FW in white matter tracts corrected for risk factors of cognitive and white matter deterioration, were used to examine the role of specific tracts on EF with a speed component, which were then ranked with random forest regression.Partial correlation analyses revealed that almost all imaging metrics showed a significant association with EF with a speed component (r = -0.213 – 0.266). Random forest regression highlighted FW in WMH and in NAWM as most important among all diffusion and structural MRI metrics. The fornix (R2=0.421, p = 0.018) and the corpus callosum (genu (R2 = 0.418, p = 0.021), prefrontal (R2 = 0.416, p = 0.026), premotor (R2 = 0.418, p = 0.021)) were associated with EF with a speed component in tract based regression analyses and had highest variables importance.In a normal aging population FW in WMH and NAWM is more closely related to EF with a speed component than standard DTI and brain structural measures. Higher amounts of FW in the fornix and the frontal part of the corpus callosum leads to deteriorating EF with a speed component.

Blood brain barrier dysfunction caused by repeated Endothelin-1 injection leads to irreversible memory impairment.

Vascular dysfunction is being increasingly recognized as a major contributor to dementia burden. Repeated occurrence of vascular insults in small vessels results in Blood Brain Barrier (BBB) dysfunction potentially contributing to cognitive impairments. The small vessel infracts is seen as white matter hyperintensities in MRI of many patients. Postmortem studies have shown BBB damage in dementia including AD and accumulation blood-derived proteins as well as loss of BBB associated cells like pericytes. In view of such a scenario we wanted to establish an animal model to study multiple small vessel insults impacting BBB leading to learning and memory deficits. C57/BL6J mice aged 4-5 months was implanted with cannula on left side of the hemisphere. ET-1 (Endothelin- 1), a 21 amino acid vasoconstricting peptide was infused through guide cannula into the intracerebroventricular space of lateral ventricle. Mice were injected for 3 doses of ET-1 at intervals of 3 weeks over a period of 9 weeks. The animals were assessed for associative learning and spatial memory deficits with different behavioral task. Animals were perfused and brain was processed for immunohistochemistry to assess vascular pathology. To simulate the clinical conditions the animals were injected over a period of three weeks to make sure that animal completely recovers from first vascular insult and then subsequent insults were given. There was BBB leakage, discrepancies in the blood vessel integrity and loss of pericytes after multiple ET-1 injection. Further there was significant memory deficits in novel object task, contextual fear conditioning test and Morris water maze. Our results demonstrated that chronic vascular insults cause BBB dysfunction and cognitive deficits seen as memory impairment. We were able to establish that repeated vasoconstriction by ET-1 in small vessels leads to BBB breach resulting in irreversible learning and memory deficits. This animal model could help us to study molecular underpinnings of white matter hyperintensities.

Migraine in patients with rheumatoid arthritis and its relation to disease activity

BackgroundThe comorbidity between rheumatoid arthritis (RA) and migraine is complex and not completely understood.ObjectiveThis study aimed to evaluate migraine frequency in patients with RA and its relation to disease activity.MethodsA cross-sectional study was carried out on 210 consecutive RA Egyptian patients fulfilling the 2010 EULAR/ACR criteria (joint distribution, serology, symptom duration and acute phase reaction).ResultsPrevalence of migraine in RA was 28.2%. Disease activity, fibromyalgia and functional losses were significantly higher in migraine group with RA versus non-migraine group (P < 0.001). Disease Activity Score (DAS-28) was independently significant predictor as increasing DAS-28 score was associated with an increased likelihood of exhibiting migraine (5.5-times higher odds per one-unit increase in DAS-28 score). Prevalence of brain MRI white matter hyper-intensities (WMHs) in RA with migraine was 54.8%. WMHs were significantly higher in migraine patients with aura than migraine patients without aura, especially in older patients, longer migraine duration, longer rheumatoid duration and elevated ESR (p < 0.047, p < 0.034, P < 0.004, P < 0.015 and P < 0.22, respectively).ConclusionsMigraine is highly frequent in RA patients, especially migraine with aura. The presence of rheumatoid activity, fibromyalgia and secondary Sjogren’s syndrome, elevated ESR and CRP are associated with functional losses in RA patients with migraine, especially migraine with aura. MR imaging of brain is a mandatory tool for detection of white matter hyper-intensities in RA patients with migraine, especially migraine with aura.

