Scientific Online Resource System

Varna Medical Forum

MRI features of cerebral small vessel disease

Emilian Kalchev, Radoslav Georgiev, Boyan Balev


Cerebral small vessel disease affects brain vessels with the smallest caliber - small arteries, arterioles, venules, capillaries. There is strong association with cognitive impairment, dementia, psychiatric conditions, gait disturbances. The main markers of cerebral small vessel disease in neuroimaging are white matter hyperintensities, lacunes, microbleeds, enlarged perivascular spaces - all of which long considered to be of a separate etiology and pathogenesis. Today we have enough reason to believe that they are part of the same pathological process, in which the main role is played by the endothelium. Advances in neuroimaging allow us to give more attention to cerebral small vessel disease - an extremely important scientific and social problem.


small vessel disease, MRI, white matter hyperintensities, lacunes, microbleeds, perivascular spaces

Full Text


Wardlaw JM, Smith C, Dichgans M. Mechanisms underlying sporadic cerebral small vessel disease: insights from neuroimaging. Lancet Neurol. 2013;12(5):483-497. doi:10.1016/S1474-4422(13)70060-7

Müller K, Courtois G, Ursini MV, Schwaninger M. New insight into the pathogenesis of cerebral small-vessel diseases. Stroke. 2017;48:520-527

Tomimoto H, Akiguchi I, Suenaga T, Nishimura M, Wakita H, Nakamura S, Kimura J. Alterations of the blood-brain barrier and glial cells in white matter lesions in cerebrovascular and Alzheimer`s disease patients. Stroke. 1996;27:2069-2074

Hachinski VC, Potter P, Merskey H. Leuko-araiosis. Arch Neurol. 1987;44:21-23

de Laat KF, Tuladhar AM, van Norden AGW, Norris DG, Zwiers MP, de Leeuw F-E. Loss of white matter integrity is associated with gait disorders in cerebral small vessel disease. Brain. 2011;134:73-83

Herrmann LL, Le Masurier M, Ebmeier KP. White matter hyperintensities in late life depression: a systematic review. J Neurol Neurosurg Psychiatry. 2008;79:619-624

Valdes Hernandez M, Booth T, Murray C, Gow A, Penke L, Morris Z, Munoz ManiegaS, Royle N, Aribisala B, Bastin M, Starr J, Deary I, Wardlaw J. Brain white matter damage in aging and cognitive ability in youth and older age. Neurobiol Aging. 2013;34:2740-2747

Turner ST, Jack CR, Fornage M, Mosley TH, Boerwinkle E, de Andrade M. Heritability of leukoaraiosis in hypertensive sibships. Hypertension. 2004;43:483-487

Maillard P, Seshadri S, Beiser A, Himali JJ, Au R, Fletcher E, Carmichael O, Wolf PA, DeCarli C. Effects of systolic blood pressure on white-matter integrity in young adults in the Framingham Heart Study: a cross-sectional study. Lancet Neurol. 2012;11:1039-1047

Ferguson SC, Blane A, Perros P, McCrimmon RJ, Best JJ, Wardlaw J, Deary IJ, Frier BM. Cognitive ability and brain structure in type 1 diabetes: relation to microangiopathy and preceding severe hypoglycaemia. Diabetes. 2003;52:149-156

Gons RA, van Norden AG, de Laat KF, van Oudheusden LJ, van Uden I, Zwiers MP, Norris DG, de Leeuw FE. Cigarette smoking is associated with reduced microstructural integrity of cerebral white matter. Brain. 2011;134:2116-2124

Fisher CM. Lacunes: small, deep cerebral infarcts. Neurology. 1965;15:774-784

Kalaria RN, Kenny RA, Ballard CG, Perry R, Ince P, Polvikoski T. Towards defining the neuropathological substrates of vascular dementia. J Neurol Sci. 2004;226:75-80

Gouw AA, Seewann A, van der Flier WM, Barkhof F, Rozemuller AM, Scheltens P, Geurts JJ. Heterogeneity of small vessel disease: a systematic review of MRI and histopathology correlations. J Neurol Neurosurg Psychiatry. 2011;82:126-135

Fazekas F. Incidental periventricular white matter hyperintensities revisited: what detailed morphologic image analyses can tell us. AJNR Am J Neuroradiol. 2014;35:63-64

Wardlaw JM, Sandercock PA, Dennis MS, Starr J. Is breakdown of the blood-brain barrier responsible for lacunar stroke, leukoaraiosis, and dementia? Stroke. 2003;34:806-812

Munoz Maniega S, Valdes Hernandez M, Clayden JD, Royle NA, Murray C, Morris Z, Aribisala BS, Gow AJ, Starr JM, Bastin ME, Deary IJ, Wardlaw JM. White matter hyperintensities and normal-appearing white matter integrity in the aging brain. Neurobiol Aging. 2015;36:909-918

