Dilatation of the Virchow-Robin spaces as an indicator of unilateral carotid artery stenosis: correlation with white matter lesions

Carotid artery stenosis is related to cerebral small vessel disease magnetic resonance imaging burden

Background

Cerebral small vessel disease (CSVD) encompasses conditions that affect small blood vessels of the brain, the most common being atherosclerosis. Magnetic resonance imaging (MRI) CSVD markers include lacunar strokes (LS), white matter hyperintensities (WMH), microbleeds, enlarged perivascular spaces (EPVS), and brain atrophy. Large and small cerebral arteries share an anatomical and functional connection, but the role of large vessel atherosclerosis in atherosclerotic CSVD hasn't been established. The aim of this study was to evaluate the involvement of large vessel pathology in atherosclerotic CSVD.

Methods

This cross-sectional study included 98 patients treated at the Neurology Clinic of the University Clinical Center of Serbia in Belgrade, from February 2018 to December 2023, who had atherosclerotic CSVD confirmed by neuroimaging and underwent extracranial color duplex sonography. Data on patients' gender, age, cerebrovascular risk factors (dyslipidemia, hypertension, diabetes mellitus, smoking status), ultrasonography findings (intima-media thickness - IMT, carotid and vertebral artery stenosis, and hemodynamics), and CSVD imaging markers were collected, and the CSVD MRI burden score was calculated.

Results

Age correlated with LS and WMH (p < 0.05 for both). Hypertension correlated with WMH (p = 0.016), and smoking with LS (p = 0.043). Brain atrophy was more common in women (p = 0.016). The majority of patients had low-grade (<50 %) carotid stenosis. There was a strong correlation between all morphological parameters of internal carotid artery stenosis and the CSVD burden score (p < 0.05 for all). The hemodynamic parameters of internal carotid artery stenosis and morphological and hemodynamic parameters of vertebral artery stenosis didn't correlate with the CSVD burden score.

Conclusions

This study shows a strong correlation between cerebral large and small vessel pathology. We recommend the use of extracranial color duplex sonography in the evaluation of patients with CSVD as a supplementary method for follow-up, as this would allow the identification of patients whose condition might progress.

Association between intracranial and extracranial atherosclerosis and white matter hyperintensities: a systematic review and meta-analysis

Background

White matter hyperintensities (WMHs) are key neuroimaging markers of cerebral small vessel diseases. This study aimed to investigate whether intracranial and extracranial atherosclerotic stenosis is associated with WMHs.

Methods

Following a previously registered protocol (PROSPERO protocol: CRD42023407465), PubMed, Web of Science, and Embase were systematically searched for relevant literature published until March 2023. Cross-sectional studies examining the association between intracranial and extracranial atherosclerotic stenosis and WMHs were included. Random effects models were used to calculate the pooled estimates.

Results

Twenty-one eligible studies, including 10,841 participants, were identified. Intracranial and extracranial atherosclerotic stenosis was associated with an increased risk of WMHs (OR 1.80, 95% CI 1.25-2.57, I2 = 75%) and increased WMH volumes (SMD 0.40, 95% CI 0.18-0.63, I2 = 63%). Heterogeneity resulted from the WMHs rating method and the location. Extracranial atherosclerotic stenosis (ECAS) was significantly associated with WMHs (OR 2.10, 95% CI 1.22-3.62, I2 = 71%), but intracranial atherosclerotic stenosis (ICAS) was insignificantly associated with WMHs (OR 1.75, 95% CI 0.97-3.15, I2 = 84%). The association was stable in the subgroup analysis based on WMHs location, which included deep WMHs and periventricular WMHs.

Conclusion

Intracranial and extracranial atherosclerotic stenosis is associated with WMHs. This association is significant in ECAS, but attenuated in ICAS.

The etiology and evolution of magnetic resonance imaging-visible perivascular spaces: Systematic review and meta-analysis

Objectives

Perivascular spaces have been involved in neuroinflammatory and neurodegenerative diseases. Upon a certain size, these spaces can become visible on magnetic resonance imaging (MRI), referred to as enlarged perivascular spaces (EPVS) or MRI-visible perivascular spaces (MVPVS). However, the lack of systematic evidence on etiology and temporal dynamics of MVPVS hampers their diagnostic utility as MRI biomarker. Thus, the goal of this systematic review was to summarize potential etiologies and evolution of MVPVS.

