Better Health While Aging

Practical information for aging health & family caregivers

Cerebral Small Vessel Disease:
What to Know & What to Do

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Signs of cerebral small vessel disease. From Inzitari et al, BMJ. 2009 Jul 6;339:b2477. doi: 10.1136/bmj.b2477

This article is about the most common aging brain problem that you may have never heard of.

While leading a fall prevention workshop a few years ago, I mentioned that an older person’s walking and balance problems might well be related to the presence of “small vessel ischemic changes” in the brain, which are very common in aging adults. (This is also called “white matter disease.”)

This led to an immediate flurry of follow-up questions. What exactly are these changes, people wanted to know. Do they happen to every older adult? Is this the same as vascular dementia? And how they can best help their parents with cognitive decline?

Well, these types of brain lesions don’t happen to every older person, but they do happen to the vast majority of them.  In fact, one study of older adults aged 60-90 found that 95% of them showed signs of these changes on brain MRI.

In other words, if your older parent ever gets an MRI of the head, he or she will probably show some signs of these changes.

So this is a condition that older adults and families should know about. Furthermore, these changes have been associated with problems of consequence to older adults, including:

  • Cognitive decline,
  • Problems with walking or balance,
  • Strokes,
  • Vascular dementia.

Now, perhaps the best technical term for what I’m referring to is “cerebral small vessel disease.” But many other synonyms are used by the medical community — especially in radiology reports. They include:

  • White matter disease
  • Small vessel ischemic disease
  • Brain lesions
  • Periventricular white matter changes
  • Perivascular chronic ischemic white matter disease of aging
  • Chronic microvascular changes, chronic microvascular ischemic changes
  • Chronic microvascular ischemia
  • White matter hyperintensities
  • Age-related white matter changes
  • Leukoaraiosis

In this post, I will explain what all older adults and their families should know about this extremely common condition related to the brain health of older adults.

In particular, I’ll address the following frequently asked questions:

  • What is cerebral small vessel disease (SVD)?
  • What are the symptoms of cerebral SVD?
  • How is cerebral small vessel disease related to vascular dementia and cerebrovascular accidents?
  • What causes cerebral SVD?
  • How can cerebral SVD be treated or prevented?
  • Should you request an MRI if you’re concerned about cerebral SVD?

I will also address what you can do, if you are concerned about cerebral SVD for yourself or an older loved one.

What is cerebral small vessel disease?

Cerebral small vessel disease (SVD) is an umbrella term covering a variety of abnormalities related to small blood vessels in the brain. Because most brain tissue appears white on MRIs, these abnormalities were historically referred to as “white matter changes” or “white matter disease.”

Per this medical review article, specific examples of cerebral SVD include “lacunar infarcts” (which are a type of small stroke), “white matter hyperintensities” (which are a radiological finding), and “cerebral microbleeds” (which means bleeding in the brain from a very small blood vessel).

In many cases, cerebral SVD seems to be a consequence of atherosclerosis affecting the smaller blood vessels that nourish brain tissue. Just as one’s larger blood vessels in the heart or elsewhere can accumulate plaque, inflammation, and chronic damage over the years, so can the smaller blood vessels.

Such chronic damage can lead the small blood vessels in the brain to become blocked (which starves brain cells of oxygen, and which we technically call ischemia), or to leak (which causes bleeding, which we call hemorrhage and can damage nearby brain cells).

When little bits of brain get damaged in these ways, they can change appearance on radiological scans. So when an MRI report says “white matter disease,” this means the radiologist is seeing signs that probably indicate cerebral SVD.

(Note: In this podcast episode, a UCSF brain health expert explains that although cerebral small vessel disease is probably the most common cause of white matter changes in older adults, it’s not the only condition that can cause such changes. )

Such signs of SVD may be described as “mild”, “moderate,” or “severe/extensive,” depending on how widespread they are.

Here is an enlargement of a good image, from the BMJ article “Changes in white matter as determinant of global functional decline in older independent outpatients.”

MRI brain cerebral small vessel ischemic disease
From Inzitari et al, BMJ. 2009 Jul 6;339:b2477. doi: 10.1136/bmj.b2477.

What are the symptoms of cerebral small vessel disease?

The severity of symptoms tends to correspond to whether radiological imaging shows the white matter changes to be mild, moderate, or severe.