Risk factors analysis according to regional distribution of white matter hyperintensities in a stroke cohort

The spectrum of distribution of white matter hyperintensities (WMH) may reflect different functional, histopathological, and etiological features. We examined the relationships between cerebrovascular risk factors (CVRF) and different patterns of WMH in MRI using a qualitative visual scale in ischemic stroke (IS) patients. We assembled clinical data and imaging findings from patients of two independent cohorts with recent IS. MRI scans were evaluated using a modified visual scale from Fazekas, Wahlund, and Van Swieten. WMH distributions were analyzed separately in periventricular (PV-WMH) and deep (D-WMH) white matter, basal ganglia (BG-WMH), and brainstem (B-WMH). Presence of confluence of PV-WMH and D-WMH and anterior-versus-posterior WMH predominance were also evaluated. Statistical analysis was performed with SPSS software. We included 618 patients, with a mean age of 72 years (standard deviation [SD] 11 years). The most frequent WMH pattern was D-WMH (73%). In a multivariable analysis, hypertension was associated with PV-WMH (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.29-2.50, p = 0.001) and BG-WMH (OR 2.13, 95% CI 1.19-3.83, p = 0.012). Diabetes mellitus was significantly related to PV-WMH (OR 1.69, 95% CI 1.24-2.30, p = 0.001), D-WMH (OR 1.46, 95% CI 1.07-1.49, p = 0.017), and confluence patterns of D-WMH and PV-WMH (OR 1.62, 95% CI 1.07-2.47, p = 0.024). Hyperlipidemia was found to be independently related to brainstem distribution (OR 1.70, 95% CI 1.08-2.69, p = 0.022). Different CVRF profiles were significantly related to specific WMH spatial distribution patterns in a large IS cohort. • An observational study of WMH in a large IS cohort was assessed by a modified visual evaluation. • Different CVRF profiles were significantly related to specific WMH spatial distribution patterns. • Distinct WMH anatomical patterns could be related to different pathophysiological mechanisms.

White matter abnormalities are key components of cerebrovascular disease impacting cognitive decline.

While cerebrovascular disease can be observed in vivo using MRI, the multiplicity and heterogeneity in the mechanisms of cerebrovascular damage impede accounting for these measures in ageing and dementia studies. Our primary goal was to investigate the key sources of variability across MRI markers of cerebrovascular disease and evaluate their impact in comparison to amyloidosis on cognitive decline in a population-based sample. Our secondary goal was to evaluate the prognostic utility of a cerebrovascular summary measure from all markers. We included both visible lesions seen on MRI (white matter hyperintensities, cortical and subcortical infarctions, lobar and deep microbleeds) and early white matter damage due to systemic vascular health using diffusion changes in the genu of the corpus callosum. We identified 1089 individuals aged ≥60 years with concurrent amyloid-PET and MRI scans from the population-based Mayo Clinic Study of Aging. We divided these into discovery and validation datasets. Using the discovery dataset, we conducted principal component analyses and ascertained the main sources of variability in cerebrovascular disease markers. Using linear regression and mixed effect models, we evaluated the utility of these principal components and combinations of these components for the prediction of cognitive performance along with amyloidosis. Our main findings were (i) there were three primary sources of variability among the CVD measures—white matter changes are driven by white matter hyperintensities and diffusion changes; number of microbleeds (lobar and deep); and number of infarctions (cortical and subcortical); (ii) Components of white matter changes and microbleeds but not infarctions significantly predicted cognition trajectories in all domains with greater contributions from white matter; and (iii) The summary vascular score explained 3–5% of variability in baseline global cognition in comparison to 3–6% variability explained by amyloidosis. Across all cognitive domains, the vascular summary score had the least impact on memory performance (∼1%). Though there is mechanistic heterogeneity in the cerebrovascular disease markers measured on MRI, these changes can be grouped into three components and together explain variability in cognitive performance equivalent to the impact of amyloidosis on cognition. White matter changes represent dynamic ongoing damage, predicts future cognitive decline across all domains and diffusion measurements help capture white matter damage due to systemic vascular changes. Therefore, measuring and accounting for white matter changes using diffusion MRI and white matter hyperintensities along with microbleeds will allow us to capture vascular contributions to cognitive impairment and dementia.

NOTCH3 variants are more common than expected in the general population and associated with stroke and vascular dementia: an analysis of 200 000 participants

BackgroundCysteine-altering NOTCH3 variants identical to those causing the rare monogenic form of stroke, CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy), have been reported more common than expected...

