Cerebral small vessel disease

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1 Cerebral small vessel disease Dr. Eszter Farkas November 30, 2016

2 Vascular dementia Vascular cognitive impairment Multi-infarct dementia Binswanger disease Subcortical vascular dementia CADASIL

3 Cerebrovascular insufficiency leading to cognitive symptoms Vascular dementia (Vascular cognitive impairment) Subcortical vascular dementia Sporadic (e.g. Binswanger) Hereditary (e.g. CADASIL) Multi-infarct dementia (cortical)

4 Cerebral small vessel disease Vascular dementia (Vascular cognitive impairment) Subcortical vascular dementia Sporadic (e.g. Binswanger) Hereditary (e.g. CADASIL) Multi-infarct dementia (cortical)

5 General Introduction Small vessel disease (SVD) of the brain accounts for 25% to 30% of strokes is a leading cause of age- and hypertension related cognitive decline and disability Clinical manifestation: sudden onset stroke symptoms changes in cognitive function progressive cognitive deterioration/dementia depression (physical disability) SVD can progress silently for many years before becoming clinically evident Currently no specific treatments for SVD

Definition Pathological changes of small vessels of the brain: affect the structure or function of small vessels within the brain Sproadic and hereditary forms Major risk factors for

6 Definition Pathological changes of small vessels of the brain: affect the structure or function of small vessels within the brain Sproadic and hereditary forms Major risk factors for sporadic forms: aging, hypertension, (diabetes) Diagnosis: diffuse white matter abnormalities (hyperintensities) as seen by neuroimaging Lacunar infarcts Faraco and Iadecola, Hypertension, 2013

7 Diagnosis by imaging Lacunar infarct (Diffusion-weighed Image) CSF-containing cavity (FLAIR) White matter hyperintensiy (FLAIR) Enlarged perivascular spaces (T2-weighed imaging) Wardlaw et al., Lancet Neurology,, 2013

8 Pathologic processes Cerebral small vessel disease November The most common for hypertension-related SVD: arteriolosclerosis loss of smooth muscle cells from the tunica media deposits of fibro-hyaline material narrowing of the lumen thickening of the vessel wall fibrinoid necrosis rupture of the vessel microscopic hemorrhages or large hemorrhages (in basal ganglia or thalamus capillary rarefaction lesions in the periventricular white matter

9 Lipoyalinosis Microaneurysm Microatheroma Fibrinoid necrosis Pantoni, Lancet Neurology, 2013

10 Microvascular wall pathology Cerebral small vessel disease November (Farkas et al., Acta Neuropath, 2006)

11 Cerebral microhemorrhages Caused by structural microvscular abnormalities Tiny deposits of blood degradation products (i.e. hemosiderin) within macrophages in the close proximity of structurally abnormal vessels Detection by MRI

12 Cerebral microhemorrhages Cerebral small vessel disease November Martinez-Ramirez et al., Alzheimer's Research & Therapy, 2014

13 Cerebral microhemorrhages hypertension, aging and oxidative stress Tóth et al., Aging Cell, 2015

14 CADASIL: a specific type of SVD Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy The most common heritable cause of stroke and vascular dementia in adults (an autosomal dominant disease) Unrelated to atherosclerosis or hypertensive disease

15 Symptoms of CADASIL with respect to diagnostic criteria Chabirat et al., Lancet Neurlogy, 2009

Diagnosis and neuropathology of CADASIL Lacunar (subcortical) infarcts Macroscopy MRI Multiple, small infarctions or hemorrhages in white or

16 Diagnosis and neuropathology of CADASIL Lacunar (subcortical) infarcts Macroscopy MRI Multiple, small infarctions or hemorrhages in white or deep gray matter Histology: non-atherosclrotic, nonamyloid angiopathy: enlargement of perivascular spaces Chabirat et al., Lancet Neurlogy, 2009

17 Diagnosis and neuropathology of CADASIL Leucoencephalopathy blogspot.com/ Chabirat et al., Lancet Neurlogy, 2009

18 Diagnosis and neuropathology of CADASIL Arteriopathy: small penetrating and leptomeningeal arteries Wall thickening Lumen stenosis Osmiophilic granular depositions in media (and adventitia) SMC degeneration Chabirat et al., Lancet Neurlogy, 2009

19 CADASIL - a heritable disease: mutations in Notch3 gene on chromosome 19 NOTCH3: A receptor predominantly expressed in vascular smooth muscle cells and pericytes Critical role in the maturation and function of small vessels of the brain Chabirat et al., Lancet Neurlogy, 2009

20 CADASIL - a heritable disease: mutations in Notch3 gene on chromosome 19 Mutated NOTCH3 extracellular domain accumulates and forms microscopic aggregates around SMC Chabirat et al., Lancet Neurlogy, 2009

21 CADASIL - a heritable disease: mutations in Notch3 gene on chromosome 19 Genetic testing is the gold standard for the diagnosis of CADASIL Genetic testing is indicated if the patient has a characteristic clinical syndrome in combination with characteristic neuroimaging features or a positive family history, particularly if there is no history of hypertension

23 Examination: Written Multiple choice test Time: December 7, 16 p.m. Place: Lecture hall of the Department of Ophthalmology ( Eye Clinic )

CRITERIA FOR AD DEMENTIA June 11, 2010

CRITERIA FOR AD DEMENTIA June 11, 2010 CRITERIA F AD DEMENTIA June 11, 2010 Alzheimer s Disease Dementia Workgroup Guy McKhann, Johns Hopkins University (Chair) Bradley Hyman, Massachusetts General Hospital Clifford Jack, Mayo Clinic Rochester