The Fazekas scale describes the extent of white matter hyperintensities on MRI. Periventricular changes and changes in the deep white matter are rated separately on a scale from 0 to 3[^1][^2].
Classification
Fazekas Grade | Description |
Periventricular white matter | |
Grade 0 | No hyperintensities |
Grade 1 | "Caps" or pencil-thin lines |
Grade 2 | Smooth "halo" |
Grade 3 | Irregular periventricular signal extending into the deep white matter. |
Deep white matter | |
Grade 0 | No hyperintensities |
Grade 1 | Punctate foci |
Grade 2 | Beginning confluence |
Grade 3 | Large confluent areas |
What does Fazekas grade 2 mean?
In the deep white matter, Fazekas grade 2 means that individual lesions are beginning to merge. In the periventricular region, grade 2 instead describes a smooth hyperintense halo around the ventricles. Interpretation therefore requires knowing which region the reported grade refers to[^2].
Clinical significance
The Fazekas grade describes an imaging finding. On its own, it does not establish a diagnosis of dementia or reliably predict an individual’s symptoms or clinical course. More extensive white matter changes are associated with poorer cognitive and functional outcomes at the population level. Individual interpretation takes into account age, symptoms, vascular risk factors and the overall MRI pattern[^3].
Incidental findings and risk factors
When incidental white matter changes of presumed vascular origin are found, blood pressure and other vascular risk factors should be assessed[^3]. Aspirin should not be started for clinically covert cerebral small vessel disease solely because of this imaging finding; other indications for treatment must be considered separately[^4].