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Vol. 39, No. 2, 1998
Issue release date: February 1998
Eur Neurol 1998;39:80–89

White Matter Changes on CT and MRI: An Overview of Visual Rating Scales

Scheltens P. · Erkinjunti T. · Leys D. · Wahlund L.-O. · Inzitari D. · del Ser T. · Pasquier F. · Barkhof F. · Mäntylä R. · Bowler J. · Wallin A. · Ghika J. · Fazekas F. · Pantoni L.
Departments of a Neurology and b Diagnostic Radiology, Academisch Ziekenhuis VU, Amsterdam, The Netherlands; c Neurology and d Radiology, University of Helsinki, Finland; e Neurology, Hôpital Roger-Salengro, Lille, France; f Geriatric Medicine, Huddinge Hospital, Stockholm, g Psychiatry, Mölndal Hospital, Mölndal, Sweden; h Neurological and Psychiatric Sciences, University of Florence, Italy; i Neurology, Hospital Severo Ochoa, Madrid, Spain; j Clinical Neuroscience, Charing Cross Hospital, London, UK; k Neurology, CHUV, Lausanne, Switzerland; l Universitätsklinik für Neurologie, Graz, Austria

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Since the recognition of white matter changes on CT (leukoaraiosis), rating scales for the location and severity of white matter changes have been developed, mainly for research purposes, to investigate factors such as the relation with cognition, risk factors, and pathology. The main purpose of rating scales is to provide scores that can be used in statistical analyses. The development of the NINDS-AIREN criteria for vascular dementia have introduced a new application for these rating scales in investigating and delineating the amount of white matter changes on CT/MRI sufficient to fulfill the criteria. Furthermore, in Alzheimer’s disease, recognition of white matter changes may serve to delineate homogeneous groups and help to identify patients with different symptomatology. We reviewed the existing rating scales for CT and MRI and judged their properties and reliability. The ideal rating scale does not yet exist, but different rating scales may serve different purposes, for which some recommendations are made.

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  1. McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM: Clinical diagnosis of Alzheimer’s disease: Report of NINCDS-ADRDA work group under the auspices of Department of Health and Human Services Task Force on Alzheimer’s Disease. Neurology 1984;34:939–944.
  2. Román GC, Tatemichi TK, Erkinjuntti T, et al: Vascular dementia: Diagnostic criteria for research studies. Report of the NINDS-AIREN International Work Group. Neurology 1993;43:250–260.
  3. Fazekas F, Schmidt R, Fazekas G, Kapeller P: The relevance of white matter changes to vascular dementia; in Leys D, Scheltens Ph (eds): Vascular Dementia. Dordrecht, ICG Publications, 1994, pp 47–54.
  4. Scheltens Ph, Kamphorst W, Barkhof F, et al: Histopathological correlates of white matter changes on MRI in Alzheimer’s disease and normal aging. Neurology 1995;45:883–888.
  5. Lopez O, Becker JT, Jungreis CA, Rezek D, Estol C, Boller F, DeKosky ST: Computed tomography – but not magnetic resonance imaging – identified periventricular white matter lesions predict symptomatic cerebrovascular disease in probable Alzheimer’s disease. Arch Neurol 1995;52:659–664.
  6. Steingart A, Hachinski VC, Lau C, Fox AJ, Diaz F, Cape R, Lee D, Inzitari D, Merskey H: Cognitive and neurologic findings in subjects with diffuse white matter lucencies on computed tomographic scan (leuko-araiosis). Arch Neurol 1987;44:32–35.
  7. Steingart A, Hachinski VC, Lau C, Fox AJ, Fox H, Lee D, Inzitari D, Merskey H: Cognitive and neurologic findings in demented patients with diffuse white matter lucencies on computed tomographic scan (leuko-araiosis). Arch Neurol 1987;44:36–39.

    External Resources

  8. Jellinger K, Danielczyk W, Fischer P, Gabriel E: Clinico-pathological analysis of dementia disorders in the elderly. J Neurol Sci 1990;95:239–258.
  9. Boone KB, Miller BL, Lesser JM, et al: Neuropsychological correlates of white-matter lesions in healthy elderly subjects. A threshold effect. Arch Neurol 1992;49:549–554.
  10. Blennow K, Wallin A, Uhlemann C, Gottfries CG: White matter lesions on CT in Alzheimer patients: Relation to clinical symptomatologic and vascular factors. Acta Neurol Scand 1991;83:187–193.
  11. Erkinjuntti T, Gao F, Lee DH, Eliasziw M, Merskey H, Hachinski VC: Lack of difference in brain hyperintensities between patients with early Alzheimer’s disease and control subjects. Arch Neurol 1994;51:260–268.
  12. Scheltens Ph, Barkhof F, Valk J, Algra PR, Gerritsen Van Der Hoop R, Nauta J, Wolters ECh: White matter lesions of magnetic resonance imaging in Alzheimer’s disease: Evidence for heterogeneity. Brain 1992;115:735–743.