Many older adults with cerebral SVD will have no noticeable symptoms. This is sometimes called “silent” SVD.

But many problems have been associated with cerebral SVD, especially when it is moderate or severe. These include:

  • Cognitive impairment. Several studies, such as this one, have found that cerebral SVD is correlated with worse scores on the Mini-Mental State Exam. When problems with thinking skills are associated with SVD, this can be called “vascular cognitive impairment.”
  • Problems with walking and balance. White matter lesions have been repeatedly associated with gait disturbances and mobility difficulties. A 2013 study found that moderate or severe cerebral SVD was associated with a decline in gait and balance function.
  • Strokes. A 2010 meta-analysis concluded that white matter hyperintensities are associated with a more than two-fold increase in the risk of stroke.
  • Depression. White matter changes have been associated with a higher risk of depression in older people, and may represent a contributor to depression that is particular to having first-time depression in later life.
  • Vascular dementia. Signs of cerebral SVD are associated with both having vascular dementia, and eventually developing vascular dementia.
  • Other dementias. Research suggests that cerebral SVD is also associated with an increased risk — or increased severity — of other forms of dementia, such as Alzheimer’s disease. Autopsy studies have confirmed that many older adults with dementia show signs of both Alzheimer’s pathology and cerebral small vessel disease.
  • Transition to disability or death. In a 2009 study of 639 non-disabled older persons (mean age 74), over a three-year follow-up period, 29.5% of participants with severe white matter changes and 15.1% of participants with moderate white matter changes developed disabilities or died. In comparison, only 10.5% of participants with mild white matter changes transitioned to disability or death over three years. The researchers concluded that severity of cerebral SVD is an important risk factor for overall decline in older adults.

So what does this all mean, in terms of symptoms and cerebral SVD? Here’s how I would boil it down:

1.Overall, older adults with any of the problems listed above have a high probability of having cerebral SVD.

2. But, many older adults with cerebral SVD on MRI are asymptomatic, and do not notice any difficulties. This is especially true of aging adults with mild cerebral SVD.

3. Older adults with cerebral SVD are at increased risk of developing the problems above, often within a few years time. This is especially true of people with moderate or severe cerebral SVD.

How is cerebral small vessel disease related to vascular dementia and cerebrovascular accidents?

The term “vascular dementia” means having dementia that is mostly due to having had problems with the blood vessels in the brain.

(For more on the definition of dementia and vascular dementia, see here: Beyond Alzheimer’s: Common Types of Dementia in Aging.)

The brain has some large blood vessels; when a person develops a clot or bleed related to a large blood vessel, this causes a major stroke, also known as a cerebrovascular accident.

It is possible to get dementia after a major stroke. However, in older adults, it’s probably more common to develop vascular dementia due to injuries to the small vessels of the brain. But again, as I explained above: not everyone with signs of cerebral small vessel disease ends up developing cognitive impairment or dementia.

What causes cerebral small vessel disease?

This is a topic of intense research, and the experts in this area tend to really nerd out when discussing it. (Read the scholarly papers listed below to see what I mean.) One reason it’s difficult to give an exact answer is that cerebral SVD is a broad umbrella term that encompasses many different types of problems with the brain’s small blood vessels.

Still, certain risk factors for developing cerebral SVD have been identified. Many overlap with risk factors for stroke. They include:

  • Hypertension
  • Dyslipidemia (e.g. high cholesterol)
  • Atrial fibrillation
  • Cerebral amyloid angiopathy
  • Diabetes
  • Smoking
  • Age
  • Inflammation

There is also evidence that Alzheimer’s disease and cerebral small vessel disease frequently co-exist in older adults, and might interact to accelerate cognitive decline.

How can cerebral small vessel disease be treated or prevented?

Experts are still trying to figure out the answers to this question, and research into the prevention of cerebral SVD is ongoing.

Since worsening of white matter disease is often associated with clinical problems, experts are also trying to determine how we might prevent, or delay, the progression of SVD in older adults.

Generally, experts recommend that clinicians consider treating any underlying risk factors. In most cases, this means detecting and treating any traditional risk factors for stroke.

(For more on identifying and addressing stroke risk factors, see How to Address Cardiovascular Risk Factors for Better Brain Health: 12 Risks to Know & 5 Things to Do.)

