In This Episode:
Dr. K talks with neurologist Fanny Elahi, MD PhD, about cerebral small vessel disease and other issues related to white matter changes in the brain. Dr. Elahi sees patients and conducts research at UCSF’s Memory and Aging Center, and is an Assistant Professor of Neurology at UCSF. They discuss:
- What is the white matter in the brain, and why it often changes or is damaged with aging
- The relationship between white matter changes and cerebral small vessel disease
- How white matter changes can be thought of as a form of “scarring” in brain
- Why these brain changes can affect memory, thinking, and/or falls
- What we know about the prevention and treatment of these changes
- How white matter changes relate to vascular dementia, Alzheimer’s and other causes of dementia
- How the UCSF Memory and Aging Center evaluates white matter changes
- What is vascular parkinsonism
- What to consider for younger people with white matter changes on MRI
- Her recommendations on maintaining the brain and its blood vessels
- Ongoing research projects at UCSF and elsewhere that listeners may be able to participate in
Related episodes:
078 – Interview: The Biology of Aging & Longevity
072 – Cognitive Aging: How Memory & Thinking Change as One Gets Older
048 – How Cerebral Small Vessel Disease Affects Most Aging Brains
Related Resources:
- Cerebral Small Vessel Disease: What to Know & What to Do
- Research Opportunities at the UCSF Memory & Aging Center
- Developing biomarkers for small vessel brain disease: the Mark VCID consortium
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Can you please address a relationship of lupus and anticarolipid syndrome with white matter syndrome. I am a 66yr old female with both of these conditions.
Over the last year or more my confused state, losing things, falling have excellerated I. I have failed memory tests given by doctors and failed
More symptoms, but those are the biggest symptoms.
My mother had lupus w central nervous involment and died at 51 so I don’t think it was she related related to old age.
Has there been research on connection between cause and effect with white matter and lupus/antiocardio lipid syndrome and years of warfrin?
I would consider being in a clinical trial program but transportation would b an issue. Thanks
Sorry, but I am not an expert on autoimmune diseases and also can’t really speak to the “non garden-variety” potential causes of white matter disease.
I would recommend searching Pubmed for lupus and white matter disease, there are free full articles often available. You might also want to look for a community of similar patients online.
If you are looking for a diagnosis or a second opinion regarding proposed treatment, you could also consider one of the “second opinion” services being offered by some of the major academic medical centers. Good luck!
Dear Dr. Kernisan, what a wonderfully informative podcast. Many thanks to you and your guest for taking the time to do that. I am discovering more about White Matter Hyperintensities than I ever wished to know.
I first discovered this site last year when I was following up on “mini-strokes” with which I had been diagnosed. At that time, I had an MRI/MRA of the brain completed (in the emergency room for hypertensive urgency) and followed up with a neurologist who mentioned those WMHs and her concerns about them. To continue with that follow-up, last month I had another MRI/MRA done that showed, “Multiple irregularly shaped and varying sized hyperintense T2 FLAIR white matter lesions of both cerebral hemispheres, worse than prior study,” The study result also states that these were, “for patient age (I am 64)…greater than what would be expected for chronic ischemic small vessel disease.” While discussing the results with my neurologist I asked what the five year outlook may look like and she responded that it could be expected that I would be beginning to see signs of vascular dementia within that period of time.
I am afraid that, for a long period of time, my blood pressure was not well-controlled and that may be the cause for some of this. However, there is nothing I can do at this point to change the past. My blood pressure is now monitored closely and in good shape. I have never been a smoker and hardly ever have a drink and have exercised frequently throughout my life. My weight is good but I am reducing my sugar and fat intake. My neurologist is also putting me on a cholesterol reducer. I also plan, based on the podcast suggestion, to see if I can enroll in a study here in my area.
While going for a blood draw the day after the appointment I saw a magazine from Mayo Clinic Proceedings (March 2019) with a terrific article entitled, “White Matter Hyperintensities and Mortality” and they covered many of the same things that you and Dr. Elahi covered in the podcast but in far more technical terms as it is a medical publication for physicians.
The article did mention the fact that, infrequently, white matter can decrease. So I have a two part question. Have you ever seen that happen in your experience? Do you know of any articles on the subject that would be beneficial?
I offer my sincere thanks for all you are doing as I know it takes a great deal of time and I am certain that you are already quite busy with your “regular” work as a physician.
