Cerebrovascular disease: Neuroimaging of cerebral small vessel disease

Regional white matter hyperintensity volume predicts persistent cognitive impairment in acute lacunar infarct patients

Background

White matter hyperintensity (WMH) is often described in acute lacunar stroke (ALS) patients. However, the specific relationship between regional WMH volume and persistent cognitive impairment remains unclear.

Methods

We enrolled patients with ALS who were hospitalized at the First Affiliated Hospital of Soochow University between January 2020 and November 2022. All patients were assessed for global cognitive function using the Montreal Cognitive Assessment (MoCA) scale at 14 ± 2 days and 6 months after the onset of ALS. Manifestations of chronic cerebral small vessel disease (CSVD) were assessed via MRI scan. The distributions of regional WMH were segmented, and their relationship with cognitive impairment was evaluated.

Results

A total of 129 patients were enrolled. Baseline frontal WMH volume (OR = 1.18, P = 0.04) was an independent risk factor for long-term cognitive impairment after ALS. Furthermore, the presence of WMH at the genu of the corpus callosum (GCC) at baseline (OR = 3.1, P = 0.033) was strongly associated with persistent cognitive decline. Multivariable logistic regression analysis showed that depression (OR = 6.252, P = 0.029), NIHSS score (OR = 1.24, P = 0.011), and albumin at admission (OR = 0.841, P = 0.032) were also important determinants of long-term cognitive impairment after ALS.

Conclusions

Our study found that WMH, especially frontal WMH volume and the presence of WMH at the GCC at baseline, independently contributed to long-term cognitive decline in ALS patients. This study provides new evidence of the clinical relationship between regional WMH volume and cognitive impairment in ALS patients.

The correlation between the severity of cerebral microbleeds and serum HMGB1 levels and cognitive impairment in patients with cerebral small vessel disease

Objective

The study investigated the correlation and predictive value between the severity of cerebral microbleeds (CMBs) and the level of serum High Mobility Group Protein B1 (HMGB1) and the occurrence of cognitive impairment in patients with cerebral small vessel disease (CSVD).

Methods

A total of 139 patients with CSVD admitted to the Department of Neurology of the First Affiliated Hospital of Xinxiang Medical University from December 2020 to December 2022 were selected as study subjects. The Montreal Cognitive Assessment (MoCA) scale was used to assess the cognitive function and was divided into the cognitive impairment group and the cognitive normal group. Magnetic Resonance Imaging (MRI) and Susceptibility Weighted Imaging (SWI) were used to screen and assess the severity of CMBs. Serum HMGB1 levels of CSVD patients were measured by enzyme linked immunosorbent assay (ELISA). Multivariable logistic regression analysis was used to explore risk factors for cognitive impairment and CMBs. Pearson correlation analysis was used to investigate the correlation between HMGB1 and cognitive function. Receiver Operating Characteristics (ROC) curves were used to assess the predictive value of HMGB1 for the occurrence of cognitive impairment in patients with CMBs.

Results

High Mobility Group Protein B1, uric acid (UA), glycosylated hemoglobin (HbA1c), CMBs, lacunar cerebral infarction (LI), years of education, and history of hypertension were risk factors for cognitive impairment (P < 0.05); HMGB1 was significantly and negatively associated with total MoCA score, visuospatial/executive ability, and delayed recall ability (P < 0.05). HMGB1 was significantly and positively correlated with the number of CMBs (P < 0.05). The area under the ROC curve for HMGB1 predicting cognitive impairment in patients with CMBs was 0.807 (P < 0.001).

Conclusion

Serum HMGB1 levels are associated with the development of cognitive impairment in CSVD patients, and serum HMGB1 levels have a high predictive value for the development of cognitive impairment in CSVD patients with combined CMBs, which can be used for early clinical identification and intervention of vascular cognitive impairment.

Neuroimaging in small vessel disease

The objective of this article is to review the literature on neuroimaging in small vessel disease. A review was carried out through the Pubmed search engine, without a filter of years, using terms such as: cerebral small vessel disease; white matter hyperintensity; brain microbleed; WBC. Small vessel disease is the most common vascular pathology. Its basis is in the affectation of the small cerebral vessels that eventually causes an alteration in the blood-brain barrier. Its clinical implication is highly relevant. Using magnetic resonance imaging, different expressions of the disease have been observed, such as white matter hyperintensities, microbleeds or lacunar infarcts. Other more recent techniques, such as brain blood flow measurements, are helping to increase understanding of the pathophysiology of this disease.

