ESO Webinar Report — Small Vessel Disease

The latest ESO Educational Webinar on Small Vessel disease was moderated by Professor Anna Bersano from Milan, Italy, chair of the ESO Educational Committee and by Dr Marieta Peycheva, Vascular Neurologist from Plovdiv, Bulgaria.

The first captivating presentation was delivered by Dr. Lina Palaiodimou, Assistant Professor of Neurology at the National and Kapodistrian University of Athens, Greece. She discussed three illustrative cases of small vessel disease (SVD), engaging the audience in an online poll on several clinically relevant issues.

The first case concerned a patient with covert SVD, a condition associated with at least a twofold increased risk of stroke and dementia. Dr. Palaiodimou highlighted the absence of specific guidelines for managing such cases and the considerable variability in treatment decisions among physicians, an issue reflected in the audience’s responses to the related poll question.

The second case concerned an acute minor but disabling thalamic stroke, for which 60% of the audience voted in favor of intravenous thrombolysis (IVT). Dr. Palaiodimou noted that IVT for disabling lacunar stroke is recommended by the ESO guidelines.

The final case addressed the dilemma of administering IVT in patients with cerebral microbleeds (CMBs). In accordance with the ESO guidelines, IVT may be withheld when >10 CMBs are present. However, performing a brain-MRI prior to IVT solely to exclude multiple CMBs is not recommended. Finally, in patients with acute ischemic stroke (AIS) and atrial fibrillation who present with multiple CMBs, the most common practice is to use non–vitamin K oral anticoagulants (preferably apixaban) combined with strict blood pressure (BP) control.

In turn, Hugh Markus, Professor of Stroke Medicine at the University of Cambridge, UK, delivered an excellent talk on the diagnosis and management of SVD. He noted that SVD, a condition with a very high prevalence, is a common cause of AIS and the leading cause of intracerebral hemorrhage (ICH) and vascular dementia. Moreover, SVD frequently coexists and interacts with other etiologies of dementia.

Next, Professor Markus focused on the diagnosis of acute lacunar stroke which typically affects at least two body parts, and highlighted the importance of brain MRI, as patients with typical clinical lacunar syndromes may sometimes have other causes not clear on CT imaging, such as multiple infracts due to an embolic source.

Regarding treatment, Professor Markus discussed the results of the SPS3 and SPIRIT trials, which demonstrated an increased risk of bleeding with long-term dual antiplatelet therapy (DAPT) or oral anticoagulation compared with aspirin in patients with recent lacunar stroke. Accordingly, long-term single antiplatelet therapy is recommended.

Moreover, strict BP control is of paramount importance, as supported by the results of the SPRINT trial and it is the associated SPRINT MRI and SPRINT-MIND substudies, which demonstrated that intensive BP lowering to a systolic of 120mmHg ( compared with standard lowering to 140mmhg)  reduced the risk of cardiovascular events, and also white matter lesion progression, and cognitive decline. According to the PRESERVE study, intensive BP management is also safe in patients with severe SVD, and does not result in cerebral hypoperfusion.

Finally, targeting neurovascular unit dysfunction (endothelial cell injury, BBB leakage and inflammation) opens up a new treatment approach for SVD.

During the Q&A session, the audience raised clinical questions concerning the optimal duration of DAPT after lacunar AIS, the intensity of diabetes management, and the impact of SVD burden on acute recanalisation therapies for AIS.