Maillard P, Fletcher E, Harvey D, Carmichael O, Reed B, Mungas D, DeCarli C. White matter hyperintensity penumbra. Stroke. 2011;42:1917-1922

Fazekas F, Chawluk JB, Alavi A, Hurtig HI, Zimmerman RA. MR signal abnormalities at 1.5T in Alzheimer`s dementia and normal aging. AJR Am J Roentgenol. 1987;149:351-356

Wardlaw JM, Valdés Hernández MC, Muñoz-Maniega S. What are white matter hyperintensities made of? Relevance to vascular cognitive impairment [published correction appears in J Am Heart Assoc. 2016 Jan 13;5(1):e002006]. J Am Heart Assoc. 2015;4(6):001140

Vermeer SE, Longstreth WT Jr, Koudstaal PJ. Silent brain infarcts: a systematic review. Lancet Neurol 2007;6:611-19

Shi Y, Wardlaw JM. Update on cerebral small vessel disease: a dynamic whole-brain disease. Stroke and Vascular Neurology 2016;1:e000035. doi:10.1136/svn-2016- 000035

Roob G, Schmidt R, Kapeller P, Lechner A, Hartung HP, Fazekas F. MRI evidence of past cerebral microbleeds in a healthy elderly population. Neurology. 1999;52(5):991-4

Greenberg SM, Vernooij MW, Cordonnier C, et al. Cerebral microbleeds: a guide to detection and interpretation. Lancet Neurol. 2009;8(2):165-174. doi:10.1016/S1474-4422(09)70013-4

Fazekas F, Kleinert R, Roob G, et al. Histopathologic analysis of foci of signal loss on gradient-echo T2*-weighted MR images in patients with spontaneous intracerebral hemorrhage: evidence of microangiopathy-related microbleeds. AJNR Am J Neuroradiol. 1999;20(4):637-42

Braun H, Schreiber S. Microbleeds in cerebral small vessel disease. Lancet Neurol. 2014; 12: 735-736

Heier LA, Bauer CJ, Schwartz L, Zimmerman RD, Morgello S, Deck MDF. Large Virchow-Robin spaces: MR-clinical correlation. AJNR Am J Neuroradiol. 1989;10:929-936

MacLullich AM, Wardlaw JM, Ferguson KJ, Starr JM, Seckl JR, Deary IJ. Enlarged perivascular spaces are associated with cognitive function in healthy elderly men. J Neurol Neurosurg Psychiatry. 2004;75:1519-1523

Patankar TF, Baldwin R, Mitra D, Jeffries S, Sutcliffe C, Burns A, Jackson A. Virchow-Robin space dilatation may predict resistance to antidepressant monotherapy in elderly patients with depression. J Affect Disord. 2007;97:265-270

Doubal FN, MacLullich AM, Ferguson KJ, et al. Enlarged perivascular spaces on MRI are a feature of cerebral small vessel disease. Stroke 2010;41:450-54

Starr JM, Wardlaw J, Ferguson K, MacLullich A, Deary IJ, Marshall I. Increased blood-brain barrier permeability in type II diabetes demon- strated by gadolinium magnetic resonance imaging. J Neurol Neurosurg Psychiatry. 2003;74:70 -76

Staals J, Makin SD, Doubal FN, et al. Stroke subtype, vascular risk factors, and total MRI brain small-vessel disease burden. Neurology 2014;83:1228-34

van Dijk EJ, Breteler MM, Schmidt R, et al. The association between blood pressure, hypertension, and cerebral white matter lesions: cardiovascular determinants of dementia study. Hypertension 2004;44:625-30

Wardlaw JM, Allerhand M, Doubal FN, et al. Vascular risk factors, large-artery atheroma, and brain white matter hyperintensities. Neurology 2014;82:1331-8

Potter GM, Doubal FN, Jackson CA, et al. Counting cavitating lacunes underestimates the burden of lacunar infarction. Stroke 2010;41:267-72

Schmidt R, Enzinger C, Ropele S, et al. Progression of cerebral white matter lesions: 6-year results of the Austrian Stroke Prevention Study. Lancet 2003;361:2046-8

Munoz Maniega S, Chappell FM, Valdes Hernandez MC, et al. Integrity of normal-appearing white matter: influence of age, visible lesion burden and hypertension in patients with small-vessel disease. J Cereb Blood Flow Metab 2016. Published Online First: 1 Mar 2016

Weber R, Weimar C, Blatchford J, et al. Telmisartan on top of antihypertensive treatment does not prevent progression of cerebral white matter lesions in the prevention regimen for effectively avoiding second strokes (PRoFESS) MRI substudy. Stroke 2012;43:2336-42

Bath PM, Wardlaw JM. Pharmacological treatment and prevention of cerebral small vessel disease: a review of potential interventions. Int J Stroke 2015;10:469-78


Font Size