Imaging biomarkers of dementia: recommended visual rating scales with teaching cases

Abstract

The diagnostic work up of dementia may benefit from structured reporting of CT and/or MRI and the use of standardised visual rating scales. We advocate a more widespread use of standardised scales as part of the workflow in clinical and research evaluation of dementia. We propose routine clinical use of rating scales for medial temporal atrophy (MTA), global cortical atrophy (GCA) and white matter hyperintensities (WMH). These scales can be used for evaluation of both CT and MRI and are efficient in routine imaging assessment in dementia, and may improve the accuracy of diagnosis. Our review provides detailed imaging examples of rating increments in each of these scales and a separate teaching file. The radiologist should relate visual ratings to the clinical assessment and other biomarkers to assist the clinician in the diagnostic decision.

Teaching points: • Clinical dementia diagnostics would benefit from structured radiological reporting. • Standardised rating scales should be used in dementia assessment. • It is important to relate imaging findings to the clinically suspected diagnosis.

Keywords: Alzheimer’s disease; CT; Dementia; Imaging; MRI.

Fig. 1

A. Widening of the ventricles on MRI. Interpretation key. Numbers equal the corresponding image in the supplementary PDF file. Appropriate wording for widening of the ventricles is: no, mild, moderate or severe widening. a/1) There are no visual rating scales for the size of the ventricles. Compare to the widening of a 25-year-old healthy individual. b/2) A third ventricle with a diameter of >10 mm is pathological at any age. c/6) No widening. d/16) No widening. e/17) In between no widening and mild widening. The third ventricle is wider than usual. f/20) Mild widening. Note the slightly wide frontal horn on the left side due to the frontal infarction. g/7) Mild widening h/9) Mild widening. i/15) Approaching mild widening. j/12) Mild bifrontal widening and no widening of posterior horns. k/11) Mild bifrontal widening and a left posterior horn with moderate widening. l/3) In this case: mild, with a moderate widening of the posterior horns. m/5) Mild widening of the frontal horns and moderate of posterior horns. n/8) Mild widening, with a moderate widening of frontal horns. o/19) In between mild and moderate widening but closer to moderate. p/13) Mild central widening, with the right posterior horn a bit wider, but not yet moderate. q/10) Mild widening of frontal horns and moderate of the posterior horns, especially the left posterior horn. r/14) Moderate widening, especially of posterior horns. s/18) Severe dilatation of third ventricle and moderate widening of the posterior horns. t/4) Severe widening of the ventricles, especially of the frontal horns. B. Widening of the ventricles on CT. Interpretation key. Numbers equal the corresponding image in the supplementary PDF file. a/1) No widening. The normative key. b/7) No widening, right deep MCA infarction is seen in the image. c/3) No widening d/19) No widening but wide cavum septi pellucidi et vergae. e/11) Nearly no widening. f/14) Between no widening and mild. g/6) Normal to mild widening. h/9) Mild widening. i/12) Mild widening. j/13) Mild widening. k/18) Mild widening of ventricles. l/17) Mild widening of lateral ventricles. Cavum septi pellucidi et verge makes ventricles look wider. m/15) Mild widening of the posterior horns without exceeding into moderate widening. n/20) Mild widening of frontal horns and a mild to moderate widening of the posterior horns. o/10) Mild widening with a moderate widening of the left posterior horn. p/8) Mild widening with a moderate widening of the right posterior horn. q/16) Mild widening of frontal horns and moderate widening of posterior horns. r/4) Mild to moderate widening s/5) A pronounced widening of the third ventricle. Maybe this indicates atrophy of the basal ganglia and thalami. t/2) Moderate widening

