Korean Journal of Psychosomatic Medicine (정신신체의학)

Korean Psychosomatic Society (한국정신신체의학회)
권호 표지
DOI QR코드

DOI QR Code

The Effect of Leukoaraiosis on the Severity and Course of Delirium

백질변성이 섬망의 심각도 및 경과에 미치는 영향

  • Choi, Won-Jung (Institute of Behavioral Science in Medicine, Yonsei University College of Medicine) ;
  • Seok, Jeong-Ho (Institute of Behavioral Science in Medicine, Yonsei University College of Medicine) ;
  • Oh, Seung-Taek (Institute of Behavioral Science in Medicine, Yonsei University College of Medicine) ;
  • Chung, Tae-Sub (Department of Radiology, Yonsei University College of Medicine) ;
  • Kim, Jae-Jin (Institute of Behavioral Science in Medicine, Yonsei University College of Medicine)
  • 최원정 (연세대학교 의과대학 의학행동과학연구소) ;
  • 석정호 (연세대학교 의과대학 의학행동과학연구소) ;
  • 오승택 (연세대학교 의과대학 의학행동과학연구소) ;
  • 정태섭 (연세대학교 의과대학 영상의학교실) ;
  • 김재진 (연세대학교 의과대학 의학행동과학연구소)
  • Received : 2018.11.19
  • Accepted : 2018.12.13
  • Published : 2018.12.31
Download PDF
⟨ Previous Next ⟩

Abstract

Objectives : The significance of leukoaraiosis on brain magnetic resonance imaging (MRI) is uncertain, but it is often seen with vascular risk factors or in the context of cognitive impairment. We aimed to investigate the effect of leukoaraiosis on the severity and course of delirium. Methods : Periventricular hyperintensity and deep white matter hyperintensity on brain MRI were rated in 42 patients with delirium by semiquantative visual rating scale. Correlations between their grades and the scores of Korean version of Delirium Rating Scale-Revised-98 (K-DRS-R-98) were analyzed, and the interaction effects between the groups according to the levels of leukoaraiosis and two evaluation points were also analyzed. Results : The grade of deep white matter hyperintensity in the occipital lobe was positively correlated with the scores on the total, severity items, cognitive items, and non-cognitive items of K-DRS-R-98. The cognitive items scores of K-DRS-R-98 in the low grade group of periventricular hyperintensity showed significantly steeper decrease than the high grade group. Conclusions : A difference in severity or recovery speed of delirium according to the level of leukoaraiosis may result from disruption in brain functional connectivity. Our results have a clinical implication in that the severity and course of delirium can be possibly predicted using the level of leukoaraiosis.

연구목적 뇌 자기공명영상에서 발견된 백질변성의 소견은 인지기능 저하와 관련이 있다고 알려져 있지만 이의 중요성은 명확하게 밝혀진 바 없다. 본 연구는 뇌 자기공명영상에서 관찰되는 백질변성이 섬망의 심각도나 경과에 미치는 영향을 규명하기 위해 시행되었다. 방 법 섬망 삽화 전후에 뇌 자기공명영상이 촬영된 42명의 섬망 환자에 대하여 반정량적인 시각평가척도를 이용하여 뇌실주위 백질 고강도신호와 심부백질 고강도신호를 평가하였다. 이 고강도신호의 등급과 섬망평가척도 점수 간의 상관 관계를 분석하였고, 등급이 높은 군과 낮은 군으로 나누어 군에 따른 섬망평가척도 점수의 변화 차이를 추가로 분석하였다. 결 과 후두엽의 심부백질 고강도신호 등급과 섬망평가척도의 총점, 심각도 항목, 인지 항목 및 비인지 항목의 합과 양의 상관관계를 보였다. 또한 첫 평가와 추적 평가를 비교하였을 때 뇌실주위 백질 고강도신호의 등급이 낮은 군이 높은 군보다 섬망평가척도의 인지 항목 점수가 유의미한 경사로 가파르게 감소하였다. 결 론 뇌 백질 고강도신호 등급에 따라 섬망의 심각도와 호전 속도에 차이를 보이는 것은 뇌 백질변성이 대뇌 기능 연결성의 단절을 초래하여 유발한 결과로 볼 수 있다. 본 연구는 뇌 자기공명영상에서 발견된 고강도신호의 등급의 평가를 통해 섬망의 심각도와 경과를 예측해 볼 가능성이 있다는 점에서 임상적으로 유용할 수 있다.

Keywords

JSSCBG_2018_v26n2_194_f0001.png 이미지

Fig. 1. Changes of the sum of cognitive items in the low grade (≤ 3) and high grade (>3) groups according to the total grade scores of periventricular hyperintensity. * : p<0.05 for interaction between group and visit in repeated-measures analysis of variance.

Table 1. Subject clinical characteristics on Visit 1.

