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.”
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.
Not necessarily. In my opinion, older adults should only get MRIs of the brain if the following two things are true:
- They are experiencing worrisome clinical symptoms, and
- 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:
- CNS small vessel disease: A clinical review (2019)
- Mechanisms underlying sporadic cerebral small vessel disease: insights from neuroimaging
- Causes and consequences of cerebral small vessel disease. The RUN DMC study
- Vascular Contributions to Cognitive Impairment and Dementia: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association (2011)
- Early Cerebral Small Vessel Disease and Brain Volume, Cognition, and Gait
- Cardiovascular risk factors and small vessel disease of the brain: Blood pressure, white matter lesions, and functional decline in older persons
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!
Toni says
I am 52 years old, female, one day I could not speak and had left sided weakness as well as confusion and my left side of my face was droopy. I had a CT which showed atrophy and white matter disease and an MRI that showed small vessel disease. It has been 2 months, I still have difficulty finding words, am easily confused and am very easily overwhelmed. Prior to this I was working as an RN in an ICU. I have been unable to return to work. Any ideas? This is very worrisome to my family and friends as well. Thank you so much!!
Leslie Kernisan, MD MPH says
Weakness on one side with a drooping face is pretty worrisome for acute stroke. (If the symptoms resolve within 24 hours, this might be classified as a transient ischemic attack.) You don’t say whether you were diagnosed with an acute stroke or not, but given the symptoms you are reporting, I can certainly see why you are worried.
I wish I could be more helpful, but all I can say is that you must keep asking your neurologists for assistance. Be sure to ask them to clarify what they think happened two months ago, what might have been the underlying cause for a stroke or TIA (do they think you might have a related condition that predisposes you to stroke?), and what they think can be done. I don’t personally know much about post-stroke rehabilitation, but the neurologists should be able to advise you on that front as well.
If you are having trouble with overwhelm and thinking, then it’s essential that you not try to do this on your own. Get a family member to be your advocate, or consider hiring a professional patient advocate. Remind your family and friends that although they may be used to seeing you as the medical expert (since you are an ICU nurse), at this time you need for someone else to help you navigate your health challenges.
Good luck, I sincerely hope you find some better answers and help soon.
Nerina says
Dear Dr Kernisan
Thank you for your very helpful comments. I will follow your advice. Your blog is extremely interesting. All the best.
Nerina
Rosa says
I’m 50 and was told I have small vessels disease in the brain. What exactly does this mean?
Leslie Kernisan, MD MPH says
Generally, this means that your brain MRI is showing signs of small abnormalities, similar to the ones in the article photo. Such abnormalities reflect damage to the brain’s small blood vessels.
If you’re concerned, I would recommend reading the article again, and then bring your questions and concerns to your doctor’s attention. He or she should be able to answer questions and help you understand what this might mean for you. In most cases, it means it might be a good idea to pay extra attention to blood pressure and other cardiovascular risk factors.
Anthony says
I am a 52 year old male in pretty good physical shape (run, lift, yoga…) I just received the results of a recent MRI and the doctor stated I had “some” small-vessel ischemic disease. The reason for the MRI was because I have been experiencing tinnitus in my right ear while also having jaw pain on that side. I also suddenly had to have two root canals on this side of my mouth out of the blue. Not believing in coincidences, I pressed to have the MRI reveling the above. So my question is can this small-vessel ischemic disease cause any of the problems I’ve mentioned above? Could this be from a concussion (I played football and rugby and have been knocked out while playing the latter). How much can it affect my balance? I can tell you that almost every morning when I get up, I tend to need about 15-30 seconds to get my balance. Should I see a neurologist? The doctor who prescribed the MRI was an audiologist.
Thank you.
Leslie Kernisan, MD MPH says
I don’t know whether SVD is likely to cause jaw pain or tinnitus. Most tinnitus is peripheral in origin (related to the ear itself), but some can be central (related to the part of the brain that processes sound).
As you’ve probably heard, football and other sports that cause blows to the head are now being associated with brain changes called chronic traumatic encephalopathy. It’s certainly plausible that such blows to the head might increase one’s risk of developing cerebral SVD. In a report on the topic, the authors say “Recent reports have demonstrated that repetitive subconcussive trauma is associated with white matter abnormalities on diffusion tensor imaging and abnormal functional MRI tests. Additional findings indicate that there may be persistent and progressive inflammation and white matter degeneration after even a single TBI.”