To date, studies of hypertension treatment to prevent the progression of white matter changes have shown mixed results. It appears that treating high blood pressure can slow the progression of brain changes in some people. But such treatment may be less effective in people who are older than 80, or who already have severe cerebral SVD.

In other words, your best bet for preventing or slowing down cerebral SVD may be to properly treat high blood pressure and other risk factors before you are 80, or otherwise have significant SVD.

Furthermore, experts don’t yet agree on how low to go, when it comes to optimal blood pressure for an older person with cerebral small vessel disease. (This article explains why this has been difficult to determine.)

For now, to prevent the occurrence or progression of cerebral small vessel disease, it’s reasonable to start by observing the hypertension guidelines considered reasonable for most older adults: treat to a target of systolic blood pressure less than 150mm/Hg.

Whether to treat high blood pressure — and other cardiovascular risk factors — more aggressively should depend on an older person’s particular health circumstances. I explain a step-by-step process you can use (with links to related research) here: 6 Steps to Better High Blood Pressure Treatment for Older Adults.

You can also learn more about the research on CSVD and the effect of treating blood pressure here: The relation between antihypertensive treatment and progression of cerebral small vessel disease.

Should you request an MRI if you’re concerned about cerebral SVD?

Not necessarily. In my opinion, older adults should only get MRIs of the brain if the following two things are true:

  1. They are experiencing worrisome clinical symptoms, and
  2. The results of the MRI are needed to decide on how to treat the person.

For most older adults, an MRI showing signs of cerebral SVD will not, in of itself, change the management of medical problems.

If you have high blood pressure, you should consider treatment. If you are having difficulties with walking or balance, signs of cerebral SVD do not rule out the possibility of other common causes of walking problems, such as medication side-effects, foot pain, neuropathy, and so forth.

What if you’re concerned about memory or thinking problems? Well, you probably will find signs of cerebral SVD on an MRI, just because this is a common finding in all older adults, and it’s especially common in people who are experiencing cognitive changes.

However, the MRI cannot tell you whether the cognitive changes you are noticing are only due to cerebral SVD, versus due to developing Alzheimer’s disease, versus due one of the many other dementia mimics. You will still need to pursue a careful evaluation for cognitive impairment. And no matter what the MRI shows, you will likely need to consider optimizing cardiovascular risk factors.

So in most cases, a brain MRI just to check for cerebral SVD is probably not a good idea.

However, if an MRI is indicated for other reasons, you may find out that an older person has mild, moderate, or severe signs of cerebral SVD. In this case, especially if the cerebral SVD is moderate or severe, you’ll want to consider taking steps to reduce stroke risk, and also to monitor for cognitive changes and increased disability.

What to do if you’re worried about cerebral small vessel disease

If you are worried about cerebral SVD, for yourself or for an older relative, here a few things you can do:

  • Talk to your doctor about your concerns. You may want to discuss your options for optimizing vascular risk factors, including high blood pressure, high cholesterol, high blood sugar, smoking, and others. For more on identifying and addressing stroke risk factors, see How to Address Cardiovascular Risk Factors for Better Brain Health: 12 Risks to Know & 5 Things to Do.
  • Remember that exercise, a healthy diet (such as the Mediterranean diet), good sleep, stress reduction, and many other non-pharmacological approaches can help manage vascular risk factors. Lifestyle approaches are safe and usually benefit your health in lots of ways. Medications to treat high blood pressure and cholesterol should be used judiciously.
  • If an MRI of the brain is clinically indicated — or if one has recently been done — ask the doctor to help you understand how the findings may correspond to any worrisome symptoms you’ve noticed. But if you’ve been worried about cognitive impairment or falls, remember that such problems are usually multi-factorial (i.e. they have multiple causes). So it’s best to make sure the doctors have checked for all other common contributors to thinking problems and/or falls.

If you want to learn still more about cerebral small vessel disease, here are some scholarly articles on the subject:

I also recommend listening to this very informative podcast interview, with Dr. Fanny Elahi of the UCSF Memory and Aging Center: 084 – Interview: Understanding White Matter Changes in the Aging Brain.

Note: We’ve hit 300+ comments on this article! So we’re closing comments for this article. Thank you for your interest!

