Study Differential Diagnosis in Patients Referred to ... · Central rii cellece i e ccess Journal of Neurological Disorders & Stroke Cite this article: Atalu A, Fattahzadeh G, Abbasi

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Journal of Neurological Disorders & Stroke

Cite this article: Atalu A, Fattahzadeh G, Abbasi V, Ahmadabadi F, Zarnesar S (2018) Study Differential Diagnosis in Patients Referred to Ardabil City Hospital with Periventricular Hypersignal Lesions. J Neurol Disord Stroke 6(3): 1147. 1/5

*Corresponding authorGhasem Fattahzadeh, Department of Neurology, Ardabil University of Medical Science, Ardabil, Iran, Email: [email protected]

Submitted: 08 October 2018

Accepted: 05 November 2018

Published: 10 November 2018

Copyright© 2018 Fattahzadeh et al.

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Keywords•Differential diagnosis•White matter lesions•Brain•Ardabil

Research Article

Study Differential Diagnosis in Patients Referred to Ardabil City Hospital with Periventricular Hypersignal LesionsAbolfazl Atalu1, Ghasem Fattahzadeh1*, Vahid Abbasi1, Farzad Ahmadabadi2, and Somayeh Zarnesar3

1Department of Neurology, Ardabil University of Medical Science, Iran2Department of Pediatrics, Ardabil University of Medical Science, Iran3Faculty of Medicine, Ardabil University of Medical Science, Ardabil, Iran

Abstract

Objective: The volume and number of lesions in white matter are indicators of brain health that related with disturbances and various illnesses such as cerebrovascular and cardiovascular diseases, psychiatric disorders, multiple sclerosis and systemic lupus erythematous. The present study was conducted to investigate the differential diagnosis of patients with periventricular hyper signal lesions which referred to the MRI unit of Ardabil city hospital.

Methods: This is a descriptive-analytical study that has been done on 100 patients referred to the MRI unit of Ardabil city Hospital which hyper signal lesions around ventricle were observed in their T2-MRI (Magnetic resonance image). The necessary information were collected by study the MRI report which confirmed by a specialist.

Results: 65% of patients were female and the rest were male. The average age of the patients was 54.14 ± 16.58 years. The majority of white matter lesions including sub cortical and periventricular lesions with 34% and only periventricular lesions with 28%. Most of the differential diagnosis included small vessel disease with 38% and demyelization with 20%. Sub cortical and periventricularlesions were observed in patients with diagnosis small vessel disease and unidentified bright objects and periventricularlesions in patients with diagnosis of demyelization and Alzheimer’s dementia.

Conclusion: This study showed that the frequency of observed white matter lesions in the MRI of patients were different by diagnosed of small vessel disease, Unidentified Bright Objects, demyelization, Alzheimer’s dementia and migraine that because of the small sample size it is suggested that similar studies with larger sample sizes be do nein the future.

INTRODUCTIONSome parts of brain white matter that is observed as bright

areas in MRI with a T2 appearance are called white matter lesions (WML) which generally seen in MRI images of elderly people and its prevalence is between 5.3%-100% [1-5]. Studies have shown that WML are perivascular dilated spaces or demyelination caused by localized bloodstream which can be caused by various factors such as ischemia, cerebrovascular bleeding, gliosis, damage to the wall of small blood vessels, the wall split between the cerebrospinal fluid and the brain or destruction and deformation of myelin sheath [6,7]. In totally, the volume and number of lesions in white matter are the health indicators of the brain which related various disorders and diseases such as cerebrovascular disease, cardiovascular disease, dementia, mental disorders, bipolar disorder and schizophrenia, neurological disorders such as multiple sclerosis and normal pressure hydrocephalus and inflammatory diseases such as systemic lupusery the matous [8-17]. One of the most useful methods for differentiating diseases

from MRI is to determine the location of the anomalies in the brain. Certainly the correct diagnosis of the cause of the selesions and the differentiation of diseases from each other is very importance in patient management and treatment process. The aim of this study was to investigate the differential diagnosis of patients with periventricular hyper signal lesions.

