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Brain vascular disease overt and covert.

Work from the Leukoaraiosis and Disability (LADIS) Study Group1 and from others characterizing brain structure and function in the elderly continue to challenge myopic views of how vascular disease affects the brain. What most often demands attention and consumes resources—patients with symptoms and signs of stroke and transient ischemic attack—represents the easily recognized tip of the iceberg whose larger underwater mass goes largely ignored. More needs to be learned about covert vascular disease that erodes brain structure and function in ways less dramatic than overt disease.

Before sophisticated imaging revealed details of brain structure, symptoms and signs defined brain vascular disease. Postmortem examinations of the brain were limited to a select group of patients but foreshadowed the existence of substantial subclinical vascular disease.2 With the introduction of brain imaging, clinicians could characterize the structure of the brain in patients with acute symptoms and signs. Those with symptomatic brain vascular disease were often found on brain imaging to …