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Arba F, Mair G, Carpenter T, Sakka E, Sandercock PA, Lindley RI, Inzitari D, Wardlaw JM. Cerebral White Matter Hypoperfusion Increases with Small-Vessel Disease Burden. Data From the Third International Stroke Trial. J Stroke Cerebrovasc Dis 2017; 26:1506-1513. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.03.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 02/20/2017] [Accepted: 03/01/2017] [Indexed: 10/20/2022] Open
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52
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Li Y, Li M, Zhang X, Shi Q, Yang S, Fan H, Qin W, Yang L, Yuan J, Jiang T, Hu W. Higher blood-brain barrier permeability is associated with higher white matter hyperintensities burden. J Neurol 2017; 264:1474-1481. [PMID: 28653212 DOI: 10.1007/s00415-017-8550-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 06/15/2017] [Accepted: 06/16/2017] [Indexed: 01/11/2023]
Abstract
The pathogenesis of white matter hyperintensities (WMH) is incompletely understood but blood-brain barrier (BBB) dysfunction may play a key role. This study aimed to investigate the relationship between BBB permeability and the severity of WMH burden. Consecutive participants without symptomatic stroke history presented for physical examination were recruited in this cross-sectional study and divided into three WMH burden groups according to total Fazekas scores. They received dynamic contrast-enhanced-magnetic resonance imaging to measure BBB permeability, and received Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA). A total of 102 participants aged 49-90 years (mean age of 69.82 years) were enrolled (36 with low WMH burden, 35 with medium WMH burden, and 31 with high WMH burden). Multivariable linear regression analyses revealed that participants with higher WMH burden had significantly higher BBB leakage rate and area under the leakage curve in normal-appearing white matter, WMH, cortical gray matter, and deep gray matter (DGM) after adjustment for age, sex, and vascular risk factors. Scores on MMSE and MoCA decreased with increasing leakage rate in WMH and DGM after adjustment for age, sex, WMH burden, and education years. We found that higher BBB permeability is associated with higher WMH burden and cognitive decline. The compromised BBB integrity may be a critical contributor to the pathogenesis of WMH and part of a series of pathological processes that finally lead to cognitive impairment.
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Affiliation(s)
- Yue Li
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, South Gongti Road, Beijing, 100020, People's Republic of China
| | - Man Li
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaoyu Zhang
- Department of Neurology, Qianfoshan Hospital, Shandong University, Beijing, People's Republic of China
| | - Qinglei Shi
- Diagnosis Imaging, Siemens Healthcare Ltd., Beijing, People's Republic of China
| | - Shuna Yang
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, South Gongti Road, Beijing, 100020, People's Republic of China
| | - Huimin Fan
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, South Gongti Road, Beijing, 100020, People's Republic of China
| | - Wei Qin
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, South Gongti Road, Beijing, 100020, People's Republic of China
| | - Lei Yang
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, South Gongti Road, Beijing, 100020, People's Republic of China
| | - Junliang Yuan
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, South Gongti Road, Beijing, 100020, People's Republic of China
| | - Tao Jiang
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Wenli Hu
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, South Gongti Road, Beijing, 100020, People's Republic of China.
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53
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Blair GW, Hernandez MV, Thrippleton MJ, Doubal FN, Wardlaw JM. Advanced Neuroimaging of Cerebral Small Vessel Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017. [PMID: 28620783 PMCID: PMC5486578 DOI: 10.1007/s11936-017-0555-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Cerebral small vessel disease (SVD) is characterised by damage to deep grey and white matter structures of the brain and is responsible for a diverse range of clinical problems that include stroke and dementia. In this review, we describe advances in neuroimaging published since January 2015, mainly with magnetic resonance imaging (MRI), that, in general, are improving quantification, observation and investigation of SVD focussing on three areas: quantifying the total SVD burden, imaging brain microstructural integrity and imaging vascular malfunction. Methods to capture ‘whole brain SVD burden’ across the spectrum of SVD imaging changes will be useful for patient stratification in clinical trials, an approach that we are already testing. More sophisticated imaging measures of SVD microstructural damage are allowing the disease to be studied at earlier stages, will help identify specific factors that are important in development of overt SVD imaging features and in understanding why specific clinical consequences may occur. Imaging vascular function will help establish the precise blood vessel and blood flow alterations at early disease stages and, together with microstructural integrity measures, may provide important surrogate endpoints in clinical trials testing new interventions. Better knowledge of SVD pathophysiology will help identify new treatment targets, improve patient stratification and may in future increase efficiency of clinical trials through smaller sample sizes or shorter follow-up periods. However, most of these methods are not yet sufficiently mature to use with confidence in clinical trials, although rapid advances in the field suggest that reliable quantification of SVD lesion burden, tissue microstructural integrity and vascular dysfunction are imminent.
