ISC 2026 | Should incidentally discovered covert brain infarcts be treated with aspirin and statins?

Eric Smith

I’m Eric Smith. I’m a Professor of neurology and the Katthy Taylor Chair in Vascular Dementia at the University of Calgary, and it was my pleasure to debate Dr Joanna Wardlaw about whether we should use aspirin and statins in patients with incidentally discovered covert brain infarcts.

Joanna Wardlaw

So I’m Joanna Wardlaw. I’m based at the University of Edinburgh. I’m a neuroradiologist and this is a topic of major interest and importance because there are many people with what we call covert brain infarcts where they have had a scan for some other reason and either a cortical infarct or a subcortical infarct or other forms of vascular disease show up on the scan and then there’s a big question of what do we do?

Eric Smith

And it was my role to propose that, yes, we should take action to start aspirin and statins. And a pre-poll at the beginning of the debate indicated that most of the audience felt it was obvious that we should use statins for covert brain infarcts. But after our discussion, I think the audience got a much more nuanced view, including areas of consensus, but also areas where there are gaps in knowledge.

Joanna Wardlaw

Yeah, because I think the point is that these are not a single entity. You know, what we call silent infarcts could be a cortical type of stroke, which are commonly due to underlying cardioembolism or atheroma, for which, certainly in the form of cardioembolism, treatment of atrial fibrillation is a well-established primary prevention. But when it comes to using aspirin to treat atheromatous ischemic stroke, which is asymptomatic, then you’re really talking about about primary prevention and the guidelines in general say that although this might seem like a sensible thing to do actually there’s an increased risk of hemorrhage and so currently most of the guidelines don’t recommend routine use of aspirin. The other problem is that the cortical strokes are probably a smaller part of the burden of silent infarcts and the big part is actually more about what we call small vessel disease so small subcortical infarcts, lacunes, white matter hyperintensities and there’s quite a lot of evidence that those are a different pathology you know they’re not necessarily cardioembolism they’re probably not just atheroma. And again, these guidelines indicate that it’s not a good idea because they probably have a higher risk of bleeding. So, I mean, Eric, you’ve been involved in writing guidelines and looking at the data really closely. We don’t have any direct trials in people who’ve been found to have large amounts of white matter disease. But we do have large trials in older people where we know that they have a lot of white matter disease. We just don’t know precisely which of the people in those trials had a lot of white matter disease. And it’s those trials that show this increased hazard without much benefit. So maybe what we need is a trial specifically in people who do have a lot of white matter disease or a lot of lacunes or small subcortical infarcts you know identified carefully as such and then it would be clearer with such a trial as to whether there is a marginal benefit or actually it’s mostly harm, I mean, you know, this is a problem every day in clinics.

Eric Smith

Yeah, absolutely. And in many jurisdictions, patients can view their own radiology reports or the coming to neurologist asking about this. And so it is a big problem. And you’re right, we both agree the evidence base currently is very low. And I’ll point our listeners to the European Stroke Organization guidelines, which are the most comprehensive guidance on management of cerebral small vessel disease, which counts about 80% of the covert brain infarts. These are small lacunes seen in the brain. And I think we both agreed there are still important questions about how these lacunes originate, the extent they’re even needed by thrombotic occlusion of small vessels and we know from primary prevention trials of aspirin that the benefit in reducing cardiovascular events is modest not significant and there’s a similar increased risk of bleeding so generally not recommended.

Joanna Wardlaw

So it’s not that it isn’t a big problem it’s a huge problem because the sort of back of the envelope calculations suggest that there may be somewhere between I think in this meeting it’s been talked about 400 million and 700 million people globally who have some evidence of, you know, some of these lesions. And quite rightly, when somebody has a scan for another reason and then they get told that they’ve got white matter disease or small infarcts and they think what should I do about this and they look things up on the internet and get very alarmed about it because you know nobody wants to have a stroke nobody wants to get dementia and we know that these features carry an increased risk of both stroke and dementia. So we need to know what to do about them but at the moment we know quite a lot about maybe what’s not a good idea and not so much about what would be a good idea. Maybe another point that came up in the debate was that we need to think more about lifestyle modification and trying to encourage a sort of brain health approach. I mean, that’s a big part of your work, trying to, you know, we’ve all got bad habits and, you know, trying to encourage people to have a more healthy diet and reduce their salt intake and get more exercise and stop smoking.

Eric Smith

Yeah, it’s not just medications, right? It’s all these other changes. Most people can find some aspect of their health to work on and improve. And there’s been limited research on people’s perspective and experience after being informed that they have a covert brain infarct. There’s some degree of concern and alarm and surprise, but many people also feel like, oh, maybe it’s a time to change. So this may be a teachable moment where people are open to counseling on changing their lifestyles for their better vascular health.

Joanna Wardlaw

Yeah, and I mean, it’s not that there aren’t chinks of hope. I mean, we know from other studies that these lesions that we’re talking about, these white matter hyperintensities and so on. While over time in general they get bigger and get worse and this is associated with the higher risk of stroke and cognitive decline, we also know from a number of studies now that they can get smaller over time and that getting smaller is associated with having better mobility, better dexterity, better cognitive function, and you know real tissue changes that can be measured in the brain. So we don’t know why that happens yet we don’t know why some people you know over a period of a year you know that shows some net shrinkage and other people show growth but the fact that they do shrink kind of offers a bit of hope. And it’s also true that we, in general, understand a lot more about the underlying vascular pathology. And there are trials now underway trying to look at alternative interventions. And we’ve been hearing about some of those at this meeting, other ways ways of interfering with the thrombotic system or you know that might not carry the risk of aspirin or you know other drugs which help maintain the health of the blood vessel lining things like that that actually might be very positive

Eric Smith

Yeah absolutely. Another component is that it is very interesting that some of these areas of white matter hypertensity can regress and whether it’s a reduction in inflammation or some sort of repair process you know more basic understanding is needed to try to find druggable targets to maybe aid that process. But you can also enhance what’s called cognitive reserve so if an independent amount of damage to the brain there’s evidence that participating in cognitive stimulating activities including hobbies but also social interactions, increases the synaptic density in the brain, allows the brain to function better despite having a covert infarct or other signs of small vessel disease.

Joanna Wardlaw

The social element of this is hard to underestimate. The importance of maintaining good social interactions, being part of a community, not getting isolated. You know, unfortunately, some of the associations with things like white matter hyperintensities include things like apathy and a tendency to get more depressed. And of course, those are both things which might make people then tend to be more isolated because they don’t want to go out of the house or, you know what I mean they just it sort of puts them off interacting and so ways of trying to encourage engagement. I mean these these non-pharmaceutical interventions may actually turn out in the end to be really really really important and hard to replace with a pill yeah you know no magic bullets.
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