Hypertension and Cerebral Small Vessel Disease: A Review of the Pathophysiology, Progression, and Prevention

Chronic hypertension often leads to cerebral small vessel disease (CSVD), a condition marked by cumulative damage to the small arteries and arterioles within the brain. Radiologically, CSVD is associated with white matter hyperintensities, lacunar infarcts, and cerebral microbleeds. Clinically, it often presents with cognitive dysfunction, gait abnormalities, and an elevated risk of stroke. Histopathological changes in CSVD due to hypertension include thickening of arteriolar walls, breakdown of the blood-brain barrier, and chronic cerebral ischemia. CSVD is commonly seen in patients with long-standing hypertension, but it is not systematically screened for and is often undiagnosed. Few risk stratification models are incorporated in the outpatient management of hypertensive patients. The primary management strategy for CSVD is stringent control of blood pressure, but the precise target levels and preferred antihypertensive medications to prevent disease progression are not well-defined. Early identification of patients at risk for developing CSVD with ambulatory blood pressure monitoring, cognitive assessment, and brain imaging before the development of functional impairment may be a strategy to consider. In the future, we anticipate a more interdisciplinary care model for CSVD to help delineate the therapeutic window for treatment. Longitudinal studies that evaluate the inclusion of CSVD in the management of hypertension in standard practice will be important to incorporate.