    External Resources

  13. O’Brien JT, Ames D, Schwietzer I: White matter changes in depression and Alzheimer’s disease: A review. Int J Geriatr Psychiatry 1996;11:681–694.

    External Resources

  14. Wallin A, Blennow K: Heterogeneity of vascular dementia – Mechanisms and subgroups. Int J Geriatr Psychiatry Neurol 1993;6:177–188.
  15. Hachinsky VC: Preventable senility: A call for action against the vascular dementias. Lancet 1992;340:645–648.
  16. Erkinjuntti T, Hachinski VC: Rethinking vascular dementia. Cerebrovasc Dis 1993;3:3–23.
  17. Hachinski VC, Potter P, Merskey H: Leuko-araiosis. Arch Neurol 1987;44:21–23.
  18. Bogousslavsky J: Leucoencéphalopathie, leucoaraïose et infarctus cérébraux. Rev Neurol (Paris) 1988;144:11–17.

    External Resources

  19. Lotz PR, Ballinger WE Jr, Quisling RG: Subcortical arteriosclerotic encephalopathy: CT spectrum and pathologic correlation. Am J Neuroradiol 1986;7:817–822.
  20. Rezek DL, Morris JC, Fulling KH, Gado MH: Periventricular white matter lucencies in senile dementia of the Alzheimer type and in normal aging. Neurology 1987;37:1365–1368.
  21. Leys D, Pruvo JP, Parent M, Vermersch P, Soetaert G, Steinling M, Delacourte A, Défossez A, Rapoport A, Clarisse J, Petit H: Could wallerian degeneration contribute to ‘leuko- araiosis’ in subjects free of any vascular disorder? J Neurol Neurosurg Psychiatry 1991;54:46–50.
  22. Inzitari D, Diaz F, Fox A, Hachinski VC, Steingart A, Lau C, Donald A, Wade J, Mulic H, Merskey H: Vascular risk factors and leuko-araiosis. Arch Neurol 1987;44:42–47.
  23. Jørgensen HS, Nakayama H, Raaschou HO, Olsen TS: Leukoaraiosis in stroke patients. The Copenhagen stroke study. Stroke 1995;26:588–592.
  24. DeCarli C, Grady CL, Clark CM, Katz DA, Brady DR, Murphy DGM, Haxby JV, Salerno JA, Gillette JA, Gonzalez-Aviles A, Rapoport SI: Comparison of positron emission tomography, cognition, and brain volume in Alzheimer’s disease with and without severe abnormalities of white matter. J Neurol Neurosurg Psychiatry 1996;60:158–167.
  25. Erkinjuntti T, Ketonen L, Sulkava R, Sipponene J, Vuorialho M, Iivanainen M: Do white matter changes on MRI and CT differentiate vascular dementia from Alzheimer’s disease? J Neurol Neurosurg Psychiatry 1987;50:37–42.
  26. Tarvonen-Schröder S, Kurki T, Räïhä, Sourander L: Leukoaraiosis and cause of death: A five year follow-up. J Neurol Neurosurg Psychiatry 1995;58:586–589.
  27. Aharon-Peretz J, Cummings JL, Hill MA: Vascular dementia and dementia of the Alzheimer type: Cognition, ventricular size and leuko-araiosis. Arch Neurol 1988;45:719–721.

