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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 29  |  Issue : 1  |  Page : 59-66

Pattern of structural magnetic resonance imaging lesions in the patients with progressive cognitive decline: A single-center study in Southeast Nigeria


1 Department of Neurosurgery, Memfys Hospital for Neurosurgery; Department of Medicine, Neurology Unit, University of Nigeria Teaching Hospital, Enugu, Nigeria
2 Department of Neurosurgery, Memfys Hospital for Neurosurgery; Department of Medicine, Neurology Unit, Enugu State Teaching Hospital, Enugu, Nigeria
3 Department of Neurosurgery, Memfys Hospital for Neurosurgery, Enugu, Nigeria

Date of Submission03-Jun-2021
Date of Acceptance29-Sep-2022
Date of Web Publication15-Nov-2022

Correspondence Address:
Dr. Birinus Adikaibe Ezeala-Adikaibe
Department of Medicine, Neurology Unit, University of Nigeria Teaching Hospital, Enugu P.M.B 01129
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/wajr.wajr_23_21

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  Abstract 


Objectives: The aim of the index study was to describe the pattern and frequency of structural brain lesions in magnetic resonance imaging (MRI) of patients with dementia.
Methods: This was a retrospective, descriptive study carried out in Memfys Hospital in Enugu, South East Nigeria, to review all MRIs of patients who presented with progressive cognitive decline.
Results: Out of a total of 147 (86.5%) scan reviewed, 6 (6.8%) had normal brain scan, while 95 (64.6%) had brain atrophy, followed by white matter lesions 78 (49.7%). Strokes, including lacunar stroke, were seen in 44 (29.9%). Hydrocephalus (14.3%) and brain tumors (11.6%) were the most common surgical lesion found. Patients with atrophy (P < 0.01) and white matter lesions (P < 0.01) were significantly older compared to the average age of the cohort, while patients with normal brain scans and brain tumors were younger P < 0.01 and P = 0.02, respectively.
Conclusion: Brain atrophy and white matter lesions were the most common MRI findings in patients presenting with cognitive decline in Enugu, South East Nigeria. Such patients also tended to be older than those with normal brain scans or brain tumors.

Keywords: Dementia, white matter lesions, brain atrophy, magnetic resonance imaging, Nigeria


How to cite this article:
Ezeala-Adikaibe BA, Oti B B, Ohaegbulam SC, Ndubuisi CA, Okwudili O. Pattern of structural magnetic resonance imaging lesions in the patients with progressive cognitive decline: A single-center study in Southeast Nigeria. West Afr J Radiol 2022;29:59-66

How to cite this URL:
Ezeala-Adikaibe BA, Oti B B, Ohaegbulam SC, Ndubuisi CA, Okwudili O. Pattern of structural magnetic resonance imaging lesions in the patients with progressive cognitive decline: A single-center study in Southeast Nigeria. West Afr J Radiol [serial online] 2022 [cited 2022 Dec 7];29:59-66. Available from: https://www.wajradiology.org/text.asp?2022/29/1/59/361184




  Introduction Top


Chronic progressive cognitive decline or dementia presents with progressive memory and cognitive decline affecting individuals in their activities of daily living secondary to irreversible neuronal damage. Dementia is a disease of the elderly, with only about 2%–10% reported in people younger than 65 years of age.[1] According to the 2014 World Alzheimer's Report, dementia affects approximately 44 million people worldwide.[2] In Africa, the prevalence of dementia in people 50 years and older was estimated to be 2.4% in 2010.[1] With an increasing population of elderly people, the prevalence of dementia is set to increase in sub-Saharan Africa (SSA). Risk factors for dementia are numerous and are common among Africans.[3],[4],[5],[6],[7] There is also the added high prevalence of tobacco and alcohol use, HIV/AIDs, brain injury, and drug abuse.[8] The relative contribution of some of these risk factors, which are common among younger age groups, is not known.

Some studies have been carried out in SSA;[9],[10],[11] however, we are not aware of any study on structural radiologic findings in dementia. Common causes of dementia that may produce structural changes in the brain include degenerative brain diseases, cerebrovascular diseases, previous central nervous system infections, brain tumors, and inflammatory brain lesions.

The reported pooled crude prevalence of dementia in Nigeria is 4.9%; higher in females (6.7%), than in males (3.1%). Reported significant risk factors were age 80+, female sex, and body mass index ≤18.5.[12] In general, dementia and cognitive impairment, in general, are under-reported and under-treated in Nigeria. One of the major reasons for this is because of multiple overlapping comorbidities; thus, most of these patients end up with different specialties. Cognitive decline and dementia may also present as a complication or symptoms of several brain disorders such as tumors as well as metabolic and hormonal disorders. Furthermore, because of associated behavioral problems, many of these patients are seen by psychiatrists.