Methods

In a comprehensive literature search, out of 1,488 unique publications, 140 records assessing etiopathogenesis and dynamics of MVPVS were eligible for a qualitative summary. 6 records were included in a meta-analysis to assess the association between MVPVS and brain atrophy.

Results

Four overarching and partly overlapping etiologies of MVPVS have been proposed: (1) Impairment of interstitial fluid circulation, (2) Spiral elongation of arteries, (3) Brain atrophy and/or perivascular myelin loss, and (4) Immune cell accumulation in the perivascular space. The meta-analysis in patients with neuroinflammatory diseases did not support an association between MVPVS and brain volume measures [R: −0.15 (95%-CI −0.40–0.11)]. Based on few and mostly small studies in tumefactive MVPVS and in vascular and neuroinflammatory diseases, temporal evolution of MVPVS is slow.

Conclusion

Collectively, this study provides high-grade evidence for MVPVS etiopathogenesis and temporal dynamics. Although several potential etiologies for MVPVS emergence have been proposed, they are only partially supported by data. Advanced MRI methods should be employed to further dissect etiopathogenesis and evolution of MVPVS. This can benefit their implementation as an imaging biomarker.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=346564, identifier CRD42022346564.

Unilateral subcortical extensive dilated perivascular spaces associated with superior sagittal sinus perivenous dilated spaces

We present the MRI of a 70-year-old patient showing unilateral subcortical extensive dilated perivascular spaces with surrounding fluid-attenuated inversion recovery hyperintensities associated with the presence of small cysts and tubular hypointensities in and near the superior sagittal sinus co-locating with draining cortical veins on gadolinium-enhanced T1-weighted imaging representing probably (dilated) spaces between pial sheath and cortical vein walls. These (peri)venous superior sagittal sinus cysts seem to represent either hydrops cause (by blocking interstitial fluid flow in perivenous subpial space, via meningeal lymphatics) or consequence (where cysts might have been formed due to subpial fluid flow obstruction by unknown cause).

The relationship between severe extracranial artery stenosis or occlusion and cerebral small vessel disease in patients with large artery atherosclerotic cerebral infarction

Background and purpose

Extracranial artery stenosis (ECAS) is associated with the presence of individual markers of cerebral small vessel disease (CSVD). Here, we investigated the relationship between severe extracranial artery stenosis or occlusion and CSVD in patients with large artery atherosclerotic (LAA) cerebral infarction.

Methods

A total of 128 patients with LAA cerebral infarction who met our specific inclusion criteria were selected, including 92 males and 36 females. These patients were divided into three groups based on whether they had severe symptomatic extracranial arterial stenosis or occlusion, severe asymptomatic extracranial artery stenosis or occlusion, or severe extracranial artery stenosis or occlusion (both symptomatic and asymptomatic). Intra-group comparisons were then performed to examine whether there were any differences in the total CSVD scores and Fazekas scores.

Results

Patients with severe extracranial arterial stenosis or occlusion and those with severe asymptomatic extracranial arterial stenosis or occlusion had a significantly higher total CSVD score (P < 0.05), but there were no significant differences between the groups in terms of Fazekas scores. Furthermore, there were no significant difference in the total CSVD scores and Fazekas scores when compared between patients with or without severe symptomatic extracranial arterial stenosis or occlusion.

Conclusion

Severe stenosis or occlusion of the contralateral extracranial artery may increase the incidence of CSVD in patients with LAA cerebral infarction. Active and effective clinical intervention following comprehensive evaluation should be undertaken for unilateral cerebral infarction patients with severe stenosis or occlusion of the contralateral extracranial arterial.

Association between carotid artery perivascular fat density and cerebral small vessel disease

Studies aiming to identify the significance of the carotid artery perivascular fat density are limited. The present study investigated the distribution pattern of pericarotid fat and its association with imaging markers of cerebral small vessel disease (CSVD). In total, 572 subjects who underwent both neck computed tomography angiography and cranial magnetic resonance imaging were analyzed. The pericarotid fat density near the origin of the internal carotid artery (ICA) and imaging markers of CSVD, such as lacunes, white matter hyperintensities (WMHs) and dilated perivascular spaces (PVSs), were assessed. We found that an increased pericarotid fat density was associated with the presence of lacunes and a higher WMH grade in all subjects, but in the patients with acute ischemic stroke, there was a difference only among the WMH grades. There was no significant difference in the pericarotid fat density in different grades of PVSs. The patients with acute ischemic stroke had a significantly higher mean pericarotid fat density than those without stroke. In conclusion, our study provides evidence suggesting that an increased pericarotid fat density is associated with the presence and degree of WMHs and lacunes. Our findings suggested that features that appear to extend beyond the vessel lumen of the ICA may be linked to CSVD.

