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Cerebral Small Vascular Disease (SVD) refers to brain damage found in CT or MR brain imaging or pathological examinations.
It is believed to be caused by diseases of small blood vessels that penetrate the brain, mainly white matter and dark gray matter
.
The full spectrum includes concealed SVD (ccSVD) accidentally discovered on neuroimaging, as well as SVD-related clinical manifestations, including stroke, cognitive decline or dementia, emotional or physical dysfunction
.
The best description of pathological-anatomical brain injury is white matter hyperintensity (WMH), lacunar infarction, microhemorrhage, and abnormal expansion of the perivascular space
.
SVD is believed to be responsible for 25% of ischemic strokes and hemorrhagic strokes in most elderly patients
.
SVD is also the most common cause of vascular cognitive impairment and vascular dementia, and is common in mixed dementia accompanied by other dementia pathologies.
It is also a common cause of gait and balance problems and mood disorders in the elderly
.
However, SVD can often be found in CT or MRI brain imaging in patients with no obvious neurological history, causing these lesions to be called "concealed" SVD
.
The European Stroke Organization (ESO) guidelines provide evidence-based recommendations to help clinicians make reasonable clinical decisions in the management of ccSVD, especially white matter hyperintensity and lacunar infarction, to prevent adverse clinical outcomes
.
This guide is based on the ESO standard operating procedures and recommended classification, evaluation, development and evaluation (GRADE) method.
This article has translated the guide for reference
.
01 In patients with hidden cerebral small vessel disease (WMH and/or vena cava stenosis), whether antihypertensive treatment can reduce ischemic or hemorrhagic stroke, cognitive decline or dementia, dependence, death, major adverse cardiac events (MACE), activity or mood disorder? Recommendations: It is recommended that patients with hypertension ccSVD (≥140/90mmHg) use antihypertensive therapy to prevent the expansion of SVD lesions and related clinical manifestations
.
(Evidence level: very low; strength of recommendation: strong) Expert consensus: ① Blood pressure should be monitored and controlled appropriately
.
If blood pressure is well controlled, no specific antihypertensive treatment is recommended
.
②For ccSVD patients, there is currently insufficient evidence to advocate targeting BP levels below the standard target, although more intensive blood pressure reduction is associated with slower progress in the burden of WMH compared with traditional blood pressure reduction guidelines
.
③In ccSVD patients who recommend strengthening the blood pressure goal for other reasons, there is no strong evidence that this may be harmful
.
④Based on the current evidence, the expert group unanimously does not support systemic blood pressure reduction in ccSVD patients with normal blood pressure
.
02 In patients with hidden cerebral small vessel disease (WMH and/or lacunar), whether antiplatelet therapy can reduce ischemic or hemorrhagic stroke, cognitive decline or dementia, dependence, death, MACE, activity or Mood disorder? Recommendations: Antiplatelet therapy is recommended for patients with ccSVD to reduce clinical outcome events such as ischemic or hemorrhagic stroke, cognitive decline or dementia, dependence, death, MACE, activity or mood disorders
.
(Evidence level: very low; strength of recommendation: weak) Expert consensus: ① It is recommended not to use antiplatelet drugs to prevent the clinical outcome of ccSVD patients without other indications for treatment
.
②If there are no other indications for treatment, the use of antiplatelet drugs to prevent brain SVD progression may be harmful to elderly patients (≥70 years old)
.
03 In patients with hidden cerebral small vessel disease (WMH and/or lacunar), whether lipid-lowering treatment can reduce ischemic or hemorrhagic stroke, cognitive decline or dementia, dependence, death, MACE, activity or Mood disorder? Recommendations: No sufficient high-quality evidence has been found to prevent the clinical outcome of ccSVD, and no clear recommendations can be made for lipid-lowering
.
However, in the primary prevention of people at high risk of vascular events, lipid-lowering is effective
.
