The American Heart Association/American Stroke Association has issued a scientific statement on the prevention of stroke in patients with silent cerebrovascular disease. The statement discusses clinical considerations and offers suggestions for future research on stroke prevention in patients with 3 cardinal manifestations of silent cerebrovascular disease: silent brain infarcts, magnetic resonance imaging white matter hyperintensities (WMH) of presumed vascular origin, and cerebral microbleeds. Among the suggestions for clinical care of patients with silent cerebrovascular disease:

Diagnosis by neuroimaging:

• MRI has greater sensitivity than CT for diagnosis of silent cerebrovascular disease.

Investigations for patients with silent cerebrovascular disease:

• Assess common vascular risk factors and assess pulse for atrial fibrillation.
• Consider carotid imaging when there is silent brain infarction in the carotid territory.
• Consider echocardiography when there is an embolic-appearing pattern of silent infarction.
• Consider noninvasive CT or MR angiography when there are large (>1.0 cm) silent hemorrhages.

Prevention of stroke in patients with silent brain infarcts:

• Take a careful history to determine whether the infarction was symptomatic.
• Implement preventive care recommended by AHA/ASA guidelines for primary prevention of ischemic stroke.

Prevention of stroke in patients with WMHs of presumed vascular origin:

• Implement preventive care recommended by AHA/ASA guidelines for primary prevention of ischemic stroke.
• It is not clear whether WMH alone, in the absence of other risk factors, is a sufficient reason for aspirin therapy.

Anticoagulation and other therapies in patients with silent microbleeds:

• Silent microbleeds are not a contraindication for anticoagulation when there is an indication (eg, AF).
• When anticoagulation is needed, a novel oral anticoagulant is preferred over warfarin.
• Percutaneous closure of the left atrial appendage could be considered as an alternative to anticoagulation.
• It is reasonable to provide antiplatelet therapy to patients with microbleeds when there is an indication.

Safety of acute ischemic stroke therapy in patients with silent microbleeds:

• It is reasonable to administer intravenous alteplase to patients with acute ischemic stroke and evidence of microbleeds if it is otherwise indicated.
• It is reasonable to perform endovascular thrombectomy in patients with acute ischemic stroke and evidence of microbleeds.

Population screening:

• Screening the asymptomatic general population with MRI to detect silent cerebrovascular disease is not justified by current evidence.