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ESO Guideline on covert cerebral small vessel disease
Joanna M Wardlaw1, Stephanie Debette2,3, Hanna Jokinen4
1Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK.
Insights
European Stroke Organisation guidelines recommend controlling blood pressure in covert cerebral small vessel disease (ccSVD) to prevent stroke and cognitive decline. Lifestyle changes like smoking cessation and exercise are advised, but antiplatelet drugs are not recommended for ccSVD.
Area of Science:
- Neurology
- Vascular Neurology
- Geriatric Medicine
Background:
- Covert cerebral small vessel disease (ccSVD) is prevalent in neuroimaging and linked to increased risks of stroke, cognitive impairment, dependency, and mortality.
- Management strategies for ccSVD are crucial for preventing adverse clinical outcomes.
Purpose of the Study:
- To provide evidence-based European Stroke Organisation (ESO) guidelines for managing ccSVD, focusing on white matter hyperintensities and lacunes.
- To offer recommendations for clinical decision-making to prevent stroke, cognitive decline, dependency, and death.
Main Methods:
- Systematic literature review and evidence assessment using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.
- Prioritization of clinical outcomes including stroke, cognitive decline, dependency, death, mobility, and mood disorders.
- Consideration of interventions such as blood pressure lowering, antiplatelet drugs, lipid lowering, lifestyle modifications, and glucose lowering.
Main Results:
- Strong recommendation for well-controlled blood pressure in patients with ccSVD and hypertension, with potential benefits of lower blood pressure targets on ccSVD progression.
- No recommendation for antiplatelet drugs (e.g., aspirin) in ccSVD.
- Limited evidence for lipid-lowering therapies; strong recommendation for smoking cessation, regular exercise, healthy diet, good sleep, and weight management.
- No evidence supporting glucose control (without diabetes) or conventional Alzheimer's dementia treatments for ccSVD.
Conclusions:
- Effective management of ccSVD involves prioritizing blood pressure control and adopting healthy lifestyle modifications.
- Further high-quality randomized controlled trials with clinical endpoints are urgently needed to guide ccSVD management.
- Current evidence does not support the use of antiplatelet agents or glucose-lowering therapies in ccSVD patients without diabetes.
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.
