Covert Vascular Brain Injury Markers Tied to Stroke, Dementia, Death

I can't imagine any insurance company paying for this. Probability would suggest that is it cheaper when you factor in that 33% of strokes die. My doctor did tell me I had white matter hyperintensities but never showed me them. He was worthless.

Covert Vascular Brain Injury Markers Tied to Stroke, Dementia, Death

Meta-analysis: incidental MRI findings suggest problems down the road

• by Judy George, Contributing Writer, MedPage Today October 22, 2018
• This article is a collaboration between MedPage Today® and:
  

Action Points

• Covert (silent) vascular brain injury findings on magnetic resonance imaging (MRI) had major clinical significance for older adults.
• There was evidence that white matter hyperintensities, brain infarcts, and cerebral microbleeds were associated with an increased risk of stroke (both hemorrhagic and ischemic for all markers), dementia, and death.

Covert (silent) vascular brain injury findings on magnetic resonance imaging (MRI) had major clinical significance for older adults, a systematic review found.
In a meta-analysis that spanned 16,000 community-dwelling older persons, white matter hyperintensity burden, brain infarcts, and cerebral microbleeds were tied to increased risk of incident stroke, dementia, and death, according to Stephanie Debette, MD, PhD, of the University of Bordeaux in France, and colleagues.
When these markers were present, the risk for ischemic stroke doubled, the risk for intracerebral hemorrhage tripled, and the increased risk of death was 1.5 to two times higher, the researchers reported in JAMA Neurology.
"These markers are very frequent among people who usually do not have any symptoms and are mainly detected on brain MRI," said Ralph Sacco, MD, MS, of the University of Miami and president of the American Academy of Neurology, who was not involved with the study.
"Currently there are no evidence-based guidelines to help us decide on the best treatments to improve outcomes among individuals who have these covert markers," Sacco told MedPage Today. "We greatly need randomized clinical trials to help guide our decisions."
The meta-analysis looked at 94 prospective, longitudinal cohort studies up to December 2017, assessing four MRI markers that are thought to reflect underlying cerebral small vessel disease: white matter hyperintensities of presumed vascular origin, MRI-defined covert brain infarcts, cerebral microbleeds, and perivascular spaces.
The analysis showed that extensive white matter hyperintensity burden (n=up to 14,529 participants) was associated with higher risks of the following:

• Incident stroke (HR 2.45; 95% CI 1.93-3.12; P<0.001)
• Ischemic stroke (HR 2.39; 95% CI 1.65-3.47; P<0.001)
• Intracerebral hemorrhage (HR 3.17; 95% CI 1.54-6.52; P=0.002)
• Dementia (HR 1.84; 95% CI 1.40-2.43; P<0.001)
• Alzheimer's disease (HR 1.50; 95% CI 1.22-1.84; P<0.001)
• Death (HR 2.00; 95% CI 1.69-2.36; P<0.001)

MRI-defined covert brain infarcts (n=up to 16,012) for were tied to higher risks of:

• Incident stroke (HR 2.38; 95% CI 1.87-3.04; P<0.001)
• Ischemic stroke (HR 2.18; 95% CI, 1.67-2.85; P<0.001)
• Intracerebral hemorrhage (HR 3.81; 95% CI 1.75-8.27; P<0.001)
• Death (HR 1.64; 95% CI 1.40-1.91; P<0.001)

And the presence of cerebral microbleeds (n=up to 15,693) was associated with increased risk of:

• Stroke (HR 1.98; 95% CI 1.55-2.53; P<0.001)
• Ischemic stroke (HR 1.92; 95% CI, 1.40-2.63; P<0.001)
• Intracerebral hemorrhage (HR 3.82; 95% CI 2.15-6.80; P<0.001)
• Death (HR 1.53; 95% CI 1.31-1.80; P<0.001)

There were too few studies about perivascular spaces (n=up to 4,587) to conduct meta-analyses, but data suggested that a high burden of perivascular spaces was tied to increased risk of stroke, dementia, and death, Debette and co-authors noted.
"From a practical perspective, the discovery of these MRI markers should prompt detailed assessment of a person's risk for stroke and dementia and careful evaluation of the benefit–risk ratio for available preventive strategies," the team concluded.
This study clarifies that "while the slow, chronic accumulation of vascular damage these lesions represent may not be immediately evident, it will build up over time and lead to substantial disability and mortality," noted Alessandro Biffi, MD, of Massachusetts General Hospital in Boston, who was not involved with the study.
"Although these lesions are often identified incidentally on brain scans done for other reasons, we should take their presence seriously and counsel patients accordingly," he told MedPage Today.
But "because of the nature of the data analyzed, the authors and the scientific community at large are unable to determine risk for stroke, dementia, or death for specific individuals, based on their unique brain imaging profile," Biffi added. "While we consider lifestyle modification and blood pressure control key, we lack specific goals and recommendations to guide clinical practice. This and other key aspects of the covert vascular brain injury phenomenon still await clarification in future studies."
Debette and her team listed several limitations to their study. Despite accounting for heterogeneity in the meta-analyses, residual sources of heterogeneity might be present. Most studies in the meta-analysis used HRs; ones that used odds ratios were pooled with HRs in meta-analyses. All sensitivity analyses suggested the study's findings were robust, however.

Researchers were supported by funds from the French National Research Agency, Fondation Leducq, the European Union's Horizon 2020 Research and Innovation Programme, the European Research Council, the European Union Joint Programme–Neurodegenerative Disease Research, and the National Institute for Health Research.

• Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

last updated 10.25.2018

• Primary Source

  JAMA Neurology

  Source Reference: Debette S, et al “Clinical significance of magnetic resonance imaging markers of vascular brain injury: A systematic review and meta-analysis” JAMA Neurology 2018; DOI:10.1001/jamaneurol.2018.3122.