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Affiliation(s)
- Gordon W Blair
- Brain Research Imaging Centres, Centre for Clinical Brain Sciences, University of Edinburgh, 49 Little France Crescent, Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - Maria Valdez Hernandez
- Brain Research Imaging Centres, Centre for Clinical Brain Sciences, University of Edinburgh, 49 Little France Crescent, Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - Michael J Thrippleton
- Brain Research Imaging Centres, Centre for Clinical Brain Sciences, University of Edinburgh, 49 Little France Crescent, Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - Fergus N Doubal
- Brain Research Imaging Centres, Centre for Clinical Brain Sciences, University of Edinburgh, 49 Little France Crescent, Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - Joanna M Wardlaw
- Brain Research Imaging Centres, Centre for Clinical Brain Sciences, University of Edinburgh, 49 Little France Crescent, Chancellor's Building, Edinburgh, EH16 4SB, UK.
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Smagula SF, Beach S, Rosso AL, Newman AB, Schulz R. Brain Structural Markers and Caregiving Characteristics as Interacting Correlates of Caregiving Strain. Am J Geriatr Psychiatry 2017; 25:582-591. [PMID: 28336265 PMCID: PMC5584683 DOI: 10.1016/j.jagp.2017.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/05/2017] [Accepted: 02/16/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the association between brain structural markers and caregiving strain among older informal caregivers. DESIGN A secondary data analysis combining data from the Caregiver Health Effects Study (1993-1994) and the Cardiovascular Health Study MRI examination (1992-1994). SETTING Four United States communities. PARTICIPANTS Co-residing spousal caregivers (N = 237; mean age: 76.2 years, SD: 2.2 years). MEASUREMENTS Visually rated ventricular and white matter (WM) grades from magnetic resonance imaging, caregiving strain defined as "emotional or physical strain associated with providing care" for any of 12 activities of daily living (ADLs) and instrumental activities of daily living (IADLs), plus measures of caregiving characteristics and caregiver's health. RESULTS Overall, 56% of caregivers reported strain. We detected an interaction where strain was very common (>82%) among caregivers who helped with four or more IADLs, regardless of WM grades, and among caregivers with the worst WM grades (WM grades ≥4), regardless of the number of IADLs they helped with. Among caregivers helping with fewer than four IADLs, having WM grade 4 or greater was associated with a 55% higher prevalence ratio for reporting strain. This association remained statistically significant but was most markedly attenuated by adjustments for: care recipient's memory and behavioral problems, caregiver's depression symptoms, and caregiver's ADL impairment. CONCLUSIONS Caregiving strain is very common among older informal caregivers who provide help with many IADLs, and among caregivers who help with fewer IADLs, but have manifest signs of white matter pathology. Modern quantitative-neuroimaging studies are needed to evaluate whether more subtle variability in brain structure confers caregiving strain and the related health consequences.
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Affiliation(s)
- Stephen F Smagula
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Scott Beach
- University Center for Social and Urban Research, Graduate School of Public Health, University of Pittsburgh, PA
| | - Andrea L Rosso
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA
| | - Anne B Newman
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA
| | - Richard Schulz
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA
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55
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Pathogenesis of white matter changes in cerebral small vessel diseases: beyond vessel-intrinsic mechanisms. Clin Sci (Lond) 2017; 131:635-651. [DOI: 10.1042/cs20160380] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 01/04/2017] [Accepted: 01/16/2017] [Indexed: 01/08/2023]
Abstract
Cerebral small vessel diseases (SVDs) are a leading cause of age and hypertension-related stroke and dementia. The salient features of SVDs visible on conventional brain magnetic resonance images include white matter hyperintensities (WMHs) on T2-weighted images, small infarcts, macrohemorrhages, dilated perivascular spaces, microbleeds and brain atrophy. Among these, WMHs are the most common and often the earliest brain tissue changes. Moreover, over the past two decades, large population- and patient-based studies have established the clinical importance of WMHs, notably with respect to cognitive and motor disturbances. Here, we seek to provide a new and critical look at the pathogenesis of SVD-associated white matter (WM) changes. We first review our current knowledge of WM biology in the healthy brain, and then consider the main clinical and pathological features of WM changes in SVDs. The most widely held view is that SVD-associated WM lesions are caused by chronic hypoperfusion, impaired cerebrovascular reactivity (CVR) or blood–brain barrier (BBB) leakage. Here, we assess the arguments for and against each of these mechanisms based on population, patient and experimental model studies, and further discuss other potential mechanisms. Specifically, building on two recent seminal studies that have uncovered an anatomical and functional relationship between oligodendrocyte progenitor cells and blood vessels, we elaborate on how small vessel changes might compromise myelin remodelling and cause WM degeneration. Finally, we propose new directions for future studies on this hot research topic.