Note: This article has generated a lot of questions from people under age 60. If that describes you, please read below:

  • Please read the article on “Early Cerebral Small Vessel Disease,” the full article is available for free. This describes SVD found in people aged 40-75. In this study, 2-3% of participants in their 40s showed signs of cerebral SVD.
    • You can check for more recent research on this topic by entering the above article at scholar.google.com, and then click the “Cited by” link to find newer articles that reference this article.
  • I do not know much about cerebral SVD in younger adults; this is not the population that I personally treat nor read much about. (I’m already quite busy trying to keep up with research related to older adults.)
  • As best I can tell, most of what we currently know about health outcomes related to cerebral SVD is based on the studies of older adults. It is not clear to me whether people with cerebral SVD at younger ages should expect similar outcomes. I will not be able to answer most questions related to cerebral SVD in people under age 60.
  • If you are concerned about what caused your MRI findings, or what they might mean for the future, please don’t ask me to tell you, because I don’t have these kinds of answers and I cannot quickly find them online.
    • You should start by talking to your usual doctors, and perhaps a neurologist.
    • If you would like to learn more, consider finding someone specialized in white matter disease in younger adults (e.g. someone doing and publishing research on this topic). Such experts are usually based at an academic medical center. Good luck!
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Comments

  1. I am a 53 year old female. I have been experiencing an increase in migraines over the past 2 years or so. I had 5 in a 2 week period recently, so was sent for an MRI to see if there were any visible causes for this. I have had migraines since age 26 and now am menopausal (LMP about a year ago). The results have come back saying there’s nothing to explain the change in pattern of my migraines, but I’m showing signs of age related small vein disease? What does this mean, and should I be worried that I’m heading for Alzheimers/dementia or a stroke?

    • I really can’t say much about cerebral SVD in younger adults. (And to a geriatrician, you would be a “younger adult”.)

      Please see the additional comments I have just added to the end of my article; I’ve added some suggestions for people in your age range.

      Rather than think you are “headed for Alz/dementia or stroke,” it’s probably more sensible to assume that you may be at higher than average risk for these conditions. (And don’t forget: dementia and stroke are very common overall, especially in people who live to get old.) So it may be particularly important for you to do what you can to minimize your risk of developing dementia and/or stroke. Good luck!

  2. Mam, Thank U for your immediate response, As per our Doctor’s advice presently I am taking some more tablets i.e.Zevert,Dizitac, Etofree, Eprisan SR etc as I am having severe headache and dizziness. My question is whether headache and dizziness are due to CSVD and how can these tablets control them as the tablets are only painkiller. I also want to know whether I have to live with all these problems right through my life.

    • I can’t say whether your headache and dizziness are due to CSVD; you must ask your doctors these questions.

      Regarding your tablets, they are almost all anticholinergics or NSAIDs, which should only be used as a last resort in older adults because they become riskier as people get older. They are not particularly suited to CSVD in older adults, but you are younger and have some particular symptoms of concern, so they may or may not be a reasonable treatment choice for you.

      Only doctors who work with you in person — and correctly leverage the best available medical knowledge related to your condition — can say whether those medications are likely to help you, and are worth any risks/downsides. Likewise, only such doctors can reasonably hazard a guess as to what you might expect for the future.

      Please address any further questions regarding your situation to your own doctors.

  3. I am a 55 year old male, with parental family history of Parkinson’s, heart disease, migraines, diabetes, high blood pressure & TIA’s. I personally have had migraines for 35 years, and in the past 2 years developed high blood pressure (160/95), which is now being treated and is down to 130/85 on average. In the past two years I have also lost my sense of smell, I still can smell a few things, but overall, it has severely deteriorated. This concerns me because of the relationship to loss of smell and Parkinson’s.
    10 years ago I had an MRI scan of my brain, during a severe migraine attack, and this year I had a new MRI done by my new Neurologist, who says “it shows some small vessel disease, but nothing that is severe or significant.”
    One interesting development lately is that my migraines have diminished to almost nothing, after having a majority of the amalgam metal fillings (more than 20 ) removed from my dental work and replaced with enamel fillings.
    I wondered has any connection been made between CSVD and the dental amalgam and/or migraines?

    Also, aside from treating my BP, is there anything else I can do to try to prevent or delay any potential effects of diseases associated with CSVD?

    • Although the “party line” is that dental amalgam fillings are safe, some people have hypothesized that they release enough mercury to have health effects that might become significant over time. I don’t think it’s yet known whether dental amalgam might be associated with cerebral SVD.