Analysis of Risk Factors for Cerebral Microbleeds and the Relationship between Cerebral Microbleeds and Cognitive Impairment

(1) Background: Cerebral microbleeds (CMBs) are attracting increasing attention. Nevertheless, the risk factors for CMBs remain poorly identified, and the relationship between CMBs and cognitive impairment is still up for debate; (2) Objective: The present study analyzed the risk factors for CMBs and probed into the potential correlations between the presence, number, and location of CMBs and cognition; (3) Methods: This study enrolled 406 subjects who underwent both brain 3.0-T magnetic resonance imaging scans and cognitive testing. Spearman correlation was used to assess the relationship between the number of CMBs and cognition. Multiple linear regression was utilized to analyze the relationship between the regions of CMBs and each cognitive domain; (4) Results: Multivariate logistic regression analysis results showed that age (odds ratio (OR) = 1.045, 95% confidence interval (95%CI; 1.009, 1.082)), smoking (OR = 3.604, 95%CI (1.995, 6.509)), hypertension (OR = 3.607, 95%CI (2.204, 5.901)), total cholesterol (OR = 0.611, 95%CI (0.467, 0.799)), and Amyloid-β1-42 (Aβ1-42) (OR = 1.028, 95%CI (1.018, 1.037)) were the influencing factors of CMBs. Education years (OR = 0.959, 95%CI (0.930, 0.988)), white matter lesions (OR = 2.687, 95%CI (1.782, 4.051)), and CMBs (OR = 21.246, 95%CI (5.728, 21.576)) were the risk factors for cognitive impairment. Hypertension increased the probability of deep CMBs (OR = 12.54, 95%CI (2.21, 71.28)), while Aβ1-42 elevated the probability of lobar CMBs (OR = 1.02, 95%CI (1.00, 1.03)). There was a linear correlation between the number of CMBs and Montreal Cognitive Assessment scores (r = −0.756, p < 0.001). However, CMBs in each region were not related to specific cognitive domains (p > 0.05), except CMBs in the mixed group that were negatively correlated with attention (OR = −0.669, 95%CI (−0.034, −5.270)); (5) Conclusions: Taken together, serum Aβ1-42 levels are related to the presence of CMBs. Cognitive impairment is correlated with the number of CMBs rather than their region. These findings suggest that CMBs play a role in cognitive impairment and that CMBs mark the presence of diffuse vascular injury and neurodegenerative brain damage.

Perfusion heterogeneity of cerebral small vessel disease revealed via arterial spin labeling MRI and machine learning

Cerebral small vessel disease (CSVD) is associated with altered cerebral perfusion. However, global and regional cerebral blood flow (CBF) are highly heterogeneous across CSVD patients. The aim of this study was to identify subtypes of CSVD with different CBF patterns using an advanced machine learning approach. 121 CSVD patients and 53 healthy controls received arterial spin label MRI, T1 structural MRI and clinical measurements. Regional CBF were used to identify distinct perfusion subtypes of CSVD via a semi-supervised machine learning algorithm. Statistical analyses were used to explore alterations in CBF, clinical measures, gray and white matter volume between healthy controls and different subtypes of CSVD. Correlation analysis was used to assess the association between clinical measures and altered CBF in each CSVD subtype. Three subtypes of CSVD with distinct CBF patterns were found. Subtype 1 showed decreased CBF in the temporal lobe and increased CBF in the parietal and occipital lobe. Subtype 2 exhibited decreased CBF in the right hemisphere of the brain, and increased CBF in the left cerebrum. Subtype 3 demonstrated decreased CBF in the posterior part of the brain, and increased CBF in anterior part of the brain. The three subtypes also differed significantly in gender (p = 0.005), the proportion of subjects with lacune (p = 0.002), with periventricular white matter hyperintensity (p = 0.043), and CSVD burden score (p = 0.048). In subtype 3, it was found that widespread decreased CBF was correlated with total CSVD burden score (r = -0.324, p = 0.029). Compared with healthy controls, the three CSVD subtypes also showed distinct volumetric patterns of white matter. The current results associate different subtypes with different clinical and imaging phenotypes, which can improve the understanding of brain perfusion alterations of CSVD and can facilitate precision diagnosis of CSVD.

A training program for researchers in population neuroimaging: Early experiences

Recent advances in neuroimaging create groundbreaking opportunities to better understand human neurological and psychiatric diseases, but also bring new challenges. With the advent of more and more sophisticated and efficient multimodal image processing software, we can now study much larger populations and integrate information from multiple modalities. In consequence, investigators that use neuroimaging techniques must also understand and apply principles of population sampling and contemporary data analytic techniques. The next generation of neuroimaging researchers must be skilled in numerous previously distinct disciplines and so a new integrated model of training is needed. This tutorial presents the rationale for such a new training model and presents the results from the first years of the training program focused on population neuroimaging of Alzheimer's Disease. This approach is applicable to other areas of population neuroimaging.