Fig. 1

A. Widening of the ventricles on MRI. Interpretation key. Numbers equal the corresponding image in the supplementary PDF file. Appropriate wording for widening of the ventricles is: no, mild, moderate or severe widening. a/1) There are no visual rating scales for the size of the ventricles. Compare to the widening of a 25-year-old healthy individual. b/2) A third ventricle with a diameter of >10 mm is pathological at any age. c/6) No widening. d/16) No widening. e/17) In between no widening and mild widening. The third ventricle is wider than usual. f/20) Mild widening. Note the slightly wide frontal horn on the left side due to the frontal infarction. g/7) Mild widening h/9) Mild widening. i/15) Approaching mild widening. j/12) Mild bifrontal widening and no widening of posterior horns. k/11) Mild bifrontal widening and a left posterior horn with moderate widening. l/3) In this case: mild, with a moderate widening of the posterior horns. m/5) Mild widening of the frontal horns and moderate of posterior horns. n/8) Mild widening, with a moderate widening of frontal horns. o/19) In between mild and moderate widening but closer to moderate. p/13) Mild central widening, with the right posterior horn a bit wider, but not yet moderate. q/10) Mild widening of frontal horns and moderate of the posterior horns, especially the left posterior horn. r/14) Moderate widening, especially of posterior horns. s/18) Severe dilatation of third ventricle and moderate widening of the posterior horns. t/4) Severe widening of the ventricles, especially of the frontal horns. B. Widening of the ventricles on CT. Interpretation key. Numbers equal the corresponding image in the supplementary PDF file. a/1) No widening. The normative key. b/7) No widening, right deep MCA infarction is seen in the image. c/3) No widening d/19) No widening but wide cavum septi pellucidi et vergae. e/11) Nearly no widening. f/14) Between no widening and mild. g/6) Normal to mild widening. h/9) Mild widening. i/12) Mild widening. j/13) Mild widening. k/18) Mild widening of ventricles. l/17) Mild widening of lateral ventricles. Cavum septi pellucidi et verge makes ventricles look wider. m/15) Mild widening of the posterior horns without exceeding into moderate widening. n/20) Mild widening of frontal horns and a mild to moderate widening of the posterior horns. o/10) Mild widening with a moderate widening of the left posterior horn. p/8) Mild widening with a moderate widening of the right posterior horn. q/16) Mild widening of frontal horns and moderate widening of posterior horns. r/4) Mild to moderate widening s/5) A pronounced widening of the third ventricle. Maybe this indicates atrophy of the basal ganglia and thalami. t/2) Moderate widening

Fig. 2

A. Rating of medial temporal atrophy (MTA) on MR. Interpretation key. Answers given as (right/ left). Numbers equal the corresponding image in the supplementary PDF file. a/6) MTA0/0. b/16) MTA0 right and MTA0-1 on the left side. c/2) MTA0/1. d/4) MTA1/0-1. Both are normal. e/5) MTA1/1. f/17) MTA1/1. g/11) MTA1/1. Note the small cyst in the right hippocampus. h/8) MTA1/1. i/1) MTA2/2. Artefacts are not disturbing the rating process. The parahippocampal gyri are not atrophied. The sulci are closed. j/10) MTA2/2. k/15) MTA2/2. On the right side the image is too far behind the rating point. Left is optimal here. l/18) MTA2/2 m/14) MTA1/3. On the right side MTA is turning into MTA2 and on the left side MTA just passed from MTA2 into MTA3. n/–12) MTA2/2.The left MTA is turning into MTA3. o/13) MTA2/2. Here you need to have surrounding images to be sure of the grading. Right side might turn into MTA3. p/3) MTA3/2. A fetal band/septum on the left side. Cut it in your mind and the hippocampus will be released. q/9) MTA2-3 /2. Here it is difficult to rate. You need to have several images in a row, but even then it is difficult. The hippocampi are atrophic but there is no passage of cerebrospinal fluid around the hippocampi in this image r/7) MTA3/3. The widening of the ventricles are pronounced and sometimes the distinction between widening of ventricles and hydrocephalus of other reasons is difficult. In this case the entorhinal cortex and parahippocampal gyri are atrophied as well which makes atrophy as a cause more likely. s/19) MTA4/ 3–4. This image is noisy and it’s difficult to distinguish the entorhinal cortex from the hippocampi and parahippocampal gyri. t/20) MTA4/4.The right side is more atrophic than the left side. B. Rating of MTA on CT. Interpretation key. Answers given as (right/ left). Numbers equal the corresponding image in the supplementary PDF file. a/19) MTA0/0. b/10) MTA1/0. c/16) MTA0-1/1. d/7) MTA1/0. Basal artefacts and an acute infarction in the left temporal lobe. e/14) MTA1/1. f/18) MTA1/2. g/11) MTA2/2. Maybe too anterior on the right side for rating. h/12) MTA1/2-3. Difficult to rate on the left side. Hippocampus is thin. MTA3 is more likely. i/20) MTA2/2. j/3) MTA2/2. It is too anterior to rate the right side, parts of amygdala are still remaining and on the left side it is almost too far posteriorly. k/6) MTA1/2.Basal artefacts make it more difficult to rate. Left side is MTA2 but is turning towards MTA3. l/1) MTA3/0.Asymmetric MTA. Note the wider Sylvian fissure on the right side. m/4) MTA2-3.More atrophy on the left side. Thin hippocampi, wide temporal horns, wide sulci beneath, wide hippocampal sulci. n/15) MTA2/3. Difficult to be sure on a single image. o/8) MTA2/3. Right side is between 2 and 3 and left side between 3 and 4. Note the differences in lateral ventricle size. p/2) MTA3/3. Difficult to rate on just one image. The hippocampi adheres to the ventricular wall on both sides. The hippocampi are thin and the fissura hippocampi are wide. The temporal horns are starting to widen. Parahippocampal gyri are thin and the sulci beneath it is wide. q/13) MTA3/3.The hippocampus on the left side has a strange formation - maybe it is not fully rotated. r/17) MTA3/3.Too anterior on both sides. Parts of amygdala are remaining bilaterally. Hippocampi are thin but the sulci beneath are not wide. s/5) MTA4/4. Right side is a bit too anterior for rating. t/9) MTA4/4

