Dr. Keith Roach

DEAR DR. ROACH: A recent fall split the skin below my left eye. I went to the emergency room to see if it required stitches. Since I complained of a headache in the back of my head on the left side, they ordered an MRI, which showed “atherosclerotic vascular disease with mild small vessel ischemic disease.” They also saw plaque within my internal carotid arteries.
The ER doctors said I should see a vascular specialist soon. Of course, I am scared. I am a 76-year-old woman on Bystolic, rosuvastatin, benazepril and thyroid replacement. I also take sulfasalazine for my inflammatory arthritis. I am thin, take many vitamins and supplements, and exercise four times a week. Does the MRI mean I have dementia or Alzheimer’s? What does it mean? — R.M.
ANSWER: No, the MRI cannot make a diagnosis of dementia. Dementia is diagnosed presumptively by a clinical exam that notes impairments in cognitive functioning, such as memory, language and attention. (A definitive diagnosis of Alzheimer’s is made by a pathological evaluation of brain tissue, which is almost never obtained while a person is alive.)
What the MRI shows is a disease of the blood vessels of the brain caused by cholesterol plaque. High blood pressure, smoking, high blood cholesterol, family history, and other factors put people at risk for this condition. Some, but not all, people with the kinds of blood vessel disease you have will develop dementia, which is caused by cumulative damage to the brain tissue by multiple small strokes. In your case, both the large vessels (carotids) and small vessels are affected, suggesting that your cholesterol and blood pressure haven’t been ideal.
Your doctor has already taken some steps to slow or prevent the worsening of this condition. Careful control of your blood pressure (with Bystolic and benazepril) is essential. A statin drug (rosuvastatin) has been shown to reduce stroke risk and your overall dementia risk. I don’t know whether these are the best medicines for you or whether they are at the right doses, since only your doctor knows you well enough, but it is clear that your doctor is taking steps to protect your heart and brain.
Inflammatory arthritis (especially rheumatoid arthritis and lupus) increases the risk of blood vessel damage in the brain and heart, so early treatment is more important with people who have these conditions. Unfortunately, not all primary care doctors know how important inflammatory arthritis is when it comes to heart attack and stroke risk.
I do not believe there are any supplements or vitamins that are both safe and effective at preventing stroke overall, but there are a handful of people who may benefit from them. For example, people with high homocysteine in their blood may benefit from vitamins B12, folic acid, or their methylated counterparts.
A careful review of your overall health condition and diet is critical. You may be referred to a specialist for cognitive testing if there is any evidence of a change in your thinking ability. A few blood tests will help further stratify your risk and may show a need for additional treatment.
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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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