Fazekas scale for white matter lesions

The Fazekas scale is used to simply quantify the amount of white matter T2 hyperintense lesions usually attributed to chronic small vessel ischaemia, although clearly not all such lesions are due to this.

This classification was proposed by Fazekas et al. in 1987 1 and at the time of writing (late 2016) it remains the most widely used system for describing white matter disease severity in publications. It is not generally used in clinical practice, with terms such as 'mild', 'moderate' and 'severe' being favoured. 

Classification

The scale divides the white matter in periventricular and deep white matter, and region each is given a grade depending on the size and confluence of lesions 1

  • periventricular white matter (PVWM)
    • 0 = absent
    • 1 = “caps” or pencil-thin lining
    • 2 = smooth “halo”
    • 3 = irregular periventricular signal extending into the deep white matter
  • deep white matter (DWM)
    • 0 = absent
    • 1 = punctate foci
    • 2 = beginning confluence
    • 3 = large confluent areas

Importantly the aetiology of PVWM and DWM changes differ. The latter is chronic small vessel ischaemic in nature, whereas the former (periventricular) relates to a combination of demyelinationependymitis granularis, subependymal gliosis. Importantly they are not ischaemic in nature 2

Additionally it is important to note that it is the deep white matter component score is useful in the assessment of patients with possible dementia (see neurodegenerative MRI brain (an approach)) and it is this component that is usually reported (e.g. "Fazekas grade 2")

Neurodegenerative diseases

Neurodegenerative diseases are legion and their classification just as protean. A useful approach is to divide them according to underlying pathological process, although even using this schema, there is much overlap and thus resulting confusion.

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