Chapter 21 - Central nervous system imaging in diabetic cerebrovascular diseases and white matter hyperintensities

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Abstract

Diabetes mellitus is an important vascular risk factor for cerebrovascular disease. This occurs through pathophysiologic changes to the microcirculation as arteriolosclerosis and to the macrocirculation as large artery atherosclerosis. Imaging techniques can provide detailed visualization of the cerebrovasculature using CT (computed tomography) angiography and MR (magnetic resonance) angiography. Newer techniques focused on advanced parenchymal imaging include CT perfusion, quantitative MRI, and diffusion tensor imaging; each identifies brain lesion burden due to diabetes mellitus. These imaging approaches have provided insights into the diabetes mellitus brain and cerebral circulation pathophysiology. Imaging has taught us that diabetics develop cerebral atrophy, silent infarcts, and white matter disease more rapidly than other patient populations. Longitudinal studies are needed to quantify the rate and extent of such structural brain and blood vessel changes and how they relate to cognitive decline. Diabetes prevention and treatment strategies will then be possible to slow the development of such changes.

Introduction

Diabetes mellitus (DM) is an established independent risk factor for stroke and minimally symptomatic cerebral microvascular disease that may present with changes in cognition, gait, and mood causing high morbidity and mortality (Stegmayr and Asplund, 1995). This increased risk has been linked to pathophysiologic changes in the cerebral arteries/arterioles.

Central nervous system (CNS) imaging focusing on functional brain changes that occur in association with diabetes may shed light on the underlying mechanisms. Parenchymal brain imaging outlines brain structural anatomy, tissue status, perfusion abnormalities, atrophy, white matter hyperintensities, and small vessel brain injury. This, along with vascular imaging, which detects the abnormalities in the large extracranial and intracranial vessels, percentage of stenosis, plaque burden, occlusions, and collateral status, is commonly used in both research and clinical settings. Different imaging techniques can be used to diagnose and prognosticate DM-related acute ischemic stroke and chronic cerebrovascular disorders. These imaging modalities provide insight into the etiology of diabetes-related cerebral disorders and helps to identify candidates for acute stroke treatment and secondary preventive strategies.

We summarize different modalities of parenchymal and vascular imaging which can used in diabetic patients with acute and chronic disease manifestations. The chapter is divided into two sections. The first part provides an approach to imaging in a setting of the acute manifestations of diabetic cerebrovascular disorder. The second part will provide detailed insights into imaging used in diabetes-related chronic disorders such as lacunar infarcts, brain atrophy, and white matter hyperintensities (WMH). Methods quantifying WMH and future imaging prospects to define white matter integrity are also discussed.

Section snippets

Stroke in patients with diabetes mellitus

DM causes accelerated microvascular disease and generalized atherosclerosis that increases stroke risk 1.7–2.1-fold (Whisnant et al., 1996). Several differences exist in the manifestations of stroke in diabetic subjects as compared to nondiabetic patients. For example, ischemic stroke is proportionally more common than hemorrhagic stroke in diabetic patients compared to the general population (11: 1 versus 5: 1) (Roehmboldt et al., 1983). In the Honolulu Heart Study, the incidence of ischemic

Utility of carotid Doppler

Duplex ultrasonography is a noninvasive method to assess preclinical atherosclerosis and plaques in peripheral, extracranial carotid and vertebral arteries. The B-mode technique within carotid duplex can provide a measure of intima-media thickness (IMT). The IMT comprises endothelial cells, connective tissues, smooth muscle and is the site for lipid streak formation, and plaque formation, which may form a nidus for platelet aggregation and thrombus formation, with subsequent large artery

Conclusions

Imaging of cerebrovascular diseases has evolved considerably over the past few decades. In the setting of acute ischemic stroke with DM, CT imaging accompanied by CT angiography and whole brain coverage CT perfusion appear to be the most practical tools for acute stroke assessment. Tissue fate, occlusion site, and collateral status are crucial elements for acute stroke decision making even in diabetic subjects. MRI provides an alternative approach to CT but further work is needed to standardize

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