Clinical presentation of chronic traumatic encephalopathy
Now in terms of your balance, I would just say that many different things could cause you to feel wobbly when you stand. One of the simplest things to do is review your blood pressure readings. Especially if you are on any type of medication that might lower your BP, I would recommend checking your BP sitting and standing, and seeing if there is a difference.
Generally it’s best to start by discussing your concerns with your usual doctor. If that’s not helpful, or if your doctor recommends it, then consider a neurologist. Good luck!
Nerina says
Dear Dr Kernisan
I have found your article and your comments very interesting. I am a 63 year old woman. Employed full time. All my markers such as blood pressure, cholesterol, etc are all within healthy limits. A few years ago I felt that I must have had a mini stroke. I had numb face for a few years, I had headaches, I had trouble falling over (but I thought it may have been my feet and or eye issues). I had an MRI and the results said T2/FLAIR hyperintensities in the deep white matter are non specific in appearance…. not associatied with restricted diffusion or susceptibility artefact…. No abnormality of the IAMs. No mass lesions in the region of Meckel’s caves. Deep white matter T2/FLAIR hyperintensity are non specific in appearance and may represent changes in chronic small vessel ischaemia. I was told it was nothing to worry about by GP and neurologist. Two months ago I found I have a DVT and 2 resultant PE… I am on blood thinner… could I have a blood clotting issue. I am also worried I may be at the initial stages of dimentia…. should I be taking more assertive steps?? Thank you for your help.
Leslie Kernisan, MD MPH says
Sorry to hear of these health concerns. Deep vein thrombosis (DVT) and pulmonary embolism (PE), in particular, are serious events. It’s plausible that whatever put you at risk for your DVT might also be related to the changes seen in your MRI.
I think it’s always good to be assertive and ask extra questions. For instance, unless you were hospitalized, had surgery, or were otherwise immobilized before your DVT, I would encourage you to ask your doctors for help determining what may have predisposed you to this problem. Infections and cancers can predispose people to this, as can certain medications, certain problems with blood cells, and certain other underlying conditions. It is certainly possible to get a DVT out of the blue, but in about 90% of cases, it’s possible to identify a cause or predisposing factor.
Here is a (freely available) scholarly article on this topic: Risk Factors for Venous Thromboembolism
If you’ve been worried about possible changes in your memory, these two articles have more information on getting correctly evaluated:
How to Diagnose & Treat Mild Cognitive Impairment
How We Diagnose Dementia: The Practical Basics to Know
If your doctors tell you not to worry, one way to respond is to clarify that what’s important to you is to better understand what might be going on with your health, because you’re understandably concerned about the recent events and want to make sure you’re doing everything possible to maintain your health and prevent future problems. Be sure to express appreciation for their assistance…this will help them feel more motivated to cooperate with all your extra questions.
Good luck!
srinivas rao says
i am facing small vessel ischemic changes now my age is 53.doctor prescribed me stugil,stamlo,clopilet,aztor,zepam,repace.but i am still facing minute disease.what should i do.wheather to continue this medicne or shall i consult another doctor?
Leslie Kernisan, MD MPH says
I can’t tell you what to do, I can only provide some information and suggest questions that you can ask your doctors. Your medications are not available in the US, but looks like some are for high blood pressure, one is for cholesterol, and then you have mentioned a benzodiazepine (usually for anxiety or insomnia) and a medication for nausea. Benzodiazepines and anti-nausea medicines often have a lot of side effects in older adults. You are under age 60, but you still might want to ask your doctor to clarify how these medications are supposed to benefit you, or help you with your cerebral SVD. Good luck!
Barbara says
Your article was incredibly informative but a little troubling and confusing for me. I am a 52 year old female. My blood pressure is consistently in the 120/72 range. My blood sugar has always been in acceptable ranges at each annual physical. I smoked for 20 years but quit almost nineteen years ago (9/13/98). My cholesterol has also been consistently within normal ranges. In short, I’m healthy. However, due to a return of migraine headaches back in 2015, I had an MRI. The results were unremarkable and showed no abnormalities. Then, a little over a week ago, I had another MRI. I’ve been having speech and memory issues since my hysterectomy in August of 2015. This recent MRI states findings of chronic ischemic fosi seen in the left cerebellum. I’m trouble by your article because I’m only 52. The symptoms I have began immediately following my surgery. I was under anesthesia for just over three hours. Could this have brought on the condition? Do I look forward to it getting worse as I get older since the typical factors that bring it on are not present in my case?
