10.5826/dpc.1301a43
Introduction: Psoriasis is a systemic autoimmune disease that is associated with numerous comorbidities.
Objective: This study aimed to compare the prevalence of small vessel cerebrovascular disease (SVCD) and atrophic brain changes in MRI of patients with psoriasis and normal subjects.
Materials and Methods: This case-control study was performed on 27 patients with psoriasis and 27 normal individuals who were referred to Shohada-e-Tajrish Hospital, Tehran, Iran during 2019 and 2020. Basic demographic and clinical information of participants were recorded. Brain MRI was performed for all individuals to examine the medial temporal atrophy (MTA) score, global cortical atrophy (GCA) score, and Fazekas scale. Finally, the relative frequencies of each parameter between the two groups were compared.
Results: There was no significant difference in the frequency of the Fazekas scale, GCA, and MTA scores between the two groups. However, a mild trend was found for higher frequency of Fazekas scale, GCA, and MTA scores in controls in comparison with the case group. While there was no significant relationship between the Fazekas scale and disease duration (p=0.16), a significant and positive correlation was found between disease duration and GCA and MTA scores (p&lt;0.001). There was no significant relationship between Fazekas, GCA and MTA status and other parameters.
Conclusion: The increase in disease duration was significantly associated with increase in the incidence of cerebral atrophy, which may suggest the need for screening in terms of CNS involvement in psoriasis patients.
text/xml
2160-9381
2432
en
Mohahmmad Shahidi Dadras
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Fazekas
The Relative Frequency Of Small Vessel Cerebrovascular Disease And Brain Atrophy In MRI Of Patients With Psoriasis
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-01-31
2022-03-11
2023-01-31
2023-02-27
e2023043
Dermatol Pract Concept
Introduction: Psoriasis is a systemic autoimmune disease that is associated with numerous comorbidities.
Objective: This study aimed to compare the prevalence of small vessel cerebrovascular disease (SVCD) and atrophic brain changes in MRI of patients with psoriasis and normal subjects.
Materials and Methods: This case-control study was performed on 27 patients with psoriasis and 27 normal individuals who were referred to Shohada-e-Tajrish Hospital, Tehran, Iran during 2019 and 2020. Basic demographic and clinical information of participants were recorded. Brain MRI was performed for all individuals to examine the medial temporal atrophy (MTA) score, global cortical atrophy (GCA) score, and Fazekas scale. Finally, the relative frequencies of each parameter between the two groups were compared.
Results: There was no significant difference in the frequency of the Fazekas scale, GCA, and MTA scores between the two groups. However, a mild trend was found for higher frequency of Fazekas scale, GCA, and MTA scores in controls in comparison with the case group. While there was no significant relationship between the Fazekas scale and disease duration (p=0.16), a significant and positive correlation was found between disease duration and GCA and MTA scores (p&lt;0.001). There was no significant relationship between Fazekas, GCA and MTA status and other parameters.
Conclusion: The increase in disease duration was significantly associated with increase in the incidence of cerebral atrophy, which may suggest the need for screening in terms of CNS involvement in psoriasis patients.
Mohahmmad Shahidi Dadras
2023/01/31
10.5826/dpc.1301a43
e2023043
Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2160-9381
Fazekas
en
e2023043
Najafi P, et al. Functional and anatomical brain connectivity in psoriasis patients and healthy controls: A pilot brain imaging study after exposure to mentally-induced itch. JEADV. 2020;34:2557-65.
The Relative Frequency Of Small Vessel Cerebrovascular Disease And Brain Atrophy In MRI Of Patients With Psoriasis
https://dpcj.org/index.php/dpc/article/download/2432/1933
       The Relative Frequency of Small Vessel
  Cerebrovascular Disease and Brain Atrophy in MRI
             of Patients with Psoriasis
                  Sahar Dadkhahfar1, Mozhdeh Gheisari2, Zahra Mahboubi-Fooladi3,
                                   Mohammad Shahidi Dadras1


1 Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Department of Radiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 Department of Radiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran



Key words: psoriasis, SVCD, MTA, GCA, Fazekas
Citation: Dadkhahfar S, Gheisari M, Mahboubi-Fooladi Z, Shahidi Dadras M. The relative frequency of small vessel cerebrovascular
disease and brain atrophy in MRI of patients with psoriasis. Dermatol Pract Concept. 2023;13(1):e2023043. DOI: https://doi.org/10.5826/
dpc.1301a43
Accepted: May 19, 2022; Published: January 2023
Copyright: ©2023 Dadkhahfar et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Zahra Mahboubi-Fooladi, Department of Radiology & Medical Imaging Center, Shohada Tajrish Hospital –
Tajrish Square, Tehran, Iran (Shaheed Beheshti University of Medical Sciences Tehran – Iran.) E-mail: mahboubiz@sbmu.ac.ir




