From the Guidelines
The patient's belief that the chronic MRI brain findings are related to a SCAD event 10 years ago is likely inaccurate, and the findings are more consistent with long-standing, uncontrolled vascular risk factors. The chronic bilateral lacunar infarcts and severe white matter microangiopathic changes are characteristic of small vessel disease, which is typically caused by long-term exposure to vascular risk factors such as hypertension, hyperlipidemia, and diabetes 1. The elevated LDL of 4 mmol/L (approximately 155 mg/dL) is a significant risk factor for cerebrovascular disease and likely contributed to these chronic changes over time. Some key points to consider in this patient's management include:
- Starting a moderate to high-intensity statin (such as atorvastatin 40-80mg daily or rosuvastatin 20-40mg daily) to lower LDL cholesterol, as recommended by the ACCF/AHA guidelines for patients with coronary heart disease or equivalents 1.
- Daily aspirin therapy (typically 81mg daily) for secondary stroke prevention, as it has been shown to reduce the risk of vascular events in patients with cerebrovascular disease 1.
- Assessing and managing other vascular risk factors, including hypertension, diabetes, smoking, and physical inactivity, to reduce the risk of further cerebrovascular events. The pattern of lacunar infarcts and white matter changes typically develops gradually from chronic small vessel disease due to long-term exposure to vascular risk factors, rather than from a single acute event like SCAD, which would more likely cause a different pattern of injury if it affected brain perfusion. Given the patient's high-risk profile, it is essential to prioritize aggressive management of vascular risk factors to reduce the risk of future cerebrovascular events and improve overall quality of life, as recommended by the ACCF/AHA guidelines 1.
From the Research
Patient's Belief Regarding Chronic MRI Brain Findings
The patient believes that the chronic findings on her MRI brain scan, including bilateral lacunar infarcts and severe white matter microangiopathic changes, are related to a SCAD event 10 years ago. To assess the accuracy of this belief, we must consider the potential causes of these chronic findings.
Causes of Lacunar Infarcts and White Matter Microangiopathic Changes
- Lacunar infarcts are associated with small vessel disease (SVD) and are influenced by vascular risk factors such as hypertension, diabetes, and smoking 2, 3, 4.
- White matter microangiopathic changes, including white matter hyperintensities (WMH), are also associated with SVD and are influenced by similar vascular risk factors 2, 3, 4.
- The location and extent of lacunar infarcts and WMH can provide insight into the underlying pathology and potential risk factors 2, 4.
Relationship Between SCAD Event and Chronic Findings
- There is no direct evidence to suggest that a SCAD event 10 years ago would cause the chronic findings on the patient's MRI brain scan.
- The patient's high LDL level and lack of statin and aspirin therapy may be contributing factors to her cerebrovascular disease 2, 3, 4.
- The patient's belief may be inaccurate, as the chronic findings are more likely related to her underlying cerebrovascular disease and vascular risk factors rather than a single event 10 years ago.
Vascular Risk Factors and Cerebrovascular Disease
- Vascular risk factors such as hypertension, diabetes, and smoking are strongly associated with cerebrovascular disease and may contribute to the development of lacunar infarcts and white matter microangiopathic changes 2, 3, 4.
- The patient's high LDL level and lack of statin and aspirin therapy may be contributing to her cerebrovascular disease and increasing her risk of further vascular events.