Weinstein et. al evaluated patients from the Framingham Heart Study. The looked at different qualities of brain imaging (such as total brain volume, hippocampal volume, and white matter hyperintensity volume) to assess if there was a correlation with stroke and probable Alzheimer’s disease (AD). They also used cognitive function tests including but not limited to: Trail Making A, Trail Making B, Boston naming test, and Controlled Word Association Fluency test.

Poor function in verbal and visual memory predicted AD. Lower hippocampal volume and low total cortical volume was associated with AD. Poor executive function (such as poor performance in Trailing Making B) marked increased risk for stroke. For MRI predictors, higher white matter hyperintensity burden and low total cortical volume predicted stroke. The authors conclude that markers of vessel disease such as cognitive decline and MRI findings may precede a clinical stroke. In addition, they remark that they have found not only white matter hyperintensity a marker for stroke, but also total cortical volume. 

It makes sense to me that cortical hypertrophy, and evidence of decline in executive function maybe related to vascular disease, and such, increase the odds of these patients of having a clinical stroke, but it’s not quite clear if this will do anything for my practice. There is no clear evidence that those with clinical silent white matter disease should get the same aggressive secondary prevention of stroke as those who have clinically manifested with the condition. However, this study may suggest that we should evaluate if patients with clinically silent vascular disease may benefit from preventative treatment such as antiplatelet therapy.

My current practice when  I see a consult for incidental white matter disease (this is not that infrequent actually) is to assess the patient’s other risk factors and Framingham risk scores and make recommendations based on the risk/benefit of antiplatelet use for that category of patients. I am not sure if this will sway me towards putting elderly women with an abnormal brain scan(who tend to have higher bleeding complications for antithrombotic therapy) on aspirin unless they have other vascular risk factors.

What do you do? How do you see study affecting your clinical practice? Leave your comments below.