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56
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Cerebral blood flow and cognitive function in HIV-infected men with sustained suppressed viremia on combination antiretroviral therapy. AIDS 2017; 31:847-856. [PMID: 28121708 DOI: 10.1097/qad.0000000000001414] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To assess if HIV-infected patients on long-term successful combination antiretroviral therapy show cerebral blood flow (CBF) alterations in comparison with HIV-uninfected, otherwise similar controls. To explore whether such alterations are associated with HIV-associated cognitive impairment and to explore potential determinants of CBF alterations in HIV. DESIGN Cross-sectional comparison of CBF in an observational cohort study. METHODS Clinical, cognitive and MRI data of 100 middle-aged aviremic HIV-infected men on combination antiretroviral therapy and 69 HIV-uninfected controls were collected and compared. From pseudocontinuous arterial spin labeling MRI data, CBF-maps were calculated. The associations of mean gray matter CBF with clinical and cognitive parameters were explored in regression models, followed by a spatial delineation in a voxel-based analysis. RESULTS CBF was decreased in HIV-infected patients compared with HIV-uninfected controls (P = 0.02), adjusted for age, ecstasy use and waist circumference. Spatially distinct and independent effects of total gray matter volume and HIV-serostatus on CBF were found. Within the HIV-infected group, decreased CBF was associated with increased triglyceride levels (P = 0.005) and prior clinical AIDS (P = 0.03). No association between CBF and cognitive impairment was found. CONCLUSION Decreased CBF was observed among HIV-infected patients, which was associated with both vascular risk factors as well as with measures of past immune deficiency. These results provide support for increased vascular disease in HIV-infected patients as represented by hemodynamic alteration, but without overt cognitive consequences within the current cohort of patients on long-term successful treatment.
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57
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Muñoz Maniega S, Chappell FM, Valdés Hernández MC, Armitage PA, Makin SD, Heye AK, Thrippleton MJ, Sakka E, Shuler K, Dennis MS, Wardlaw JM. Integrity of normal-appearing white matter: Influence of age, visible lesion burden and hypertension in patients with small-vessel disease. J Cereb Blood Flow Metab 2017; 37:644-656. [PMID: 26933133 PMCID: PMC5381455 DOI: 10.1177/0271678x16635657] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
White matter hyperintensities accumulate with age and occur in patients with stroke, but their pathogenesis is poorly understood. We measured multiple magnetic resonance imaging biomarkers of tissue integrity in normal-appearing white matter and white matter hyperintensities in patients with mild stroke, to improve understanding of white matter hyperintensities origins. We classified white matter into white matter hyperintensities and normal-appearing white matter and measured fractional anisotropy, mean diffusivity, water content (T1-relaxation time) and blood-brain barrier leakage (signal enhancement slope from dynamic contrast-enhanced magnetic resonance imaging). We studied the effects of age, white matter hyperintensities burden (Fazekas score) and vascular risk factors on each biomarker, in normal-appearing white matter and white matter hyperintensities, and performed receiver-operator characteristic curve analysis. Amongst 204 patients (34.3-90.9 years), all biomarkers differed between normal-appearing white matter and white matter hyperintensities ( P < 0.001). In normal-appearing white matter and white matter hyperintensities, mean diffusivity and T1 increased with age ( P < 0.001), all biomarkers varied with white matter hyperintensities burden ( P < 0.001; P = 0.02 signal enhancement slope), but only signal enhancement slope increased with hypertension ( P = 0.028). Fractional anisotropy showed complex age-white matter hyperintensities-tissue interactions; enhancement slope showed white matter hyperintensities-tissue interactions. Mean diffusivity distinguished white matter hyperintensities from normal-appearing white matter best at all ages. Blood-brain barrier leakage increases with hypertension and white matter hyperintensities burden at all ages in normal-appearing white matter and white matter hyperintensities, whereas water mobility and content increase as tissue damage accrues, suggesting that blood-brain barrier leakage mediates small vessel disease-related brain damage.