      I would recommend you ask your neurologist for advice on reducing your risk of cerebral SVD. You might also ask whether you have any other cardiovascular risk factors that should be optimized, such as problems with blood sugar, high cholesterol, or chronic inflammation. Some research does suggest that eating a plant-based diet and minimizing (or even avoiding) meat products may be better for cardiovascular health. So if you or your doctors feel you are particularly at risk for cerebral SVD, this might be something to consider.

      Dr. Gregor of NutritionFacts.org has written a book that summarizes a lot of interesting research on the relationship between diet and health, including cardiovascular health and neurological health.

    • Hi Stephen.

      My mother (now early 60s but most of these have been going on slowly progressing for almost 3 decades) has migraines, major depression, copd, early dementia, atherosclerosis and a clot or aneurysm in her aorta (I forget the term they used), high BP (controlled), high cholesterol (controlled), mild but untreated diabetes, zollinger Ellison syndrome, a cyst in the ventricles of her brain. We’ve family history of Alzheimer’s, Parkinson’s, neuroendocrine tumors of the brain, spine, stomach, adrenal gland, ovaries, Petit mal and absence seizures, autonomic dysfunction, strokes, and heart attacks. Neuroendocrine tumors are rare hormone secreting tumors often benign, sometimes cancerous. As you can see a significant and complex medical and family history. I’ve really had to push hard to get testing and treatment for her regarding some of these things that escalated to life threatening the last few years but she improved some. However I’m still pushing to see if they can treat her better.

      Dr. Kernisan, my mother has just about every risk factor for small vessel ischemic disease. However, could the neurological risk factors (alzheimers, Parkinson’s, neuroendocrine tumors in the brain, spinal cord, adrenal glands that cause high blood pressure and diabetes) be the cause of the said, or be comorbid? The new neurologist is trying to determine which of these things are causing her declining cognitive ability and one sided body tremor.

      • I’m sorry I forgot to say her MRI does say small vessel ischemic disease along with that ventricular cyst which has been referred to as a few different terms in each of her MRIs. Arachnoid cyst, subependymal cyst, intraventricular cyst. She’s also had hydrocephalus or intraventriculitis in the past as well as hypertensive crises, afib, possibly stroke and/or heart attack but we’ve gotten mixed messages from different drs about that. Could the svd be a result of these things, or just one more thing in addition to these things?

        • Wow, sounds like she has an unusually complicated medical history. Her cerebral SVD may well be multifactorial. The neurologist can hopefully tell you whether it seems likely that the cysts and hydrocephalus are related to the blood vessel issues.

      • Sorry to hear that your mother has been going through so many health challenges. If she has many traditional risk factors for cerebral SVD, I think it would be hard to determine how much of a role — if any — the additional family risk factors have played.

        I’m glad you have found a neurologist and that you are helping to advocate for her. In older adults, it’s often many different factors that are contributing to a problem like cognitive decline. You will want to work with the neurologist to determine which might be amenable to treatment or management. Understanding what’s going on can also help you plan for the future. Good luck!

  4. I’m 54 years old and I have been suffering from CSVD for the past 6 months. I’m not able to walk as my left leg has been swelled. My left hand also not perfectly operative. Taking Ecosprin and Lipitab for the past 4 months but of little use. Not able to concentrate on any work. Putting frequent leave in Office. Nobody is explaining about this Small Vessel Disease. I am worried about my life expectancy. What is the remedy? Kindly explain

    • Unfortunately, it’s not possible for me to figure out what might be causing your symptoms. On this site, my goal is to help people understand common conditions that affect lots of older people.

      What you are describing certainly does sound concerning, so I would encourage you to follow up with your doctor. If your doctor isn’t helpful, or isn’t sure what might be causing your symptoms, then you may want to consider seeing a specialist, such as a neurologist. Neurologists in academic medical centers may be better equipped to evaluate unusual cases, compared to those in private community practice.

      Your doctors will have to help you figure out the diagnosis and the underlying cause of these problems, in order to direct you to the right remedy.

      Try to not worry about your life expectancy at this time; I don’t see how anyone could venture a guess without knowing more about what’s causing your difficulties.

      Focus on getting your problem thoroughly evaluated, and ask for help managing your symptoms and disabilities. Good luck!

