Gillian Gordon Perue MBBS; DM

Klarenbeek P, VanOostenbrugge RJ, Rouhl RP, Knottnerus IL, Staals J, Ambulatory Blood Pressure in Patients With Lacunar Stroke: AssociationWith Total MRI Burden of Cerebral Small Vessel Disease. Stroke. 2013

Studies that evaluate the association between cerebral small vessel disease (cSVD) and preclinical MRI biomarkers such as asymptomatic lacunar stroke, white matter disease, enlarged perivascular spaces, and cerebral microbleeds  often examine each biomarker in isolation. However, I am sure we have all seen several of these biomarkers occuring in one patient.  

In a recent article in Stroke Klarenbeek etal introduce a new pragmatic ordinal scale that quantifies the total burden of cSVD on MRI.  In this scale, one point is assigned to the presence of each of the preclinical biomarkers. The scale ranged from  zero to four (0-4)points. Then in a cross sectional study of first ever lacunar strokes, 24 hour ambulatory blood pressures were recorded and follow up MRI scan ( 1.5 or 3T) done to assess total burden of cSVD. In an ordinal regression analysis, the association between daytime and nighttime mean blood pressures and the total burden of cSVD were explored.

Among 122 patients, eighteen (15%) had no biomarkers of cSVD, twenty-four (20%) had one, the majority (n= 45;  37%) had two biomarkers and only six patients (5%) had all four biomarkers. Consistent with the known literature, higher mean ambulatory blood pressure levels were associated with increasing total burden of cSVD after adjusting for age and sex. However there was no clear trend in the appearance of each biomarker in relation to levels of hypertension and any combination of one or more biomarkers was seen to occur.
This article is important as it begins to unify in one scale all known preclinical markers of cSVD and suggests a research standard for validation and use in future research trials. It would be quite interesting  to follow these patients longitudinally and determine whether patients with night time dips in blood pressure (so called dippers vs. non dippers) had a difference in total MRI burden of cSVD. What effect, if any, does antihypetensive treatment have on the burden of cSVD? While the results of this article is not likely to change my current clinical practice, this cohort is definitely one to watch.