  ABSTRACT             Introduction: Psoriasis is a systemic autoimmune disease that is associated with numerous comorbidities.
                       Objective: This study aimed to compare the prevalence of small vessel cerebrovascular disease (SVCD)
                       and atrophic brain changes in MRI of patients with psoriasis and normal subjects.
                       Methods: This case-control study was performed on 27 patients with psoriasis and 27 normal individuals
                       who were referred to Shohada-e-Tajrish Hospital, Tehran, Iran during 2019 and 2020. Basic demographic
                       and clinical information of participants were recorded. Brain MRI was performed for all individuals to
                       examine the medial temporal atrophy (MTA) score, global cortical atrophy (GCA) score, and Fazekas scale.
                       Finally, the relative frequencies of each parameter between the two groups were compared.
                       Results: There was no significant difference in the frequency of the Fazekas scale, GCA, and MTA
                       scores between the two groups. However, a mild trend was found for a higher frequency of Fazekas
                       scale, GCA, and MTA scores in controls in comparison with the case group. While there was no signif-
                       icant relationship between the Fazekas scale and disease duration (p=0.16), a significant and positive
                       correlation was found between disease duration and GCA and MTA scores [p<0.001). There was no
                       significant relationship between Fazekas, GCA and MTA status and other parameters.
                       Conclusions: The increase in disease duration was significantly associated with an increase in the
                       incidence of cerebral atrophy, which may suggest the need for screening in terms of CNS involvement
                       in psoriasis patients.



Original Article | Dermatol Pract Concept. 2023;13(1):e2023043                                                                       1
Introduction                                                      cosmetic concerns. They also had no considerable history
                                                                  of dermatological disease or previous medical diseases. The
Psoriasis is a polygenic immune-inflammatory skin disease         control subjects were matched to patients by age and sex.
[1]. A variety of environmental factors may elicit disease        Both groups did not declare past medical history of neuro-
in predisposed individuals. It affects 0.6-5% of the general      logical disease. This case-control study was approved by the
population in different communities [2]. Psoriasis affects        institutional review board and ethical committee of Shahid
about 8 million adults in the United States, and its overall      Beheshti University of Medical Sciences. Written informed
prevalence in developed countries is about 2% to 3% [3].          consent forms were signed by all individuals, including case
The incidence of psoriasis in Iran has been reported between      and control participants. Demographic data of all patients,
1.3% and 2.5% (4, 5]. About 75% of psoriasis patients have        including gender and age, as well as their medical history,
at least one comorbidity such as dyslipidemia, hypertension,      habitual history (including smoking habit), disease duration,
diabetes, cardiovascular disease, uveitis, inflammatory bowel     nail involvement, and other comorbidities were recorded.
disease, osteoporosis and bone involvement, and obstructive          Brain MRI was performed for all patients and controls
pulmonary disease [6].                                            with the following setting: TR = 9.8 ms; TE = 4.6 ms; flip
    Some studies have described various neurological              angle = 8; section thickness = 1.2 mm; number of sections =
and psychiatric involvement such as seizure, stroke, Guil-        120; no section gap; whole-brain coverage; FOV = 224 mm;
lain-Barré syndrome, migraine, and myasthenia gravis in pa-       matrix = 192; reconstruction matrix = 256. Finally, the MTA
tients with psoriasis. Additionally, there seems to be a higher   score, GCA score and Fazekas scale were calculated by an
incidence of cardiovascular and cerebrovascular disease in        assistant professor of diagnostic radiology with 4 years of
patients with psoriasis even after eliminating confounding        experience, to estimate the frequency of brain atrophy and
risk factors of vascular disease such as stroke[7].               small vessel cerebrovascular disease in each group. The ra-
    Small vessel cerebrovascular disease (SVCD) is caused         diologist was blind to whether the images belonged to the
by damage to cerebral microcirculation and often affects the      case or control group. MTA is a score from 0 to 4 for the
white matter of the brain [8]. About 45% of dementia is           assessment of cognitive impairment. The GCA scale is a
caused by SVCD and it accounts for approximately 20% of           qualitative rating system from 0 to 3 established to measure
all strokes worldwide [9, 10]. Clinically, these lesions can      cerebral atrophy. The Fazekas scale is used to quantify high
range from silent disease to evidence of lacunar infarction,      signal lesions on T2-weighted imaging in deep white mat-
vascular dementia, and other distinct neurological symp-          ter and periventricular regions that are usually attributed to
toms [11]. Radiological findings include subcortical infarcts,    chronic small vessel disease (Figure 1) [13].
and in advanced stages can be characterized as white matter
hyperintensities (WMH), enlargement of the perivascular           Statistical Analysis
spaces, lacunae, cerebral microbleeds and atrophy [8, 12].        The results were presented as mean ± standard deviation
Depression, cognitive impairment and gait problems, stroke,       (SD) for quantitative variables and were summarized by ab-
dementia, and mood disturbance are also commonly found            solute frequencies and percentages for categorical variables.
in patients who suffer from SVCD[8]. To the best of our           Categorical variables were compared using chi-square test
knowledge, no study has examined the extent and the inci-         or Fisher’s exact test. Quantitative variables were also com-
dence of CSVD in conventional brain MRI of patients with          pared with t-test or Mann U test. In this study, p<0.05 was
psoriasis. Therefore, we designed and conducted a study to        considered statistically significant. The SPSS software (IBM,
compare the prevalence of SVCD and atrophic changes in            version 19) was applied for the analysis of data.
conventional MRI of patients with psoriasis in compari-
son with the control group using medial temporal atrophy
                                                                  Results
(MTA) score, global cortical atrophy (GCA) score and Faze-
kas scale.                                                        A total number of 27 consecutive patients with psoriasis and
                                                                  a mean age of 48.14 ± 5.41 years old were entered into the