Fig. 2

A. Rating of medial temporal atrophy (MTA) on MR. Interpretation key. Answers given as (right/ left). Numbers equal the corresponding image in the supplementary PDF file. a/6) MTA0/0. b/16) MTA0 right and MTA0-1 on the left side. c/2) MTA0/1. d/4) MTA1/0-1. Both are normal. e/5) MTA1/1. f/17) MTA1/1. g/11) MTA1/1. Note the small cyst in the right hippocampus. h/8) MTA1/1. i/1) MTA2/2. Artefacts are not disturbing the rating process. The parahippocampal gyri are not atrophied. The sulci are closed. j/10) MTA2/2. k/15) MTA2/2. On the right side the image is too far behind the rating point. Left is optimal here. l/18) MTA2/2 m/14) MTA1/3. On the right side MTA is turning into MTA2 and on the left side MTA just passed from MTA2 into MTA3. n/–12) MTA2/2.The left MTA is turning into MTA3. o/13) MTA2/2. Here you need to have surrounding images to be sure of the grading. Right side might turn into MTA3. p/3) MTA3/2. A fetal band/septum on the left side. Cut it in your mind and the hippocampus will be released. q/9) MTA2-3 /2. Here it is difficult to rate. You need to have several images in a row, but even then it is difficult. The hippocampi are atrophic but there is no passage of cerebrospinal fluid around the hippocampi in this image r/7) MTA3/3. The widening of the ventricles are pronounced and sometimes the distinction between widening of ventricles and hydrocephalus of other reasons is difficult. In this case the entorhinal cortex and parahippocampal gyri are atrophied as well which makes atrophy as a cause more likely. s/19) MTA4/ 3–4. This image is noisy and it’s difficult to distinguish the entorhinal cortex from the hippocampi and parahippocampal gyri. t/20) MTA4/4.The right side is more atrophic than the left side. B. Rating of MTA on CT. Interpretation key. Answers given as (right/ left). Numbers equal the corresponding image in the supplementary PDF file. a/19) MTA0/0. b/10) MTA1/0. c/16) MTA0-1/1. d/7) MTA1/0. Basal artefacts and an acute infarction in the left temporal lobe. e/14) MTA1/1. f/18) MTA1/2. g/11) MTA2/2. Maybe too anterior on the right side for rating. h/12) MTA1/2-3. Difficult to rate on the left side. Hippocampus is thin. MTA3 is more likely. i/20) MTA2/2. j/3) MTA2/2. It is too anterior to rate the right side, parts of amygdala are still remaining and on the left side it is almost too far posteriorly. k/6) MTA1/2.Basal artefacts make it more difficult to rate. Left side is MTA2 but is turning towards MTA3. l/1) MTA3/0.Asymmetric MTA. Note the wider Sylvian fissure on the right side. m/4) MTA2-3.More atrophy on the left side. Thin hippocampi, wide temporal horns, wide sulci beneath, wide hippocampal sulci. n/15) MTA2/3. Difficult to be sure on a single image. o/8) MTA2/3. Right side is between 2 and 3 and left side between 3 and 4. Note the differences in lateral ventricle size. p/2) MTA3/3. Difficult to rate on just one image. The hippocampi adheres to the ventricular wall on both sides. The hippocampi are thin and the fissura hippocampi are wide. The temporal horns are starting to widen. Parahippocampal gyri are thin and the sulci beneath it is wide. q/13) MTA3/3.The hippocampus on the left side has a strange formation - maybe it is not fully rotated. r/17) MTA3/3.Too anterior on both sides. Parts of amygdala are remaining bilaterally. Hippocampi are thin but the sulci beneath are not wide. s/5) MTA4/4. Right side is a bit too anterior for rating. t/9) MTA4/4