  5. Hi I’m 38 years old and have recently had an mri as I had been experiencing painful headaches that then led to dizziness and speech and balance problems. The results of the mri showed a cavernoma and cerebral moderate small vessel disease are these linked in any way and what would it mean for my future as everything seems to mention it seen in older adults. I’m still awaiting an outcome from a neurologist as I have had to be referred to another hospital as I had moved house away from previous neurologist location. Would be good to find out a little more about svd in younger adults as still not heard from hospital. Many thanks. Louise

    • Unfortunately, I don’t know much about brain problems in people your age. What you are describing doesn’t sound very common, but a neurologist would know better than I would.

      If your problem is, in fact, a less common neurological problem, then you may want to look for a neurologist who specializes in small vessel disease, or perhaps in early-onset neurovascular problems. Such specialists are often easier to find in academic medical centers. Some people with unusual conditions also find it helpful to connect online with other patients like them. Sorry to hear of your condition and good luck!

      • Thanks for reply . I’m finally seeing another neurologist now and awaiting results for another mri scan. He is going to look into my small vessel disease and do a memory test too. At east it’s moving forward finally.

        • Hi Louise sorry to hear that you have the same I’m 38 and I have just had MRI scan results show that I have small vessel disease i have problems with balance cognitive problems and paralysis on left side of my body terrible headaches i have got a neurologist I’m waiting to hear from hospital looking for support please reply

          • Sorry to hear of your symptoms. Unfortunately our commenting system doesn’t notify people when someone has replied to their comment, so you may not hear back from Louise 🙁

            If you search online at PatientsLikeMe and SmartPatients, you may be able to find other people your age (e.g. 30s-40s) with similar health concerns. That can be a good source of support. Good luck!

          • Interesting. I’m also 38 and have been diagnosed with moderate microangiopathic changes / CSVD. I’m also suffering similar symptoms to the ladies above.

  6. hi i am 53yrs and recently had an mri for hemi facial spasm
    conclusion was multiple cerebral and pontine hyperintensities are beyond that expected for age
    findings most likely reflect small vessel ischaemic damage
    i am concerned because my mother developed alzhmiers at age 62 am i at risk of this?
    i have no symptoms and am healthy

    thanks patricia

    • Hm. It sounds unusual to have so many hyperintensities at your age.

      I would recommend that you discuss your MRI findings and your concerns with a doctor, perhaps a neurologist if possible. They could advise you on whether it’s worth repeating the scan (was it done with correct technique? was it correctly read?), on what might be causing those hyperintensities, and on what actions you might take to protect your brain from further changes.

      A good neurologist should also be able to address your questions regarding what to expect in the future. Generally, people who have a parent with early-onset Alzheimer’s do have a higher risk of developing Alzheimer’s. But a higher risk is not destiny.

      Good luck!

  7. Hi – had a MRI last year – and it said that their was a considerable chance I had chronic small vessel disease – was quite shocked as I’m 53 none smoker non drinker exercise and have kept my weight under control most of my life – I am going for another MRI next week for confirmation – if it is chronic does that mean Ian going to die in three years time I have no cognitive problems nor do I have any physical problems of major- do I have a better chance of longevity because I’m younger – I have never suffered from high blood pressure either. Cheerrs

    • Hm. I’m not sure how common it is for people your age to have signs of cerebral SVD on MRI. Some ideas/thoughts:

      – Does the MRI say whether it’s mild versus moderate? (hard to imagine it being “severe” at your age, esp if you are otherwise healthy)
      – Consider having another radiologist read the images of the first MRI. Neuroradiologists are especially trained to read brain scans. You might either be able to get a second reading at whatever hospital did it the first time, or you might be able to request the images on a DVD and bring it to another radiologist.

      In terms of prognosis and life-expectancy, the studies that I cite in this article were generally done in people much older than you are, so I would not use them to try to forecast your future.

      I would encourage you to focus on confirming that there is a finding in your brain (scans are sometimes misread) and working with your doctors to learn more about what is going on. Only then will you and your doctors be in a position to talk about what it might mean for your future. Good luck!

    • Hello Marie Lowe, I hope all is well. I would love to know how your life is now and if you are feeling more positive. Hope to hear from you soon.

