Small Vessel Disease: A Stroke Trigger?

Small vessel disease (SVD) is a common brain condition in older adults, characterised by abnormalities in the small blood vessels of the brain. It is an umbrella term for a variety of abnormalities, including atherosclerosis, cerebral amyloid angiopathy, and arteriolosclerosis. SVD can cause a range of symptoms, including cognitive impairment, problems with walking and balance, and depression. It is also a significant risk factor for stroke and dementia.

Small vessel disease and its impact on the brain

Small vessel disease (SVD) is a common condition among older adults that affects the brain's small blood vessels. It is an umbrella term for a range of conditions resulting from damage to these blood vessels, which can lead to reduced blood flow to the brain and internal bleeding. This, in turn, can cause vascular dementia and increase the risk of other forms of dementia, including Alzheimer's disease.

The specific causes of SVD are not yet fully understood, but it is believed to be the result of a build-up of plaque and hardening of the arteries (atherosclerosis). This damage can block blood flow through the small blood vessels in the brain, depriving brain cells of oxygen, or it can cause the vessels to leak and bleed, damaging nearby neurons.

The impact of SVD on the brain can be significant. It is a leading cause of vascular dementia and is associated with an increased risk of other forms of dementia, including Alzheimer's disease. SVD can also lead to cognitive impairment, problems with walking and balance, depression, strokes, and nervous system problems such as slurred speech and difficulty swallowing. These symptoms can have a profound impact on an individual's quality of life, affecting their ability to communicate, move, and perform daily tasks.

The severity of SVD can vary, and some people with mild cases may not experience any noticeable symptoms. However, as the disease progresses, the impact on the brain can become more pronounced, leading to more severe cognitive and physical impairments.

Currently, there is no cure for SVD, and treatment options are limited. The focus of management is on reducing risk factors and preventing or delaying complications such as stroke and dementia. This includes managing conditions such as high blood pressure, high cholesterol, and diabetes, as well as adopting healthy lifestyle habits such as regular exercise and a nutritious diet.

The link between small vessel disease and stroke

Small vessel disease (SVD) is an umbrella term for a range of abnormalities related to small blood vessels in the brain. It is a common finding on CT and MRI scans of elderly people and is related to vascular risk factors and cognitive and motor impairment. SVD can ultimately lead to dementia or parkinsonism in some cases. However, the relationship between SVD and these conditions is weak, and not all subjects with SVD will develop these conditions. This could be due to the diversity of underlying pathologies of both white matter lesions (WML) and normal-appearing white matter (NAWM).

SVD can be caused by arteriolosclerosis and cerebral small vascular atherosclerosis, which are associated with vascular risk factors such as hypertension, diabetes, smoking, high cholesterol, obesity, and dyslipidemia. These conditions can lead to reduced cerebral blood flow, impaired cerebral autoregulation, and increased blood-brain barrier permeability, resulting in stroke.

Cerebral amyloid angiopathy (CAA) is another cause of SVD, characterised by the accumulation of amyloid protein in the walls of small-to-medium-sized arteries and arterioles. CAA is the dominant cause of lobar intracerebral hemorrhage and is an important component of senile plaques found in patients with Alzheimer's disease. CAA can also lead to stroke and cognitive impairment.

The precise diagnosis of SVD depends on neuropathological examination, which is challenging in clinical practice. Therefore, the clinical diagnosis is based on clinical features, neuroimaging of the brain parenchyma, and the use of other investigative techniques such as ultrasonography and the consideration of risk factors.

The prognosis for SVD is generally better than for other types of strokes in the short term due to the small size of the primary lesion, and the rate of recovery is often rapid. However, SVD can increase the risk of stroke, dementia, and death if left untreated.

