Cerebral small vessel disease Dr. Eszter Farkas November 30, 2016
Vascular dementia Vascular cognitive impairment Multi-infarct dementia Binswanger disease Subcortical vascular dementia CADASIL
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)
Cerebral small vessel disease Vascular dementia (Vascular cognitive impairment) Subcortical vascular dementia Sporadic (e.g. Binswanger) Hereditary (e.g. CADASIL) Multi-infarct dementia (cortical)
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 sporadic forms: aging, hypertension, (diabetes) Diagnosis: diffuse white matter abnormalities (hyperintensities) as seen by neuroimaging Lacunar infarcts Faraco and Iadecola, Hypertension, 2013
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
Pathologic processes Cerebral small vessel disease November 30 2016 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
Lipoyalinosis Microaneurysm Microatheroma Fibrinoid necrosis Pantoni, Lancet Neurology, 2013
Microvascular wall pathology Cerebral small vessel disease November 30 2016 (Farkas et al., Acta Neuropath, 2006)
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
Cerebral microhemorrhages Cerebral small vessel disease November 30 2016 Martinez-Ramirez et al., Alzheimer's Research & Therapy, 2014
Cerebral microhemorrhages hypertension, aging and oxidative stress Tóth et al., Aging Cell, 2015
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
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 deep gray matter Histology: non-atherosclrotic, nonamyloid angiopathy: enlargement of perivascular spaces Chabirat et al., Lancet Neurlogy, 2009
Diagnosis and neuropathology of CADASIL Leucoencephalopathy http://multiple-sclerosis-research. blogspot.com/ http://www.neuroradiologycases.com/ Chabirat et al., Lancet Neurlogy, 2009
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
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
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
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
Examination: Written Multiple choice test Time: December 7, 16 p.m. Place: Lecture hall of the Department of Ophthalmology ( Eye Clinic )