    • Hi Marie
      I am 51 years of age and have been diagnosed with mild- moderate Small Vessel Disease of the Brain.
      I am wondering how you are doing and if you have any signs of the disease at all? Have you found any more research or info regards people of our age with this condition?
      Any info is helpful! Thank you in advance!
      May Thomson

      • Thank you for posting a comment. Unfortunately our commenting system doesn’t provide any alerts or updates to people who have previously commented, so you may not hear back from Marie. But if you look online, you may be able to find online communities of people your age with this condition. It’s an excellent idea to get in touch with others, to learn from each other and support each other. A recent NY Times article offers suggestions on finding online patient communities: Sometimes Patients Simply Need Other Patients
        Good luck!

  8. Hello Dr. K – I’m a heart attack survivor with a subsequent diagnosis of Coronary Microvascular Disease (MVD), a non-obstructive disorder (sometimes known as Small Vessel Disease). It makes sense to me that if the tiniest blood vessels supplying oxygen to my heart muscle are affected by MVD that other small blood vessels in my body (for example, supplying the brain) might also be affected by the same physiology. Can you tell me what you know about this connection?

    Many thanks,
    regards,
    C.

    • Great question, thanks Carolyn for bringing this up.

      I tried looking for scholarly research related to this question and didn’t find much. My guess is that this may be because the research on cerebral small vessel disease (SVD) is being mainly done by neurologists and neuroradiologists, whereas research on coronary microvascular disease is done by cardiologists. I did find one study correlating other types of microvascular dysfunction (brain, retina, kidney) with cognition:
      Microvascular and Macrovascular Abnormalities, and Cognitive and Physical Function In Older Adults: Cardiovascular Health Study.

      This article is also suggestive: Associations Between Left Ventricular Dysfunction and Brain Structure and Function: Findings From the SABRE (Southall and Brent Revisited) Study.

      I think it’s quite plausible that the small vessels in both the heart and the brain will be subject to similar mechanisms of injury and malfunction. So I’d be very surprised if coronary microvascular disease were studied and had no association with cerebral SVD.

      Some separate but related questions are how worried should you be, and what, if anything, should people with coronary microvascular disease do differently?

      Again, we don’t know for sure what’s likely to provide benefit, in that no one has randomized people like you to different treatment approaches, and then studied to see what happened in terms of SVD. But in general, probably whatever actions you are taking to take good care of your coronary microvessels will be good for your brain’s small vessels. Unlike many people, you are actually paying attention to the wellbeing of your blood vessels, so it’s even possible that in later life you may end up with less cerebral SVD than the average North American does.

      Do let me know if you learn more about this connection between microvascular heart health and brain health!

      • Thanks, Dr. K for your prompt and thoughtful response. I’ll check into both those study links, but I’m guessing that the Left Ventricular Dysfunction one might be the most appropriately related research.

        And I sure hope you’re correct (that everything I’m already doing to address my MVD symptoms will be somehow helping to ward off future SVD issues!

        Thank you again for taking the time to respond so thoroughly.

        regards (and Happy Mother’s Day to you this weekend!)
        C.

      • I am 62 I recently was diagnosed with evidence mild stable chronic small vessel ischemic changes. What can I do to prevent it going further.

  9. When I am going up or down a curb, I often pause for a momement. I wonder is this to allow my leg to get ready for the step or my brain to get ready for the step

    • Interesting. Hard to know what to make of it without knowing more details about you, and without doing more of neurological exam.

      I would recommend you discuss it with your doctor if you’re concerned, especially if you’ve noticed any other changes in the way your body moves.

  10. Hello Dr. Kernisan. My mother had an MRI and CT Scan in the hospital 1 1/2 years ago. She was taken to the emergency room for Dizziness, Weakness, Nausea. The released her with a Vertigo diagnosis. The CT Scan indicated: Periventricular and subcortical white matter hypodensity which is nonspecific. But, compatible with chronic microvascular ischemic change. There are atherosclerotic calcifications fo the intracranial circulation. There is generalized parenchymal volume loss without hydrocephalus, midline shift, or apparent mass effect. Impression: No eveidence of acute infarct, hemmorrhage, or hydrocephalus. MRI indicated: Chronic microvascular changes are seen in both cerebral hemispheres with mild symmetric parenchymal volume loss. Flow-voids are seen in the basilar and internal carotid arteries as well as in the large posteriour dural sinuses. Impression: Chronic microvascular changes but no specific eveidence of acute abnormality.