(Evidence level: very low; strength of recommendation: weak) Expert consensus: Even if there are no other indications for statin therapy, statins can be considered to reduce blood lipids in ccSVD patients to delay the progression of ccSVD, despite this delay The clinical significance of the progress has yet to be confirmed
.
04 In patients with hidden cerebrovascular disease (WMH and/or lacunar), can life>Recommendations: ①In patients with ccSVD, physical exercise is beneficial to cognition, and may also be beneficial to mobility, the incidence of cerebrovascular events, and all-cause mortality.
Therefore, regular physical exercise is recommended
.
However, no specific physical intervention can be recommended based on current evidence
.
(Evidence level: very low; strength of recommendation: weak) ②In ccSVD patients, there is no clear evidence that other non-physical life>
.
(Level of evidence: very low) Expert consensus: There is no direct evidence that any specific life>
.
However, the recommended healthy life>
.
05 For patients with hidden cerebrovascular disease (WMH and/or lacunar) who may (or may not) need hypoglycemic therapy, can the use of drugs that lower blood sugar levels reduce ischemic or hemorrhagic stroke and cognition? Decreased ability or dementia, dependence, death, MACE, activity or mood disorders? Recommendations: In diabetic patients with ccSVD, it is recommended to use hypoglycemic therapy based on current guidelines as appropriate, including recommended blood glucose and HbA1C targets, to manage diabetes in individual patients
.
However, no specific hypoglycemic treatment is recommended
.
(Level of evidence: very low) Expert consensus: ① Blood glucose levels should be properly monitored to control them according to medical care standards
.
②Do not recommend any specific drugs to get proper blood sugar control
.
③There is not enough evidence to recommend targeting specific glucose or HbA1c levels that are different from standard targets
.
④There is no evidence to support that any therapeutic intervention can reduce normal blood glucose levels
.
06 For patients with hidden cerebral small vessel disease (WMH and/or vena cava disease), can the use of traditional anti-dementia drugs (such as memantine, donepezil, galantamine, etc.
) reduce cognitive decline or dementia? Recommendations: For patients with ccSVD, it is recommended not to use conventional anti-dementia drugs, including cholinesterase inhibitors or memantine, as a means to reduce cognitive decline or dementia
.
(Evidence level: very low; strength of recommendation: weak) Expert consensus: ①Considering the current lack of evidence of cholinesterase inhibitors and memantine in ccSVD patients, as well as the small impact in patients with VCI or vascular dementia, it is recommended Do not use these anti-dementia drugs in ccSVD patients to prevent or reduce cognitive decline
.
②There is insufficient evidence for the use of any other anti-dementia drugs to prevent or reduce cognitive decline in ccSVD patients
.
07 Summary Occult (without any clear clinical symptoms) small vessel disease is a common result in brain imaging scans, especially in people 50-55 years of age or older, and will increase future stroke, dementia, dependence, activity and The risk of mood disorders
.
Patients with ccSVD should check their blood pressure.
If the patient's blood pressure is high, blood pressure should be strictly controlled according to the current blood pressure guidelines
.
ccSVD patients can receive statin therapy, because ccSVD represents a group of people with increased risk of vascular events, and lipid lowering is beneficial to the primary prevention of vascular diseases
.
ccSVD patients should not smoke, they should exercise regularly, because in addition to the general health benefits of exercise, it may also help prevent cognitive decline and delay the onset of dementia
.
A healthy diet including plenty of green leafy vegetables, avoiding overweight and good sleeping habits are all important to good health
.
According to the current diabetes guidelines, patients with diabetes and ccSVD should focus on keeping blood sugar under good control
.
In addition, there is no evidence that the drugs currently used to treat Alzheimer's dementia, such as cholinergic drugs or memantine, are helpful for ccSVD patients, unless there are other reasons for taking these drugs
.
Yimaitong compiled from: Wardlaw JM, Debette S, Jokinen H, et al.
ESO Guideline on covertcerebral small vessel disease.
Eur Stroke J.
