Cerebral small vessel disease: pearls and pitfalls from unexplored risk factors to treatment

Cerebral small vessel disease (CSVD) is a major cause of ischemic stroke and cognitive impairment, often accompanied by gait disturbances and neuropsychiatric symptoms that remain underrecognized. Age and hypertension are key risk factors, but emerging evidence points to the influence of genetic polymorphisms and clonal hematopoieses. The pathophysiology of CSVD is closely linked to neuroimaging features, as outlined in the Standards for Reporting Vascular changes on neuroimaging (STRIVE) criteria, which reflect the two most prevalent mechanisms: arteriosclerosis and cerebral amyloid angiopathy. As a clinico-radiological syndrome, CSVD encompasses imaging and histopathological findings. Despite its burden on function and quality of life, treatment remains limited to risk factor control. Ongoing studies aim to clarify the underlying mechanisms, validate biomarkers and identify novel therapeutic targets.