Magnetic resonance imaging in cerebral small vessel disease and its use as a surrogate disease marker

Cerebral small vessel disease is an important cause of vascular cognitive impairment and dementia. On brain imaging, discrete lacunar infarcts and/or more diffuse regions of white matter hyperintensities or leucoaraiosis are seen. Magnetic resonance imaging plays a crucial role in diagnosis, and advanced magnetic resonance imaging techniques are providing new information on disease mechanisms and offering potential as surrogate disease markers. Longitudinal studies have demonstrated detectable progression of lesion load over short time periods, and weak correlations with cognition. Stronger correlations with cognition have been found with diffusion tensor imaging, which is more sensitive to white matter tract structure, supporting a role for disconnection in the pathogenesis of cognitive impairment. Brain volume also consistently correlates with cognition in asymptomatic small vessel disease, sporadic small vessel disease, and Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy. Gradient echo magnetic resonance imaging identifies microbleeds in a significant proportion of patients with small vessel disease, although their role in clinical management remains to be determined. Surrogate markers to monitor disease progression and evaluate new therapies would have major clinical use. The greater sensitivity of diffusion tensor imaging parameters and brain volume to change, and the stronger correlation of these parameters with cognition, suggest that they may be more powerful surrogates. However, data from longitudinal and intervention studies are required to determine if this is indeed the case. In this systematic review, we describe the use of both conventional and advanced magnetic resonance imaging techniques in patient groups with the full spectrum of clinical small vessel disease, from normal populations with WMH to patients groups with lacunar stroke and dementia.