Risk factors for small vessel disease

Small vessel disease (SVD) is a condition in which the walls of the small arteries in the heart and brain aren't working properly, reducing the flow of oxygen-rich blood. It is a common neurological disease that affects the perforating arterioles, arterioles, capillaries, venules, and venules in the brain. SVD is more common in women and people with diabetes, high blood pressure, or high cholesterol. Here are some risk factors for SVD:

• Hypertension: SVD patients are three times more likely to have hypertension than those without the disease. It is a significant risk factor for both lacune and white matter hyperintensity (WMH), which are markers of SVD.
• Diabetes: Diabetics are twice as likely to develop SVD, specifically lacune and WMH.
• Hyperlipidemia: Those with high cholesterol or abnormal lipid levels have a higher risk of SVD, particularly lacune and WMH.
• Smoking: Current or former smokers have a 50% higher chance of developing SVD, especially lacune and WMH.
• Age: Older age is a risk factor for SVD, with the likelihood of developing the disease increasing after 45 in men and 55 in women.
• Obesity: A body mass index (BMI) of 30 or higher is a risk factor for SVD.
• Family History: SVD has a genetic component, with a higher risk among those with a family history, especially in women.
• Polycystic Ovary Syndrome: This condition is associated with an increased risk of SVD.

While drinking alcohol was not found to be a significant risk factor for SVD in the overall population, it was identified as a risk factor for WMH in elderly individuals.

Symptoms of small vessel disease

Small vessel disease (SVD) is a condition in which the walls of the small arteries in the heart are damaged and don't function properly. This reduces the flow of oxygen-rich blood to the heart, which can lead to chest pain (angina), shortness of breath, and other signs and symptoms of heart disease. While SVD can sometimes be asymptomatic, it often presents with symptoms that mimic a heart attack.

Chest Pain and Discomfort

People with SVD often experience chest pain or discomfort, known as angina. This pain may be squeezing or pressing and can radiate to the left arm, jaw, neck, back, or abdomen. It may be triggered or worsened by physical activity or emotional stress.

Rapid Heart Rate

A rapid heart rate, also known as tachycardia, of over 100 beats per minute is a common symptom of SVD. This can be measured by a doctor or with a pulse oximeter.

Lightheadedness and Fainting

Due to the reduced blood flow and oxygen supply to the heart, people with SVD may experience lightheadedness or even fainting spells.

Nausea and Vomiting

Nausea and vomiting are also possible symptoms of SVD, often accompanying the chest pain and discomfort.

Cognitive Impairment

In some cases, SVD can lead to cognitive impairment, including problems with thinking skills and memory. This is often seen in more severe cases of the disease.

Walking and Balance Problems

SVD can affect an individual's gait and balance, making it difficult to walk or maintain stability.

Stroke-like Symptoms

If SVD causes a stroke, individuals may experience numbness or weakness, particularly on one side of the body, trouble speaking or understanding language, vision loss, loss of balance or coordination, and a sudden, severe headache. These symptoms require immediate medical attention.

It is important to note that diagnosing SVD can be challenging, and a doctor will need to evaluate medical history, family history, and symptoms, along with performing diagnostic tests such as an electrocardiogram (EKG/ECG), echocardiogram, cardiac catheterization, magnetic resonance imaging (MRI), or computed tomography (CT) scan.

Treatment and prevention of small vessel disease

Treatment for small vessel disease focuses on controlling the narrowing of the small blood vessels to prevent a heart attack and to relieve pain. This includes medication such as:

• Nitroglycerin to relax the coronary arteries and improve blood flow.
• Beta-blockers to slow the heart rate and decrease blood pressure.
• Calcium channel blockers to relax the muscles around the coronary arteries and increase blood flow to the heart.
• Statins to lower bad cholesterol and relax the blood vessels of the heart.
• ACE inhibitors and ARBs to open blood vessels and lower blood pressure.
• Ranolazine to ease chest pain by altering sodium and calcium levels.
• Aspirin to limit inflammation and prevent blood clots.
• Metformin to improve blood vessel health.

In addition to medication, small vessel disease can be prevented and managed by making heart-healthy lifestyle changes, such as:

• Losing weight if overweight.
• Getting regular physical activity.
• Eating a healthy diet that's low in salt and rich in fruit, vegetables, lean protein, and whole grains.
• Quitting smoking or tobacco use.

Frequently asked questions