Diagnosis and Management of Cerebral Small Vessel Disease

Abstract

OBJECTIVECerebral small vessel disease (CSVD) is a common neurologic condition that contributes to considerable mortality and disability because of its impact on ischemic and hemorrhagic stroke risk and dementia. While attributes of the disease have been recognized for over two centuries, gaps in knowledge remain related to its prevention and management. The purpose of this review is to provide an overview of the current state of knowledge for CSVD.LATEST DEVELOPMENTSCSVD can be recognized by well-defined radiographic criteria, but the pathogenic mechanism behind the disease is unclear. Hypertension control remains the best-known strategy for stroke prevention in patients with CSVD, and recent guidelines provide a long-term blood pressure target of less than 130/80 mm Hg for patients with ischemic and hemorrhagic stroke, including those with stroke related to CSVD. Cerebral amyloid angiopathy is the second leading cause of intracerebral hemorrhage and may be increasingly recognized because of newer, more sensitive imaging modalities. Transient focal neurologic episodes is a relatively new term used to describe “amyloid spells.” Guidance on distinguishing these events from seizures and transient ischemic attacks has been published.ESSENTIAL POINTSCSVD is prevalent and will likely be encountered by all neurologists in clinical practice. It is important for neurologists to be able to recognize CSVD, both radiographically and clinically, and to counsel patients on the prevention of disease progression. Blood pressure control is especially relevant, and strategies are needed to improve blood pressure control for primary and secondary stroke prevention in patients with CSVD.

10 Things You Should Know About Cerebral Small Vessel Disease

“…CSVD contributes to morbidity and mortality through increasing ischemic and hemorrhagic stroke risk and association with cognitive decline and dementia. 4 Studies have demonstrated similar prevalence rates between men and women; however, women are more likely to have acute stroke presentations. There is limited evidence for strong differences across racial and ethnic groups, although some studies suggest that Black and Hispanic patients presenting with intracerebral hemorrhage (ICH) have a greater CSVD burden.…”

“…Some data also suggest that sociodemographic factors, including lower education in childhood, are associated with worse CSVD. 4 HYPERTENSION Duration and lifetime exposure to hypertension remain two of the most important independent modifiable risk factors in the development of CSVD in long-term prospective population studies. Lipohyalinosis, a process of wall thickening and luminal narrowing with fibrinoid necrosis, is thought to be the primary mechanism by which hypertension causes CSVD.…”

“…5 However, a target BP goal for the prevention or reduction of CSVD is unknown. 4 Despite the high prevalence of hypertension in the United States and the range The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. of pharmacological antihypertensives, data show that >50% of patients do not meet target BP at 3 months poststroke.…”

“…CSVD contributes to morbidity and mortality through increasing ischemic and hemorrhagic stroke risk and association with cognitive decline and dementia. 4…”

“…Some data also suggest that sociodemographic factors, including lower education in childhood, are associated with worse CSVD. 4…”