Differential Diagnosis

• Single most likely diagnosis
  • Chronic small vessel ischemic disease: This is the most likely diagnosis given the presence of mild chronic small ischemic changes on the imaging, which is consistent with long-standing small vessel disease.
• Other Likely diagnoses
  • Hypertensive encephalopathy: Although there's no evidence of acute hemorrhage or infarct, chronic hypertension can lead to small vessel disease and ischemic changes.
  • Chronic cerebral vasculitis: This condition can cause small vessel ischemic changes, but it would typically require additional clinical context and laboratory findings to support the diagnosis.
  • Leukoaraiosis: This condition is characterized by white matter changes, often due to small vessel disease, and could be a contributing factor to the observed ischemic changes.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Cerebral amyloid angiopathy: Although less likely, this condition can cause small vessel disease and ischemic changes, and is important to consider due to its potential for hemorrhagic complications.
  • Moyamoya disease: A rare condition that affects the blood vessels in the brain, leading to small vessel ischemic changes, and would require prompt diagnosis and treatment to prevent further complications.
  • Vasculitis (e.g., giant cell arteritis): While less common, vasculitis can cause small vessel ischemic changes and would be critical to diagnose due to its potential for serious complications.
• Rare diagnoses
  • CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy): A rare genetic disorder that affects the blood vessels in the brain, leading to small vessel disease and ischemic changes.
  • Fabry disease: A rare genetic disorder that can cause small vessel disease and ischemic changes due to the accumulation of a specific lipid in the blood vessels.