JSSCBG_2018_v26n2_194_t0001.png 이미지

Table 2. Correlations between the level of deep white matter hyperintensity (DWMH) in the occipital lobe and scores of Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-R-98) on Visit 1

JSSCBG_2018_v26n2_194_t0002.png 이미지

References

  1. Burns A, Gallagley A, Byrne J. Delirium. J Neurol Neurosurg Psychiatry 2004;75:362-367. https://doi.org/10.1136/jnnp.2003.023366
  2. Laurila JV, Laakkonen ML, Tilvis RS, Pitkala KH. Predisposing and precipitating factors for delirium in a frail geriatric population. J Psychosom Res 2008;65:249-254. https://doi.org/10.1016/j.jpsychores.2008.05.026
  3. Warshaw G, Mechlin M. Prevention and management of postoperative delirium. Int Anesthesiol Clin 2009;47:137-149. https://doi.org/10.1097/AIA.0b013e3181b47ea8
  4. Meagher DJ, Leonard M, Donnelly S, Conroy M, Saunders J, Trzepacz PT. A comparison of neuropsychiatric and cognitive profiles in delirium, dementia, comorbid delirium-dementia and cognitively intact controls. J Neurol Neurosurg Psychiatry 2010;81:876-881. https://doi.org/10.1136/jnnp.2009.200956
  5. Jabbar F, Leonard M, Meehan K, O'Connor M, Cronin C, Reynolds P, Meaney AM, Meagher D. Neuropsychiatric and cognitive profile of patients with DSM-IV delirium referred to an old age psychiatry consultation-liaison service. Int Psychogeriatr 2011;23:1167-1174. https://doi.org/10.1017/S1041610210002383
  6. Lamar M, Catani M, Price CC, Heilman KM, Libon DJ. The impact of region-specific leukoaraiosis on working memory deficits in dementia. Neuropsychologia 2008;46:2597-2601. https://doi.org/10.1016/j.neuropsychologia.2008.04.007
  7. Grueter BE, Schulz UG. Age-related cerebral white matter disease (leukoaraiosis): a review. Postgrad Med J 2012;88: 79-87. https://doi.org/10.1136/postgradmedj-2011-130307
  8. O'Sullivan M. Leukoaraiosis. Pract Neurol 2008;8:26-38. https://doi.org/10.1136/jnnp.2007.139428
  9. Chowdhury MH, Nagai A, Bokura H, Nakamura E, Kobayashi S, Yamaguchi S. Age-related changes in white matter lesions, hippocampal atrophy, and cerebral microbleeds in healthy subjects without major cerebrovascular risk factors. J Stroke Cerebrovasc Dis 2011;20:302-309. https://doi.org/10.1016/j.jstrokecerebrovasdis.2009.12.010
  10. Bucur B, Madden DJ, Spaniol J, Provenzale JM, Cabeza R, White LE, Huettel SA. Age-related slowing of memory retrieval: contributions of perceptual speed and cerebral white matter integrity. Neurobiol Aging 2008;29:1070-1079. https://doi.org/10.1016/j.neurobiolaging.2007.02.008
  11. Lee SJ, Kim JS, Lee KS, An JY, Kim W, Kim YI, Kim BS, Jung SL. The leukoaraiosis is more prevalent in the large artery atherosclerosis stroke subtype among Korean patients with ischemic stroke. BMC Neurol 2008;8:31. https://doi.org/10.1186/1471-2377-8-31
  12. Yamada S, Saiki M, Satow T, Fukuda A, Ito M, Minami S, Miyamoto S. Periventricular and deep white matter leukoaraiosis have a closer association with cerebral microbleeds than age. Eur J Neurol 2012;19:98-104. https://doi.org/10.1111/j.1468-1331.2011.03451.x
  13. Shioiri A, Kurumaji A, Takeuchi T, Matsuda H, Arai H, Nishikawa T. White matter abnormalities as a risk factor for postoperative delirium revealed by diffusion tensor imaging. Am J Geriatr Psychiatry 2010;18:743-753. https://doi.org/10.1097/JGP.0b013e3181d145c5
  14. Soiza RL, Sharma V, Ferguson K, Shenkin SD, Seymour DG, Maclullich AM. Neuroimaging studies of delirium: a systematic review. J Psychosom Res 2008;65:239-248. https://doi.org/10.1016/j.jpsychores.2008.05.021
  15. Morandi A, Gunther ML, Vasilevskis EE, Girard TD, Hopkins RO, Jackson JC, Pandharipande P, Ely EW. Neuroimaging in delirious intensive care unit patients: a preliminary case series report. Psychiatry 2010;7:28-33.
  16. Alsop DC, Fearing MA, Johnson K, Sperling R, Fong TG, Inouye SK. The role of neuroimaging in elucidating delirium pathophysiology. J Gerontol A Biol Sci Med Sci 2006;61:1287-1293. https://doi.org/10.1093/gerona/61.12.1287
  17. Choi SH, Lee H, Chung TS, Park KM, Jung YC, Kim SI, Kim JJ. Neural network functional connectivity during and after an episode of delirium. The Am J Psychiatry 2012;169: 498-507. https://doi.org/10.1176/appi.ajp.2012.11060976
