International Modified Delphi Consensus on Assessment and Management of Covert Brain Infarction

BackgroundCovert brain infarction (CBI) is a frequent incidental neuroradiological finding increasingly recognized as clinically relevant due to its association with stroke, cognitive decline, and other adverse outcomes. However, substantial uncertainty remains regarding its optimal assessment and management, and existing guidelines provide limited and heterogeneous recommendations. We aimed to develop an international expert consensus on the evaluation and management of CBI using a modified Delphi methodology.MethodsA modified Delphi process was conducted with an international, multidisciplinary panel of 21 experts from 15 countries, including neurologists, neuroradiologists, neuroepidemiologists, and geriatricians. An initial questionnaire was developed from a structured literature review and identified clinical practice gaps. The survey included 91 statements across four domains: (1) prognosis, etiology, and screening; (2) neuroimaging-based management and follow-up; (3) cardiac evaluation; and (4) pharmacological management. Two iterative rounds were conducted, with anonymized responses, controlled feedback, and structured discussion. A five-point Likert scale was used. Consensus was defined a priori as ≥70% agreement.ResultsConsensus was reached on 33/91 statements (36.3%), moderate agreement on 43/91 (47.2%), and no consensus on 15/91 (16.5%). The panel agreed that CBI is associated with increased risk of ischemic stroke, cognitive impairment, and dementia, and that risk is higher with multiple lesions. Consensus supported targeted clinical evaluation, including a cardiac workup with transthoracic echocardiography in all patients and vascular imaging in selected cases. Routine population screening and systematic post-procedural imaging were not supported. Regarding management, consensus favored optimizing vascular risk factors, particularly strict blood pressure control in hypertensive patients. There was no consensus on routine antiplatelet therapy for incidental CBI, and anticoagulation was generally not supported in the absence of cardioembolic indications. Lipid-lowering showed limited consensus regarding specific benefits for CBI-related outcomes.ConclusionThis Delphi consensus highlights substantial variability in the perceived management of CBI and identifies areas of convergence, particularly in risk stratification and control of vascular risk factors. Key uncertainties remain regarding antithrombotic strategies, lipid-lowering therapy, and long-term surveillance. These results provide a pragmatic, expert-based framework to support clinical decision-making and further highlight the need for prospective studies and randomized trials in this rapidly evolving field.