From the Guidelines
The MRI findings suggest chronic small vessel disease, and management should focus on controlling vascular risk factors to prevent disease progression. The MRI results indicate no acute stroke or brain tumor, as there is no restricted diffusion suggesting recent infarct or hypercellular lesion 1. The brain structure appears normal without any midline shift, abnormal fluid collection, or bleeding within the brain tissue. There are small areas of signal changes in the white matter of the cerebral hemispheres, which are nonspecific but could represent evidence of chronic small vessel disease, a common finding related to aging or vascular risk factors like hypertension or diabetes. Some key points to consider in the management of small vessel disease include:
- Controlling vascular risk factors through blood pressure management, as studies have shown that higher blood pressure is associated with greater leakage in white matter hyperintensities (WMH) 1
- Cholesterol control, as dyslipidemia is a known risk factor for small vessel disease
- Lifestyle modifications, including regular exercise and a heart-healthy diet, to prevent progression of the small vessel disease
- Regular follow-up with a neurologist to monitor these vascular changes over time, as studies have reported an association between BBB leakage and worse functional outcome at long-term follow-up 1. Blood flow through the central brain vessels appears normal, which is a positive finding. However, the presence of small vessel disease still warrants attention and management to prevent further progression. Overall, the key to managing small vessel disease is to control vascular risk factors and monitor the disease progression over time, as evidenced by studies such as those reported by Heye (2016) and Li (2018) 1.
From the Research
MRI Results
- The MRI results show no restricted diffusion to suggest recent infarct or hypercellular lesion.
- There is no midline shift or abnormal extra-axial fluid collection.
- The results are negative for intraparenchymal hematoma.
- Several small subcortical foci of signal intensity are noted in the white matter of cerebral hemisphere, which are nonspecific and could represent sequels of chronic small vessel ischemia disease 2.
- Central intracranial flow voids are preserved.
Potential Causes and Associations
- The presence of small subcortical foci of signal intensity in the white matter may be associated with chronic small vessel ischemia disease, which can be caused by various factors such as hypertension 3.
- Hypertension has been shown to be a risk factor for antiplatelet resistance, which can increase the risk of adverse ischemic events 3.
- The ISCHEMIA trial found that patients with a history of heart failure or left ventricular dysfunction were at increased risk for cardiovascular outcomes, and an initial invasive approach was associated with better event-free survival in this subgroup 4.
Management and Treatment
- The use of antiplatelet therapy for stroke prevention in patients with cerebral small vessel disease is supported by evidence, with a 22% relative risk reduction in recurrent stroke compared to placebo 2.
- Conservative management of lumbar radiculopathy, which may be related to the MRI findings, should focus on providing patients with information about the condition, individualized physical activity, and directional preference exercises, supported with NSAIDs in the acute stage 5.
- Surgical versus conservative management of spinal cord cavernous malformations, which may be related to the MRI findings, depends on various factors, including disease severity and individual patient characteristics, with surgical management associated with better long-term functional outcomes and reduced risk of recurrent hemorrhage 6.