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The contribution of acute infarcts to cerebral small vessel disease progression.

Ann Neurol. 2019 Jul 24. doi: 10.1002/ana.25556. [Epub ahead of print]

Authors/Editors: Ter Telgte A, Wiegertjes K, Gesierich B, Marques JP, Huebner M, de Klerk JJ, Schreuder FHBM, Araque Caballero MA, Kuijf HJ, Norris DG, Klijn CJM, Dichgans M, Tuladhar AM, Duering M, de Leeuw FE.
Publication Date: 2019



OBJECTIVE: To determine the contribution of acute infarcts, evidenced by diffusion-weighted imaging positive (DWI+) lesions to progression of white matter hyperintensities (WMH) and other cerebral small vessel disease (SVD) markers.

METHODS: We performed 10 monthly 3 T MRIs in 54 elderly individuals with SVD. MRI included high-resolution multi-shell DWI, and 3D FLAIR, T1 and SWI. We determined DWI+ lesion evolution, WMH progression rate (mL/month), and number of incident lacunes and microbleeds, and calculated for each marker the proportion of progression explained by DWI+ lesions.

RESULTS: We identified 39 DWI+ lesions on 21/472 DWI scans in 9/54 subjects. Of the 36 DWI+ lesions with follow-up MRI, two evolved into WMH, four into a lacune (three of which with cavity < 3 mm), three into a microbleed, and 27 were not detectable on follow-up. WMH volume increased at a median rate of 0.027 (0.005-0.073) mL/month, but was not significantly higher in subjects with DWI+ lesions compared to those without (p = 0.195). Of the two DWI+ lesions evolving into WMH on follow-up, one explained 23% of the total WMH volume increase in one subject, whereas WMH regressed in the other subject. DWI+ lesions preceded 4/5 incident lacunes, and 3/10 incident microbleeds.

INTERPRETATION: DWI+ lesions explain only a small proportion of the total WMH progression. Hence, WMH progression seems to be mostly driven by factors other than acute infarcts. DWI+ lesions explain the majority of incident lacunes and small cavities, and almost a third of incident microbleeds, confirming that WMH, lacunes, and microbleeds, although heterogeneous on MRI, can have a common initial appearance on MRI.

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