    External Resources

  28. Wallin A, Blennow K, Gottfries CG, Langstrom G, Uhlemann C: White matter low attenuation on CT in dementia of the Alzheimer type and vascular dementia. Acta Neurol Scand 1989;80:518–523.
  29. Van Swieten JC, Hijdra A, Koudstaal PJ, van Gijn J: Grading white matter lesions on CT and MRI: A simple scale. J Neurol Neurosurg Psychiatry 1990;53:1080–1083.
  30. Streifler JY, Eliasziw M, Benavente OR, Hachinski VC, Fox AJ, Barnett HJM: Lack of relationship between leukoaraiosis and carotid artery disease. Arch Neurol 1995;52:21–24.
  31. Leys D, Pruvo JP, Scheltens Ph, Rondepierre Ph, Godefroy O, Leclerc X, De Reuck J: Leuko-araiosis: Relationship with the types of focal lesions occurring in acute cerebrovascular disorders. Cerebrovasc Dis 1992;2:169–176.
  32. Charletta D, Gorelick PB, Dollear TJ, Freels S, Harris Y: CT and MRI findings among African-Americans with Alzheimer’s disease, vascular dementia and stroke without dementia. Neurology 1995;45:1456–1461.
  33. Erkinjuntti T, Benavente O, Eliasziw M, Munoz DG, Sulkava R, Haltia M, Hachinski VC: Diffuse vacuolization and arteriolosclerosis in the frontal white matter occurs in vascular dementia. Arch Neurol 1996;53:325–332.
  34. Leifer D, Buonanno FS, Richardson EP: Clinicopathologic correlations of cranial magnetic resonance imaging of periventricular white matter. Neurology 1990;40:911–918.
  35. Fazekas F, Kleinert R, Offenbacher H, et al: The morphologic correlate of incidental punctate white matter hyperintensities on MR images. Am J Neuroradiol 1991;12:915–921.
  36. Fazekas F, Kleinert R, Offenbacher H, et al: Pathologic correlates of incidental MRI white matter signal hyperintensities. Neurology 1993;43:1683–1689.
  37. Van Swieten JC, van den Hout JHW, van Ketel BA, Hijdra A, Wokke JHJ, van Gijn J: Periventricular lesions in the white matter on magnetic resonance imaging in the elderly. A morphometric correlation with arteriolosclerosis and dilated perivascular space. Brain 1991;114:761–774.

    External Resources

  38. Sze G, DeArmond S, Brant-Zawadski M, Davis RL, Norman D, Newton TH: Foci of MRI signal (pseudo lesions) anterior to the frontal horns: Histologic correlations of a normal finding. Am J Neuroradiol 1986;7:381–387.
  39. George AE, De Leon MJ, Kalnin A, et al: Leukoencephalopathy in normal and pathologic aging. 2. MRI of brain lucencies. Am J Neuroradiol 1986;7:567–570.

    External Resources

  40. Awad IA, Spetzler RF, Hodak JA, Awad CA, Carey R: Incidental subcortical lesions identified on magnetic resonance imaging in the elderly. 1. Correlation with age and cerebrovascular risk factors. Stroke 1986;17:1084–1089.
  41. Zimmerman RD, Fleming CA, Lee BCP, Saint-Louis LA, Deck MDF: Periventricular hyperintensity as seen by magnetic resonance: Prevalence and significance. Am J Roentgenol 1986;146:433–450.
  42. Brilliant M, Hughes L, Anderson D, Ghobrial M, Elble R: Rarefied white matter in patients with Alzheimer disease. Alzheimer Dis Assoc Disord 1995;9:39–46.
  43. Gerard G, Weisberg LA: MRI periventricular lesions in adults. Neurology 1986;36:998–1001.
  44. Fazekas F, Chawluk JB, Alavi A, Hurtig HI, Zimmerman RA: MR signal abnormalities at 1.5 T in Alzheimer’s dementia and normal aging. Am J Neuroradiol 1987;8:421–426.
  45. Leys D, Soetaert G, Petit H, Fauquette A, Pruvo JP, Steinling M: Periventricular and white matter magnetic resonance imaging hyperintensities do not differ between Alzheimer’s disease and normal aging. Arch Neurol 1990;47:524–527.
  46. Kozachuck WE, DeCarli C, Schapiro MB, Wagner EE, Rapoport SI, Horwitz B: White matter hyperintensities in dementia of Alzheimer’s type (DAT) and in healthy subjects without cerebrovascular risk factors. Arch Neurol 1990;47:1306–1310.
  47. Scheltens Ph, Barkhof F, Leys D, Pruvo JP, Nauta JJP, Vermersch P, Steinling M, Valk J: A semiquantitative rating scale for the assessment of signal hyperintensities on magnetic resonance imaging. J Neurol Sci 1993;114:7–12.
  48. Kertesz A, Black SE, Tokar G, Benke T, Carr T, Nicholson L: Periventricular and subcortical hyperintensities on magnetic resonance imaging: ‘rims, caps, and unidentified bright objects’. Arch Neurol 1988;45:404–408.
  49. Bracco L, Campani D, Baratti E, Lippi A, Inzitari D, Pracucci G, Amaducci L: Relation between MRI features and dementia in cerebrovascular disease patients with leukoaraiosis: A longitudinal study. J Neurol Sci 1993;120:131–136.
  50. Hunt AL, Orrison WW, Yeo RA: Clinical significance of MRI white matter lesions in the elderly. Neurology 1989;39:1470–1474.
  51. Herholz K, Heindel W, Rackl A, Neubauer W, Steinbrich W, Pietrzyk H, Korber E, Heiss WD: Regional cerebral blood flow in patients with leuko-araiosis and atherosclerotic carotid artery disease. Arch Neurol 1990;47:392–396.
  52. Shimada K, Kawamoto A, Matsubayashi K, Ozawa T: Silent cerebrovascular disease in the elderly. Stroke 1990;16:692–699.
  53. Wahlund LO, Agartz I, Almqvist O, et al: The brain in healthy aged individuals: MR imaging. Radiology 1990;174:675–679.

