21 Jun 18. Featured Paper
Small Vessel Disease; a Big Problem, But Fixable
As the recipient of the William M. Feinberg Award for Excellence in Clinical Stroke, Professor Wardlaw has written this Special Report on Small vessel disease (SVD).
Research - How did it start?
Like much in stroke, this research journey started with a clot although this clot and this stroke were different. In 2000 AD, a 70-year-old man presented to our hospital with a recent lacunar stroke. His computed tomographic scan showed a small, low attenuation area, consistent with a recent small subcortical (lacunar) infarct, but there were 3 odd features.
Through examing previous patients scans with acute lacunar stroke and consulting informative papers by C Miller Fisher we were aware that the search for modifiable risk factors should extend beyond conventional concurrent vascular risk factors, the main message being that lacunar stroke and SVD are not simply a small version of large artery cardioathero-thrombo-embolic stroke.
From our initial research we then considered:
- SVD Risk Occurs Across the Life Span
- The Blood-Brain Barrier
- What About Ischemia?
- Is Small Vessel Brain Damage Permanent?
- What can be done to prevent or correct subtle BBB leakage, stiff vessels, and poor vasoreactivity?
SVD is not silent, permanent, or untreatable. Importantly, advances made in recent years open new insights, offering new therapeutic targets. SVD is a common cause of stroke and worsens all stroke outcomes.
As Hachinksi has said, the commonest form of cerebrovascular disease is dementia not stroke, vascular dementia is the second commonest dementia with SVD as the commonest cause, vascular dysfunction occurs early in Alzheimer disease, and dementia prevention and treatment are currently limited, yet many drugs with known vascular effects might prevent or delay progression of dementia.
Stroke, dementia, and cardiovascular experts should combine their strengths because a united approach offers hope not just for stroke but also for dementia.