From the Research
The primary management approach for patients with small vessel ischemic disease identified on MRI focuses on controlling vascular risk factors, with a recent guideline recommending single antiplatelet treatment long-term, blood pressure control, and lipid lowering according to current guidelines 1.
Key Management Strategies
- Aggressive management of hypertension, targeting blood pressure below 130/80 mmHg using appropriate antihypertensive medications such as ACE inhibitors or ARBs
- Statin therapy regardless of baseline cholesterol levels, typically atorvastatin 20-80 mg daily or rosuvastatin 10-40 mg daily
- Antiplatelet therapy with aspirin 81-100 mg daily for secondary prevention in patients with prior stroke or TIA
- Lifestyle modifications, including smoking cessation, limiting alcohol consumption, maintaining a Mediterranean or DASH diet, regular physical activity, and achieving optimal weight
- Blood glucose control for diabetic patients, targeting HbA1c below 7%
Rationale
These interventions aim to prevent disease progression by addressing the underlying pathophysiology of small vessel disease, which involves endothelial dysfunction, oxidative stress, and chronic inflammation affecting the small perforating arteries in the brain 2.
Additional Considerations
- Genetic predisposition to higher systolic and diastolic blood pressure, diabetes, obesity, smoking, and higher triglyceride levels are associated with an increased risk of small vessel disease, while genetic predisposition to higher HDL concentrations and moderate-to-vigorous physical activity are protective 3
- Cilostazol may be considered as an alternative to aspirin for secondary prevention in patients with cerebral small vessel disease, as it has been shown to reduce the risk of ischemic vascular events compared to aspirin 4
- Regular follow-up every 3-6 months is recommended to monitor treatment efficacy and adjust management as needed 1