Associations of Vascular Risk Factors and APOE Genotype With Perivascular Spaces Among Community-Dwelling Older Adults

Background Evidence suggests that enlarged perivascular spaces (PVSs) may represent a marker for cerebral small-vessel disease. We investigated whether vascular risk factors are correlated with visible PVS in older adults. Methods and Results This population-based study included 530 participants (age ≥60 years) who were free from dementia and functional dependence, derived from the Swedish National study on Aging and Care in Kungsholmen (2001-2003). We collected data on demographics, vascular risk factors, and health conditions through interviews, clinical examinations, laboratory tests, and patient registers. Cerebral PVSs and white matter hyperintensities on magnetic resonance images were visually assessed with semiquantitative visual rating scales. Data were analyzed using the general linear regression models. After controlling for demographics and cardiovascular disease, very high blood pressure (≥160/100 mm Hg) was significantly associated with global PVS score (β-coefficient, 1.30; 95% CI, 0.06-2.53) and orthostatic hypotension was associated with PVS score in the basal ganglia (β-coefficient 0.37; 0.03-0.70), but the associations became non-significant when adjusting for white matter hyperintensity load. Orthostatic hypotension was significantly associated with global and lobar PVS scores in carriers but not in noncarriers of the APOE ε4 allele. Global or regional PVS score was not significantly associated with other traditional vascular risk factors such as smoking, diabetes mellitus, physical inactivity, and overweight or obesity. Conclusions This study provides limited evidence supporting a correlation of magnetic resonance imaging-visible PVS with traditional vascular risk factors in older adults. The association of orthostatic hypotension with lobar PVS among APOE ε4 carriers suggests that lobar PVS may be a marker for amyloid-associated small-vessel disease.

Association Between Steno-Occlusive Middle Cerebral Artery and Basal Ganglia Perivascular Spaces

Objectives: Enlarged perivascular spaces in the basal ganglia (BG-EPVS) share common vascular risk factors with atherosclerosis. However, little is known about the relationship between steno-occlusive middle cerebral artery (MCA) and BG-EPVS. In this cross-sectional study, we aimed to test the hypothesis that severe MCA stenosis or occlusion is associated with increased MRI-visible BG-EPVS. Methods: We retrospectively reviewed 112 patients with a steno-occlusive MCA from Fujian Medical University Union Hospital between January 2014 and December 2018. We rated BG-EPVS, white matter hyperintensities (WMH), and lacunes as markers of cerebral small vessel disease (CSVD) on magnetic resonance image (MRI). The severity of steno-occlusive MCA was assessed by computed tomography angiography (CTA) and was classified into moderate (50-69%), severe (70-99%), and occlusion (100%). We evaluated the association of steno-occlusive MCA for >10 BG-EPVS using logistic regression model adjusted for age, gender, hypertension, MR-visible WMH, and lacunes. We also compared the number of BG-EPVS between the affected side and unaffected side in patients with only unilateral steno-occlusive MCA. Results: In multivariable logistic regression analysis, age (OR = 1.07, 95%CI: 1.03-1.13, p = 0.003), hypertension (OR = 2.77, 95%CI: 1.02-7.51, p = 0.046), severe MCA stenosis (OR = 3.65, 95%CI: 1.12-11.87, p = 0.032), or occlusion (OR = 3.67, 95%CI: 1.20-11.27, p = 0.023) were significantly associated with >10 BG-EPVS. The number of BG-EPVS in the affected side was higher than the unaffected side in patients with severe MCA stenosis (12 [9-14] vs. 8 [6-11], p = 0.001) or occlusion (11 [7-14] vs. 8 [5-11], p = 0.028). Conclusions: BG-EPVS were more prevalent in patients with severe MCA atherosclerosis. Our findings suggest a biological link between severe steno-occlusive MCA and increased BG-EPVS. These results need confirmation in prospective studies.