Thank you for your comment, I’m so glad if the information on the site or the podcast has been helpful to you. Personally I’m not sure I’ve seen white matter lesions improve, but honestly, I usually care for people who are much older than you are. We do know that sometimes intensive lifestyle changes do seem to result in great health improvements. If you haven’t already seen it, I would recommend reviewing the article on 12 cardiovascular risk factors. I think that in some people, really changing the diet and improving exercise and reducing stress can have significant effects. The mind-body connection can be very powerful too, so I recommend finding a way to not worry too much about the future, if possible. (Do address advance care planning, however.) Good luck!
How to Address Cardiovascular Risk Factors for Better Brain Health: 12 Risks to Know & 5 Things to Do
Hello again, I would like to follow up on your reply and ask one other brief question. That article you attached is good and I have already taken steps to get “vulnerable” areas under control.
My question involves the relationship between fatigue and white matter. I have had amazing fatigue since a viral illness two years ago and have been seeing a rheumatologist for it but tests have been inconclusive so far. (C-reactive protein is good, btw.). I’ve recently seen articles from valid institutions that speak of the relationship between white matter and fatigue. What is your opinion of the relationship, if any, between increasing white matter as it relates to fatigue. Thank you again in advance.
Very informative thank you. I am finding all your podcasts so helpful. I’d like you to explore more on diet & Dementia. I’ve read that dairy & calcium build up in the brain could be a factor to calcification & scaring. What are your thoughts? I have a mother with Dementia & want to do what I can to help my risk factors.
Thank you again.
Calcification can be a problem for blood vessel health, but for most people, it is less about dairy intake per se, and more about inflammation levels in the body and other general factors. Dairy may be inflammatory for some people but not necessarily for most. I have more on protecting blood vessel health (including some suggestions re diet) in this article: How to Address Cardiovascular Risk Factors for Better Brain Health: 12 Risks to Know & 5 Things to Do.
Otherwise, if you are interested in diet and brain health, I recommend Lisa Mosconi PhD’s book Brain Food; she is a neuroscientist at the Alzheimer’s Prevention Clinic at Weill Cornell.
Hi, I just subscribed to your web page after listening to this podcast about the Understanding White Matter Changes of the Brain. I would like to get more input from some MRI results and participate in ongoing studies if possible. I will expand this message in my email to you with more details and questions. This podcast was really interesting and informative for me.
Thank you for your interest in the podcast, I’m glad if you found it interesting. Unfortunately, I’m not able to correspond with readers or listeners to offer input on specific results. I would recommend asking the provider who ordered your MRI to discuss the results with you. You can also look for a neurologist for a second opinion. Good luck!
Dear Dr. Kernisan, My Mother is 86 and began experiencing problems approximately 6 years ago. She has difficulty verbalizing what she is experiencing. She feels better when lying down, the morning is more tolerable than later in the day. She feels sort of detached or spaced out, sometimes has shaky legs, unsteady gait, balance issues, and lately her feet have been feeling strange. She does not appear to have cognitive issues. She is always exhausted but pushes herself most days to do house work and gardening, but she is miserable all of the time, her head always feels strange, and she needs to continually recline. If she is depressed now it would seem it stems from her frustration and inability to do what she wants to do and from feeling so terrible all of the time – luckily she is not in pain. She also has tight irritated eyes and is extremely sensitive to light, more so following cataract surgery last August. Perhaps the eye problems might be a separate issue. A MRI (w/o contrast) from June 2016 indicated unspecified white matter disease, mild small vessel ischemic disease. A MRI (w and w/out contrast) just done on 5/21/19 reports unspecified white matter disease but is now progressive small vessel ischemic disease. I understand that these findings are very common in the elderly, and I haven’t seen her specific symptoms listed in articles pertaining to white matter disease, except for the unsteady gait/balance issues. Any doctor she has seen reports that she is very healthy and any problems are age related. I listened to your podcast 084 with Dr. Elahi and so impressed with your compassion and deeper understanding of this disease and in attempting to treat it before it becomes more of a problem. We live on Long Island in NY. Is there anyone you can recommend we see that might be able to help my Mom with this debilitating problem? I just read one of your comments that indicates you can’t offer input, but perhaps a good neurologist that specializes in these problems and is located nearby? Thank You so much I appreciate any information or guidance you can give.
