Leucoaraiosis and silent subcortical infarcts

Silent brain infarcts and leucoaraiosis are frequently observed in patients with transient ischemic attack (TIA) and ischemic stroke. Patients with silent brain infarcts and leucoaraiosis at baseline are a high-risk group with an increased long-term risk for recurrent stroke, cognitive decline, and dementia. Effects on short-term outcomes are less clear, but leucoaraiosis appear to increase the risk of early infarct growth as determined by MRI in mismatch areas of the brain. After acute thrombolytic therapy, presence of silent cerebrovascular disease increases the risk of intracerebral hemorrhage, but the increased risk does not negate the overall benefit of this therapy. Similarly, presence of leucoaraiosis is associated with an increased risk of intracerebral bleeding during long-term anticoagulant therapy, but because the risk-benefit ratio has not been well delineated, degree of leucoaraiosis should not influence clinical decision-making at present. Carotid endarterectomy for symptomatic carotid stenosis appears equally effective across different degrees of baseline leucoaraiosis, despite an increased perioperative risk in those with moderate to severe leucoaraiosis. Long-term blood pressure lowering appears equally effective in patients with silent cerebrovascular disease at baseline, and there is some support that blood pressure lowering may decrease the risk of progression of leucoaraiosis.