Cerebral Small Vessel Ischemic Disease

Cerebral small vessel disease (CSVD) refers to a spectrum of pathological processes affecting the small perforating arteries, arterioles, capillaries, and venules of the brain. It produces characteristic MRI features including white matter hyperintensities, lacunar infarcts, microbleeds, enlarged perivascular spaces, and cerebral atrophy. CSVD accounts for approximately 25 percent of ischemic strokes and is the most common cause of vascular cognitive impairment.

Most cases are sporadic and related to chronic hypertension, diabetes mellitus, smoking, and aging. Less common are genetic forms such as CADASIL (NOTCH3 mutation), CARASIL, Fabry disease, and cerebral amyloid angiopathy. Clinical presentations include lacunar syndromes (pure motor or sensory hemiparesis, ataxic hemiparesis, dysarthria-clumsy hand), gait disturbance, depression, and progressive cognitive decline.

Diagnosis relies on brain MRI with FLAIR, susceptibility-weighted imaging, and cognitive testing. Management focuses on aggressive vascular risk-factor control: blood pressure target below 130/80 mmHg, statin therapy, glycemic control, smoking cessation, antiplatelet therapy in established disease, and physical activity. Anticoagulation is generally avoided in extensive microbleeds. Cognitive rehabilitation and treatment of depression improve quality of life.