The pathogenesis of cerebral small vessel disease and vascular cognitive impairment

Summary

This comprehensive narrative review synthesises advances in understanding the pathogenesis of cerebral small vessel disease (cSVD), a heterogeneous group of conditions affecting small brain vessels and accounting for approximately one quarter of ischaemic strokes, the majority of spontaneous intracranial haemorrhages, and at least 20% of dementias globally. The authors appraise recent molecular, genetic, and imaging innovations to elucidate mechanisms by which cSVD alters vessel structure and function, generates brain lesions, and contributes to cognitive decline. The review establishes a framework for clinical intervention development whilst identifying outstanding mechanistic questions and challenges for future research.

Regional applicability

As cSVD is a common cause of stroke and dementia in ageing populations, the pathophysiological insights and clinical frameworks presented are directly applicable to UK clinical practice and dementia prevention strategies. However, the review does not address population-specific epidemiology or UK healthcare system implementation pathways.

Key measures

Neuroimaging markers (infarct/lacune size <20 mm, cerebral microbleeds, white matter hyperintensities, perivascular space volume, brain atrophy); clinical outcomes (ischaemic stroke incidence, spontaneous haemorrhage incidence, dementia prevalence and aetiology)

Outcomes reported

The paper reviews cardinal neuroimaging features of cerebral small vessel disease (cSVD)—including lacunes, microbleeds, white matter hyperintensities, perivascular space enlargement, and brain atrophy—and synthesises current understanding of how cSVD damages small brain vessel structure and function, causes brain lesions, and impairs cognition.

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