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Affiliation(s)
| | | | | | - Paul A Armitage
- 2 Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
| | - Stephen D Makin
- 1 Division of Neuroimaging Sciences, University of Edinburgh, Edinburgh, UK
| | - Anna K Heye
- 1 Division of Neuroimaging Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Eleni Sakka
- 1 Division of Neuroimaging Sciences, University of Edinburgh, Edinburgh, UK
| | - Kirsten Shuler
- 1 Division of Neuroimaging Sciences, University of Edinburgh, Edinburgh, UK
| | - Martin S Dennis
- 1 Division of Neuroimaging Sciences, University of Edinburgh, Edinburgh, UK
| | - Joanna M Wardlaw
- 1 Division of Neuroimaging Sciences, University of Edinburgh, Edinburgh, UK
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58
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Henriksen OM, Hansen NL, Osler M, Mortensen EL, Hallam DM, Pedersen ET, Chappell M, Lauritzen MJ, Rostrup E. Sub-Clinical Cognitive Decline and Resting Cerebral Blood Flow in Middle Aged Men. PLoS One 2017; 12:e0169912. [PMID: 28095458 PMCID: PMC5241142 DOI: 10.1371/journal.pone.0169912] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 12/22/2016] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Although dementia is associated with both global and regional cerebral blood flow (CBF) changes, little is known about cerebral perfusion in the early pre-clinical stages of cognitive decline preceding overt cognitive dysfunction. The aim of this study was to investigate the association of early sub-clinical cognitive decline with CBF. MATERIALS AND METHODS The study participants were recruited from a cohort of Danish men born in 1953. Based on a regression model we selected men who performed better (Group A, n = 94) and poorer (Group B, n = 95) on cognitive testing at age 57 than expected from testing at age 20. Participants underwent supplementary cognitive testing, blood sampling and MRI including measurements of regional and global CBF. RESULTS Regional CBF was lower in group B than in group A in the posterior cingulate gyrus and the precuneus. The associations were attenuated when corrected for global atrophy, but remained significant in regions of interest based analysis adjusting for regional gray matter volume and vascular risk factors. No influence of group on global CBF was observed. CONCLUSIONS We conclude that early sub-clinical cognitive decline is associated with reduced perfusion in the precuneus and posterior cingulate gyrus independently of regional atrophy and vascular risk factors, but cannot be statistically separated from an association with global atrophy.
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Affiliation(s)
- Otto Mølby Henriksen
- Functional Imaging Unit, Dept. of Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital Rigshospitalet Glostrup, Glostrup, Denmark
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
- Dept. of Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital Rigshospitalet Blegdamsvej, Copenhagen, Denmark
| | - Naja Liv Hansen
- Functional Imaging Unit, Dept. of Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital Rigshospitalet Glostrup, Glostrup, Denmark
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
- Dept. of Clin. Physiology and Nuclear Medicine, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Merete Osler
- Dept. of Public Health, University of Copenhagen, Copenhagen, Denmark
- Research Center for Prevention and Health, Copenhagen University Hospital Rigshospitalet Glostrup, Glostrup, Denmark
| | - Erik Lykke Mortensen
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
- Dept. of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Dorte Merete Hallam
- Dept. of Radiology, Copenhagen University Hospital Rigshospitalet Glostrup, Glostrup, Denmark
| | - Esben Thade Pedersen
- Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Michael Chappell
- Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
- Oxford Centre for Functional MRI of the Brain, Nuffield Dept. of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Martin Johannes Lauritzen
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
- Dept. of Neuroscience & Pharmacology, University of Copenhagen, Copenhagen Denmark
- Dept. of Clinical Neurophysiology, Copenhagen University Hospital Rigshospitalet Glostrup, Glostrup, Denmark
| | - Egill Rostrup
- Functional Imaging Unit, Dept. of Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital Rigshospitalet Glostrup, Glostrup, Denmark
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
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59
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Wardlaw JM, Horsburgh K. Small vessels, dementia and chronic diseases-molecular mechanisms and pathophysiology. Clin Sci (Lond) 2016; 130:1875-9. [PMID: 27660310 DOI: 10.1042/cs20160376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 08/04/2016] [Indexed: 01/31/2023]
Affiliation(s)
- Joanna M Wardlaw
- Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh EH16 4SB, U.K.