Leslie Kernisan, MD MPH says
I don’t know how common it is for surgical anesthesia to be associated with brain vessel changes, but presumably it’s possible. However, the cerebellum is usually involved in balance and motor control rather than speech and memory.
I would recommend talking to a neurologist about your concerns and questions. The MRI finding may or may not be related to your symptoms.
In terms of whether you will get worse: in general, almost all older adults develop more of these brain changes as they get older, it’s just a matter of when and at what severity. Even people who don’t have high blood pressure or other typical risk factors will develop these changes, because if nothing else, they can be caused by non-specific age-related inflammation and degradation of the blood vessels.
Remember, it’s impossible to predict the future with certainty. Yes, you are at risk for this progressing. But by working closely with a health professional in person, you should be able to learn more about your option for reducing your risk of progression.
Perhaps even more important is to make sure your memory and speech difficulties have been properly evaluated. Otherwise, maintain your brain and health as best you can. Good luck!
gloria constine says
At age 28 I was put on serial C, a contraceptive pill, which affected me so that I had a BP of 276 over 185 pulse rate doubled for four months till it was detected. They found nothing wrong functionally ie. kidneys, etc. now aged 72 I have small vessel ischemia. Could the high BP have affected my small arteries/ blood vessels at that time. I also have blocked small arteries in my calf and feet.
Could this unfortunate incident have damaged my vessels so as to raise my cholesterol to heal the damaged vessels.
Thank you in advance. Gloria
Leslie Kernisan, MD MPH says
If you have blocked arteries in your calves and feet, then it sounds like you are also experiencing some vascular disease in other parts of your body.
I can’t say how likely it is that your period of high blood pressure caused all this. Four months of high BP is a lot of strain on the blood vessels, so it’s plausible that this would cause damage.
At this point, I would say that it’s important for you to focus on learning more about what you can do now, to minimize your risk of cerebral SVD progressing, or of other cardiovascular events. A neurologist may be the best type of specialist to help you do this. Good luck!
netmouse says
A CT scan diagnosed mild chronic microvascular white matter ischemic changes. I am female age 70. What does the word “chronic” signify – widespread? Of is this just another term for the same disease you wrote about.
BTW, diagnosed with afib a year ago, and on an anticoagulant, I was glad to see no brain bleeds. Will the anticoagulant help reduce future ischemic changes, being a “blood thinner”?
Leslie Kernisan, MD MPH says
In medicine, “chronic” means that a condition is not new or “acute.” The time span used to define “acute” vs “chronic” actually varies depending on the condition in question, but chronic usually means something has been going on for at least a few months. Chronic also means we expect a condition to persist indefinitely.
And yes, “chronic microvascular white matter ischemic changes” would be another term for cerebral small vessel disease. In your report, it sounds like they said it is “mild,” which is reassuring.
I don’t think it’s known whether an anticoagulant helps reduce future microvascular ischemic changes, but it certainly does reduce the risk of major stroke in people with afib, so it’s usually recommended for people with afib.
Dave MacLeod says
I’m 76 and recently had a very mild stroke, left thalamus consistent with an acute lacunar-type infarct with correlative ADC map hypointensity. Since in my 40s I’ve have numerous cardiovascular interventions, angioplasties, vascular surgeries both legs and a quad bypass 15 years ago. A Pet scan last fall showed no further changes to my heart. I try and do all the right things – those I can control.
After the MTI I had CT scans of both the neck & head. Those showed mild SVD, no significant accumulation of plaque in the arteries and no obstructions of flow. I just wore a Holter monitor and I’m having a Bubble Echo of my heart tomorrow.
I read every question and response above. Collectively you’ve answered any possible question I could have of you at this time. I could not just close out this site without commending you on such great service and advice to so many. Thank you!
Leslie Kernisan, MD MPH says
Thank you for sharing your story and for your comment! This article has certainly benefitted from others adding their questions and health details, and I’m glad if it helps anyone understand their health a little better.
Good luck with your next steps for your health!