Brain atrophy is the most frequently described magnetic resonance imaging (MRI) finding in dementias, especially degenerative dementias.[2],[3],[13],[14] Cortical atrophy of the hippocampus and entorhinal complex occurs early in Alzheimer's disease[13],[14],[15] and serves as the early maker of neurodegeneration and disease severity.[16],[17],[18] However, it is commonly seen in the elderly and brain ischemia.[18] The variability of atrophy in the normal aging process makes it difficult to use MRI as a definitive diagnostic technique.[3] Focal brain atrophy can occur at different stages of degenerative dementia; however, asymmetrical cerebral atrophy is usually not in favor of the diagnosis of AD.[3],[18]

Vascular dementia (VD) is not a homogeneous entity and is the second-most common form of dementia.[1] Large-vessel involvement results in different forms of stroke and causes poststroke dementia and strategic infarct dementia, while small-vessel disease manifests as lacunar infarcts, lacunes, white matter hyperintensities (WMH), enlarged perivascular spaces, and cerebral microhemorrhages.[13],[14] The most common radiologic finding in VD is WMH[13],[14] which is also significantly correlated with vascular risk factors. WMH is a risk factor for AD, increases with age and is seen in up to a third of older people without dementia.[13],[14] Previous large strokes may be distinguished as focal atrophy, encephalomalacia, or gliosis in MRI.

Lacunar stroke is defined as a round or ovoid, subcortical, fluid-filled cavity measuring between 3 mm and 15 mm in diameter.[2],[13],[14] This is consistent with a previous acute small deep brain infarct or hemorrhage in the territory of one perforating arteriole.[13] Lacunes are more frequent in dementia patients than in normal controls.[13],[14] The relative contribution of lacunes to VD may also be related to the background burden of MWH.[3],[19] Cerebral Microinfarcts better distinguished in 3T MRI and above have been associated with cardiovascular risk factors as well as cognitive decline.[3],[19],[20],[21],[22],[23] Similar to WMH, cerebral microbleeds can occur in cognitively normal elderly people.[2],[3],[24]

Progressive cognitive decline may be associated with or complicate several brain lesions which are treatable. Structural lesions such as hydrocephalus may also result from central nervous system infections, brain tumors, and stroke. However, it may occur independently as a cause of dementia. Mechanisms of cognitive decline in brain tumors are likely to be multifaceted and depend on both the location, type, and size of the tumor.

As the burden of dementia increases in the continent, there is a need to implement standard criteria in investigating such cases. Current European guidelines as well as other established guidelines recommend the use of MRI or computed tomography (CT) as part of the initial work-up of patients with cognitive decline.[25],[26] MRI offers the advantage of producing clear images of the brain parenchyma than CT; hence, it is better in delineating treatable lesions. Imaging is also useful in early diagnosis, follow-up, and classification of dementias.

The aim of the index study was to describe the pattern and frequency of structural brain lesions in MRI of patients with dementia.


  Methods Top


This was a retrospective, descriptive study carried out in a private tertiary neuroscience Hospital in in Enugu, the capital of Enugu State, southeast Nigeria. The hospital is a referral neurology/neurosurgery center. The hospital introduced the first MRI scan in Southeast Nigeria and received it from all parts of Nigeria. Although most of the patients scanned were referred from other hospitals, many were also seen in the hospital. Noncontrast and contrast brain MRIs were conducted using the BT1-0.35T system. Images were obtained in Sagittal T1, T2, GRE Stir; axial and coronal T1 and T2 sequences. We reviewed only those with the diagnosis of dementia and or progressive cognitive impairment. MRI reports were written by consultant radiologists and reviewed by two neurologists. MRI reports included in the study were done between December 2010 and February 2018.

Inclusion and exclusion criteria

[Figure 1] shows the flow chart for the selection of cases. All adult cases (18 years and above) of progressive cognitive decline, dementia, VD, multi-infarct dementia, and memory impairment of more than 3 months duration were included. Patients with documented clinical signs suggestive of acute or subacute focal neurologic deficits were excluded. Cases with acute stroke and brain tumors as differential diagnosis were excluded. Patients were also excluded if they had focal neurologic deficits or seizures. Nine reports were excluded. Patients with possible major organ dysfunction, such as renal failure, were excluded. Cases with possible background mental illness, if indicated in the notes, were also excluded. If the duration of cognitive impairment, age, or gender were not documented, such cases were excluded. In the case of repeat MRI, the last scan was selected. The study was reviewed and approved by the hospital's ethics committee.
Figure 1: Flow chart of patient selection

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Statistical methods

Brain MRI was performed at various intervals from the onset of the ailment. Data on age, gender, symptoms, and radiologic findings were entered into a questionnaire and transferred to the personal computer. For database management and statistical analyses, we used the SPSS version 23 (IBM Corporation, New York, USA). Data were presented in tables and figures. Continuous variables, mean values, and standard deviation were calculated. Rates were expressed as percentages. Categorical values were compared using the Chi-Square test. Mean age was compared using the independent t-test. In all, P < 0.05 was regarded as statistically significant. Conclusions were drawn at a 95% confidence interval.