MATERIALS AND METHODSThis was a descriptive-analytical study that has been done

on 100 patients referred to the MRI unit of Ardabilcity hospital during year 2017 with hyper signal lesions around ventricle which confirmed by a T2 MRI and a specialist doctor. Necessary data including age, sex, clinical symptoms, type of lesion and its extent, area involved in MRI sequence and complementary tests collected by a checklist.

Statistical analysis Collected data analyzed using statistical methods in SPSS

version 16software. P<0.05 was considered as meaningful.

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MRI protocol and WML classification

White matter disorders or leukoencephalopathies comprise all disorders that exclusively or predominantly affect the white matter of the brain. Leuko dystrophies are genetically determined leukoencephalopathies. There are many different leukoencephalopathies, which can occur at all ages, be progressive or static, and be genetic or acquired. MRI has proven to be pivotal in the diagnostic workup of patients with leukoencephalopathies. First, the presence of white matter abnormalities is usually established with MRI. CT may show white matter hypo density, but it is much less sensitive than MRI and gives no details. Secondly, it has been shown repeatedly that individual leukoencephalopathies present themselves with distinct patterns of MRI abnormalities, which are homogeneous among patients with the same disorder and different in patients with different disorders, indicating the high diagnostic value of MRI patterns. MRI pattern recognition is a way to systematically analyze many details on MR images and integrate these into

patterns per disease. The scoring of MRI details is easy, but it is time consuming and not practical in routine practice. Systematic MRI pattern recognition is important for research purposes, especially for the definition of novel disorders or description of phenotypic variation. For routine practice, the main lines of MRI pattern recognition suffice. They help to establish a reasonably short differential diagnosis. We endeavored to provide a simple scheme to facilitate diagnostics, mainly based on MRI details (Figure 1) [18].

White matter lesions, commonly seen on MRIs of elderly people, are related to various geriatric disorders, including cerebrovascular diseases, cardiovascular diseases, dementia, and psychiatric disorders. Currently, white matter lesions are divided into periventricular white matter lesions and deep white matter lesions. We have reviewed the distinctions between periventricular white matter lesions and deep white matter lesions in terms of etiology, histopathology, functional correlates, and imaging methodologies. We suggest a new sub classification

Figure 1 MRI algorithm.

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of white matter lesions that might have better etiological and functional relevance than the current simple dichotomization. The new categories are juxtaventricular, periventricular, deep white, and juxtacortical. This new classification scheme might contribute to reducing the heterogeneity of white matter lesion findings in future research. The areas in cerebral white matter that appear hyper intense on T2-weighted magnetic resonance imaging (MRI) and hypo intense on computed tomography are commonly referred to as white matter lesions (WMLs). White matter lesions are commonly seen on MRI of elderly people [19].

RESULTSThe average age of the patients was 54.14 ± 16.58 in range

17-86 years old and most of patients with 25% were in the age group 40-49 years (Figure 2). 65% of the patients were female and the rest were male. Most of the white matter lesions were related to sub cortical and periventricularlesions with 34% and only periventricular lesions with 28% that sub cortical and periventricular lesions with 41.5% prevalent among women and periventricularlesions with40% prevalent among men which was no statistically significant (Figure 3). The lowest average age with 45 ± 14.4 years was for frontal, periventricular and sub cortical lesions and the highest mean age was 59.5 ± 14.8 for parito-occipital and periventricular lesions and the difference was not statistically significant (Table 1). The most of sub cortical and periventricularlesions were seen in patients with small vessel disease (55.3%) and Unidentified Bright Objects (40%)

and the most of periventricular lesions were seen in patients with Alzheimer’s dementia (67.7%) and the most frontal and periventricular lesions were seen in patients diagnosed with migraine (33.3%) and migraine with small vessel disease (42.9%) (Table 2). Hypertension was seen in 51% and chronic headache in 46% of patients and the most final diagnoses were small vessel disease with 38% and demyelination with 20% which was not statistically significant (Figure 4).