Fig. 3

A. Global cortical atrophy (GCA) rating on MR. Interpretation key. Numbers equal the corresponding image in the supplementary PDF file. a/1) GCA0. b/17) GCA0-1. c/7) GCA0-1. Note the powerful widening of the lateral ventricles and especially the frontal horns. Normal pressure hydrocephalus? d/8) GCA0-1 with bifrontal GCA1. Note the widening of the posterior horns of the lateral ventricles. e/14) Bifrontal GCA1 and biparietal GCA0. Note the wide lateral ventricles. f/11) GCA0. Some atrophy of one or two of the temporal gyri and widening of the Sylvian fissure, especially on the left side, GCA2. g/2) GCA1 in the parietal lobe. GCA1 and 2 in the frontal lobes. h/4) GCA1. GCA2 in the left side at the junction between the frontal and parietal lobes. i/5) GCA1-2, but mostly GCA2. j/16) GCA1 going towards GCA2. k/9) GCA1. Maybe atrophy in the frontal midsagital region with mild atrophy of the anterior cingulate gyri, GCA2? l/6) GCA2 m/13) BifrontalGCA1 and biparietal GCA2. n/20) GCA2, more atrophy left parietal. o/18) Bifrontal GCA2 and biparietal GCA1. p/19) GCA0 except for anterior gyri in both temporal lobes, GCA 2–3 left temporal and GCA1-2 right temporal. q/3) GCA2 in the left frontal lobe and GCA2-3 in the right. A few gyri with GCA3.GCA0-1 in the parietal lobes. Note the widening of the frontal horns of lateral ventricles and the atrophy of the anterior cingulate gyri. r/10) BifrontalGCA 2–3 and biparietal GCA0-1. Note atrophy of the cingulate gyrus and wide frontal horns. s/12) GCA3 in the temporal lobe on the left side. GCA1 on the right side and GCA2 in the cerebellum. t/15) GCA2 and maybe GCA3 in the Sylvian fissure. Biparietal GCA1. B. Global cortical atrophy (GCA) rating on CT. Interpretation key. Numbers equal the corresponding image in the supplementary PDF file. a/1) GCA0 b/17) GCA0-1. c/5) GCA1. d/2) GCA1. e/8) GCA1. f/10) GCA1. g/18) GCA1 in the right hemisphere and GCA2 in left hemisphere. h/9) GCA1 in the more frontal part of the frontal lobes. GCA2 in general. i/19) In-between GCA1-2, but closer to GCA2. j/13) In-between GCA1-2, GCA2 bifrontal. Note the cavum septi pellucidi. k/3) Bifrontal GCA2 and biparietal GCA1.Note the wide frontal horns. l/6) Bifrontal GCA2, biparietal GCA1. m/7) GCA2 fronto-parietal. n/20) GCA2. o/16) GCA2, frontal lobe left.GCA1 in the right frontal lobe and GCA0 in the parietal lobes. Note the atrophy in the anterior cingulate gyri. p/11) Biparietal GCA2 and bifrontal GCA1. q/14) Another image of the same patient, GCA2. r/12) Note the side difference. GCA2 along the left hemisphere, GCA1 on the right side. s/15) GCA2 in supraorbital part of the frontal lobes and in the anterior part of the temporal lobes.GCA0 in the more posterior part of the temporal lobes. t/4) GCA3 in a few parietal gyri on the right side. Bifrontal GCA2 and GCA1 left parietal

