Tuesday, January 22, 2008

Small vessel disease

Large vessels check out with drama--devastating strokes where one side is paralyzed, a big heart attack, an aortic aneurysm, a gangrenous foot. Small vessel disease is insidious, and, once established, also devastating in a progressive sort of way.

Some years ago, my sixty-something year old patient with difficult-to-control hypertension was noted to have 'hypertensive retinopathy.' In other words, when her retina was visualized through dilated pupils by her opthamologist, the small vessels visible therein were noted to be thickened and narrowed (an appearance likened to copper wire), the arterioles smashed the little veins when their paths crossed (AV nicking), and 'cotton wool spots' denoted areas of inadequate blood flow.

The small blood vessels of the retina, which are the only small vessels that can be directly visualized during a physical exam, are quite similar to those of the brain. If you've got retinopathy, indicating that the blood supply to the back of the eye has been adversely affected by elevated blood pressure, your risk of similar troubles in the little blood vessels that supply the white matter of your brain is raised as well. In persons with similar risk factors for stroke such as hypertension, cigarette smoking, and elevated cholesterol, those with retinopathy are at 2-4 times greater risk for stroke than those without.

Dang if this patient did not go on to have an ischemic stroke* about five years after her retinopathy was found. An MRI done at the time of her stroke revealed extensive white matter disease. These little 'bright spots' noted on MRI deep within the brain are not bright spots for the brain at all, but rather represent areas with inadequate blood akin to the cotton wool spots seen in retinopathy. Cotton wool in the eyes and bright spots in the brain are dim prognostic signs for one's future health--in the Atherosclerosis Risk in Communities study, the five-year relative risk of stroke among subjects with both findings was 18 times greater than in participants with neither one.

The risk factors underlying such small vessel disease are aging, smoking, hypertension, diabetes and elevated cholesterol. This lady aged, she smoked, and her blood pressure was hard to control (multiple medications made her dizzy and prone to falling).

Yesterday, I got lab work back on another patient. Her estimated glomerular filtration rate or EGFR*** had fallen compared with the value from a year ago. She had an MRI done a year ago for an unrelated problem and was noted to have white matter disease. She's just my age (not so aged!), a non-smoker, her blood pressure is perfect on meds, and her cholesterol and blood sugar are fine. A newly published study in the journal Stroke** correlates decreasing kidney function with cerebral small vessel disease, supporting a link between vascular disease in the kidney with the same in the brain. She's off to a neurologist to see if she's a candidate for preventive blood thinners.
_____
*An ischemic stroke is caused by an interruption of blood flow whereas a hemorrhagic stroke is caused by a ruptured blood vessel in the brain.
**Ikram, MA, et al. Stroke. 2008; 39:55-61.
***For an explanation of EGFR, see EGFR.

27 comments:

Laura in L.A. said...

You've given me even more to think about! Small vessel disease! It was disconcerting to read about the younger patient in good health who didn't smoke who had it. That could be me in a few years--I'm 42.

Thank you for putting it all into words that are easy to understand.

JeanMac said...

Excellent post again - and it reminded me to call to book eye exams. His BP is medication controlled now.

Mauigirl said...

Great, another thing to worry about! I'm on blood pressure medication which controls my blood pressure nicely. But it sounds as if that may not be enough!

Anonymous said...

I am 51 w/ small vessel disease, I have had multiple strokes...lost a lucretive job..about to looose my home...I'm scared!

Femail doc said...

I guess no one gives small vessel disease much thought, perhaps few even know about it.

Anonymous: I'm so sorry that you are struggling with this; I will keep you in my thoughts and prayers.

Anonymous said...

"Anonymous said...
I am 51 w/ small vessel disease"

I know this isn't any help, but you aren't alone. I'm a year younger than you. Along with small vessel disease I've got Trigeminal neuralgia and a seizure disorder. Hang in there! Those that you least expect to help may come through to help. My prayers are with you and all.

Anonymous said...

Please explain the difference in small vessel disease of the subcortical white matter of brain and multi infarct dementia. Where does binswangers(spelling?) fit in here. Thanks Hannah

femail doc said...

Hi Hannah: These are all the same things.

Anonymous said...

