Simpson S W, Jackson A, Baldwin R C, Burns A
Manchester Royal Infirmary, England.
Int Psychogeriatr. 1997 Sep;9(3):257-75. doi: 10.1017/s1041610297004432.
Subcortical hyperintensities are easily visualized areas of signal abnormality that are seen on T2-weighted magnetic resonance imaging (MRI). Characteristically they occur in the white matter of the brain and are more common in elderly people. In depression, little is known of the clinical significance of subcortical hyperintensities or their contribution to the prognosis. Fifty-eight consecutive patients with DSM-III-R depression and an age range of 65 to 85 years were prospectively collected from an old-age psychiatry service. Response to treatment was assessed with a clinical global outcome measure. A neuropsychology battery was completed on all patients after treatment. Forty-four patients completed MRI scanning. The scans were scored using a regional rating system for hyperintensities. Forty-eight percent of patients had a favorable response to treatment on the clinical global outcome scale. Poor outcome was associated with female sex (p = .07), poor physical health (p = .040), diabetes (p = .018), psychosis (p = .026), and an early age at onset of first episode of depression (p = .036). Even after adjustment for confounding effects, there were significant neuropsychological associations with the regional hyperintensities. Distribution in the periventricular area correlated with delayed recall after distraction (p = .025), and punctate lesions in the basal ganglia correlated with impaired category production (p = .020). Pontine reticular formation hyperintensities were related to impaired psychomotor speed (p = .04). Location in the frontal deep-white matter (p = .024), basal ganglia (p = .03), and pontine reticular formation (p = .02) was associated with a poor acute response to treatment. However, the response to treatment was not related to total cerebral white-matter hyperintensity load. A logistic regression equation included all the significant prognostic features and found four independent predictors of poor outcome: More than five punctate lesions of the basal ganglia, diabetes, lower mean arterial pressure, and hyperintensity of the pontine reticular formation significantly predicted outcome. These four factors correctly predicted 95.6% of patients with a poor outcome and 85.7% with a favorable outcome. In late-life depression, subcortical hyperintensities are common. Lesions in the cerebral white matter are predominantly associated with memory disturbance, and those in deeper infratentorial areas, with psychomotor slowing and executive deficits. Total white-matter load has no prognostic value, and although some subcortical regions are associated with poor response, individually they have little specificity. However, a combination of involvement in three areas (basal ganglia, pons, and frontal lobe) is clinically relevant and predicts outcome with great accuracy (91%). Patients with lesions in the basal ganglia and deep white matter had an especially poor response to pharmacotherapy.
皮质下高信号是在T2加权磁共振成像（MRI）上可见的易于观察到的信号异常区域。其特征是出现在脑白质中，在老年人中更为常见。在抑郁症中，关于皮质下高信号的临床意义及其对预后的影响知之甚少。我们从老年精神病科前瞻性收集了58例年龄在65至85岁之间、符合DSM-III-R抑郁症诊断标准的连续患者。使用临床总体结局指标评估治疗反应。所有患者在治疗后完成了一套神经心理学测试。44例患者完成了MRI扫描。扫描结果使用区域高信号评分系统进行评分。在临床总体结局量表上，48%的患者对治疗有良好反应。预后不良与女性性别（p = 0.07）、身体健康状况差（p = 0.040）、糖尿病（p = 0.018）、精神病（p = 0.026）以及首次抑郁发作的发病年龄较早（p = 0.036）相关。即使在调整混杂效应后，区域高信号与神经心理学仍存在显著关联。脑室周围区域的分布与分心后延迟回忆相关（p = 0.025），基底节的点状病变与类别生成受损相关（p = 0.020）。脑桥网状结构高信号与精神运动速度受损相关（p = 0.04）。额叶深部白质（p = 0.024）、基底节（p = 0.03）和脑桥网状结构（p = 0.02）的病变与治疗的急性反应不佳相关。然而，治疗反应与全脑白质高信号负荷无关。一个逻辑回归方程纳入了所有显著的预后特征，发现有四个独立的预后不良预测因素：基底节有超过五个点状病变、糖尿病、平均动脉压较低以及脑桥网状结构高信号显著预测预后。这四个因素正确预测了95.6%的预后不良患者和85.7%的预后良好患者。在老年抑郁症中，皮质下高信号很常见。脑白质病变主要与记忆障碍相关，幕下较深区域的病变与精神运动迟缓及执行功能缺陷相关。全脑白质负荷没有预后价值，虽然一些皮质下区域与反应不佳相关，但单独来看它们的特异性较低。然而，三个区域（基底节、脑桥和额叶）受累的组合具有临床相关性，且能非常准确地预测预后（91%）。基底节和深部白质有病变的患者对药物治疗的反应特别差。
