Two decades of epidemiologic research show that silent cerebrovascular disease is common and associated with an increased risk of stroke and dementia. To summarize evidence for the diagnosis and management of silent cerebrovascular disease to prevent stroke, the Stroke Council of the American Heart Association (AHA) convened a writing committee to evaluate existing evidence, to discuss clinical considerations, and to offer suggestions for future research on stroke prevention. The committee focused on patients with three cardinal manifestations of silent cerebrovascular disease: silent brain infarcts, MRI white matter hyperintensities of presumed vascular origin, and cerebral microbleeds. The committee’s report, which was published as a Scientific Statement from the AHA and the American Stroke Association (ASA), appeared online ahead of print December 15, 2016, in Stroke. The American Academy of Neurology affirmed the value of the AHA/ASA statement as an educational tool for neurologists.
The AHA/ASA writing committee found strong and consistent evidence that silent cerebrovascular disease is a common problem of aging and that silent brain infarcts and white matter hyperintensities are strongly associated with future symptomatic stroke risk, entailing a two- to threefold increase in relative risk, even after controlling for vascular risk factors such as hypertension. Among patients with cerebral microbleeds, evidence suggests that those treated with thrombolysis for acute ischemic stroke have a moderately increased risk of symptomatic intracranial hemorrhage, but little prospective evidence indicates the risk of symptomatic hemorrhage in patients who receive anticoagulation, said lead author and chair of the writing committee, Eric E. Smith, MD, MPH, Associate Professor of Neurology and the Katthy Taylor Chair in Vascular Dementia in the Department of Clinical Neurosciences at the University of Calgary, Alberta, and Hotchkiss Brain Institute. There were no randomized controlled trials targeted specifically to stroke prevention in participants with silent cerebrovascular disease.
Eric E. Smith, MD, MPH
According to the AHA/ASA Scientific Statement, primary stroke prevention is indicated in patients with silent brain infarcts, white matter hyperintensities, or microbleeds. The AHA/ASA statement further advises that accurate and reliable radiologic reporting using consensus terms understood by radiologists and nonradiologists alike will be essential to identify patients with silent cerebrovascular disease for appropriate treatment. Adoption of standard terms and definitions for silent cerebrovascular disease, as provided by prior AHA/ASA statements and by a consensus group, may facilitate diagnosis and communication of findings from radiologists to clinicians.
—Glenn S. Williams
Suggested Reading
Smith EE, Saposnik G, Biessels GJ, et al. Prevention of stroke in patients with silent cerebrovascular disease: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016 December 15 [Epub ahead of print].