Baseline correlations between [18F]GTP1 PET SUVR and MRI white matter hyperintensities in prodromal‐to‐mild Alzheimer's disease suggest independent contributions to cognitive impairment

AbstractBackgroundWhite matter hyperintensities (WMH) on MRI are commonly seen in Alzheimer’s disease (AD) and thought to represent co‐morbid microvascular ischemic disease. However, the relationship between WMH and tau pathology in AD remains incompletely understood. We explored this question using screening/baseline data from a Phase 2 study of the anti‐tau antibody semorinemab (Tauriel; NCT03289143), which included both MRI and [18F]GTP1 tau PET imaging.MethodParticipants in the Tauriel study are aged 50‐80, meet criteria for AD dementia or mild cognitive impairment (MCI), have MMSE of 20‐30, global Clinical Dementia Rating (CDR) of 0.5 or 1, evidence of significant amyloid pathology, and significant episodic memory impairment (RBANS delayed memory index &lt; 85), and undergo screening MRIs, with WMH quantified using the Fazekas scale. Analyses were performed on a subset of participants (n=381) who received baseline [18F]GTP1 tau PET scans. Relationships between WMH, [18F]GTP1 SUVR in an AD‐specific temporal lobe ROI, age, and cognitive scales were assessed graphically and quantified using Pearson correlations, Cohen’s D, t‐tests, and multiple linear regression.ResultTauriel participants had Fazekas scores of zero (n=161), one (n=208), or two (n=12). Per the Figure, participants with Fazekas scores &gt; 0 tended to be older (Cohen’s D=0.69, p &lt; 0.001) and have lower temporal [18F]GTP1 SUVR (Cohen’s D=0.35, p&lt;0.001). The relationship between temporal [18F]GTP1 SUVR and baseline ADAS‐Cog13 (r=0.39, p&lt;0.001) remained significant after adjusting for Fazekas score and age via multiple regression (p&lt;0.001).ConclusionGiven the circumscribed range of disease severity seen in prodromal‐to‐mild AD participants at screening/baseline in the Tauriel study, the relationships between MRI WMH and [18F]GTP1 tau PET suggest that these pathologies have additive and independent contributions to cognition that may be age‐related. Clinical trials of anti‐tau therapeutics in similar patient populations may need to account for cerebrovascular co‐morbidities in patient selection and/or efficacy analyses.

Perivascular space dilation in white matter mediates a significant relationship between white matter hyperintensity burden and venous collagenosis

AbstractBackgroundPeriventricular T2 MRI white matter hyperintensities (WMH) are commonly observed in older individuals and are associated with cognitive and motor decline. While likely vascular in origin, the specific etiology of WMH remains unknown. Vascular insufficiency due to venous collagenosis has been implicated. Collagenosis may also interfere with perivascular fluid flow leading to dilation of perivascular spaces (PVS). PVS are thus an unexplored potential mediating factor between collagenosis and periventricular WMH.MethodBrain tissue from 25 Oregon Alzheimer’s Disease Center subjects was selected based on availability of in vivo 1.5 Tesla MRI (Table 1), which was used to quantify whole brain WMH burden. Three paraffin embedded 6μm thick coronal blocks of tissue per subject from anterior, middle and posterior white matter abutting the ventricle were stained with Masson’s Trichrome and Smooth Muscle Actin (SMA). Slides were scanned and an automated hue based algorithm identified 547 vessels and segmented them into blue collagen vessel walls, lumen holes within them and perivascular spaces outside them (Figure 1). Pearson correlation coefficients were calculated to assess relationships between PVS, periventricular WMH and collagenosis. Coregistered SMA images were used to classify vessels into veins (n=163) and arteries (n=251). Multiple linear regressions accounting for sex, age at death, and MRI to death interval followed by a Sobel test of mediation were calculated to determine the mediating effect of PVS on the relationship between collagenosis and periventricular WMH.ResultPeriventricular WMH volume, collagenosis and PVS were correlated with each other (p&lt;.001) (Figure 1). In separate regression models, PVS and collagenosis in veins were significant predictors of WMH volume (p=.005, p=.007) but not in arteries (p=.256, p=.244). A Sobel test of the mediating effect of PVS on the relationship between collagenosis in veins and WMH burden was significant (p=.027) and the remaining direct effect of collagenosis on WMH was not significant (p=.21) (Figure 2).ConclusionPerivascular space dilation is an under recognized mechanism which may mediate the relationship between the development of venous collagenosis and periventricular WMH in an aged population.

White Matter Hyperintensities Related to Parkinson's Disease Executive Function.

