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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 blood pressure control for covert cerebral small vessel disease (ccSVD) to prevent stroke. Lifestyle changes like exercise and smoking cessation are advised, but antiplatelet drugs are not recommended for ccSVD.
Area of Science:
- Neurology
- Vascular Neurology
- Geriatrics
Background:
- Covert cerebral small vessel disease (ccSVD) is prevalent in asymptomatic individuals.
- ccSVD increases risks of stroke, cognitive decline, dependency, and mortality.
- Current management strategies for ccSVD require evidence-based recommendations.
Purpose of the Study:
- To provide European Stroke Organisation (ESO) guidelines for managing ccSVD.
- To offer recommendations for preventing adverse clinical outcomes associated with ccSVD.
- To guide clinical decisions on interventions for ccSVD.
Main Methods:
- Systematic literature review following ESO standard operating procedures and GRADE methodology.
- Prioritization of clinical outcomes including stroke, cognitive decline, dependency, and death.
- Formulation of evidence-based recommendations and expert consensus statements.
Main Results:
- Strong recommendation for well-controlled blood pressure in ccSVD patients with hypertension; lower targets may slow progression.
- No recommendation for antiplatelet drugs (e.g., aspirin) in ccSVD.
- Limited evidence for lipid-lowering interventions; smoking cessation and regular exercise are prioritized.
Conclusions:
- Lifestyle modifications including exercise, healthy diet, and stress management are beneficial for general health in ccSVD.
- No evidence supports glucose control (without diabetes) or conventional Alzheimer's treatments for ccSVD.
- Urgent need for randomized controlled trials with clinical endpoints to advance ccSVD research.
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.