Correlation of Serum C-Peptide, Soluble Intercellular Adhesion Molecule-1, and NLRP3 Inflammasome-Related Inflammatory Factor Interleukin-1β after Brain Magnetic Resonance Imaging Examination with Cerebral Small Vessel Disease

Objective. To explore the correlation of serum c-peptide, soluble intercellular adhesion molecule-1 (sICAM-1), and NLRP3 inflammasome-related inflammatory factor interleukin-1β (IL-1β) after brain magnetic resonance imaging (MRI) examination with cerebral small vessel disease (CSVD). Methods. A total of 72 CSVD patients treated in our hospital from December 2018 to December 2019 were selected as the case group and another 72 patients who presented cerebrovascular risk factors but obtained normal brain MRI examination result in the same period were selected as the control group. The serum specimen of patients in the two groups were collected, their serum c-peptide levels were measured by radio immunoassay, and their serum sICAM-1 and NLRP3 inflammasome-related inflammatory factor IL-1β were measured by enzyme-linked immunosorbent assay (ELISA), so as to analyze the correlation between these indicators and CSVD. Results. Compared with the control group, the level values of serum c-peptide, sICAM-1, and IL-1β were significantly higher in the case group ( $P<0.001$ ), with CSVD being the dependent variable, and age, smoking, uric acid, history of stroke, serum c-peptide, sICAM-1, and IL-1β being the independent variables. A logistic regression analysis was conducted, and the result showed that age, smoking, serum c-peptide, sICAM-1, and IL-1β were the risk factors for CSVD, and by drawing the ROC curves, it could be concluded that the area under sICAM-1 curve was larger than that of other single indicator. Conclusion. Elevation of level values of serum c-peptide, sICAM-1, and NLRP3 inflammasome-related inflammatory factor IL-1β is correlative with CSVD, and age, smoking, serum c-peptide, sICAM-1, and IL-1β are the independent risk factors for CSVD.

Pathogeneses and Imaging Features of Cerebral White Matter Lesions of Vascular Origins

White matter lesion (WML), also known as white matter hyperintensities or leukoaraiosis, was first termed in 1986 to describe the hyperintense signals on T2-weighted imaging (T2WI) and fluid-attenuated inversion recovery (FLAIR) maps. Over the past decades, a growing body of pathophysiological findings regarding WMLs have been discovered and discussed. Currently, the generally accepted WML pathogeneses mainly include hypoxia-ischemia, endothelial dysfunction, blood-brain barrier disruption, and infiltration of inflammatory mediators or cytokines. However, none of them can explain the whole dynamics of WML formation. Herein, we primarily focus on the pathogeneses and neuroimaging features of vascular WMLs. To achieve this goal, we searched papers with any type published in PubMed from 1950 to 2020 and cross-referenced the keywords including “leukoencephalopathy”, “leukoaraiosis”, “white matter hyperintensity”, “white matter lesion”, “pathogenesis”, “pathology”, “pathophysiology”, and “neuroimaging”. Moreover, references of the selected articles were browsed and searched for additional pertinent articles. We believe this work will supply the robust references for clinicians to further understand the different WML patterns of varying vascular etiologies and thus make customized treatment.

Magnetic Resonance Imaging Markers of Cerebral Small Vessel Disease in Adults with Moyamoya Disease