Sorry to hear of your mother’s health difficulties. Hard to say what might be causing them, but as they are affecting her quality of life, I think it makes sense to try to look into things further. If she is 86, you could try to see if you could find a geriatrician, or you could look for a neurologist. It’s possible she has something more unusual. You could also consider paying for one of the “Second Opinion” services at a major medical center, such as this one based in NYC. Good luck!
I have cardiac issues including small vessel ischemic disease. I thought I was doing a great job on my diet until, based on having renal artery stenosis, I was told to eat a low oxalate diet. It seems that the two diets are mutually exclusive in many ways (e.g., for my heart, whole grain, green vegetables, avoid dairy; for kidney, white bread, dairy, few vegetables meet the standard for low oxalates). Any suggestions on how I can balance these?
Hm, that’s a good question. I’m not sure how to balance those two dietary suggestions. I would recommend working closely with a good nutritionist or dietician. Good luck!
I’m in my early 50’s and I’m having cognitive issues and tremors ( hands and now my head that don’t seem to be improving ) I recently had an MRI and found out I have age related microvascular changes..( according to my MRI results and my neurologist. I have no idea what this means or what is the next step? Where do I go from here? My Mom has Parkinson’s and Dementia. She was diagnosed around my age.
Hi Elizabeth. Sounds like you are concerned about the influence of your family history on your own health, which is understandable. I can tell you that most cases of Parkinson’s disease are not hereditary, and depending on the type of dementia your mom has, it may not be hereditary either. The biggest risk factor for dementia is older age – and you don’t want to stop aging!
I’m not sure what to make of your tremors – there are many things that can cause tremors from neurological disorders to medications, and many types of tremor are of unknown cause (like “essential tremor”). Here’s a little video I made about tremors.
When it comes to microvascular change, this blog post by Dr. K. has some very good practical advice. I hope you find it reassuring to know that there are things you can put into action to preserve your brain health.
I had sudden death twice in Fib-Ablation nick my pulmonary artery. I had a large blood clot in my heart, 5 blood clots in my right lung when I was 57 years old. In 2012
I had small TIAs in 2004. I had speech, PT on right leg at 49 years old.
I have memory loss, thinking, organization skills, very hard to learn new things, getting lost easily. Last several months it all has progressed.
The Neurologist I went to sent me a message saying I have Small Vessel Ischemic Disease & possibility Alzheimer’s.
I had a MRI & blood tests. I am 64 years old.
Hi Lindy. Sorry to hear about all of the challenges you have had. People who have strokes are at increased risk for vascular dementia, which is a lot like Alzheimer’s disease, in that it causes difficulty with thinking and functioning, as you describe, but Vascular dementia (or VaD) is caused by stroke changes in the brain. It’s also important to recognize that the changes we recommend for heart health can also benefit the aging brain.
Excellent podcast and great info Leslie I really enjoyed it. I am 63 recently had MRI that said “minimal nonspecific white matter changes could be related to small vessel ischemic disease. These have also been described a migraine headache and vasculitis. A demyelinating process cannot be excluded.” Your podcast helped me to understand quite a bit of it. Although all of the risk factors have been managed for me for years. I have also been very active physically all of my life and am surprised that these things would be occurring so early in my “aging process”. Nevertheless I appreciate the work you are doing and the information you shared. Thank you much !
Hi Doug and I’m so glad that you found the podcast helpful.
It can be frustrating when risk factors are absent, or well managed, and we still see changes that we would prefer to avoid (like the ones you describe on your MRI). When that happens in my practice, I tell my patient that their efforts to be physically active have not been in vain, and that perhaps they would have had changes even earlier (say, in their 40’s or 50’s) if they hadn’t had such healthy habits.
I would suggest continuing to be active and regularly following up with your doctor in case new symptoms develop. Thanks again for your feedback!
Please guide me about the best medication for sleeping, my mom is 86 years old, she is suffering from Dementia and Chronic illnesses( Diabetes, Hyper tension), her prescription is Citalopram 20mg and she is not tolerate the benzodiazepines ( Colonazepam 2mg). She is not sleeping properly.
Please guide me.
Sleep problems are common in older adults, especially those with dementia. Here’s an article that might be of interest. You’ll notice that most of the time, medications aren’t the answer to the sleep issue and can even make things worse.
We also recommend against using long acting benzodiazepines, like clonazepam because their use can increase the risk of falls and confusion.
