Management of Chronic Microvascular Ischemic Gliosis
Aggressively control all three vascular risk factors—blood pressure, blood glucose, and cholesterol—as chronic microvascular ischemic changes represent cumulative small vessel disease that significantly impairs cognition and increases stroke risk, with hypertension and diabetes being the primary drivers requiring immediate intervention. 1, 2, 3
Blood Pressure Management
- Target systolic blood pressure to 130 mmHg and below 130 mmHg if tolerated, but never below 120 mmHg. 1
- Initiate treatment with a RAAS blocker (ACE inhibitor or ARB) combined with either a calcium channel blocker or thiazide/thiazide-like diuretic. 1
- Target diastolic blood pressure below 80 mmHg, but not below 70 mmHg. 1
- The combination therapy approach is superior to monotherapy for patients with diabetes and microvascular disease. 1
Blood Glucose Management
- Measure HbA1c immediately if not done within the past 3 months, and target HbA1c to less than 7% (53 mmol/mol) for most patients to reduce microvascular complications. 1, 4
- For older adults over 65 years with multiple comorbidities or history of severe hypoglycemia, target HbA1c less than 8%. 1, 4
- Initiate or optimize metformin combined with lifestyle modifications as first-line therapy unless contraindicated. 4
- Add an SGLT-2 inhibitor (empagliflozin, canagliflozin, or dapagliflozin) if eGFR is 30 to less than 90 mL/min/1.73 m² to reduce cardiovascular events and renal endpoints. 1, 4
- Monitor glucose every 3 months until stable control is achieved, then reduce to every 6 months. 4
Cholesterol Management
- Target LDL-cholesterol below 55 mg/dL (1.4 mmol/L) with at least 50% LDL-C reduction from baseline, as patients with microvascular disease are at very high cardiovascular risk. 1, 4
- Initiate statin therapy as first-choice lipid-lowering treatment. 1, 4
- Target non-HDL-cholesterol below 85 mg/dL (2.2 mmol/L) as a secondary goal. 1
- If LDL-C target is not reached with maximum tolerated statin, add ezetimibe or PCSK9 inhibitor. 1
- Hypercholesterolemia is independently associated with both ischemic and hemorrhagic stroke risk in patients with microvascular disease. 5
Antiplatelet Therapy
- Initiate aspirin therapy for secondary stroke prevention, as microvascular ischemic changes indicate established cerebrovascular disease. 1
- Antiplatelet therapy should be started before discharge and continued indefinitely unless contraindicated. 1
Lifestyle Modifications
- Limit daily fat intake to 30% or less of total calories, with less than 7% from saturated fat. 4
- Restrict sodium intake to 1,500 mg or less per day. 4
- Exercise 30-60 minutes daily at minimum brisk walking intensity. 4
- Smoking cessation is mandatory, as smoking accelerates microvascular damage. 1
Monitoring and Follow-up
- Screen annually for chronic kidney disease by assessing eGFR and urinary albumin-to-creatinine ratio, as microvascular disease affects multiple organ systems. 1
- Monitor for cognitive decline, as cortical microinfarcts and white matter demyelination explain 27.9% of cognitive variability in aging. 2
- Assess for new neurological symptoms at each visit, as any acute change warrants urgent neuroimaging to exclude acute stroke or hemorrhage. 6
Critical Pitfalls to Avoid
- Never assume stable microvascular disease means no intervention is needed—these patients are at very high risk for future stroke and progressive cognitive decline. 2, 3
- Avoid aggressive blood pressure lowering below 120 mmHg systolic, as this may worsen cerebral perfusion in patients with chronic microvascular disease. 1
- Do not delay SGLT-2 inhibitor initiation in patients with impaired renal function (eGFR 30-90), as these agents provide cardiovascular and renal protection beyond glucose control. 1
- Hypertension and diabetes are the two independent predictors that must be controlled, as they drive 80% of microvascular ischemic risk. 3, 7