Association between Enlarged Perivascular Spaces and Internal Carotid Artery Stenosis: A Study in Patients Diagnosed by Digital Subtraction Angiography

OBJECTIVE

An enlarged perivascular space (EPVS) is an imaging marker of cerebral small vessel disease, and its relationship with large artery disease is elusive. We investigated the EPVS in patients with internal carotid artery stenosis (ICAS) with the use of digital subtraction angiography (DSA) and tested the relationship between the degree of EPVS and the degree of ICAS; as well as the relationship between the degree of EPVS and white matter hyperintensity (WMH).

METHOD

A total of 202 patients with or without ICAS diagnosed by DSA were enrolled. The maximal ICAS rates, the degrees of EPVS and WMH were measured. The patients' clinical characteristics and laboratory parameters were recorded. Univariable analysis and multivariable regression were used to test their correlations. In a unilateral stenosis subgroup, the EPVSs in the ipsilateral hemisphere of stenosis and in the contralateral hemisphere were compared.

RESULTS

According to univariable analysis, there were significant differences in age (P = .000), Hg1bc (P = .035) and folic acid (P = .008) among the subgroups based on the degrees of EPVS in the basal ganglia (BG). Age (P = .000) and the level of fibrinogen (P = .018) differed statistically among the subgroups based on the degrees of EPVS in the white matter (WM). The correlation between the degrees of WM-EPVS and the ICAS levels was tested with a gamma test: G = .280, P = .001. The ordinal multivariable regression model showed that age was independently associated with both BG-EPVSs and WM-EPVSs. A current smoker status was also independently associated with WM-EPVSs. ICAS level was associated with the severity of WM-EPVSs after adjusting for other risk factors. The degree of BG-EPVS was not correlated with the degree of stenosis. (P = .101). In 59 patients with unilateral ICAS, as tested by the Wilcoxon signed ranks test, the WM-EPVS scores in the ipsilateral hemisphere of stenosis were higher than those in the contralateral hemisphere. (P = .004), but there was no difference in BG-EPVSs (P = .070). Both BG-EPVSs and WM-EPVSs were independently correlated with WMH.

CONCLUSIONS

BG-EPVSs and WM-EPVSs have different risk factors. WM-EPVSs but not BG-EPVSs are correlated with ICAS.

Insulin Resistance Is Independently Associated With Enlarged Perivascular Space in the Basal Ganglia in Nondiabetic Healthy Elderly Population

OBJECTIVES

To investigate the association between insulin resistance (IR) and enlarged perivascular space (EPVS) in the basal gangliain nondiabetic healthy elderly population.

METHODS

A total of 235 nondiabetic healthy elderly population were recruited. A 3-level scale was used to evaluate the burden of EPVSs. The homeostasis model assessment-estimated insulin resistance index (HOMA-IR) was used for IR estimation. Correlation between IR and severity of EPVS was assessed using the regression model after adjusting demographics and cardiovascular risk factors.

RESULTS

The top quartile of HOMA-IR was 2.52, and 25.11% of patients showed IR. The proportion of patients with IR was higher in the moderate to severe EPVS group than in the mild group (36.51% vs 20.93%, P = .015). In multivariate logistic analysis, IR was positively correlated with the moderate to severe EPVS (adjusted odds ratio: 3.532, 95% confidence interval: 1.633-7.636, P = .001) after adjusting classical risk factors.

CONCLUSIONS

Insulin resistance was independently correlated with EPVS in the basal ganglia in nondiabetic healthy elderly population.

Correlation Between Intracranial Arterial Calcification and Imaging of Cerebral Small Vessel Disease