    My mom takes a lot of medication for artheroclerosis, high cholesterol, high blood pressure. Her sugar count is usually higher. But, not on any meds for that. She has had one carotid cleaned out in the neck. She has back problems, gait and dizziness problems. memory problems, hears noises at night, door bell ringers. someone on her roof, basketball being throw at her windows or on her back deck, Seeing someone with a gun on the back of her property BB gun being shot at her window, etc….

    We installed a security camera system, and we haven’t seen anything of this nature.

    Her MD wants her to have another MRI, she won’t comply. She lives alone, has fallen once outside the lab. No one saw her. She was able to get up on her own. And almost fallen several other times.

    I’m wondering if she has Cerebral Small Vessel Disease? No doctor has diagnosed her from these brain scans.

    Thank you so much, if you are able to reply.

    • Yes, your mother’s radiology report is extremely typical. This does sound like cerebral small vessel disease. It could be a contributor to her thinking problems and balance problems.

      However, I am not all surprised to hear that she hasn’t had a diagnosis, because this is a finding that shows up on lots and lots of reports for older people. I think doctors are very used to it, in the way that historically they were used to almost all older people having high blood pressure. (It’s extremely common for older adults to develop high blood pressure as they age, and in medical school they used to say that normal BP is your age plus 100. However now high blood pressure is not considered “ok” in older adults and we try to treat it.)

      Since this is such a common finding, I think many doctors do not consider it worth mentioning, especially since for now there is no particular treatment to pursue, other than considering treatment of high blood pressure and other vascular risk factors. This is like seeing arthritis on an xray of the knee; medical professionals think “of course that’s there.”

      Now, some experts are saying that this problem “has only recently been recognised for the serious problem that it is.” We are also developing an increased awareness of vascular cognitive impairment, which is a common result of cerebral small vessel disease.

      In terms of your mother’s symptoms and difficulties, you don’t say how old she is, but they are certainly quite common in older adults, especially in people aged mid-80s or older. Normally it would be reasonable to evaluate her for signs of other neurological problems, for falls, and for cognitive issues. Although her MRI is consistent with cerebral SVD, she might also be experiencing additional health problems that are making her balance and thinking worse, so it’s important to not just call it “cerebral SVD” and stop evaluation there.

      You might find this article helpful: 6 Causes of Paranoia in Aging & What to Do.

      If she’s reluctant to cooperate with medical care, then you and her doctors should pick your battles carefully. Before insisting on an MRI, you might ask her doctor to clarify how he or she expects an MRI to help them diagnose her, and more importantly, make a plan to help her optimize her thinking and walking. Good luck!

      • Thank you Dr. My mom is 76 years old. I can only assume that this may progress over time.

      • Hello Dr.kernisan. I’m written in about my sis sonya knazze. She was acute blood vessel disease. She was having a lot of migraine headaches finally went to the doctor they did an MRI and they found it on the MRI in her brain she’s only 54 years old.

        • Sorry to hear of your sister’s health challenges. For more on migraines and cerebral small vessel disease, see this comment.

    • You may wish to CADASIL – Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy. It is a rare genetic disease, that might be helpful, to learn a little more.

      • I am not very familiar with CADASIL, but it seems it is a cause of stroke in younger adults. Experts estimate that this genetic condition affect 1-5 people per 100,000.

        Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) as a model of small vessel disease: update on clinical, diagnostic, and management aspects

        Note that CADASIL is much more rare than migraine or even cerebral SVD in people aged 40s. So…most younger people experiencing these problems probably don’t have CADASIL. But it still may be worth asking the doctor about, especially if there is a family history of similar problems. It can be diagnosed via genetic tests and skin biopsy.

      • Hellomy MRI SHOWS MILD SUBCRITICAL WHITE MATTER DISEASE, related to a small vessel DISEASE. Can this be the cause of my migraines? If not what can be the cause.my bp is now nice and low.I do suffer with cronic neck and back pain

        • So, research has found that people with migraines are more likely to have white matter hyperintensities on MRI. They are also at higher risk for stroke.

          It is not clear, however, that the MRI changes cause migraines; probably it’s more that both the migraines and the cerebral small vessel changes are related to other factors affecting the brain and the brain’s blood vessels.

          Here is an article reviewing the research on this topic:
          Migraine and stroke

          I would recommend you ask your usual doctors for more information on what might be causing your migraines.

    • You need to have her checked for cadasil which is a rare genetic mutation in the brain. Similar symptoms to what you describe but no cure for.

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