| | - Karen Horsburgh
- Centre for Neuroregeneration, Chancellor's Building, University of Edinburgh, Edinburgh EH16 4SB, U.K
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60
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Shi Y, Thrippleton MJ, Makin SD, Marshall I, Geerlings MI, de Craen AJM, van Buchem MA, Wardlaw JM. Cerebral blood flow in small vessel disease: A systematic review and meta-analysis. J Cereb Blood Flow Metab 2016; 36:1653-1667. [PMID: 27496552 PMCID: PMC5076792 DOI: 10.1177/0271678x16662891] [Citation(s) in RCA: 207] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 07/08/2016] [Indexed: 11/15/2022]
Abstract
White matter hyperintensities are frequent on neuroimaging of older people and are a key feature of cerebral small vessel disease. They are commonly attributed to chronic hypoperfusion, although whether low cerebral blood flow is cause or effect is unclear. We systematically reviewed studies that assessed cerebral blood flow in small vessel disease patients, performed meta-analysis and sensitivity analysis of potential confounders. Thirty-eight studies (n = 4006) met the inclusion criteria, including four longitudinal and 34 cross-sectional studies. Most cerebral blood flow data were from grey matter. Twenty-four cross-sectional studies (n = 1161) were meta-analysed, showing that cerebral blood flow was lower in subjects with more white matter hyperintensity, globally and in most grey and white matter regions (e.g. mean global cerebral blood flow: standardised mean difference-0.71, 95% CI -1.12, -0.30). These cerebral blood flow differences were attenuated by excluding studies in dementia or that lacked age-matching. Four longitudinal studies (n = 1079) gave differing results, e.g., more baseline white matter hyperintensity predated falling cerebral blood flow (3.9 years, n = 575); cerebral blood flow was low in regions that developed white matter hyperintensity (1.5 years, n = 40). Cerebral blood flow is lower in subjects with more white matter hyperintensity cross-sectionally, but evidence for falling cerebral blood flow predating increasing white matter hyperintensity is conflicting. Future studies should be longitudinal, obtain more white matter data, use better age-correction and stratify by clinical diagnosis.
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Affiliation(s)
- Yulu Shi
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom Department of Neurology, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Michael J Thrippleton
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Stephen D Makin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Ian Marshall
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Mirjam I Geerlings
- University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Anton J M de Craen
- Department of Gerontology and Geriatrics, Leiden University Medical Centre, Leiden, Netherlands
| | - Mark A van Buchem
- Department of Radiology, Leiden University Medical Centre, Leiden, Netherlands
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
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61
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Shi Y, Wardlaw JM. Update on cerebral small vessel disease: a dynamic whole-brain disease. Stroke Vasc Neurol 2016; 1:83-92. [PMID: 28959468 PMCID: PMC5435198 DOI: 10.1136/svn-2016-000035] [Citation(s) in RCA: 283] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 09/05/2016] [Accepted: 09/07/2016] [Indexed: 12/12/2022] Open
Abstract
Cerebral small vessel disease (CSVD) is a very common neurological disease in older people. It causes stroke and dementia, mood disturbance and gait problems. Since it is difficult to visualise CSVD pathologies in vivo, the diagnosis of CSVD has relied on imaging findings including white matter hyperintensities, lacunar ischaemic stroke, lacunes, microbleeds, visible perivascular spaces and many haemorrhagic strokes. However, variations in the use of definition and terms of these features have probably caused confusion and difficulties in interpreting results of previous studies. A standardised use of terms should be encouraged in CSVD research. These CSVD features have long been regarded as different lesions, but emerging evidence has indicated that they might share some common intrinsic microvascular pathologies and therefore, owing to its diffuse nature, CSVD should be regarded as a 'whole-brain disease'. Single antiplatelet (for acute lacunar ischaemic stroke) and management of traditional risk factors still remain the most important therapeutic and preventive approach, due to limited understanding of pathophysiology in CSVD. Increasing evidence suggests that new studies should consider drugs that target endothelium and blood-brain barrier to prevent and treat CSVD. Epidemiology of CSVD might differ in Asian compared with Western populations (where most results and guidelines about CSVD and stroke originate), but more community-based data and clear stratification of stroke types are required to address this.