This article about an approach to insomnia might also be of interest.
Hi,I enjoyed the topic.I just turned 59,previously very active.Long term problems with high blood pressure.ckd3.
MRI white matter lessons. I on ongoing tension at the back of my head league almost to the crown of my head every day.I am aware of poor concentration. I on medication including diuretic.Sometims my blood pressure is too high or to low.I am a lost as what best approach to manage. I am scared I may have a stroke or something sinister. Please can you advise. The tension at the back of my head is most worrying
Stephen
Many people are worried about the connection between high blood pressure and headache, which is usually unfounded. In fact, I read a study of over 20000 individuals in Norway which found that high blood pressure was associated with a reduced risk of non-migraine headache.
Pls help me! No one seems to be doing anything for me except sending me for multiple MRIs. I am 45 years old and have had many TIAs and 3 strokes. CSVD and white matter changes have been thrown around. Yet I have had no definitive diagnosis. I am terrified of dementia and the results of my next stokes. I exercise, eat fairly well, do not smoke nor drink. I take bp plavix and Cholesterol medication as preventative measures but the levels for those things are relatively good. How do I slow this progression and prevent another stroke? I pray that you’ll read and respond. All the best, Jane
I can understand being concerned about another stroke, and it sounds like you’re on the right track with managing risk factors like high blood pressure, high cholesterol and being on an anti-platelet agent. It’s unusual for someone in your age group to have multiple strokes, but some strokes occur with no obvious cause. An evaluation at a stroke clinic would be valuable to make sure that there’s no other underlying cause that your team has overlooked (like a heart defect that can predispose to stroke, or an unusual blood clotting condition that can do the same).
If all of these issues have been checked out, then it would be a matter of continuing to do your best along with your healthcare team to prevent another event. The Heart and Stroke foundation in your area may have support groups or information that would help, and you can contact them here.
Hi, I wish my husband would help more round house!
Many women would probably share this sentiment. I’m not sure if white matter changes could be blamed for that behaviour!
Great podcast, thank you. I am in my early 50’s and have been having memory and cognitive issues for some years now, recently documented by neuro-psych testing and an MRI with one finding of “Nonspecific white matter changes, possibly reflecting early chronic small vessel ischemic disease”. Cognitive and memory deficiencies are affecting my ability to work, made worse by the fact that my symptoms seem to be exacerbating bi-polar 1 symptoms. Are you aware of any specialists that focus on any part of this and/or any studies in which I may participate? (Minute 22 of the podcast really resonated in terms of what I’m experiencing). Thank you!
Hi Kimberly and I’m sorry to hear about the changes you’re noticing. Glad you enjoyed the podcast.
This website has a list of clinical trials that might help you to find one in your area that you could enroll in: https://clinicaltrials.gov/ct2/show/NCT04318119
Thank you!
where is there a center of excellence on white matter disease (WMD) in the northern New Jersey area or nearby? we need help in identifying the cause of white matter disease and what to do to slow or reverse the WMD progression by addressing the cause
Hi Bob and thanks for your comment. I couldn’t find a center of excellence for white matter disease, but it most likely would be something that a stroke or dementia research center would include.
Check out the Rutgers Brain Health Institute: https://brainhealthinstitute.rutgers.edu/
Hi I have recently been diagnosed with small vessel disease of the brain but I am only 55 years of age.
I have in the past had small spells of feeling unsteady on my feet, my mood has been very low at times and I suffer from lack of motivation which is out of character to the rest of my life. I was also 2 years ago diagnosed with mild dilated cardiomyopathy but I’m not sure if the two are related and not sure where I go from here being only 55.
Can you offer any specific advise.
Thank you
Kevin
Small vessel disease can be associated with changes in walking and depression (https://pubmed.ncbi.nlm.nih.gov/32715831/). The dilated cardiomyopathy might be related to the brain issue (if both are caused by blocked or narrowed arteries), or may be a separate process.
Don’t lose hope! Small vessel disease appears to be caused by the same processes that cause heart attack and stroke, so making changes to reduce your cardiovascular and cerebrovascular risk profile could help prevent progression! You’ve probably heard that exercise, eating a Mediterranean diet, seeing your doctor about your blood pressure and cholesterol, can all help reduce cardiovascular risk. I’m sorry my advice isn’t more specific but working with your health care team, I’m sure you’ll be able to develop a lifestyle plan that will move you in the right direction.