Cerebral small blood vessel disease (in standard preoperative
imaging reports) is independently associated with increased risk of CV death following
carotid endarterectomy. This statement is produced by an article published in the European Journal of vascular and endovascular surgery2020.
1). What is cerebral small blood vessel disease?
Cerebral small
vessel disease (CSVD) is composed of several diseases affecting the small
arteries, arterioles, venules, and capillaries of the brain, and refers to
several pathological processes and etiologies. Neuroimaging features of CSVD
include recent small subcortical infarcts, lacunes, white matter
hyperintensities, perivascular spaces, microbleeds, and brain atrophy. The main
clinical manifestations of CSVD include stroke, cognitive decline, dementia,
psychiatric disorders, abnormal gait, and urinary incontinence.
2). What are
cerebral small blood vessels?
Cerebral small
vessels comprise two components. First, the leptomeninges vasoganglion, which
is derived from subarachnoid space covering, and the convex surface of the brain.
Second, perforating arteries are derived from anterior, middle, posterior
cerebral arteries that supply the subcortical parenchyma. The cerebral small
vessels are crucial to the maintenance of adequate blood flow to the sub-surface
brain structure. They include small arteries, arterioles, venules, and
capillaries which are commonly sized at 50–400 µm.
3). What are the
outcomes of cerebral small vessel disease (CSVD) of the brain?
Small vessel
disease accounts for up to 25% of all ischemic strokes but also put
patients at twice the risk for these conditions. In addition, CSVD is a
leading cause of functional loss, disability and cognitive decline in the
elderly.
4). What are the
neuroimaging findings of CSVD?
Neuroimaging of
CSVD primarily involves visualizing recent small subcortical infarcts, lacunar
infarct, WMH, microbleeds, enlarged perivascular spaces, and brain atrophy.
5). What are
lacunar infarcts?
Gattringer and
colleagues recommended the new term ‘recent small subcortical infarct’ instead
of the lacunar infarct.
Gattringer T,
Eppinger S, Pinter D, Pirpamer L, Berghold A, Wunsch G, Ropele S, Wardlaw JM,
Enzinger C, Fazekas F. Morphological MRI
characteristics of recent small subcortical infarcts. Int J Stroke. 2015;10(7):1037–1043.
Lacunar stroke
accounts for up to a quarter of all acute ischemic strokes. it is a small
fluid-filled cavity that was thought to mark the healed stage of a small deep
brain infarct. In neuroimaging, a lacuna is a round or ovoid, subcortical,
fluid-filled cavity with a similar signal to cerebrospinal fluid (CSF). It
measures between 3–15 mm in diameter, which is consistent with a previous acute
small deep brain infarct or hemorrhage in the territory of one perforating
arteriole. Lacunar infarcts
are typically located in the basal ganglia, internal capsule, thalamus, corona
radiata, centrum semiovale (CSO), and brainstem. Poirier and colleagues divided
the lacunas into three subtypes based on the formation: Subtype I lacunas are
secondary to old lacunar infarction; subtype II lacunas secondary to old
hemorrhagic lesions; subtype Ⅲ lacunas are secondary to enlarged
perivascular spaces. Herve and colleagues classified the lacunar lesions by
three-dimensional MRI reconstruction, according to their shapes into four
types: Slab, stick, multiple components, or ovoid/spheroid, then proposing that
most of the lacunar infarcts (83%) were ovoid or spheroid. Infarct lesions manifest
isolated, adjacent to or fused into white matter hyperintensity.
Moreau and
colleagues found that lacunas almost always present at 90 days after acute
lacunar infarction and appear as a central CSF-like hypointensity with or
without a surrounding border of hyperintensity on FLAIR sequence but only
CSF-like hypointensity and hyperintensity on T1-weighted and T2-weighted,
respectively. Moreover, the sensitivity of FLAIR for cavitation was greatly
lower than for T1-weighted sequences.
6). What is the effect of CSVD on people undergoing carotid endarterectomy?
The presence of SVD in pre-operative brain imaging reports can
serve as a predictor for the three-year risk of cardiovascular death in
symptomatic patients undergoing CEA but does not predict peri-operative or long
term risk of stroke. Published: April 21, 2020DOI:https://doi.org/10.1016/j.ejvs.2020.02.004
