Original Article
A New Classification System for Ischemia Using a Combination of Deep and Periventricular White Matter Hyperintensities

https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.06.002Get rights and content

The Clinical Research Center for Dementia of South Korea (CREDOS) group developed a new classification system for ischemia using a combination of deep and periventricular white matter hyperintensities (WMHs). In this study, we aimed to evaluate the validity of the CREDOS ischemia classification system. A total of 352 patients with cognitive impairments were included. Their WMH scores were rated using the CREDOS WMH visual rating scale. These patients were divided into 3 groups according to the CREDOS ischemia classification system. The volume of WMH was also automatically measured. The number of lacunes and microbleeds (MBs) were counted. The CREDOS ischemia classification system was revised with factor analysis using vascular risk factors and cerebrovascular disease (CVD) markers (WMH volume, lacunes, and MBs). External validation was performed in another group of patients with cognitive impairment using multinomial logistic regression analysis. The CREDOS WMH visual rating scale showed excellent correlation with the automatically measured volume of WMH. The factor analysis showed that the severe group was expanded to D3P1 and D3P2 in the revised CREDOS ischemia classification system. In the validation group, the presence of vascular risk factors and the severity of CVD markers could be distinguished according to the revised CREDOS ischemia classification. We validated a newly developed classification system for ischemia. This simple visual classification system was capable of providing information on vascular risk factors and CVD markers by simply rating WMH on magnetic resonance imaging.

Section snippets

Participants

A total of 385 patients who had been diagnosed with MCI or dementia were identified. These patients underwent magnetic resonance imaging (MRI) scanning, including high-resolution T1-weighted volumetric imaging, at Samsung Medical Center from April 2000 to February 2008. The cognitive impairment of these patients was believed to be caused by either AD or vascular disruptions of small-vessel type. Patients with degenerative etiologies other than clinical or preclinical AD were excluded from the

Correlations between the CREDOS WMH Visual Rating Scale and the Automatically Measured Volume of WMH

The distribution of participants according to the CREDOS WMH visual rating scale is shown in Table 2. The number of patients classified as D3P1 and D3P2 was too small (n = 2, 1 for each group, respectively). The WMH visual rating scale showed good correlation with the volume of WMH. The correlation between the D score and the DWMH volume was excellent (Spearman ρ = .70, P < .001; Fig 1, A). The P score and PWMH volume showed excellent correlation (Spearman ρ = .81, P < .001; Fig 1, B). The

Discussion

Our major findings were as follows: first, the CREDOS WMH visual rating scale correlated with the automated measured volume of WMH, and second, a severe degree of DWMH might be important in the classification of severe ischemia regardless of the severity of PWMH. Finally, the revised CREDOS ischemia classification system distinguished the presence of vascular risk factors and the severity of CVD markers in the validation group. Taken together, our findings suggested that the revised CREDOS

Acknowledgment

This study was supported by a grant from the Korean Healthcare Technology R&D Project, Ministry for Health, Welfare and Family Affairs, Republic of Korea (no. A102065 and A120798); by the Korean Science and Engineering Foundation National Research Laboratory program grant funded by the Korean government (Ministry of Education, Science and Technology; 2011-0028333); and by the Samsung Medical Center Clinical Research Development Program grant (CRL-108011 and CRS 110-14-1).

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