I have a problem. My husband has been dealing with an illness for 4 years and finally the doctors admitted it was small vessel disease. His blood pressure is for the most part good as well as his blood sugar and cholesteral. The problem I am having is finding a doctor that will treat him. No one seems to want to bother with him and when he does see a doctor, they look at him and say "I have nothing new for you." What am I to do? I am desperate for help.

femail doc said...

Dear Anon, I appreciate how frustrating this is for you. My understanding, however, is that other than blood pressure, blood sugar, and cholesterol control, there aren't any proven therapies for small vessel disease. I just checked PubMed on the latest research on using antiplatelet therapy (such as Plavix or Aggrenox) in this case and found nothing. I have been down this same road with my mom and some of my patients. I wish I had some good ideas for you.

Anonymous said...

I'm 63 years old and have suffered with severe headaches since 1988. Last month I had a MRI/MRA and discovered I have mild small vessel disease of the brain. For treatment the Dr put me on a variety of vitamins, minerals and antioxidents. In the past, weather changes had always triggered these headaches. This week we had several days of severe weather and I had only mild headaches. Don't know if these vitamins, etc are the reason but this is the best I have felt in years. My Mother has Alzheimers so some of the articles I read have had me worried, also. Anyone had any experience with vitamin treatments?
Concerned 63 year old

Karen Day-Lyon said...

I know that this is three years "after the fact" of the publishing date, but I am a 59 year old female health care professional (RN), just diagnosed with small vessel disease resulting from metabolic syndrome, primary hypercoagulability syndrome,multiple vitamin deficiencies (B12, D, Folate, B6) and hypertension that remains uncontrolled on massive doses of meds. My mother had severe multiple infarct dementia when she died in 2006 at the age of 84, and I am having cognitive deficits already, and there is concern on my part and that of my neurologist as to whether or not I remain safe to continue working in my profession. This is enough to make me a little antsy. Anything new on this since the post was originally written?

femail doc said...

Hi Karen,

How worrisome-my mother also had multi-stroke dementia and died at age 88. The very day you commented here, I was discussing MRI results with a woman in her late 70's distraught due to increasing lapses, the latest at church where she remained standing when the rest of the choir sat down. Her MRI showed white matter disease.

I'm sorry to say that I have no wise words to add. I hope you can find a good way to control your blood pressure. Dr. Larry McCleary has interesting suggestions of supplements in his book "The Brain Trust Program." Perhaps you've already looked into some of these compounds.

Best wishes,
Judy

Anonymous said...

I see everyone's post on here and their age. Well, I'm 36 years old and was diagnosed with Small Vessel Disease last August. It's really scarey being this young and not knowing what the future holds for me. I am on bp medication along with a blood thinner and medication for the headaches. I also have 2 children. I lost my mom at 17 and worry every single day if I will be here for them.

Beth said...

Hello, I'm 45 and was diagnosed with CSVD about 3 yrs ago due to me insisting something was wrong. I was falling a lot and was scared of having MS. The neurologist told me it was CSMD and that I had several plaque deposits in my brain, equivalent to someone in their 70's, but he didn't say anything else, so I assumed it was not a big deal. I go through periods where my mind is foggy or slow, and I fall often. It's as if I'm moving in slow motion when I fall but I can't seem to get my body to react to catch myself or regain my balance. Recently I'm having a hard time remembering words, forgetting what I'm talking about, and sometimes whatever I'm reading looks like a foreign language, nothing makes sense that I'm reading. Other days I feel more alert and can concentrate, it's so odd. I recently switched family doctors and she did some cognitive tests and said I need to see my neurologist again and have further cognitive testing. I am terrified of losing my mind at such a young age. My son doesn't seem to think what I have is a big deal. Am I over reacting? Is this disease common in younger people diagnosed at 42, like myself? Please please give me some answers, now I'm getting very scared! TIA.

Beth said...

Sorry, I meant CSVD, not CSMD.

Beth said...

Anonymous, I thought I was young, bless your heart you are way to young for this. I'm so sorry. I am also on meds for migraines, aspirin, lipitor, and 2 depression meds, with a mood stabilizer. I'm curious, is depression part of CSVD, does anyone know? Also, what about mood disorders? Is there any connection?

augusta-louise said...

do you think that the cure may be within stem-cell research? My father has the disease 2005 following a series of small strokes and we like others are desperate for a cure and some hope...

