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The diagnosis of cerebrovascular disease has changed dramatically over the past several decades with the introduction of CT and MRI. These technologies have made it apparent that “silent” cerebral infarction (i.e., without an associated history of TIA or stroke) is more prevalent than clinically symptomatic infarction. Between 8% and 20% of people 50–75 years of age have such findings.1 In the Cardiovascular Health Study (CHS), an ongoing epidemiologic study of cardiovascular risk factors in the elderly, 28% of seniors, average age 75 years, had “silent” infarcts on MRI scanning,2 and ∼18% of those without baseline silent strokes on MRI had new “silent” infarcts on a 5-year follow-up MRI.3 Several studies have shown that these “silent” infarcts are not benign. In the Rotterdam study, a longitudinal study of 1,000 healthy elderly between ages 60 and 90 years who were followed for 4 years, participants with baseline “silent” infarcts (≥3 mm) had more rapid cognitive decline than those without infarcts, with twice the risk of incident dementia.4 In the CHS study, approximately 87% of silent infarcts on follow-up MRI were 3–20 mm, of which 20% were ≤5 mm. This subgroup demonstrated higher levels of …
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