Materials and Methods                                             study. The majority of cases (17 out of 27 (63%)) were males.
                                                                  The basic demographic and disease characteristics of all pa-
This case-control study was conducted on 27 patients with         tients are summarized in Table 1. Most patients (74.1%) had
psoriasis and 27 healthy individuals aged 18-60 years old         nail involvement. Approximately 33% of patients exhibited
who had been referred to the dermatology department of            arthritis and exacerbation. The mean disease duration and
Shohadaye Tajrish Hospital (Tehran, Iran) between 2019            PASI score were 10.59 years and 13.74 respectively.
and 2020. Healthy controls were age and sex-matched in-              Comparison of the Fazekas scale, GCA and MTA scores
dividuals who were referred to the dermatology clinic for         between study participants are shown in Table 2. There was



2                                                                     Original Article | Dermatol Pract Concept. 2023;13(1):e2023043
           Figure 1. Magnetic resonance imaging of 51-year-old Male Known Case with 16 Years Involvement with psoriasis.
           Mild periventricular and subcortical T2-weighted hyper signal lesions are seen due to small vessel disease (arrows)


   Table 1: The basic demographic and clinical                          Table 2: Comparison of the Fazekas, GCA and
            characteristics of patients.                                     MTA between patients and control.
               Variables                          Results                                    Control            Case         p-value
 Age (Years)                                   48.14 ± 5.41            Fazekas scale
 Gender                                                                0                   15 (55.5%)       14 (51.8%)           0.13
 Male (%)                                       17 (63%)               1                    7 (25.9%)        9 (33.3%)
 Female (%)                                     10 (37%)               2                    5 (18.5%)        5 (18.5%)
 Smoking                                                               3                     0 (0.0%)         0 (0.0%)
 Yes (%)                                        4 (14.8%)
                                                                       GCA scale
 No (%)                                        23 (85.2%)
                                                                       0                   24 (88.9%)       20 (74.1%)           0.75
 Underlying diseases
                                                                       1                    3 (11.1%)        4 (14.8%)
 No (%)                                        23 (85.2%)
                                                                       2                    0 (0.00%)         2 (7.4%)
 Hyperlipidemia (%)                              1 (3.7%)
 Hyper TG (%)                                    1 (3.7%)              3                    0 (0.00%)         1 (3.7%)

 Diabetes (%)                                    2 (7.4%)              MTA scale
 Nail involvement                                                      0                   25 (92.6%)       25 (92.6%)           0.87
 Yes (%)                                       20 (74.1%)              1                     2 (7.4%)         2 (7.4%)
 No (%)                                         7 (25.9%)              2                    0 (0.00%)        0 (0.00%)
 Arthritis                                                             3                    0 (0.00%)        0 (0.00%)
 Yes (%)                                        9 (33.3%)              4                    0 (0.00%)        0 (0.00%)
 No (%)                                        18 (66.7%)
 Exacerbation
 Yes (%)                                        10 (37%)              no significant difference in the frequency of the Fazekas scale,
 No (%)                                         17 (63%)              GCA and MTA scores between the two groups. However, a
 Disease duration (year)                       10.59 ± 7.91           mild trend was found for a higher frequency of Fazekas, GCA
 PASI score                                    13.74 ± 4.42           and MTA with normal status in controls than case group.
 Drug therapy                                                              The relationships between the Fazekas scale, GCA and
 Methotrexate (month)                          27.7 ± 17.65           MTA scores with other parameters are shown in Table 3.
 Phototherapy (session)                        15.23 ± 8.3            While there was no significant relationship between the
 Cyclosporin (month)                           14.48 ± 6.5            Fazekas scale and disease duration (p=0.16), a significant
 Acitretin (month)                               2.3 ± 0.4            and positive correlation was found between disease dura-
 Sinora (month)                                 15.7 ± 3.4            tion with GCA and MTA scores (p<0.001). There was no