Background and Purpose: Vascular calcification is part of the atherosclerotic process. Intracranial artery calcification is closely associated with cerebral small vessel disease (SVD). The present study aimed to investigate the distribution pattern of intracranial arterial calcification and its association with magnetic resonance imaging (MRI) markers of SVD in patients with acute ischemic cerebrovascular disease. Methods: Two hundred and seventy six consecutive patients with transient ischemic attack (TIA) or acute ischemic stroke who underwent both computed tomography (CT) angiography and MRI were enrolled in this study. Intracranial arterial calcium scores were evaluated using Agatston method. MRI was performed to assess cerebral infarction, white matter hyperintensities (WMHs), lacunes, cerebral microbleeds (CMBs), and enlarged perivascular spaces (EPVSs). Results: Intracranial artery calcification was present in 200 (72.46%) patients, with the highest prevalence in the internal carotid arteries (ICA) (64.8%). The severity of intracranial arterial calcification was associated with the presence of WMHs (P = 0.0001), lacunes (P = 0.0001), and CMBs (P = 0.0001); however, there was no association between calcifications and the presence of EPVSs (P = 0.058). The correlation coefficients (r_s) were 0.350, 0.142, 0.285, and 0.251 for WMHs, EPVSs, lacunes, and CMBs, respectively. The adjusted odds ratios (ORs) of intracranial arterial calcification were: 2.747 for WMH (grade 1-2), 3.422 for WMH (grade 3), 2.902 for lacunes, 2.449 for CMB, 0.88 for EPVS (grade 1), and 0.295 for EPVS (grade 2-4). Conclusion: Intracranial artery calcification is common in patients with ischemic cerebrovascular disease and the intracranial carotid artery is most frequently affected. Intracranial arterial calcifications might be associated with imaging markers of SVD and are highly correlated with WMHs, lacunes, and CMBs. Quantification of calcification on CT provides additional information on the pathophysiology of SVD. Intracranial arterial calcification could act as a potential marker of SVD.

Extracranial Artery Stenosis Is Associated With Total MRI Burden of Cerebral Small Vessel Disease in Ischemic Stroke Patients of Suspected Small or Large Artery Origins

Background and Purpose: Extracranial artery stenosis (ECAS) is related to individual imaging markers of cerebral small vessel disease (cSVD). However, little has been reported on the association between ECAS and the total burden of cSVD as assessed by magnetic resonance imaging (MRI). The purpose of this study was to investigate the relationship between ECAS and cSVD burden in patients with ischemic stroke of suspected small or large artery origin.

Methods: We reviewed consecutive patients with ischemic stroke of suspected small or large artery origin who underwent color Doppler ultrasonography and brain MRI. Bilateral extracranial cerebral arteries including common carotid artery, internal carotid artery (ICA), and proximal vertebral artery (VA, ostium, V2–3 segments) were assessed using color Doppler ultrasonography. ECAS severity was classified as no/mild stenosis, moderate stenosis, severe stenosis, or occlusion. The total cSVD score was assessed by awarding one point according to the load of each of these cSVD markers as determined using MRI; lacunar infarction, white matter hyperintensities, cerebral microbleeds, and enlarged perivascular spaces. The relationship between ECAS severity and cSVD burden according to MRI was examined.

Results: Two hundred and twenty one patients were included in this study (mean age 61 ± 12 years, 75.6% male). Hypertension, current smoking, hyperlipidaemia, and diabetic mellitus were frequent among the patients (67.4, 45.7, 43.9, and 36.7%, respectively), while the other vascular risk factors including previous stroke or TIA and alcohol excess were less frequent (19.0 and 15.4%, respectively). Patients with higher total cSVD burden was significantly older and had severer ECAS. The frequency of hypertension was significantly higher in patients with higher total cSVD burden. This analysis indicated that that increasing ECAS severity (from no stenosis through to 100%) was independently associated with increasing total cSVD score after adjusting for other vascular risk factors (odds ratio 1.76, 95% CI [1.16–2.69]).

Conclusions: In this study, high levels of ECAS from ultrasound evidence were associated with coexisting advanced cerebral cSVD in ischemic stroke patients of suspected small or large artery origin. Further studies are required to determine if and how extracranial arterial imaging helps reduce cSVD burden or improves cognitive function.

White matter hyperintensities and their subtypes in patients with carotid artery stenosis: a systematic review and meta-analysis

OBJECTIVE

We aimed to perform a systematic review and meta-analysis to clarify the association between white matter hyperintensities (WMHs) and carotid artery (CA) stenosis.

STUDY DESIGN

Systematic review and meta-analysis.

PARTICIPANTS

CA stenosis was set at ≥50%, and WMHs were assessed by MRI and evaluated quantitatively or semiquantitatively.

DATA SOURCES

A comprehensive literature search was performed in PubMed, EMBASE and Cochrane Library for studies evaluating the association between WMHs and CA stenosis ≥50% from inception to 13 September 2017.