2021;6(2):IV.
doi:10.
1177/23969873211027002
It is believed to be caused by diseases of small blood vessels that penetrate the brain, mainly white matter and dark gray matter
.
The full spectrum includes concealed SVD (ccSVD) accidentally discovered on neuroimaging, as well as SVD-related clinical manifestations, including stroke, cognitive decline or dementia, emotional or physical dysfunction
.
The best description of pathological-anatomical brain injury is white matter hyperintensity (WMH), lacunar infarction, microhemorrhage, and abnormal expansion of the perivascular space
.
SVD is believed to be responsible for 25% of ischemic strokes and hemorrhagic strokes in most elderly patients
.
SVD is also the most common cause of vascular cognitive impairment and vascular dementia, and is common in mixed dementia accompanied by other dementia pathologies.
It is also a common cause of gait and balance problems and mood disorders in the elderly
.
However, SVD can often be found in CT or MRI brain imaging in patients with no obvious neurological history, causing these lesions to be called "concealed" SVD
.
The European Stroke Organization (ESO) guidelines provide evidence-based recommendations to help clinicians make reasonable clinical decisions in the management of ccSVD, especially white matter hyperintensity and lacunar infarction, to prevent adverse clinical outcomes
.
This guide is based on the ESO standard operating procedures and recommended classification, evaluation, development and evaluation (GRADE) method.
This article has translated the guide for reference
.
01 In patients with hidden cerebral small vessel disease (WMH and/or vena cava stenosis), whether antihypertensive treatment can reduce ischemic or hemorrhagic stroke, cognitive decline or dementia, dependence, death, major adverse cardiac events (MACE), activity or mood disorder? Recommendations: It is recommended that patients with hypertension ccSVD (≥140/90mmHg) use antihypertensive therapy to prevent the expansion of SVD lesions and related clinical manifestations
.
(Evidence level: very low; strength of recommendation: strong) Expert consensus: ① Blood pressure should be monitored and controlled appropriately
.
If blood pressure is well controlled, no specific antihypertensive treatment is recommended
.
②For ccSVD patients, there is currently insufficient evidence to advocate targeting BP levels below the standard target, although more intensive blood pressure reduction is associated with slower progress in the burden of WMH compared with traditional blood pressure reduction guidelines
.
③In ccSVD patients who recommend strengthening the blood pressure goal for other reasons, there is no strong evidence that this may be harmful
.
④Based on the current evidence, the expert group unanimously does not support systemic blood pressure reduction in ccSVD patients with normal blood pressure
.
02 In patients with hidden cerebral small vessel disease (WMH and/or lacunar), whether antiplatelet therapy can reduce ischemic or hemorrhagic stroke, cognitive decline or dementia, dependence, death, MACE, activity or Mood disorder? Recommendations: Antiplatelet therapy is recommended for patients with ccSVD to reduce clinical outcome events such as ischemic or hemorrhagic stroke, cognitive decline or dementia, dependence, death, MACE, activity or mood disorders
.
(Evidence level: very low; strength of recommendation: weak) Expert consensus: ① It is recommended not to use antiplatelet drugs to prevent the clinical outcome of ccSVD patients without other indications for treatment
.
②If there are no other indications for treatment, the use of antiplatelet drugs to prevent brain SVD progression may be harmful to elderly patients (≥70 years old)
.
03 In patients with hidden cerebral small vessel disease (WMH and/or lacunar), whether lipid-lowering treatment can reduce ischemic or hemorrhagic stroke, cognitive decline or dementia, dependence, death, MACE, activity or Mood disorder? Recommendations: No sufficient high-quality evidence has been found to prevent the clinical outcome of ccSVD, and no clear recommendations can be made for lipid-lowering
.
However, in the primary prevention of people at high risk of vascular events, lipid-lowering is effective
.