DISCUSSIONWhite matter lesions are commonly seen in the MR scan of

healthy and unhealthy elderly people and it can be a sign of a benign to serious situation .In the present study the most WML were sub cortical and periventricular lesions with 34% and periventricular lesions with28%. In Lee wand et al, study, 8% of patients had no sub cortical lesions, 20% had no periventricular lesions and 5% had no lesions which the extent of Leeuw study was more than our study [2]. The highest average age of this study was related to paritooxipitaland periventricular lesions and the lowest was related to frontal, periventricular and sub cortical lesions. Ina study, 13% of elderly patients in age group 60-70 had no sub cortical lesions and32% had no periventricularlesions as while this value was less than 5% for subjects in age group 80-90years, respectively [2]. In many studies, the frequently distribution of WML has been reported based on age and sex and the prevalence and severity of WML in women is more than men. In the present study, the number of women with WML was more than men and periventricular and sub cortical lesions respectively were the most common lesions among men and women ,however in some studies there was no significant difference between two sexes [1,2].White matter lesions affects mental and physical performance and it is associated with degenerative changes in small vessels and various cerebrovascular that in line with other studies in this study, the small vessel disease with 38% was the most diagnostic disease [2,15,16]. The prevalence of white matter lesions related with perceived defects in patients with Alzheimer’s so that, more lesions are associated with higher beta Amyloid deposition in these patients. Also, some studies have shown lesions in white matter and sometimes in the cerebral cortex of patients with migraine. In this study, frequency of migraines and Alzheimer’s dementia were 18% and 12%respectively, that migraine was associated with periventricularlesions and Alzheimer’s dementia was associated

Figure 2 The age groups of patients.

Figure 3 The frequency of lesions in patients.

Figure 4 The frequency of chronic diseases in patients.

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Table 1: Relation between type of lesions and demographic data.

Type of lesions

Sex

p-value Mean of age p-valueTotal

m f

n % n % n %

Subcortical +Periventricular 8 22.9 27 41.5

0.31

54±18.2

0.25

35 35

Periventricular 14 40 13 20 59.2±12.9 27 27

Frontal+Periventricular 6 17.1 12 18.5 52.6±18.7 18 18

Frontal+Subcortical+Periventricular 4 11.4 8 12.3 45±14.4 12 12

Parieto-occipital+Periventricular 2 5.7 4 6.2 59.5±14.8 6 6

Parieto-occipital+Periventricular+Subcortical 1 2.9 1 1.5 54.1±16.6 2 2

Table 2: Relation between type of lesions and final diagnosis.

DiagnosisType of lesions

Small vessel disease

Demyelina-tion

Migraine +small vessel

diseaseMigraine

Alzhe-imer's de-

mentia

Unidentified bright objects p-value

n % n % n % n % n % n %Subcortical+ periventricular 21 55.3 5 25 2 28.6 4 22.2 1 8.3 2 40 0.07

periventricular 5 13.2 6 30 2 28.6 4 22.2 8 67.7 2 40

Frontal+periventricular 3 7.9 3 15 3 42.9 6 33.3 2 16.7 1 20

Frontal+Subcortical+periventricular 7 18.4 2 10 0 0 2 11.1 1 8.3 0 0

Parieto-occipital+periventricular 1 2.6 3 15 0 0 2 11.1 0 0 0 0

Parieto-occipital+periventricular+Subcortical

1 2.6 1 5 0 0 0 0 0 0 0 0

with frontal and periventricularlesions. There is also evidence that per ventricular lesions associated with cognitive decline and sub cortical lesions are associated with depression. In the present study, sub cortical and periventricular lesions were associated with small vessel disease and periventricular with Alzheimer’s dementia [17-20]. Studies have shown that white matter lesions are strongly associated with vascular risk factors and it can be a sign of secondary inflammation due to ischemic injury. Also, the severity of brain white matter lesions can be used to identify people at risk for stroke, especially in combination with other cardiovascular risk factors such as high blood pressure and diabetes. In line with other studies in this study, half of the people had heart disease and 22% had diabetes [15,21,22].

CONCLUSIONThe results of this study showed that the most of white

matter lesions in MRI of patients with different types of diagnosis (small vessel disease, Unidentified Bright Objects, demyelination, Alzheimer’s dementia and migraine) were different. Of course given the small sample size, it is suggested that similar studies with larger sample sizes be proposed in the future.

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Atalu A, Fattahzadeh G, Abbasi V, Ahmadabadi F, Zarnesar S (2018) Study Differential Diagnosis in Patients Referred to Ardabil City Hospital with Periventricular Hypersignal Lesions. J Neurol Disord Stroke 6(3): 1147.

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