MAIN OUTCOMES AND MEASURES

Standardised mean difference (SMD) with 95% CI was used to evaluate the association between WMHs and CA stenosis. Results were presented in a forest plot with a fixed-effects model or random-effects model. We assessed the quality of included studies using the Newcastle-Ottawa Scale. Funnel plots and Egger's and Begg's tests were conducted to assess publication bias. Sensitivity analysis was performed to evaluate the influence of each individual study.

RESULTS

Eight studies enrolling 677 patients were included. There was a positive relationship between the total WMHs and CA stenosis, with a pooled fixed-effects SMD of 0.326 (95% CI 0.194 to 0.459, p=0.000). Heterogeneity and publication bias were low among these studies. Subgroup analysis of three studies enrolling 225 patients showed an association between periventricular WMHs and CA stenosis, with a pooled fixed-effects SMD of 0.412 (95% CI 0.202 to 0.622, p=0.000).

CONCLUSION

This meta-analysis showed that the total WMHs and periventricular WMHs were associated with CA stenosis. WMHs may be considered as an individual risk stratification score when choosing a proper plan for therapy of CA stenosis.

Extent of Microstructural Tissue Damage Correlates with Hemodynamic Failure in High-Grade Carotid Occlusive Disease: An MRI Study Using Quantitative T2 and DSC Perfusion

BACKGROUND AND PURPOSE

Chronic hemodynamic impairment in high-grade carotid occlusive disease is thought to cause microstructural abnormalities that might be subclinical or lead to subtle symptoms including cognitive impairment. Quantitative MR imaging allows assessing pathologic structural changes beyond macroscopically visible tissue damage. In this study, high-resolution quantitative T2 mapping combined with DSC-based PWI was used to investigate quantitative T2 changes as a potential marker of microstructural damage in relation to hemodynamic impairment in patients with unilateral high-grade carotid occlusive disease.

MATERIALS AND METHODS

Eighteen patients with unilateral high-grade ICA or MCA stenosis/occlusion were included in the study. T2 values and deconvolved perfusion parameters, including relative CBF, relative CBV, and the relative CBF/relative CBV ratio as a potential indicator of local cerebral perfusion pressure, were determined within areas with delayed TTP and compared with values from contralateral unaffected areas after segmentation of normal-appearing hypoperfused WM and cortical regions. Hemispheric asymmetry indices were calculated for all parameters.

RESULTS

Quantitative T2 was significantly prolonged (P < .01) in hypoperfused tissue and correlated significantly (P < .01) with TTP delay and relative CBF/relative CBV reduction in WM. Significant correlations (P < .001) between TTP delay and the relative CBF/relative CBV ratio were found both in WM and in cortical areas.

CONCLUSIONS

Quantitative T2 can be used as a marker of microstructural tissue damage even in normal-appearing GM and WM within a vascular territory affected by high-grade carotid occlusive disease. Furthermore, the extent of damage correlates with the degree of hemodynamic failure measured by DSC perfusion parameters.

Enlarged Virchow Robin spaces associate with cognitive decline in multiple sclerosis

The clinical significance of Virchow Robin spaces (VRS) in inflammatory brain disorders, especially in multiple sclerosis (MS), is still undefined. We analysed enlarged VRS (eVRS) by means of phase sensitive inversion recovery (PSIR) MRI sequence and investigated their association with inflammation or brain atrophy, and to clinical or physical disability. Forty-three MS patients (21 clinically isolated syndrome suggestive of MS [CIS], 15 RRMS, 7 progressive [PMS]) and 10 healthy controls (HC) were studied. 3DT1, 3DFLAIR and 2DPSIR images were obtained with a 3T MRI scanner. eVRS number and volume were calculated by manual segmentation (ITK-SNAP). Freesurfer was used to assess brain parenchymal fraction (BPF). All patients underwent clinical (EDSS) and cognitive (Rao’s BRB and DKEFS) evaluation.