Fig. 3

A. Global cortical atrophy (GCA) rating on MR. Interpretation key. Numbers equal the corresponding image in the supplementary PDF file. a/1) GCA0. b/17) GCA0-1. c/7) GCA0-1. Note the powerful widening of the lateral ventricles and especially the frontal horns. Normal pressure hydrocephalus? d/8) GCA0-1 with bifrontal GCA1. Note the widening of the posterior horns of the lateral ventricles. e/14) Bifrontal GCA1 and biparietal GCA0. Note the wide lateral ventricles. f/11) GCA0. Some atrophy of one or two of the temporal gyri and widening of the Sylvian fissure, especially on the left side, GCA2. g/2) GCA1 in the parietal lobe. GCA1 and 2 in the frontal lobes. h/4) GCA1. GCA2 in the left side at the junction between the frontal and parietal lobes. i/5) GCA1-2, but mostly GCA2. j/16) GCA1 going towards GCA2. k/9) GCA1. Maybe atrophy in the frontal midsagital region with mild atrophy of the anterior cingulate gyri, GCA2? l/6) GCA2 m/13) BifrontalGCA1 and biparietal GCA2. n/20) GCA2, more atrophy left parietal. o/18) Bifrontal GCA2 and biparietal GCA1. p/19) GCA0 except for anterior gyri in both temporal lobes, GCA 2–3 left temporal and GCA1-2 right temporal. q/3) GCA2 in the left frontal lobe and GCA2-3 in the right. A few gyri with GCA3.GCA0-1 in the parietal lobes. Note the widening of the frontal horns of lateral ventricles and the atrophy of the anterior cingulate gyri. r/10) BifrontalGCA 2–3 and biparietal GCA0-1. Note atrophy of the cingulate gyrus and wide frontal horns. s/12) GCA3 in the temporal lobe on the left side. GCA1 on the right side and GCA2 in the cerebellum. t/15) GCA2 and maybe GCA3 in the Sylvian fissure. Biparietal GCA1. B. Global cortical atrophy (GCA) rating on CT. Interpretation key. Numbers equal the corresponding image in the supplementary PDF file. a/1) GCA0 b/17) GCA0-1. c/5) GCA1. d/2) GCA1. e/8) GCA1. f/10) GCA1. g/18) GCA1 in the right hemisphere and GCA2 in left hemisphere. h/9) GCA1 in the more frontal part of the frontal lobes. GCA2 in general. i/19) In-between GCA1-2, but closer to GCA2. j/13) In-between GCA1-2, GCA2 bifrontal. Note the cavum septi pellucidi. k/3) Bifrontal GCA2 and biparietal GCA1.Note the wide frontal horns. l/6) Bifrontal GCA2, biparietal GCA1. m/7) GCA2 fronto-parietal. n/20) GCA2. o/16) GCA2, frontal lobe left.GCA1 in the right frontal lobe and GCA0 in the parietal lobes. Note the atrophy in the anterior cingulate gyri. p/11) Biparietal GCA2 and bifrontal GCA1. q/14) Another image of the same patient, GCA2. r/12) Note the side difference. GCA2 along the left hemisphere, GCA1 on the right side. s/15) GCA2 in supraorbital part of the frontal lobes and in the anterior part of the temporal lobes.GCA0 in the more posterior part of the temporal lobes. t/4) GCA3 in a few parietal gyri on the right side. Bifrontal GCA2 and GCA1 left parietal

Fig. 4

A. Rating of white matter hyperintensities (WMH) according to the Fazekas scale on MRI. Interpretation key. Numbers equal the corresponding image in the supplementary PDF file. a/2) Fazekas 0. Entire cerebrum is without punctate WMH. WMH in the pons and in the cerebellum are not included in the rating – but should be mentioned in the referral. b/19) Fazekas 1. c/14) Fazekas 1. Still punctate WMH. d/15) Fazekas 1. One single lesion < 2 cm and some punctate lesions. e/1) Fazekas 1. Small punctate WMH grouped but separated along the left posterior horn of the lateral ventricle. f/3) Fazekas 1. Grouped but not linked WMH. g/9) Fazekas 1. Many separate WMH. h/12) Fazekas 1. i/18) Fazekas 1. All WMH are seen as separate dots. No connecting bridges. j/17) Fazekas 2, Connecting bridges. k/20) Fazekas 2. Connecting bridges close to the right posterior horn. l/4) Fazekas 2. WMH are linked, but can still be seen as separate lesions. m/7) Fazekas 2. The WMH are beginning to confluate. Individual WMH are still seen. n/13) Fazekas 2. Connecting bridges between lesions. o/10) Fazekas 2. Borderline to Fazekas 3 with bridging between WMH still visible, starting to confluate. p/11) Fazekas 2–3. q/8) Fazekas 3. Borderline Fazekas 2, but the WMH on the left side measures more than 2 cm and grouped WMH are confluent to some extent. r/5) Fazekas 3. s/6) Fazekas 3. Confluent lesions around the frontal horns and confluent thin lesions in the right external capsule, and not so pronounced in the same area on the left side. t/16) Fazekas 3 .B. Rating of white matter hyperintensities (WMH) according to the Fazekas scale on CT. Interpretation key. Numbers equal the corresponding image in the supplementary PDF file. a/2)Fazekas 0–1. No lesions are seen, however punctate lesion may exist. b/7) Fazekas 1. Punctate lesions frontal bilaterally, more obvious right frontal. c/11) Fazekas 1. Lesion in the external capsule bilaterally. d/17) Fazekas 1.Single lesion frontal left. e/15) Fazekas 1. Just small caps around the frontal horns and 2 smaller diffuse punctate lesions in the frontal lobe on the right side. f/20) Fazekas 2. Lesions in the external capsules with connecting bridges. g/3) Fazekas 2. Small lesions close to frontal and posterior horns and small lesions in the external capsules.h/4) Fazekas 2. Small lesions in the external capsule, bilaterally. i/13) Fazekas 2. j/18) Fazekas 2. Lesions in the external capsules. k/12)Fazekas 2–3 depending on the size of the lesions surrounding posterior horns. l/1)Fazekas 3. Confluating lesions around the frontal and posterior horns and in both external capsules.m/5) Fazekas 3.n/6) Fazekas 3. o/8)Fazekas 3. p/9) Fazekas 3. q/10) Fazekas 3. r/14) Fazekas 3. s/19) Fazekas 3. t/16) Fazekas 3