  18. First MB, Gibbon M. User's guide for the structured clinical interview for DSM-IV axis I disorders: SCID-1 clinician version: American Psychiatric Pub;1997.
  19. Lee Y, Ryu J, Lee J, Kim HJ, Shin IH, Kim JL, Trzepacz PT. Korean version of the delirium rating scale-revised-98: reliability and validity. Psychiatry Invest 2011;8:30-38. https://doi.org/10.4306/pi.2011.8.1.30
  20. Kang YW, Na DL, Hahn SH. A validity study on the Korean Mini-Mental Status Examination (K-MMSE) in dementia patients. J Kor Neurol Asso 1997;15:1-9.
  21. Scheltens P, Barkhof F, Leys D, Pruvo JP, Nauta JJ, Vermersch P, Steinling M, Valk J. A semiquantative rating scale for the assessment of signal hyperintensities on magnetic resonance imaging. J Neurol Sci 1993;114:7-12. https://doi.org/10.1016/0022-510X(93)90041-V
  22. Hales RE, Yudofsky SC, Gabbard GO, American Psychiatric Publishing. The American Psychiatric Publishing textbook of psychiatry. 5th ed. Washington, DC: American Psychiatric Pub.;2008.
  23. Filley CM. White matter: organization and functional relevance. Neuropsychol Rev 2010;20:158-173. https://doi.org/10.1007/s11065-010-9127-9
  24. Mocellin R, Walterfang M, Velakoulis D. Neuropsychiatry of complex visual hallucinations. Aust N Z J Psychiatry 2006; 40:742-751. https://doi.org/10.1080/j.1440-1614.2006.01878.x
  25. Herrmann LL, Le Masurier M, Ebmeier KP. White matter hyperintensities in late life depression: a systematic review. J Neurol Neurosurg Psychiatry 2008;79:619-624.
  26. Sheline YI, Price JL, Vaishnavi SN, Mintun MA, Barch DM, Epstein AA, Wilkins CH, Snyder AZ, Couture L, Schechtman K, McKinstry RC. Regional white matter hyperintensity burden in automated segmentation distinguishes late-life depressed subjects from comparison subjects matched for vascular risk factors. Am J Psychiatry 2008;165:524-532. https://doi.org/10.1176/appi.ajp.2007.07010175
  27. Taylor WD, MacFall JR, Steffens DC, Payne ME, Provenzale JM, Krishnan KR. Localization of age-associated white matter hyperintensities in late-life depression. Prog Neuropsychopharmacol Biol Psychiatry 2003; 27:539-544. https://doi.org/10.1016/S0278-5846(02)00358-5
  28. Peritogiannis V, Stefanou E, Lixouriotis C, Gkogkos C, Rizos DV. Atypical antipsychotics in the treatment of delirium. Psychiatry Clin Neurosci 2009;63:623-631. https://doi.org/10.1111/j.1440-1819.2009.02002.x
  29. Grover S, Kumar V, Chakrabarti S. Comparative efficacy study of haloperidol, olanzapine and risperidone in delirium. J Psychosom Res 2011;71:277-281. https://doi.org/10.1016/j.jpsychores.2011.01.019
  30. Han CS, Kim YK. A double-blind trial of risperidone and haloperidol for the treatment of delirium. Psychosomatics 2004; 45:297-301. https://doi.org/10.1016/S0033-3182(04)70170-X
  31. Straker DA, Shapiro PA, Muskin PR. Aripiprazole in the treatment of delirium. Psychosomatics 2006;47:385-391. https://doi.org/10.1176/appi.psy.47.5.385
  32. Garde E, Mortensen EL, Krabbe K, Rostrup E, Larsson HB. Relation between age-related decline in intelligence and cerebral white-matter hyperintensities in healthy octogenarians: a longitudinal study. Lancet 2000;356:628-634. https://doi.org/10.1016/S0140-6736(00)02604-0
  33. Pantoni L. Pathophysiology of age-related cerebral white matter changes. Cerebrovasc Dis 2002;13 Suppl 2:7-10.
  34. Farkas E, de Vos RA, Donka G, Jansen Steur EN, Mihaly A, Luiten PG. Age-related microvascular degeneration in the human cerebral periventricular white matter. Acta Neuropathol 2006;111:150-157. https://doi.org/10.1007/s00401-005-0007-y
  35. van Montfort SJT, van Dellen E, van den Bosch AMR, Otte WM, Schutte MJL, Choi SH, Chung TS, Kyeong S, Slooter AJC, Kim JJ. Resting-state fMRI reveals network disintegration during delirium. Neuroimage Clin 2018;20:35-41. https://doi.org/10.1016/j.nicl.2018.06.024
  36. Kapeller P, Barber R, Vermeulen RJ, Ader H, Scheltens P, Freidl W, Almkvist O, Moretti M, del Ser T, Vaghfeldt P, Enzinger C, Barkhof F, Inzitari D, Erkinjunti T, Schmidt R, Fazekas F; European Task Force of Age Related White Matter Changes. Visual rating of age-related white matter changes on magnetic resonance imaging: scale comparison, interrater agreement, and correlations with quantitative measurements. Stroke 2003;34:441-445. https://doi.org/10.1161/01.STR.0000049766.26453.E9