eVRS number and volume resulted significantly higher on 2D-PSIR compared to both 3D-T1 (p<0.001) and 3D-FLAIR (p<0.001) and were significantly increased in CIS compared to HC (p<0.05), in PMS and RRMS compared to CIS (p<0.001) and in male versus female patients (p<0.05). eVRS volume increased significantly with disease duration (r = 0.6) but did not correlate with EDSS. eVRS significantly correlated with SPARTd (r = -0.47) and DKEFSfs (r = -0.46), especially when RRMS and PMS were merged in a single group (r = 0.89, p = 0.002 and r = 0.66, p = 0.009 respectively), while no correlation was found with BPF (r = 0.3), gadolinium-enhancing lesions (r = 0.2) and WMT2 lesion volume (r = 0.2). 2DPSIR allowed the detection of an impressive higher number of eVRS compared to 3DT1 and 3DFLAIR. eVRS associate with SPARTd and DKEFSfs failure in relapse-onset MS, suggesting they may contribute to cognitive decline in MS.

Brain Atrophy Correlates with Severe Enlarged Perivascular Spaces in Basal Ganglia among Lacunar Stroke Patients

BACKGROUND

Enlarged perivascular spaces (EPVS) correlate with cognitive impairment and incident dementia. However, etiologies for severe basal ganglia EPVS (BG-EPVS) are still unclear. Our aim was to investigate the independent risk factors for severe BG-EPVS in patients with acute lacunar stroke.

METHODS

We prospectively identified patients with lacunar stroke (diameter on DWI ≤ 20mm) from Jan 2011 to May 2015. Patients with severe BG-EPVS were identified on T2 weighted MRI. Age (± 1 year) and sex matched controls were also recruited in the same population (two controls for one case). Vascular risk factors, clinical data, EPVS in centrum semiovale (rated 0 to 4), white matter hyperintensities (WMH) (by Fazekas scale), brain atrophy (rated 0 to 6) were compared between two groups. Logistic regression was performed to determine independent risk factors for severe BG-EPVS.

RESULTS

During study period, 89 patients with severe BG-EPVS and 178 matched controls were included. Vascular risk factors did not differ between two groups. Patients with severe BG-EPVS had lower level of HbA1c and diastolic BP at admission, but presented with larger infarct size, more severe WMH (including total WMH, periventricular WMH and deep WMH) and brain atrophy. In logistic regression, brain atrophy (OR = 1.40; 95%CI 1.13, 1.73) and deep WMH (OR = 1.88; 95%CI 1.24, 2.83) were independent risk factors for severe BG-EPVS.

CONCLUSIONS

Brain atrophy and deep WMH are independent risk factors for severe BG-EPVS, supporting the hypothesis that brain atrophy may be associated with the development of EPVS in basal ganglia.

Brain diffusion changes in unilateral carotid artery stenosis with non-shunt endarterectomy: Correlation with white matter lesions

OBJECTIVE

Carotid stenosis is associated with hemodynamic cerebral ischemia. Diffusion-weighted MR imaging allows for the assessment of changes related to alterations in tissue integrity. The aim of this study was to investigate (a) whether white matter lesions (WML) and apparent diffusion coefficient (ADC) values differ between ipsilateral and contralateral hemispheres, (b) whether ADC values are related to WMLs and common vascular risk factors, and (c) whether ADC values differ after carotid endarterectomy (CEA) without a shunt in patients with unilateral internal carotid artery stenosis (ICAS).

METHODS

Twenty-five patients (16 men, 9 women; mean age of 68 years) with unilateral ICAS (≥ 70% carotid stenosis) were assessed with brain MRI before and after CEA, prospectively. Two experienced radiologists scored the WMLs. Bilateral ADC values in anterior and posterior periventricular WM, occipital WM, and thalamus were evaluated on preoperative and postoperative MRI. Differences in ADC values and WML scores between the two hemispheres were assessed and associations between ADC values, WML scores, and explanatory variables (e.g., age, sex, vascular risk factors) were analyzed.

RESULTS

WMLs were significantly greater and ADC values were elevated in the ipsilateral cerebral WM. After CEA, ADC values rapidly decreased but remained higher than within the contralateral hemisphere. Ipsilateral hemispheric ADC values were associated with basal ganglia WMLs. No association between ADC values and vascular risk factors was found.

CONCLUSION

ICAS is associated with increased diffusion in normal-appearing WM in comparison to more prominent chronic ischemic lesions. CEA has a partial effect on diffusion. These cerebral changes may be related to chronic low-grade ischemic damage that is induced by ICAS.