Abstract
Objectives White matter hyperintensities (WMH) are a common incidental finding on magnetic resonance imaging (MRI) of the brain. Evidence has emerged supporting these lesions as portending an increased risk of stroke, cognitive impairment, dementia, and death. This commonly prompts referral to the neurology clinic and there are currently no specific guidelines. This guideline will support clinicians to implement appropriate investigation and management of incidentally found WMH.
Methods This guideline was formed by narrative review and expert opinion (14 consultant neurologists in Australia and New Zealand) sought through a modified Delphi consensus. Quality of evidence was assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.
Results Key recommendations include the following: appropriate investigations include measurement of blood pressure, ECG, and tests for hypercholesterolaemia and diabetes mellitus (13/14 experts in favour, no GRADE assessment due to lack of data). Intensive cardiovascular risk management should be commenced (11/14 experts in favour, GRADE: very low). A systolic blood pressure target of less than 120mmHg is unlikely to result in added benefit (8/14 experts in favour, GRADE assessment: very low), and antiplatelets or anticoagulants should not be prescribed for incidental WMH in the absence of another indication (supported by 12/14 experts, GRADE: very low).
Conclusions Incidental finding of WMH on MRI represents an opportunity to screen for and address cardiovascular risk factors to prevent progression to cognitive or other neurological impairment. With this guideline such management can be provided by non-neurologist clinicians without delay in waiting for an outpatient neurology review.