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Affiliation(s)
- Yulu Shi
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Department of Neurology, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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62
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Zhong G, Lou M. Multimodal imaging findings in normal-appearing white matter of leucoaraiosis: a review. Stroke Vasc Neurol 2016; 1:59-63. [PMID: 28959465 PMCID: PMC5435207 DOI: 10.1136/svn-2016-000021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 04/23/2016] [Accepted: 04/26/2016] [Indexed: 01/16/2023] Open
Abstract
Leucoaraiosis (LA), also referred to as white matter hyperintensities (WMHs), are usually seen as patchy or confluent hyperintense areas on T2-weighted or fluid-attenuated inversion recovery MRI in the elderly. It is often asymptomatic in its early stages, yet its persistent evolution to more advanced stages may lead to substantial neurological dysfunction including dementia, stroke and death. Despite its clinical significance, the pathogenic mechanisms underlying LA development are uncertain. In patients with LA, the pathophysiological changes in white matter (WM) are suggested to be continuous from WMHs to its neighbourhood ‘normal-appearing white matter (NAWM)’ on conventional MRI sequences. Multimodal imaging studies revealed that the so-called ‘NAWM’ was actually abnormal with regard to underlying haemodynamic and microstructural changes. On the basis of positron emission tomography CT, xenon-CT, perfusion MRI, etc, the cerebral blood flow of NAWM was found to be significantly reduced in patients with LA, compared with healthy controls. Meanwhile, the integrity of microstructures and blood–brain barrier in NAWM was also demonstrated to be impaired with diffusion tensor imaging and dynamic contrast-enhanced MRI studies, respectively. In addition,the integrity of NAWM correlated much stronger with cognitive performance than did WMHs load. It is reasonable to assume that the subtle injury of NAWM would be more reversible than WMHs themselves. Therefore, multimodal imaging modalities could be appropriately applied to future interventional studies targeting at early pathophysiological changes of NAWM. In this paper, we summarise current knowledge about NAWM of LA mainly acquired from multimodal imaging studies in vivo, and attempt to give options for future work.
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Affiliation(s)
- Genlong Zhong
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, Zhenjiang, China
| | - Min Lou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, Zhenjiang, China
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63
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Smagula SF, Aizenstein HJ. Brain structural connectivity in late-life major depressive disorder. BIOLOGICAL PSYCHIATRY: COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2016; 1:271-277. [PMID: 27430029 DOI: 10.1016/j.bpsc.2015.11.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Disrupted brain connectivity might explain both the pathogenesis and consequences of late-life major depressive disorder (LLD). However, it remains difficult to ascertain whether and how specific circuits are affected. We reviewed literature regarding brain connectivity in LLD, and we specifically focused on the role of structural pathology. LLD is associated with greater levels of cerebrovascular disease, and greater levels of cerebrovascular disease are associated with both depression development and treatment responsiveness. Cerebrovascular disease is most often measured as white matter hyperintensity (WMH) burden, and histopathology studies suggest WMH reflect myelin damage and fluid accumulation (among other underlying pathology). WMHs appear as confluent caps around the ventricles (periventricular), as well as isolated lesions in the deep white matter. The underlying tissue damage and implications for brain connectivity may differ by WMH location or severity. WMHs are associated with lower white matter microstructural integrity (measured with diffusion tensor imaging) and altered brain function (measured with functional MRI). LLD is also associated with lower white matter microstructural integrity and grey matter loss which may also alter the network properties and function of the brain. Damage to brain structure reflected by WMH, reduced white matter microstructural integrity, and atrophy may affect brain function, and are therefore likely pathophysiological mechanisms of LLD. Additional research is needed to fully characterize the developmental course and pathology underlying these imaging markers, and to understand how structural damage explains LLD's various clinical manifestations.
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Affiliation(s)
- Stephen F Smagula
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Howard J Aizenstein
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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