    External Resources

  54. Agartz I, Marions O, Saaf J, Wahlund L-O, Wetterberg L: Visual rating of magnetic resonance images of human cerebrospinal fluid spaces and white brain matter: Relation to sex and age in healthy volunteers. Magn Reson Imaging 1992;10:135–142.
  55. Harrel LE, Duvall E, Folks DG, et al: The relationship of high-intensity signals on magnetic resonance images to cognitive and psychiatric state in Alzheimer’s disease. Arch Neurol 1991;48:1136–1140.
  56. Figiel GS, Krishan KRR, Doraiswamy M, et al: Subcortical hyperintensities on brain magnetic resonance imaging: A comparison between late age onset and early onset depressed subjects. Neurobiol Aging 1991;26:245–247.

    External Resources

  57. Mirsen TR, Lee DH, Wong CJ, et al: Clinical correlates of white-matter changes on magnetic resonance imaging scans of the brain. Arch Neurol 1991;48:1015–1021.
  58. Liu CK, Miller BL, Cummings JL, Mehringer CM, Goldberg MA, Howng SL, Benson DF: A quantitative MRI study of vascular dementia. Neurology 1992;42:138–143.
  59. Davis PC, Gray L, Albert M, et al: The consortium to establish a registry for Alzheimer’s disease (CERAD). 3. Reliability of a standardized MRI evaluation of Alzheimer’s disease. Neurology 1992;42:1676–1680.
  60. Schmidt R, Fazekas F, Kleinert H, Offenbacher H, Gindl K, Payer W, Freidl K, Niederkorn K, Lechner H: Magnetic resonance imaging signal hyperintensities in the deep and subcortical white matter. A comparative study between stroke patients and normal volunteers. Arch Neurol 1992;49:825–827.
  61. Ylikoski R, Ylikoski A, Erkinjuntti T, Sulkava R, Raininko R, Tilvis R: White matter changes in healthy elderly persons correlate with attention and speed mental processing. Arch Neurol 1993;50:818–824.
  62. Breteler MM, van Amerongen NM, van Swieten JC, Claus JJ, Grobbee DE, van Gijn J, Hofman A, van Harskanp F: Cognitive correlates of ventricular enlargement and cerebral white matter lesions on magnetic resonance imaging. The Rotterdam study. Stroke 1994;25:1109–1115.
  63. Victoroff J, Mack WJ, Grafton ST, Schreiber SS, Chui HC: A method to improve interrater reliability of visual inspection of brain scans in dementia. Neurology 1994;44:2267–2276.
  64. Manolio TA, Kronmal RA, Burke GL, Poirier V, Oleary DH, Gardin JM, Fried LP, Steinberg EP, Bryan RN: Magnetic resonance abnormalities and cardiovascular disease in older adults. The cardiovascular health study. Stroke 1994;25:318–327.
  65. Longstreth WT, Manolio TA, Arnold A, Burke GL, Bryan N, Jungreis CA, Enright PL, Oleary D, Fried L: Clinical correlates of white matter findings on cranial magnetic resonance imaging of 3301 elderly people. The cardiovascular health study. Stroke 1996;27:1274–1282.
  66. Bryan RN, Manolio TA, Schertz LD, Jungreis C, Poirier VC, Elster AD, Kronmal AR: A method for using MR to evaluate the effects of cardiovascular disease on the brain: The cardiovascular health study. Am J Neuroradiol 1994;15:1625–1633.
  67. Fukuda H, Kitani M: Differences between treated and untreated hypertensive subjects in the extent of periventricular hyperintensities observed on brain MRI. Stroke 1995;26:1593–1597.
  68. Godefroy O, Rousseaux M, Leys D, Destée A, Scheltens Ph, Pruvo JP: Frontal lobe dysfunction in unilateral lenticulostriate infarcts. Prominent role of cortical lesions. Arch Neurol 1992;49:1285–1289.
  69. Coffey CE, Figiel GS, Djang WT, Weiner RD: Subcortical hyperintensity on magnetic resonance imaging: A comparison of normal and depressed elderly subjects. Am J Psychiatry 1990;147:187–189.

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