What is cerebral vascular disease in an adult with a history of substance abuse and chronic pain?

What is Cerebral Vascular Disease?

Cerebrovascular disease is a heterogeneous group of pathological processes affecting the brain's blood vessels—including arteries, arterioles, capillaries, and venules—that can manifest as either hemorrhagic events (bleeding) or ischemic events (vessel blockage), leading to stroke, cognitive impairment, or other neurological deficits. 1, 2, 3

Major Categories of Cerebrovascular Disease

Cerebrovascular disease divides into two primary pathophysiologic categories 1, 3:

Ischemic Cerebrovascular Disease (87% of strokes)

• Large vessel disease: Atherosclerotic stenosis or occlusion of major cerebral arteries 1, 3
• Small vessel disease (cerebral microangiopathy): The most common chronic form, affecting arterioles, capillaries, and small veins supplying white matter and deep brain structures 2, 4
• Cardioembolic disease: Emboli from cardiac sources causing arterial occlusion 3
• Lacunar stroke: Small subcortical infarcts resulting from small vessel occlusion 2, 5

Hemorrhagic Cerebrovascular Disease (13% of strokes)

• Intracerebral hemorrhage (10%): Bleeding into brain parenchyma 1
• Subarachnoid hemorrhage (3%): Bleeding into the subarachnoid space, often from aneurysm rupture 1

Clinical Manifestations

Acute presentations include 1, 2:

• Sudden neurological deficits (stroke symptoms)
• Lacunar syndromes: pure motor hemiparesis, pure sensory symptoms, ataxic hemiparesis, or clumsy hand-dysarthria syndrome 5
• Headache or seizures (less common) 1

Chronic/progressive presentations include 2:

• Cognitive impairment and dementia (cerebrovascular disease contributes to 45% of dementias) 4
• Gait disturbances 2
• Mood disorders, particularly depression 2
• Vascular parkinsonism 6

Pathophysiology and Risk Factors

The most common form—age-associated and vascular risk factor-associated microangiopathy—develops chronically in response to 2:

• Hypertension (primary risk factor) 5, 4
• Diabetes mellitus 5, 4
• Smoking 1, 5
• Hypercholesterolemia 1

Endothelial dysfunction and blood-brain barrier failure play pivotal early roles in disease pathophysiology, allowing plasma component leakage into brain tissue and contributing to white matter damage 2, 5

Special Considerations in Substance Abuse

In patients with substance abuse history, cerebrovascular disease has distinct characteristics 7, 8:

• Psychomotor stimulants (amphetamine, cocaine, ecstasy) are now the largest cause of intracerebral hemorrhage in young adults, replacing traditional hypertensive causes 7, 8
• Contrary to historical teaching, drug-related intracerebral hemorrhage frequently involves underlying vascular malformations (aneurysms in 6/10 patients, arteriovenous malformations in 3/10 patients in one series) rather than simple hypertensive hemorrhage 7
• Cannabis and opioids are less commonly implicated but still associated with stroke risk 8
• Toxicology screening should be performed in young stroke patients with no obvious cause 8
• Cerebral angiography should be part of the evaluation in most young patients with nontraumatic intracerebral hemorrhage, as underlying vascular malformations are common 7

Diagnostic Approach

MRI is the key diagnostic modality for cerebrovascular disease, particularly for chronic small vessel disease 2, 4:

• White matter hyperintensities on T2/FLAIR sequences indicate chronic ischemic damage 2
• Enlarged perivascular spaces (Virchow-Robin spaces) 2
• Lacunar infarcts (small deep lesions) 5, 6
• Microhemorrhages 5

For acute stroke evaluation, CT remains the initial imaging modality to rapidly exclude hemorrhage before thrombolytic therapy, followed by vascular imaging (CTA or MRA) to assess for large vessel occlusion amenable to endovascular thrombectomy 1

Critical Clinical Pitfalls

• Mixed pathology is extremely common: Vascular disease frequently coexists with Alzheimer's disease pathology, occurring in up to 38% of elderly patients 2, 6
• Confluent white matter hyperintensities (Fazekas grade 2-3) alone are sufficient to cause clinical cognitive impairment, even without acute infarcts 2
• In young patients with hemorrhage and substance abuse, do not assume simple hypertensive hemorrhage—actively search for underlying vascular malformations with angiography 7
• Cerebrovascular disease is a marker of systemic atherosclerosis: Patients face greater risk of myocardial infarction than recurrent stroke in many cases, requiring comprehensive cardiovascular risk management 1