Anonymous said...

Hi, I am 34 yrs. old and just been diagnosed with mild small vessel disease. the only information I am finding are for people 50-80 yrs. old. I haven't seen my neurologist yet and am really scared. I am a single mom with three boys. Should I be writing a will? I have a great job, but am finding it harder and harder to function. Feel like my days are numbered cuz not only am I going thru this, but I am having brain seizures as well. Am I a rare case? Can anyone around my age relate or help with any information on how I am suppose to live with this? Doctor info and meds are on thing, just trying to find out how many cases are like mine and how u cope.. Thanks!

Anonymous said...

I am 48 have never had high blood pressure my tri glycerates are little high doctor has put me on lipitor but my symptems seem to be getting worse having bad memory loss seems to be worse at night. I am very physically fit and the doctor does not seem to know why i have small vessel disease all the large vessels are perfect. The nuerologist has said my condition is serious how long does it take usually for things to get real bad and any suggestions?

Anonymous said...

I am 56 yrs old and beleive I had small vessel disease long before they discovered it. My entire familt seems to have it and it has been a long battle to get some answers but in my case they believe it is related to Rheumatic Heart Disease which can cause a whole host of illness if not properly diagnosed. My family wasn't diagnosed. I had a cervical fusion and got a staph infection that went untreated and they believe the staph infection is what caused the diseased vessels.It went undiagnosed for so long that it has destroyed all the arteries and affected every organ system. In my case treating it with antibiotics has helped some. Maybe a consult with infectious disease would be beneficial.

Anonymous said...

I'm 40 had a strange experience a couple of weeks ago. Now been told it was a mini Tia been put on a high dose of asprin they also found high blood pressure so on tablets for that now as well. Had a MRI the found white vessel matter disease. Doctor said normally see this on a 70 year olds brain. My gran had vascular dementia and Alzheimers should I be worried im also having problems with my muscles aching and feeling tight. X

Anonymous said...

hi just been given diagnosis of svd worried for future I work full time and care for my husband

Kate said...

70 yrs old , hemorratic stroke 10yrs ago, dizzy, balance walking problems diagnoses with small vessell disease and cerebral atrophy. Blood press (high) under control with meds, diabetic taking metformin. worry been having small time lapses and starting again with headache. Question is doctor does not seem concerned, check up every 3 months. worry how fast it is progressing . Memory is like typical 70 year old but some depression, no motivation (unlike me) and fatigue. Are these normal signs or are they all age related. I walk with a cane. Thank you

denverdoc said...

To all of you who have stopped here and left comments, I wish I had great answers for you. Some of you report the usual risk factors such as diabetes, hypertension, and high cholesterol, one 'anonymous' reported a history of rheumatic heart disease, spine surgery and a staph infection. Anything that causes inflammation such as rheumatic heart disease, chronic joint degeneration as in arthritis leading to a need for surgery, and chronic infections including gum disease can cause damage in both large and small blood vessels. Those of you who have developed small vessel disease in your 30s or 40s must be so stressed and distressed to be up against this problem without reasonable solutions.

Kate, you mention depression and 'no motivation' which is also a symptom of depression. Interestingly, stress and depression are also risk factors of vascular disease. This could become a vicious circle where having small vessel disease is depressing and the chemicals the body produces when depressed lead to further progression of the disease.

I too worry about small vessel disease as my mother, her two siblings, and her father all checked out with the piecemeal loss of function associated with the mini-strokes accompanying this condition. There is interesting research on beta-blockers as good preventive medicine for dementia as well as cancer (see my August 25, 2013 post for more info on the latter). Don't forget exercise for blood vessel health.

I appreciate everyone who's stopped by to comment!

Judy Paley aka Denver Doc

Anonymous said...

i have just been diagnosed with svd,also psoratic arthritis are they connected do you think

denverdoc said...

Unfortunately, anything that causes inflammation in the body such as psoriatic arthritis (or gum disease, smoking, trans fats, diabetes, central obesity, etc) increases risk of blood vessel troubles.