In clinical work, the magnetic resonance imaging markers of cerebral small vessel disease (CSVD) are frequently observed in moyamoya disease (MMD), but the clinical significance of these markers in MMD remains unclear. This study aimed to fill this gap and systematically investigate its clinical significance. In this retrospective cohort study, we screened all adult patients with MMD hospitalized from January 2016 to January 2020 and collected their baseline clinical and imaging information. Univariate and multivariate logistic regression analyses were then performed to determine which imaging markers were independently associated with MMD characteristics, including cerebrovascular morphology, cerebral hemodynamics, cerebrovascular events, and postoperative collateral formation (PCF). A total of 312 cerebral hemispheres images were collected from the 156 patients with MMD. Using multivariate logistic regression analysis, the following results were generated: (1) The presence of lacunes (OR, 2.094; 95% CI, 1.109-3.955; p = 0.023) and severe white matter hyperintensities (WMH) (OR, 3.204; 95% CI, 1.742-5.892; p < 0.001) were associated with a Suzuki stage ≥ IV; (2) the presence of lacunes (OR, 6.939; 95% CI, 3.384-14.230; p < 0.001), higher numbers of enlarged perivascular spaces in centrum semiovale (CSO-EPVS) (OR, 1.046; 95% CI, 1.024-1.067; p < 0.001), and severe WMH (OR, 2.764; 95% CI, 1.463-5.223; p = 0.002) were associated with the reduced regional cerebral blood flow; (3) the presence of lacunes (OR, 12.570; 95% CI, 2.893-54.624; p = 0.001), higher numbers of CSO-EPVS (OR, 1.103; 95% CI, 1.058-1.150; p < 0.001), and severe WMH (OR, 5.982; 95% CI, 1.727-20.716; p = 0.005) were associated with ischemic cerebrovascular events; (4) the higher number of CSO-EPVS (OR, 1.077; 95% CI, 1.026-1.131; p = 0.003) was associated with good PCF. The lacunes, WMH, and CSO-EPVS were independently associated with these MMD characteristics. In conclusion, this study provided a novel and potential framework for the practical assessment of MMD by magnetic resonance imaging.

Cognition and Cerebrovascular Reactivity in Midlife Women With History of Preeclampsia and Placental Evidence of Maternal Vascular Malperfusion

Background: Preeclampsia is emerging as a sex-specific risk factor for cerebral small vessel disease (SVD) and dementia, but the reason is unknown. We assessed the relationship of maternal vascular malperfusion (MVM), a marker of placental SVD, with cognition and cerebral SVD in women with and without preeclampsia. We hypothesized women with both preeclampsia and MVM would perform worst on information processing speed and executive function.

Methods: Women (n = 45; mean 10.5 years post-delivery; mean age: 41 years; 42.2% Black) were classified as preeclampsia-/MVM-, preeclampsia+/MVM-, or preeclampsia+/MVM+. Information processing speed, executive function, and memory were assessed. In a pilot sub-study of cerebrovascular reactivity (CVR; n = 22), cerebral blood flow during room-air breathing and breath-hold induced hypercapnia were obtained via arterial spin labeling MRI. Non-parametric tests and regression models were used to test associations.

Results: Between-group cognitive differences were significant for information processing speed (p = 0.02); preeclampsia+/MVM+ had the lowest scores. Cerebral blood flow increased from room-air to breath-hold, globally and in all regions in the three groups, except the preeclampsia+/MVM+ parietal region (p = 0.12). Lower parietal CVR (less change from room-air breathing to breath-holding) was correlated with poorer information processing speed (partial ρ = 0.63, p = 0.005) and executive function (ρ = 0.50, p = 0.03) independent of preeclampsia/MVM status.

Conclusion: Compared to women without preeclampsia and MVM, midlife women with both preeclampsia and MVM have worse information processing speed and may have blunted parietal CVR, an area important for information processing speed and executive function. MVM in women with preeclampsia is a promising sex-specific indicator of cerebrovascular integrity in midlife.

The Predictive Values of Different Small Vessel Disease Scores on Clinical Outcomes in Mild ICH Patients

Aim: To explore the predictive values of different small vessel disease (SVD) scores on functional recoveries and the clinical cerebrovascular events in mild intracerebral hemorrhage (ICH).

Methods: In this study, we enrolled conscious and mild ICH patients without surgery and further divided them into the cerebral amyloid angiopathy (CAA)-ICH group and hypertension (HTN)-ICH group. The severity of individual SVD markers, including lacunes, cerebral microbleeds (CMBs), enlarged perivascular spaces (EPVS), white matter hyperintensity (WMH), and cortical superficial siderosis (cSS), was evaluated. The original SVD score, modified SVD score, refined SVD score, and CAA-SVD score and the total number of SVD markers were further calculated. Functional recoveries were evaluated using the modified Rankin scale. Recurrences of stroke were defined as readmission to the hospital with a definite diagnosis of stroke.

Results: A total of 163 ICH patients (60 CAA-ICH and 103 HTN-ICH) were included in the study. The CAA-SVD score (OR=3.429; 95% confidence interval (CI)=1.518–7.748) had the best predictive effect on functional dependence in the CAA-ICH group, among which cSS severities probably played a vital role (OR=4.665; 95% CI=1.388–15.679). The total number of SVD markers [hazard ratio (HR)=3.765; 95% CI=1.467–9.663] can better identify stroke recurrences in CAA-ICH. In HTN-ICH, while the total number of SVD markers (HR=2.136; 95% CI=1.218–3.745) also demonstrated association with recurrent stroke, this effect seems to be related with the influence of lacunes (HR=5.064; 95% CI=1.697–15.116).