Original Article | Dermatol Pract Concept. 2023;13(1):e2023043                                                                          3
Table 3: The relationship between Fazekas, GCA                    case-control design revealing that psoriasis significantly as-
       and MTA with other parameters.                             sociates with impaired cognitive function.
                                                                      Similarly, Brown et al. [13], reported that psoriasis may
                            Fazekas        GCA        MTA
                                                                  be associated with increased cognitive impairment in these
 Age                           0.37        0.29       0.41
                                                                  patients. In another study, Innamorati et al., [14] evaluated
 Gender                        0.64        0.26       0.69
                                                                  the association between psoriasis and cognitive impairment
 Smoking                       0.72        0.28       0.41
                                                                  in 50 patients with psoriasis and 50 normal individuals.
 Underlying diseases           0.28        0.3        0.47        They found that patients with psoriasis had more prominent
 Nail involvement              0.42        0.23       0.28        cognitive impairment, anxiety, depression as well as poorer
 Arthritis                     0.52        0.67       0.39        quality of life.
 Exacerbation                  0.35        0.29       0.45            Recently, Najafi et al., [15] examined the anatomical and
 PASI score                    0.54        0.46       0.54        functional status of the brain in 14 patients with psoriasis
 Disease duration              0.16      <0.001      <0.001       and 15 healthy individuals. They also found that chronic
                                                                  psoriasis could alter brain anatomy. The results of this study
                                                                  are closely consistent with the findings of our research em-
significant relationship between the Fazekas scale, GCA           phasizing that psoriasis could affect brain structures. As in
and MTA scores with other parameters such as age, gender,         our study, they showed an increased risk of cerebral atrophy
smoking, nail involvement, PASI score, and GCA.                   in patients with long-term psoriasis. Highlighting the signif-
                                                                  icance of CNS investigation in patients with relevant history
                                                                  and symptoms.
Discussion                                                            Conversely, in a recent population-based study, Elena
In this study, the relative frequency of brain atrophy and        Pezzolo et al.[4] found that cognitive test scores and vol-
small vessel cerebrovascular disease in brain MRI of patients     umetric, microstructural, focal measures on brain MRI
with psoriasis and normal subjects was compared to age and        did not differ between psoriasis and non-psoriasis partici-
sex-matched normal individuals. Our results showed that           pants. They concluded that in this population-based study,
there was no significant difference in chronic small vessel       psoriasis was not associated with preclinical markers or
disease measured by Fazekas score. Additionally, the indices      higher dementia risk. This study differs from our study in
of GCA (referring to brain atrophy) and MTA (referring to         terms of the method of white matter evaluation since we
cognitive impairment) were not significantly different among      subjectively illustrated the white matter changes by Faze-
the case and control groups.                                      kas score.
    According to our results, age, sex, smoking, disease se-
verity (measured by PASI score) and nail involvement did          Limitations
not have an impact on GCA, MTA scales and Fazekas score.          One of the limitations of this study was the small sample
    Interestingly, brain atrophy and cognitive impairment         size, which probably affected the comparative results be-
measured by GCA and MTA scales respectively were found            tween the control and patient groups to achieve significant
to significantly correlate with the disease duration in psoria-   differences. Therefore, another study with larger sample size,
sis patients. Longer duration of the disease was significantly    as well as a long-term cohort can be performed to investigate
associated with an increase in cerebral atrophy. This finding     the association of psoriasis with these parameters.
can be associated with the fact that chronic plaque psoria-
sis is an immune-mediated inflammatory skin disease that
                                                                  Conclusions
is strongly associated with the clinical features of metabolic
syndrome, and metabolic syndrome can cause alteration in          Results from the current case-control study support that
the brain [2, 3]. To the best of our knowledge, the current       psoriasis patients are at risk of developing brain atrophy
investigation was the first to reveal an association between      evaluated by Fazekas score. Our study showed that the dis-
psoriasis and increased risk of cerebral atrophy.                 ease duration in psoriasis patients exhibited a significant re-
    Several studies have reported the association between         lationship with cerebral atrophy. An increase in the disease
psoriasis and other brain disorders, including cognitive dis-     duration was significantly associated with an increase in the
orders. For example, Gisondi et al.[2], examined the as-          incidence of cerebral atrophy, which can confirm the impor-
sociation between psoriasis and cognitive impairment in a         tance of follow-up for these patients.




4                                                                      Original Article | Dermatol Pract Concept. 2023;13(1):e2023043
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                                                                          8.   Wolfe F, Michaud K. The effect of methotrexate and anti–tumor
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Original Article | Dermatol Pract Concept. 2023;13(1):e2023043                                                                                 5