  Results Top


General characteristics of the sample population

Over the period under review, a total of 170 scans were done for progressive cognitive impairment. Out of this number, 147 (86.5%) cases met the inclusion criteria and were reviewed. Eighty-eight (59.9%) were males and 59 (40.1%) were females, with a male-to-female ratio of 1.5:1. The participants' age ranged from 19 to 85 years, averaging 63.4 ± 16.1. There was no significant difference between the age of the males and females. Mean age: males, 62.7 ± 17.4 versus females, 64.4 ± 14 years, P = 0.54. The median age was 68 years, with most of the patients aged 65 years and above [Table 1],[Table 2],[Table 3].
Table 1: Age and gender distribution of the patients

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Table 2: Gender distribution of major presenting complaints

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Table 3: Age and mean age±standard deviation distribution of major presenting complaints

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Most patients, 109 (74.1%), presented without additional symptoms at the time of scanning and a high proportion of 70 (80.5%) of patients 65 years fell into this category. The most common symptoms were headache 18 (12.2%) and difficulty walking 5 (3.4%). The three-most common symptoms below 65 years of age were headache 15 (25%), poor vision 3 (5%), and behavioral changes 2 (3.3%), while above that age, they were difficulty walking 5 (5.7%), headache and incontinence 3 (3.4%) and confusion/hallucination 2 (2.3%). The mean age of presentations of symptoms is shown in [Table 3].

MRI findings are shown in [Table 4] and [Figure 1]. Six (6.8%) had normal brain scan, while 95 (64.6%) had brain atrophy, followed by WMH 78 (49.7%). Strokes, including lacunar stroke, were seen in 44 (29.9%). Patients with atrophy (P < 0.01), WMH (P < 0.01) were significantly older compared to the average age of the cohort. Patients with normal brain scans and brain tumors were younger. P <0.01 and P = 0.02, respectively. The pattern of other findings is shown in [Figure 2].
Figure 2: Distribution of less common MRI findings. MRI: Magnetic resonance imaging

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Table 4: Age distribution of magnetic resonance imaging findings

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When patients were categorized based on symptomatology, patients who had additional clinical symptoms were much younger, and had more normal brain images (P = 0.01) and more cases of hydrocephalus (P = 0.02) [Table 5]. Nonsignificant higher numbers of brain tumors and stroke were also recorded among them. In addition to being older, patients who had only progressive memory loss at presentation had more cases of brain atrophy and WMH. A sample of the MRI scan is shown in [Figure 3]a and [Figure 3]b.
Figure 3:

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Table 5: Distribution of magnetic resonance imaging findings in patients with and without additional symptoms

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  Discussion Top


The incidence and prevalence of dementia in sub-Saharan Africa are growing. The current lack of data and socioeconomic deprivation in the continent may not allow for an accurate classification of dementia types as well as the true burden of the disease. Dementia is not only a single disease entity and can complicate other disorders such as meningitis, AIDS, and metabolic disorders. In Nigeria, few studies have addressed the prevalence and pattern of dementia and its subtypes. There are, however, no studies to the best of our knowledge that addressed the radiologic findings in people with dementia or progressive cognitive decline.

The index study evaluated a total of 170 cases, out of which 147 met the inclusion criteria and were analyzed. The distribution MRI findings showed that 95 (64.6%) had brain atrophy, 78 (49.7%) had WMH, and 44 (29.9%) had stroke. Surgically remediable lesions like brain tumors were more prevalent in younger people. Patients who had additional clinical symptoms were younger and had more normal brain images.

The age distribution of the patients supports the established fact that dementia is primarily a disease of the elderly, with most people 60 years and above.[1] An estimated 2%–10% of those affected are younger than 65 years,[1] which is slightly lower than 20.4% in the index study. The relatively large proportion below 60 years (25.9%) may reflect the contribution of disorders such as stroke, which has been noted to peak between 50 and 60 years in Nigerians.[27],[28] Another reason for a large proportion of young people in the index study may be because the study focused on possible causes of cognitive decline among people who were scanned. The study is not clinic-based but a review of previously done MRI scans.

The major clinical presentation in dementia is usually memory loss which can acutely worsen with added infection. Over time patients may develop complications such as hallucinations and incontinence. Such deteriorations may warrant admission and hence a brain scan. Most of the symptoms seen among our patients may be explained as complications of dementia and/or markers of disease severity. These include gait problems, confusion/hallucination, incontinence, and behavioral changes. Other symptoms may be attributed to manifestations of dementia. Tremor and gait problems may be features of Parkinson's disease. Together with dysphagia, they may be seen in various forms of vascular cognitive decline. The high prevalence of headache among these patients cannot be explained by cognitive decline alone and may be due to acute infections such as fever. Causes of dementia, such as brain tumors, may be also implicated. It is important to note that many of these patients may be on non-steroidal anti-inflammatory agents, which may cause chronic headache.