Conclusions: The CAA-SVD score and the total number of SVD markers might identify mild CAA-ICH patients with poor prognosis. However, it would be better to focus on lacunes rather than on the overall burden of SVD to predict recurrent strokes in HTN-ICH.

Cerebral Small Vessel Disease

Cerebral small vessel disease (CSVD) represents a cluster of various vascular disorders with different pathological backgrounds. The advanced vasculature net of cerebral vessels, including small arteries, capillaries, arterioles and venules, is usually affected. Processes of oxidation underlie the pathology of CSVD, promoting the degenerative status of the epithelial layer. There are several classifications of cerebral small vessel diseases; some of them include diseases such as Binswanger’s disease, leukoaraiosis, cerebral microbleeds (CMBs) and lacunar strokes. This paper presents the characteristics of CSVD and the impact of the current knowledge of this topic on the diagnosis and treatment of patients.

White matter hyperintensities and risks of cognitive impairment and dementia: A systematic review and meta-analysis of 36 prospective studies

BACKGROUND

White matter hyperintensities of presumed vascular origin (WMH) are one of the imaging features of cerebral small vessel disease. Controversies persist about the effects of WMH on cognitive dysfunction. This meta-analysis aimed to identify the associations of WMH with risks of cognitive impairment and dementia.

METHODS

We searched PubMed, EMBASE and Cochrane Library for prospective studies. Primary analyses of cognitive dysfunction and sub-analyses of specific outcomes and study characteristics were conducted using random-effect models.

RESULTS

Thirty-six prospective studies with 19,040 participants were included. WMH at baseline conferred a 14 % elevated risk of cognitive impairment and all-cause dementia (ACD). WMH also conferred 25 % elevated risk of Alzheimer's disease and 73 % elevated risk of vascular dementia. Risk effects of high-grade WMH and continually increasing WMH (in volume or severity) on ACD were revealed. Periventricular WMH conferred a 1.51-fold excess risk for dementia.

CONCLUSIONS

WMH were associated with increased risk of cognitive dysfunction and could become a neuroimaging indicator of dementia.

Resting state connectivity within the basal ganglia and gait speed in older adults with cerebral small vessel disease and locomotor risk factors

BACKGROUND AND AIM

The basal ganglia are critical for planned locomotion, but their role in age-related gait slowing is not well known. Spontaneous regional co-activation of brain activity at rest, known as resting state connectivity, is emerging as a biomarker of functional neural specialization of varying human processes, including gait. We hypothesized that greater connectivity amongst regions of the basal ganglia would be associated with faster gait speed in the elderly. We further investigated whether this association was similar in strength to that of other risk factors for gait slowing, specifically white matter hyperintensities (WMH).

METHODS

A cohort of 269 adults (79-90 years, 146 females, 164 White) were assessed for gait speed (m/sec) via stopwatch; brain activation during resting state functional magnetic resonance imaging, WMH, and gray matter volume (GMV) normalized by intracranial volume via 3T neuroimaging; and risk factors of poorer locomotion via clinical exams (body mass index (BMI), muscle strength, vision, musculoskeletal pain, cardiometabolic conditions, depressive symptoms, and cognitive function). To understand whether basal ganglia connectivity shows distinct clusters of connectivity, we conducted a k-means clustering analysis of regional co-activation among the substantia nigra, nucleus accumbens, subthalamic nucleus, putamen, pallidum, and caudate. We conducted two multivariable linear regression models: (1) with gait speed as the dependent variable and connectivity, demographics, WMH, GMV, and locomotor risk factors as independent variables and (2) with basal ganglia connectivity as the dependent variable and demographics, WMH, GMV, and locomotor risk factors as independent variables.

RESULTS

We identified two clusters of basal ganglia connectivity: high and low without a distinct spatial distribution allowing us to compute an average connectivity index of the entire basal ganglia regional connectivity (representing a continuous measure). Lower connectivity was associated with slower gait, independent of other locomotor risk factors, including WMH; the coefficient of this association was similar to those of other locomotor risk factors. Lower connectivity was significantly associated with lower BMI and greater WMH.

CONCLUSIONS

Lower resting state basal ganglia connectivity is associated with slower gait speed. Its contribution appears comparable to WMH and other locomotor risk factors. Future studies should assess whether promoting higher basal ganglia connectivity in older adults may reduce age-related gait slowing.