Fig. 4

A. Rating of white matter hyperintensities (WMH) according to the Fazekas scale on MRI. Interpretation key. Numbers equal the corresponding image in the supplementary PDF file. a/2) Fazekas 0. Entire cerebrum is without punctate WMH. WMH in the pons and in the cerebellum are not included in the rating – but should be mentioned in the referral. b/19) Fazekas 1. c/14) Fazekas 1. Still punctate WMH. d/15) Fazekas 1. One single lesion < 2 cm and some punctate lesions. e/1) Fazekas 1. Small punctate WMH grouped but separated along the left posterior horn of the lateral ventricle. f/3) Fazekas 1. Grouped but not linked WMH. g/9) Fazekas 1. Many separate WMH. h/12) Fazekas 1. i/18) Fazekas 1. All WMH are seen as separate dots. No connecting bridges. j/17) Fazekas 2, Connecting bridges. k/20) Fazekas 2. Connecting bridges close to the right posterior horn. l/4) Fazekas 2. WMH are linked, but can still be seen as separate lesions. m/7) Fazekas 2. The WMH are beginning to confluate. Individual WMH are still seen. n/13) Fazekas 2. Connecting bridges between lesions. o/10) Fazekas 2. Borderline to Fazekas 3 with bridging between WMH still visible, starting to confluate. p/11) Fazekas 2–3. q/8) Fazekas 3. Borderline Fazekas 2, but the WMH on the left side measures more than 2 cm and grouped WMH are confluent to some extent. r/5) Fazekas 3. s/6) Fazekas 3. Confluent lesions around the frontal horns and confluent thin lesions in the right external capsule, and not so pronounced in the same area on the left side. t/16) Fazekas 3 .B. Rating of white matter hyperintensities (WMH) according to the Fazekas scale on CT. Interpretation key. Numbers equal the corresponding image in the supplementary PDF file. a/2)Fazekas 0–1. No lesions are seen, however punctate lesion may exist. b/7) Fazekas 1. Punctate lesions frontal bilaterally, more obvious right frontal. c/11) Fazekas 1. Lesion in the external capsule bilaterally. d/17) Fazekas 1.Single lesion frontal left. e/15) Fazekas 1. Just small caps around the frontal horns and 2 smaller diffuse punctate lesions in the frontal lobe on the right side. f/20) Fazekas 2. Lesions in the external capsules with connecting bridges. g/3) Fazekas 2. Small lesions close to frontal and posterior horns and small lesions in the external capsules.h/4) Fazekas 2. Small lesions in the external capsule, bilaterally. i/13) Fazekas 2. j/18) Fazekas 2. Lesions in the external capsules. k/12)Fazekas 2–3 depending on the size of the lesions surrounding posterior horns. l/1)Fazekas 3. Confluating lesions around the frontal and posterior horns and in both external capsules.m/5) Fazekas 3.n/6) Fazekas 3. o/8)Fazekas 3. p/9) Fazekas 3. q/10) Fazekas 3. r/14) Fazekas 3. s/19) Fazekas 3. t/16) Fazekas 3