What is chronic small vessel disease (cerebral small vessel disease) in the brain?

From the Guidelines

Chronic small vessel disease in the brain is a condition characterized by the pathological processes of the small vessels in the brain, including age-associated and vascular risk factor–associated microangiopathy, which may manifest as acute symptoms or slowly progressive damage. This condition affects the tiny arteries, veins, and capillaries that supply deep brain structures and white matter, leading to reduced blood flow to brain tissue. According to a review and consensus recommendations published in 2019 in the journal Alzheimer's and Dementia 1, cerebral small vessel disease (cSVD) is an umbrella term that covers all pathological processes of the small vessels in the brain. The damage typically occurs gradually and can result in small strokes, bleeding, or chronic poor blood supply to affected areas.

Key Characteristics and Risk Factors

• Common signs include white matter lesions, lacunar infarcts (small strokes), microbleeds, and enlarged perivascular spaces that can be seen on brain imaging
• Risk factors include aging, high blood pressure, diabetes, smoking, and genetic factors
• Symptoms may include cognitive decline, problems with walking and balance, mood changes, and urinary issues, though many people with mild disease may not show obvious symptoms

Management and Prevention

• Management focuses on controlling risk factors through blood pressure medication, cholesterol management, blood sugar control for diabetics, lifestyle modifications including regular exercise, healthy diet, smoking cessation, and limited alcohol consumption
• Early intervention to address modifiable risk factors is crucial for slowing progression, as the disease can contribute to vascular dementia and increase stroke risk over time 1

From the Research

Definition and Characteristics of Chronic Small Vessel Disease

• Cerebral small vessel disease (cSVD) is a heterogeneous group of diseases caused by in situ damages of small brain vessels, commonly related to aging, hypertension, or genetic factors 2.
• The disease is characterized by small (< 20 mm) infarcts or lacunes, cerebral microbleeds, white matter hyperintensities, enlarged perivascular spaces, and brain atrophy 2, 3.
• cSVD represents one of the major problems facing global society today, causing a quarter of all ischemic strokes, the vast majority of spontaneous hemorrhages, and accounting for 20% or more of all dementias 2.

Pathological Mechanisms and Diagnosis

• The diagnosis of cSVD relies on the identification of small subcortical infarcts, lacunes, white matter hyperintensities, perivascular spaces, and microbleeds using neuroimaging 3.
• The most widely accepted approach to cSVD treatment is to mitigate vascular risk factors and adopt a healthier lifestyle, due to the poor understanding of pathophysiology in cSVD 3.
• Endothelial dysfunction, blood-brain barrier impairment, and white matter change are key mechanisms in cSVD development, with inflammation also playing a role 3, 4.

Prevalence and Impact

• cSVD is observed in 25% of strokes worldwide and is the most common pathology of cognitive decline and dementia in the elderly 3, 5.
• The disease contributes to about 20% of strokes, including 25% of ischemic strokes and 45% of dementias, making it a significant public health concern 5.
• Despite its high prevalence, there are still no mechanism-based treatments for cSVD, highlighting the need for further research and understanding of the disease mechanisms 2, 4.