(Evidence level: very low; strength of recommendation: weak) Expert consensus: Even if there are no other indications for statin therapy, statins can be considered to reduce blood lipids in ccSVD patients to delay the progression of ccSVD, despite this delay The clinical significance of the progress has yet to be confirmed
.
04 In patients with hidden cerebrovascular disease (WMH and/or lacunar), can life>Recommendations: ①In patients with ccSVD, physical exercise is beneficial to cognition, and may also be beneficial to mobility, the incidence of cerebrovascular events, and all-cause mortality.
Therefore, regular physical exercise is recommended
.
However, no specific physical intervention can be recommended based on current evidence
.
(Evidence level: very low; strength of recommendation: weak) ②In ccSVD patients, there is no clear evidence that other non-physical life>
.
(Level of evidence: very low) Expert consensus: There is no direct evidence that any specific life>
.
However, the recommended healthy life>
.
05 For patients with hidden cerebrovascular disease (WMH and/or lacunar) who may (or may not) need hypoglycemic therapy, can the use of drugs that lower blood sugar levels reduce ischemic or hemorrhagic stroke and cognition? Decreased ability or dementia, dependence, death, MACE, activity or mood disorders? Recommendations: In diabetic patients with ccSVD, it is recommended to use hypoglycemic therapy based on current guidelines as appropriate, including recommended blood glucose and HbA1C targets, to manage diabetes in individual patients
.
However, no specific hypoglycemic treatment is recommended
.
(Level of evidence: very low) Expert consensus: ① Blood glucose levels should be properly monitored to control them according to medical care standards
.
②Do not recommend any specific drugs to get proper blood sugar control
.
③There is not enough evidence to recommend targeting specific glucose or HbA1c levels that are different from standard targets
.
④There is no evidence to support that any therapeutic intervention can reduce normal blood glucose levels
.
06 For patients with hidden cerebral small vessel disease (WMH and/or vena cava disease), can the use of traditional anti-dementia drugs (such as memantine, donepezil, galantamine, etc.
) reduce cognitive decline or dementia? Recommendations: For patients with ccSVD, it is recommended not to use conventional anti-dementia drugs, including cholinesterase inhibitors or memantine, as a means to reduce cognitive decline or dementia
.
(Evidence level: very low; strength of recommendation: weak) Expert consensus: ①Considering the current lack of evidence of cholinesterase inhibitors and memantine in ccSVD patients, as well as the small impact in patients with VCI or vascular dementia, it is recommended Do not use these anti-dementia drugs in ccSVD patients to prevent or reduce cognitive decline
.
②There is insufficient evidence for the use of any other anti-dementia drugs to prevent or reduce cognitive decline in ccSVD patients
.
07 Summary Occult (without any clear clinical symptoms) small vessel disease is a common result in brain imaging scans, especially in people 50-55 years of age or older, and will increase future stroke, dementia, dependence, activity and The risk of mood disorders
.
Patients with ccSVD should check their blood pressure.
If the patient's blood pressure is high, blood pressure should be strictly controlled according to the current blood pressure guidelines
.
ccSVD patients can receive statin therapy, because ccSVD represents a group of people with increased risk of vascular events, and lipid lowering is beneficial to the primary prevention of vascular diseases
.
ccSVD patients should not smoke, they should exercise regularly, because in addition to the general health benefits of exercise, it may also help prevent cognitive decline and delay the onset of dementia
.
A healthy diet including plenty of green leafy vegetables, avoiding overweight and good sleeping habits are all important to good health
.
According to the current diabetes guidelines, patients with diabetes and ccSVD should focus on keeping blood sugar under good control
.
In addition, there is no evidence that the drugs currently used to treat Alzheimer's dementia, such as cholinergic drugs or memantine, are helpful for ccSVD patients, unless there are other reasons for taking these drugs
.
Yimaitong compiled from: Wardlaw JM, Debette S, Jokinen H, et al.
ESO Guideline on covertcerebral small vessel disease.
Eur Stroke J.
2021;6(2):IV.
doi:10.
1177/23969873211027002
