From the Guidelines
Management of Subcortical Vascular Dementia (Binswanger's disease) should focus on controlling vascular risk factors, managing symptoms, and considering pharmacological interventions such as cholinesterase inhibitors and memantine, as recommended by the Canadian Stroke Best Practice Recommendations, 7th edition practice guidelines update, 2024 1. The cornerstone of treatment involves aggressive management of hypertension, diabetes, and cholesterol control, as well as antiplatelet therapy.
- Vascular risk factors should be managed aggressively, including:
- Hypertension control with antihypertensive medications
- Diabetes management with target HbA1c below 7%
- Cholesterol control using statins
- Smoking cessation
- Antiplatelet therapy with aspirin or clopidogrel should be guided by existing primary and secondary stroke or vascular prevention indications, as recommended by the guidelines 1.
- Pharmacological management of cognitive symptoms may include cholinesterase inhibitors (donepezil, rivastigmine, and galantamine) and the NMDA receptor antagonist memantine, which have shown small magnitude benefits in cognitive outcomes 1.
- Physical therapy and occupational therapy can help maintain mobility, prevent falls, and assist with daily living activities.
- Depression, which commonly accompanies Binswanger disease, may require treatment with SSRIs. The disease progresses gradually, with management focusing on slowing progression through vascular risk factor control and maintaining quality of life through symptom management and supportive care.
- The use of ASA in individuals with VCI or VaD who have covert brain infarcts detected on neuroimaging without a history of stroke could be considered, but the benefit is unclear, and should be guided by the CSBPR Secondary Prevention of Stroke module and CSBPR ASA for Prevention of Vascular Events module 1.
From the Research
Management of Subcortical Vascular Dementia (Binswanger's disease)
The management of Subcortical Vascular Dementia (Binswanger's disease) involves several approaches, including:
- Control of risk factors such as hypertension, diabetes, smoking, hyperfibrinogenemia, hyperhomocystinemia, orthostatic hypotension, and cardiac arrhythmias 2
- Use of anticholinergic medications, atypical antipsychotic agents, and antidepressants (e.g., selective serotonin reuptake inhibitors) 2
- Novel therapeutic approaches using the administration of anti-thrombin and cyclo-oxygenase-2 inhibitors as well as immunosuppressants may be useful for preventing the progression of Binswanger's disease 3
- Primary and secondary prevention of stroke and cardiovascular disease decreases the burden of Vascular Dementia (VaD), which includes Binswanger's disease 2
Diagnostic Approaches
Diagnosis of Binswanger's disease can be aided by:
- Clinical and imaging characteristics, neuropsychological profile, and cerebrospinal fluid analysis 4
- Biomarkers such as large white matter lesions with axonal damage, blood-brain barrier disruption, and neuropsychological evidence of executive dysfunction 5
- A multimodal approach using a combination of these features can define the SIVD-BD spectrum disorder 5
Pathogenesis and Therapeutic Targets
The pathogenesis of Binswanger's disease is likely to be chronic cerebral ischemia due to hypertensive small artery disease with capillary collagenosis, which causes multiple lacunes and alterations in the glia and axons 3
- Arterial hypertension and a subsequent dysfunction of the blood-brain barrier (BBB) may cause white matter lesions 3
- A compromised BBB will permit the entry of serum components, immunoglobulins, complements, and fibrinogen into the perivascular neural parenchyma, leading to glial activation and myelin damage 3