SUMMARY Patchy subcortical foci of increased signal intensity are frequently identified on magnetic resonance imaging (MRI) in the elderly. The incidence and clinical correlates of these lesions remain unknown. In this report, 240 consecutive MRI scans performed over a 6-month period were reviewed (excluding patients with recent brain trauma or known demyelinating disease). Subcortical incidental lesions (ILs) were identified, which could not be accounted for by the patient's current clinical diagnosis, neurological status, or CT scan. The ILs were graded according to size, multiplicity, and location. The incidence and severity of ILs increased with advancing age (p < 0.0005). Among patients over 50 years of age, the incidence and severity of ILs were correlated with a previous history of ischemic cerebrovascular disease (p < 0.05) and with hypertension (p < 0.05). Multivariable regression analysis identified age, prior brain ischemia, and hypertension as the major predictors of ILs in the elderly. Diabetes, coronary artery diseases, and sex did not play a significant role. With the exception of cerebrovascular disease, there was no association between ILs and any particular clinical entity, including dementia. It is concluded that subcortical parenchyma! lesions are frequent incidental findings on MRI in the elderly, and may represent an index of chronic cerebrovascular diseases in such patients. Stroke Vol 17, No 6, 1986MAGNETIC RESONANCE IMAGING (MRI) of the brain has become a recognized and increasingly popular diagnostic modality. Unprecedented spacial resolution, flexibility in imaging, and the lack of ionizing radiation have all contributed to its widespread use. Furthermore, MRI has proven to be highly sensitive to subtle changes in brain parenchyma which accompany a wide variety of neurologic disorders. ' '«• l7 They are usually subcortical and multiple, and exhibit increased signal intensity on T 2 weighted images. Lesions of this nature have been described in conjunction with known cerebrovascular disease, but are difficult to correlate with previous symptoms.1 3 1 7 Similar lesions have been reported in association with dementia 4 ' 7 ' " and in asymtomatic elderly patients.3 ' 17 While there has been much speculation about the nature of such lesions, little is known about their clinical significance, prevalence in various age groups, or pathologic correlates.In this report, a definition and a grading scheme for incidental MRI lesions are proposed, and their incidence and clinical associations are examined in 240 consecutive patients undergoing MRI at our institution. Multivariable regression analysis is used to determine the impact of age and cerebrovascular risk factors on the incidence and severity of these lesions. In an accompanying report, the pathological correlates of these lesions are investigated, and an etiologic hypothesis is presented to account for their clinical and pathological associations.2

Seizures persist or recur in 20-60% of patients after resective surgery for intractable partial epilepsy. Further information about the natural course of these seizures is lacking in the literature. During one decade of epilepsy surgery at a single institution, we identified 72 patients with recurrent postoperative seizures after resective procedures for epilepsy. Prospectively compiled seizure diaries, hospital records, and outpatient office records were reviewed and supplemented by telephone communications to assess subsequent seizure frequency. Follow-up data was available ranging from 6 months to 7 years 5 months (mean 3 years 5 months). The likelihood of persistent seizures and recurrent intractability was examined with life-tables. Seizures recurred within the first postoperative year in 86% of patients and were similar to preoperative events in 74% of patients. After the first seizure recurrence, there was 80% likelihood of persistent seizures in the next 6 years and 40% likelihood of intractability (more than one seizure a month despite optimal medical therapy). The interval until recurrence within the first postoperative year did not affect the likelihood of subsequent seizures or intractability. Late seizure recurrence (after the first year) was not associated with any instances of subsequent intractability. Recurrent seizures after extratemporal resections were more likely to become persistent and intractable than seizures recurring after temporal resections. This information provides rational prognostication and assists in counseling patients with recurrent seizures after resective surgery for intractable epilepsy.

With the advent of magnetic resonance imaging (MRI) of the brain, a large number of incidental lesions (ILs) are being identified. The prevalence and clinical significance of these ILs are not known. The MRI and clinical records of 86 consecutive patients who underwent technically satisfactory brain imaging at a large urban referral center were reviewed. Patients with definite or probably demyelinating disease were excluded. Incidental lesions were defined as parenchymal areas of increased signal intensity on T2-weighted imaging, which could not be directly explained by the patient's current clinical diagnosis, neurological status, or computed tomographic (CT) scan. The ILs were noted and graded according to size, multiplicity, and location and were correlated with age, clinical presentation, CT scan findings, and risk factors for cerebrovascular disease. One or more IL were identified in 22% of patients under 40 years of age, in 57% of patients 41 to 60 years of age, and in 90% of patients over 60 years of age. Large patches of confluent ILs were not encountered in any patient less than 40 years of age; they were present in 10% of patients 41 to 60 years of age, and in 30% of patients over 60 years of age. The incidence of severity of ILs correlated significantly with age (P less than 0.0005) and with risk factors for cerebrovascular disease (P less than 0.02). Patients with most severe ILs also had areas of vague periventricular leukomalacia on the CT scan. The clinical significance of incidental MRI lesions in various age groups is discussed in detail.(ABSTRACT TRUNCATED AT 250 WORDS)

The iWellnessExam offers the health care provider an excellent method for identifying eyes at risk using very reliable technology. High specificity and sensitivity was obtained when reviewed by a well trained eye care clinician. It would be valuable to repeat the study with a novice and/or student clinician reviewing the same data set to ascertain interobserver variability, as well as the impact of clinical experience on accurate referral, based on the screening data.

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