BackgroundPeople with Parkinson's disease (PD) can develop multidomain cognitive impairments; however, it is unclear whether different pathologies underlie domain‐specific cognitive dysfunction.ObjectivesWe investigated the contribution of vascular copathology severity and location, as measured by MRI white matter hyperintensities (WMHs), to domain‐specific cognitive impairment in PD.MethodsWe studied 85 PD (66.6 ± 9.2 years) and 18 control (65.9 ± 6.6) participants. Using the Fazekas scale for rating the severity of WMH, we subdivided PD into 14 PD–WMH+ and 71 PD–WMH–. Participants underwent global, executive, visuospatial, episodic memory, and language testing. We performed nonparametric permutation testing to create WMH probability maps based on PD‐WMH group and cognitive test performance.ResultsThe PD–WMH+ group showed worse global and executive cognitive performance than the PD–WMH– group. On individual tests, the PD–WMH+ group showed worse Montreal Cognitive Assessment (MoCA), Stroop, Symbol Digit Modalities Test (SDMT), and Digit Span scores. WMH probability maps showed that in the PD–WMH+ group, worse Stroop was associated with lesions centered around the corticospinal tract (CST), forceps major, inferior‐fronto‐occipital fasciculus, and superior longitudinal fasciculus; worse SDMT with lesions around the CST, forceps major, and posterior corona radiata; worse Digit Span with lesions around the posterior corona radiata; and worse MoCA with lesions around the CST.ConclusionsWe found that WMH severity was associated with PD executive dysfunction, including worse attention, working memory, and processing speed. Disruption of key white matter tracts in proximity to vascular lesions could contribute to these specific cognitive impairments. Early treatment of vascular disease might mitigate some executive dysfunction in a subset of patients with PD.

Brain MRI features and scoring of leukodystrophy in adult-onset Krabbe disease.

To perform a systematic analysis and scoring of brain MRI white matter hyperintensities (WMH) in adult-onset Krabbe disease. We retrospectively collected basic clinical data and the first available brain MRI from patients with confirmed Krabbe disease with first clinical manifestations beyond 10 years of age. Data were obtained from our reference center for lysosomal diseases (n = 6) and from contacted authors of published articles describing patients with adult-onset Krabbe disease (n = 15). T2-weighted fluid-attenuated inversion recovery images of each patient were analyzed and scored using a radiologic score of WMH in a single center. The corticospinal tract was always affected by WMH (100% of patients), however, with some distinctions along the tract: the precentral gyrus (100%), corona radiata (95%), and posterior internal capsule (81%) were highly abnormal, whereas the mesencephalon (57%), pons (52%), and medulla oblongata (5%) were less affected. WMH were also frequently present in the posterior lateral periventricular white matter (95%), optic radiations (86%), postcentral gyrus (71%), medial lemniscus (62%), and corpus callosum, especially in the isthmus (71%), whereas the genu was always normal. A few patients did not have the classical MRI pattern but extensive hyperintensities (n = 3), or patchy distribution of hyperintensities mimicking an acquired etiology (n = 2), or very subtle hyperintensities of the corticospinal tract (n = 1). We specified the main locations of WMH, which were observed in the earliest stages of the disease and were also present in patients with atypical MRI pattern, highlighting the importance of radiologic features to guide the diagnosis.

New insights in radiation-induced leukoencephalopathy: a prospective cross-sectional study.

Radiation-induced leukoencephalopathy (RIL) is the most threatening delayed complication of cerebral radiotherapy (RT) and remains roughly defined by cognitive dysfunction associated with diffuse FLAIR MRI white matter hyperintensities after brain irradiation. We documented clinical, neuropsychological, and radiological aspects of RI in order to refine diagnostic criteria. Patients referred to our center for deterioration in cognitive complaint at least 6months after completing a focal or whole brain RT underwent a systematic cross-sectional assessment including clinical examination, neuropsychological tests, and a standardized MRI protocol. Patients with progressive tumor were excluded. Forty patients were prospectively enrolled. Of these, 26 had received a focal RT, median dose of 53Gy (range 50 to 60), and 14 had received a whole brain RT, median dose of 30Gy. Cognitive complaints, gait apraxia, and urinary troubles were reported in 100, 67, and 38% of cases, respectively. On neuropsychological examination, patients displayed a global and severe cognitive decline through a subcortical frontal mode. The cognitive changes observed were not hippocampic, but related to executive dysfunction. On MRI, 68% of the patients had extensive FLAIR hyperintensities with anterior predominance, 87% had brain atrophy, and 21% had intraparenchymal cysts. T2*-weighted MRI showed small asignal areas in 53% of the patients. These abnormalities are evocative of cerebral small vessel disease. Fractional anisotropy in the corpus callosum correlated with the cognitive evaluation. No differentiation in terms of cognitive and MRI features could be made between patients treated with focal brain RT (glioma) and patients treated with WBRT (for brain metastases or PCNSL). RIL can be defined by clinical symptoms (subcortical frontal decline, gait apraxia, urinary incontinence) and MRI criteria (cortico-subcortical atrophy, spread FLAIR HI, T2* asignals). This condition mimics a diffuse progressive cerebral small vessel disease triggered by RT, independent of RT protocol.