From the Guidelines
White matter changes on brain MRI, often called white matter hyperintensities (WMH), require management focused on underlying vascular risk factors rather than the lesions themselves, as indicated by the most recent study in 2023 1. These changes appear as bright areas on T2-weighted or FLAIR MRI sequences and typically indicate small vessel disease in the brain. Management should target modifiable risk factors including:
- Hypertension (aim for BP <140/90 mmHg)
- Diabetes (target HbA1c <7%)
- Hyperlipidemia (consider statins like atorvastatin 10-80mg daily)
- Lifestyle modifications such as:
- Smoking cessation
- Regular exercise (150 minutes weekly)
- Weight management
- Limited alcohol consumption Antiplatelet therapy (aspirin 81mg daily) may be appropriate for those with cardiovascular risk factors. Cognitive assessment is important as WMH are associated with increased risk of cognitive decline, gait disturbances, and stroke, as supported by a study in 2022 2. The severity and progression of white matter changes correlate with prognosis - extensive or rapidly progressing lesions suggest poorer outcomes. These changes result from chronic ischemia, blood-brain barrier dysfunction, and inflammation affecting small penetrating arteries in the brain. Regular follow-up with neuroimaging every 1-2 years helps monitor progression, with more aggressive risk factor management indicated if lesions worsen significantly, as suggested by guidelines in 2019 3 and 2015 4, 5, 6.
Key considerations in the management of white matter changes include:
- The role of advanced MRI techniques in evaluating the course of MS pathology
- The importance of standardization in multicentre settings
- The potential for new MRI biomarkers to focus on additional and alternative aspects of MS pathology, such as grey matter pathology
- The need for individualized treatment approaches that include conventional targets and new targets such as neuroprotection and remyelination.
Overall, the management of white matter changes on brain MRI should prioritize the reduction of vascular risk factors and the monitoring of disease progression, with a focus on improving patient outcomes and reducing the risk of cognitive decline and other complications.
From the Research
Implications of White Matter Changes on MRI Brain
- White matter changes (WMC) on Magnetic Resonance Imaging (MRI) of the brain are commonly observed in the elderly and can reflect covert vascular brain injury 7
- These changes can produce substantial neurologic, psychiatric, and medical morbidity 7
- WMC are associated with an increased risk of ischemic stroke, particularly in small vessel stroke 8
- The presence and severity of WMC can be evaluated using modified Blennow/Fazekas scale and age-related white matter changes scale 8
Management of White Matter Changes
- Pharmacological agents that may have a role in mitigating WMC include those used for secondary stroke prevention 7
- Individuals with vascular white matter lesions on MRI may represent a potential target population likely to benefit from these therapies 7
- Management of WMC should also consider the underlying cause, such as small vessel disease or other pathogenic subtypes of ischemic stroke 8
Association with Dementia
- WMC are commonly seen in patients with Alzheimer's disease (AD) and mild cognitive impairment (MCI) 9, 10
- The amount and size of WMC in the periventricular and subcortical regions of the brain correlate with the severity of dementia 9
- WMC may play a role in the dementia process and accelerate cognitive decline in individuals with MCI 10
Diagnostic Considerations
- WMC should be separated from physiological changes in the ageing brain, such as periventricular caps and bands, and from dilated Virchow-Robin spaces 11
- Magnetic resonance angiography and diffusion-weighted MRI can be used to rule out large vessel disease and identify new ischemic lesions 11
- The differential diagnosis of WMC includes hereditary leukodystrophies, acquired disorders, and multiple sclerosis (MS) 11