From the Guidelines
The patient's MRI findings of minimal periventricular and subcortical T2/FLAIR hyperintensities are most likely representative of microvascular ischemic angiopathy, and management should focus on aggressive vascular risk factor modification to prevent further cerebral small vessel disease progression. The presence of white matter hyperintensities on T2/FLAIR sequences is a common finding in older adults and represents areas of chronic small vessel damage, as described in the Canadian Stroke Best Practice Recommendations: Vascular Cognitive Impairment, 7th edition practice guidelines update, 2024 1. According to these guidelines, MRI is the modality of choice for describing markers of cerebral small vessel disease (CSVD) and amyloid angiopathy by consensus criteria.
The patient's management plan should include:
- Blood pressure control with a target of <130/80 mmHg
- Statin therapy, such as atorvastatin 20-40mg daily
- Antiplatelet therapy, if indicated, with aspirin 81mg daily
- Diabetes management, if applicable, with a target HbA1c <7%
- Smoking cessation
- Lifestyle modifications, including regular exercise and a Mediterranean diet
As noted in the guidelines, the threshold of vascular damage required to cause clinical cognitive dysfunction is not clear, and will likely vary between patients due to differing levels of cognitive reserve 1. However, beginning confluent or confluent subcortical white matter hyperintensities on the Fazekas scale is sufficient to cause clinical cognitive impairment in many individuals. Further evaluation for other neurological causes of the patient's weakness is warranted, including comprehensive neurological examination, laboratory studies, and possibly neuromuscular testing if peripheral weakness is suspected. Aggressive risk factor management is essential to prevent further damage to the cerebral vasculature and reduce the risk of stroke, cognitive decline, and gait problems associated with small vessel disease.
From the Research
Cerebral Small Vessel Disease
The patient's MRI results showing minimal periventricular and subcortical T2/FLAIR hyperintensities are consistent with microvascular ischemic angiopathy, a condition often associated with cerebral small vessel disease (CSVD) 2. CSVD is a common neurological disease that can lead to various symptoms, including stroke and dementia.
Risk Factors
Several risk factors have been identified as contributing to the development of CSVD, including:
- Hypertension (odds ratio 3.16,95% confidence interval 2.22-4.49) 2
- Diabetes (odds ratio 2.15,95% confidence interval 1.59-2.90) 2
- Hyperlipidemia (odds ratio 1.64,95% confidence interval 1.11-2.40) 2
- Smoking (odds ratio 1.47,95% confidence interval 1.15-1.89) 2
Atherosclerosis
Atherosclerosis is a systemic disease that can affect both large and small vessels, leading to various clinical events 3. The distribution of lesions can vary depending on factors such as age, race, and the presence of risk factors like hypertension, diabetes, and smoking.
Treatment and Prevention
Several treatments have been shown to be effective in preventing atherosclerotic cardiovascular disease (ASCVD), including:
- Aspirin (relative risk 0.90,95% confidence interval 0.85-0.96) 4
- Statins (relative risk 0.75,95% confidence interval 0.70-0.81) 4
- Blood pressure-lowering therapy (relative risk 0.84,95% confidence interval 0.79-0.90 for coronary heart disease and relative risk 0.64,95% confidence interval 0.56-0.73 for stroke) 4
- Tobacco cessation drugs (odds ratio range 1.82-2.88) 4
Antiplatelet Therapy
Antiplatelet therapy has been shown to be effective in preventing stroke in patients with lacunar stroke, with a 22% relative risk reduction in recurrent stroke (RR 0.77,95% CI 0.62-0.97) 5. The use of antiplatelet therapy in patients with cerebral small vessel disease is supported by current evidence, although further research is needed to determine the optimal treatment strategy.