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Tuesday, September 16, 2014
White matter microinfarcts
My mother is a 74 y/o who has suffered from vertigo for several years. Her gait is very unstable, she says she feels she is walking on air. Recently she has an MRI and MRA of the brain. The findings are as follows: "There are multiple scattered periventricular and subcortical white matter high-signal density focal lesions on T2W and flair images consistent with white matter microinfarcts, probably related to samll vessel ischemic disease. The changes are considered mild to moderate, more than expected for patient`s age. Water diffusion images of the brain demonstrate no evident acute or subacute cerebral infarct. There is no cortical based cerebral infarct, SOL, or hemorrahage. The ventricles, cisterns, and subarachnoid spaces appear well preserved for the patient`s age without evident involutional changes. the visualized cranial nerves appear unremarkable. MR arteriography of the intracerebral corotid arties, bsilar artery, Circle of Willis and cerebral arteris demonstrate no evident stenotic lesion, aneurysm or AVM.
Does the above findings mean that my mother had a stroke? Today she had a carotid u/s to see if there is any blockage. Could her vertigo, which she`s had now for years, but seem to getting worst be related to these findings? Or could she also have an inner ear problem? Her Neurologist believe that this will be a progressive problem and that she will indeed have a stroke, I find his findings to be a bit extreme. I don`t feel that this is incredibly bad. What is your take? My mother`s PMH is hypertension, high cholesterol. Her heart is healthy, her blood work is unremarkable other than her hyperlipidemia. She is currently taking a baby aspirin, Lipitor, metopolol and Diovan. Should we be in high alert that a stroke is indeed iminent? Please advise. Thank you and be well.
I have written extensively about white matter disease in previous questions--please refer to these for more information about what these findings represent.
A physician who can take a whole history and do a full examination is always in a better position to make an accurate assessment, and I am hesitant to contradict a previous opinion. However, from what you told me, there is no reason to believe that there is an imminent stroke in her future since there is no clear stenosis or blockage of the major blood vessels. There is higher risk for stroke if you have multiple risk factors such as high blood pressure and high cholesterol (as she seems to have, based upon her medications). Having white matter changes also has been shown to increase stroke risk slightly--the more there are, the more the risk (hers sound mild or moderate, when described as "scattered", rather than severe which carries highest risk).
So while I cannot give you an answer with any certainty, it seems that she is doing all that can be done to prevent a stroke by taking an aspirin and modifying risk factors. It is worth considering that the vertigo could be due to an inner ear problem, or perhaps due to other causes (medication side effects, etc).
I hope this helps!
Brett Kissela, MD
Assistant Professor of Neurology
Director, Neurology Residency Program
College of Medicine
University of Cincinnati