From the Guidelines
Small vessel ischemic changes on brain MRI should be managed by controlling vascular risk factors to prevent progression, with a focus on maintaining blood pressure below 130/80 mmHg, controlling blood sugar, lowering cholesterol, smoking cessation, regular exercise, and following a Mediterranean or DASH diet. These changes are typically associated with aging, hypertension, diabetes, and smoking, and can increase the risk for cognitive decline, stroke, and gait problems. The management of small vessel ischemic changes on brain MRI involves a multifaceted approach, including:
- Maintaining blood pressure below 130/80 mmHg with medications like ACE inhibitors or ARBs, as recommended by recent guidelines 1
- Controlling blood sugar, with a target HbA1c <7% for diabetics
- Lowering cholesterol with statins, with a target LDL <70 mg/dL for high-risk patients
- Smoking cessation
- Regular exercise, with a goal of 150 minutes of moderate activity weekly
- Following a Mediterranean or DASH diet Daily aspirin (81mg) may be recommended for some patients with cardiovascular risk factors, but this should be individualized based on the patient's risk profile. Regular follow-up with a neurologist is important, typically every 6-12 months with repeat imaging as clinically indicated, to monitor for progression of small vessel disease and adjust the management plan as needed. The presence of cerebral microbleeds (CMBs) on MRI, which are associated with small vessel disease, can also inform the management plan, as patients with CMBs may be at higher risk for recurrent intracerebral hemorrhage (ICH) and ischemic stroke 1. Overall, early intervention through risk factor modification is crucial to prevent further damage to brain tissue and preserve cognitive function.
From the Research
Small Vessel Ischemic Changes on MRI of Brain
- Small vessel ischemic changes on MRI of the brain are a common feature of cerebral small vessel disease (SVD) 2, 3, 4, 5, 6
- These changes can include white matter hyperintensities, lacunes, cerebral microbleeds, and perivascular spaces 2, 3, 4, 5
- The total burden of SVD on MRI has been shown to be associated with vascular risk factors, such as age, male sex, hypertension, and smoking 2
- A combined measure of white matter hyperintensities, lacunar, gray matter, and hippocampal volumes has been shown to be a powerful predictor of long-term cognitive decline and functional disability 3
- Progressive ischemic changes, including new infarcts and white matter hyperintensities, can occur despite anticoagulation 4
- Traditional risk factors for cerebrovascular disease, such as hypertension and ischemic heart disease, are associated with progression of SVD 4
- MRI-proven incident ischemia, including recurrent ischemic stroke, incident lacunes, and incidental diffusion-weighted imaging-positive lesions, may be a useful marker of disease progression in SVD 6
Risk Factors and Associations
- Age, male sex, hypertension, and smoking are significantly and independently associated with the total SVD score 2
- Lacunar stroke subtype is also associated with a higher total SVD score 2
- Volumes of white matter hyperintensities, lacunes, gray matter, and hippocampi are independent predictors of cognitive impairment 3
- Hypertension and ischemic heart disease are more prevalent in patients with progressive ischemic changes 4
Clinical Implications
- SVD is a common cause of stroke and vascular dementia, but the underlying pathogenesis is poorly understood 5
- The determination of which vascular dysfunctions are most important in pathogenesis, which abnormalities are reversible, and why lesion progression and symptomatology are so variable are major challenges in SVD research 5
- MRI-proven incident ischemia may become a plausible outcome for future clinical trials in SVD 6