Lacunar infarcts/lacunes, white matter hyperintensities (WMH), and cerebral microbleeds (CMBs) are considered various manifestations of
cerebral small vessel disease (SVD). Since the exact mechanisms of these manifestations differ, their associated risk factors differ.
High blood pressure is the most consistent risk factor for all of these manifestations. However, a "J curve" phenomenon in terms of blood pressure probably exists for WMH. The association between
cholesterol levels and
lacunar infarcts/lacunes or WMH was less consistent and sometimes conflicting; a low
cholesterol level probably increases the risk of CMBs.
Homocysteinemia appears to be associated with WMH. It is noteworthy that the risk factors profile may also differ between different lacunar patterns and CMBs located at different parts of the brain. Thrombolysis,
antihypertensives, and
statins are used to treat patients with symptomatic
lacunar infarction, just as in those with other
stroke subtypes. However, it should be remembered that
bleeding risks increase in patients with extensive WMH and CMBs after thrombolysis
therapy. According to the
Secondary Prevention of Small Subcortical
Strokes trial results, a blood pressure reduction to <130 mmHg is recommended in patients with symptomatic
lacunar infarction. However, an excessive blood pressure decrease may induce
cognitive decline in older patients with extensive WMH. Dual antiplatelet
therapy (
aspirin plus
clopidogrel) should be avoided because of the excessive risk of
intracerebral hemorrhage. Although no particular antiplatelet is recommended, drugs such as
cilostazol or
triflusal may have advantages for patients with SVD since they are associated with less frequent
bleeding complications than
aspirin.