Fazekas Grade 2 and 3 Differences in Small Vessel Disease

Radiological Differences

Fazekas grade 2 is characterized by beginning confluent white matter hyperintensities that are starting to merge but still maintain some distinction between individual lesions, while Fazekas grade 3 shows fully confluent white matter hyperintensities with extensive involvement of white matter regions 1, 2
The American Academy of Neurology recommends describing white matter hyperintensities according to Standards for Reporting Vascular Changes on Neuroimaging (STRIVE) guidelines, which includes using the Fazekas scale to facilitate cross-study comparison and clinical decision-making 1, 2

Beginning confluent (grade 2) or confluent (grade 3) subcortical white matter hyperintensities is sufficient to cause clinical cognitive impairment in many individuals, but grade 3 is associated with more severe cognitive deficits 1, 2
Patients with Fazekas grade 3 may require more aggressive management of vascular risk factors, particularly hypertension, compared to those with grade 2, according to the American Heart Association 1, 2

Radiology reports should describe white matter hyperintensities according to Standards for Reporting Vascular Changes on Neuroimaging (STRIVE) guidelines, which includes using the Fazekas scale to facilitate cross-study comparison and clinical decision-making 1, 2
The American College of Radiology recommends using the Fazekas scale consistently to facilitate cross-study comparison and clinical decision-making, and considering additional quantification methods for research purposes, such as volumetric assessment with correction for intracranial volume 3, 4

Cognitive assessment is particularly important in patients with Fazekas grade 3, as they have higher risk of cognitive impairment and dementia, according to the American Academy of Neurology 1, 2
Blood pressure management should be carefully considered in patients with Fazekas grade 3, as both hypertension and hypotension can worsen outcomes, and the American Heart Association recommends aggressive management of vascular risk factors 1, 2