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NEUROLOGY 2004;63:139-144
© 2004 American Academy of Neurology


Medical Hypothesis

White matter lesion progression

A surrogate endpoint for trials in cerebral small-vessel disease

R. Schmidt, MD, Ph. Scheltens, MD, T. Erkinjuntti, MD, L. Pantoni, MD PhD, H. S. Markus, FRCP, A. Wallin, MD, F. Barkhof, MD and F. Fazekas, MD for the European Task Force on Age-Related White Matter Changes

From the Department of Neurology (Drs. Schmidt and Fazekas), Medical University Graz, Austria; Department of Neurology (Dr. Scheltens) and Image Analysis Center (Dr. Barkhof), Vrije Universiteit Medical Center, Amsterdam, the Netherlands; Memory Research Unit (Dr. Erkinjuntti), Department of Clinical Neurosciences, Helsinki University Central Hospital, Finland; Department of Neurological and Psychiatric Sciences (Dr. Pantoni), University of Florence, Italy; Clinical Neuroscience (Dr. Markus), St. George’s Hospital Medical School, London, UK; and Institute of Clinical Neuroscience (Dr. Wallin), Sahlgrenska University Hospital, Mölndahl, Sweden.

Address correspondence and reprint requests to Dr. R. Schmidt, Department of Neurology, Medical University Graz, Auenbruggerplatz 22, A-8036 Graz, Austria; e-mail: reinhold.schmidt{at}meduni-graz.at

There is neuropathologic evidence that confluent MRI white matter lesions in the elderly reflect ischemic brain damage due to microangiopathy. The authors hypothesize that measuring changes in the progression of white matter lesions as shown by MRI may provide a surrogate marker in clinical trials on cerebral small-vessel disease in which the currently used primary outcomes are cognitive impairment and dementia. This hypothesis is based on evidence that confluent white matter lesions progress rapidly as shown in a recent follow-up study in community-dwelling subjects. The mean increase in lesion volume was 5.2 cm3 after 3 years. Based on these data in a clinical trial, 195 subjects with confluent lesions would be required per treatment arm to demonstrate a 20% reduction in the rate of disease progression over a 3-year period. Like any other MRI metric, the change in white matter lesion volume cannot be considered preferable to clinical outcomes unless it has been demonstrated that it matters to the patient in terms of function.


Received November 20, 2003. Accepted in final form February 23, 2004.




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