ESO Guideline on covert cerebral small vessel disease.

Joanna M Wardlaw,Hanna Jokinen,Raffaele Ornello,Frank-Erik De Leeuw,Arne G Lindgren,Salvatore Rudilosso,Sebastian Eppinger,Julie Staals,Charlotte Cordonnier,Leonardo Pantoni,Fergus Doubal,Stephanie Debette,Martin Taylor-Rowan,Christian Enzinger,Sabrina Schilling,Hugues Chabriat

doi:10.1177/23969873211027002

Abstract

‘Covert’ cerebral small vessel disease (ccSVD) is common on neuroimaging in persons without overt neurological manifestations, and increases the risk of future stroke, cognitive impairment, dependency, and death. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist with clinical decisions about management of ccSVD, specifically white matter hyperintensities and lacunes, to prevent adverse clinical outcomes. The guidelines were developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We prioritised the clinical outcomes of stroke, cognitive decline or dementia, dependency, death, mobility and mood disorders, and interventions of blood pressure lowering, antiplatelet drugs, lipid lowering, lifestyle modifications, glucose lowering and conventional treatments for dementia. We systematically reviewed the literature, assessed the evidence, formulated evidence-based recommendations where feasible, and expert consensus statements. We found little direct evidence, mostly of low quality. We recommend patients with ccSVD and hypertension to have their blood pressure well controlled; lower blood pressure targets may reduce ccSVD progression. We do not recommend antiplatelet drugs such as aspirin in ccSVD. We found little evidence on lipid lowering in ccSVD. Smoking cessation is a health priority. We recommend regular exercise which may benefit cognition, and a healthy diet, good sleep habits, avoiding obesity and stress for general health reasons. In ccSVD, we found no evidence for glucose control in the absence of diabetes or for conventional Alzheimer dementia treatments. Randomised controlled trials with clinical endpoints are a priority for ccSVD.

Highlights

Cerebral small vessel disease (SVD) refers to the presence of brain lesions found on CT or MR brain imaging or pathology examination, thought to have resulted from disease of the small blood vessels that perforate into the brain, primarily the white matter and deep grey matter
We identified one study in patients with covert cerebral SVD (ccSVD) (Figure 3, Table 4),[64] and a second study in a population that can be considered at high risk for ccSVD, where antiplatelet therapy was trialled for preventing the specified clinical outcomes defined in this guideline document.[64,65]
We suggest against antiplatelet treatment in patients with ccSVD as a means to reduce the clinical outcome events of ischaemic or haemorrhagic strokes, cognitive decline or dementia, dependency, death, major adverse cardiac events (MACE), mobility, or mood disorders

Summary

Introduction

Cerebral small vessel disease (SVD) refers to the presence of brain lesions found on CT or MR brain imaging or pathology examination, thought to have resulted from disease of the small blood vessels that perforate into the brain, primarily the white matter and deep grey matter. The full spectrum includes covert cerebral SVD (ccSVD) detected incidentally on neuroimaging, and SVD-related clinical presentations with stroke, cognitive decline or dementia, mood or physical dysfunction. SVD is the commonest cause of vascular cognitive impairment and vascular dementia and is common in mixed dementias with other dementia pathologies, and is a common cause of gait and balance problems and mood disorders in older people.[2] Individuals with SVD may present to stroke services, cognitive, movement disorder or neuropsychiatry clinics.[3]

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