It is interesting to note that most patients with added symptoms (especially headache and poor vision) were <65 years, with mean ages 20 and 26 years younger than the average age of the cohort. Similarly, patients presenting with memory loss alone were older and more frequent, above 65 years. These findings may suggest that symptoms of cognitive decline may vary with age [Table 1],[Table 2],[Table 3],[Table 4].

This study has revealed that 15% of people with cognitive decline below 65 years have normal MRI findings. This proportion is significantly higher than in those older than 65 years. The importance of negative imaging in such chronic disease such as dementia cannot be underestimated because such results will reassure the patients and their families. Below 65 years, the most common possible causes of dementia were ischemic cerebrovascular lesions, as evidenced by WMH (31.7%) and stroke (23.3%). However, other possible causes (hydrocephalus and brain tumors) were also found, hence the need for MRI in such patients. From 65 years and above, the pattern is similar; however, there is the added burden of subdural hematoma. These findings support the established guideline on neuroimaging in dementia.

Brain atrophy and WMH were by far the most common findings in both age groups and need further comment. These lesions are seen very frequently in the elderly and can co-occur in the same patient and with any of the other lesions, especially stroke. Brain atrophy is the most frequently described MRI finding in dementias, especially degenerative dementias.[2],[3],[13],[14] Atrophy of the hippocampus and entorhinal complex occur early in degenerative dementia[3],[13] and serve as early makers of neurodegeneration and disease severity.[16],[17] The large proportion seen in the index study may suggest end-stage disease as well as the contributions of aging and other pathologies such as brain ischemia to the evolution of dementia. The variability of atrophy in the normal aging process makes it difficult to use MRI as a definitive diagnostic technique;[3] however, it has a high sensitivity and specificity for predicting the progression of dementia.[29] Although focal forms of brain atrophy can occur at different stages of degenerative dementia, the observation of asymmetrical cerebral atrophy is usually not in favor of the diagnosis of AD.[3],[18]

The second-most common form of dementia is VD.[1] VD involves both large and small vessels of the brain. In the index study, we grouped lacunes and other forms of stroke as “stroke.” With the high prevalence of risk factors for VD in SSA n the true burden of VD in the continent may be underestimated. The current study supports the fact that the most common radiologic finding in VD is WMH[30],[31] and that VD is possibly the second-most common cause of dementia in the continent.[1] Cerebral microinfarcts which are better distinguished in MRIs of 3T and above and could not be reliably defined in the index study.[32]

Patients with additional symptoms had more treatable lesions such as tumors and hydrocephalus (though this was not statistically significant for tumors), while atrophy and WMH were significantly more in those who presented with only cognitive impairment. Progressive cognitive decline may be a symptom of several brain lesions which are treatable. Lesions such as hydrocephalus may also be a complication of other diseases that cause dementia, such as brain infections, tumors, and stroke; nevertheless, it may occur independently as a cause of dementia. Descriptive studies have shown that brain tumors are frequent radiologic findings in brain imaging of patients with epilepsy, headache, and stroke. In a CT-based study on patients presenting with different neurologic disorders in Enugu, brain tumors were reported in 8.8% (in headache), 20.4% (epilepsy), and 4.2% (stroke) cases.[33],[34],[35] Mechanisms of cognitive decline in brain tumors are likely to be multifaceted and depend on both the location, type, and size of the tumor.

Limitations

The limitations of this present study are similar to those characteristics of retrospective studies. Clinical examinations were done by residents and sometimes by medical officers; hence, clinical clues to positive findings suggestive of brain mass lesions on MRI may have been missed. Patients with structural lesions who were referred from other centers were not followed up to establish the cost-benefit ratio on MRI. None of the MRI findings were categorized using the Fazekas score. This may be related to the strength of the MRI scanner available in the hospital. This has been added in the limitations. Another important limitation in the index study is that only MRI reports and not images were reviewed; thus, the authors could state how gliosis was differentiated from microangiopathy and demyelination as well as the diagnostic criteria for other lesions reported. The use of 0.35T MRI may have underestimated the frequency of ischemic changes in these patients.


  Conclusion Top


Brain atrophy and white matter lesions were the most common MRI findings in patients presenting with cognitive decline in Enugu South East Nigeria. Such patients also tended to be older than those with normal brain scans or brain tumors.

Acknowledgments

We would like to thank the Medical Records Department of Memfys Hospital for Neurosurgery for their assistance in data collection.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors are staff of Memfys Hospital.



 
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