The Evolving Role of Cardiac and Carotid Ultrasound in the Assessment of Cerebral Small Vessel Disease: A Contemporary Review

Abstract

Cerebral small vessel disease (CSVD) is a significant contributor to vascular cognitive impairment, stroke, and functional decline in the aging population. Although brain MRI remains the diagnostic gold standard, its limitations in accessibility and early detection have necessitated the search for more widely available, non-invasive screening tools. This review synthesizes current evidence regarding the evolving role of cardiac and carotid artery ultrasonography in the assessment of CSVD. Echocardiographic parameters—particularly left ventricular concentric hypertrophy, left atrial dysfunction, and impaired diastolic filling—are consistently associated with a higher neuroimaging burden of CSVD and cognitive decline, independent of traditional risk factors. Carotid ultrasound metrics, including increased intima-media thickness, plaque burden, elevated pulsatility and stiffness indices, reduced end-diastolic velocity, and low wall shear stress, similarly correlate with lacunes, white matter hyperintensities, and enlarged perivascular spaces. Emerging evidence supports an integrated “cardiac-carotid-cerebral” hemodynamic axis, wherein dysfunction at the cardiac pump or large artery conduit level propagates microvascular injury. Combined multiparametric ultrasound profiles, enhanced by machine learning algorithms, show promise for early risk stratification and for distinguishing between CSVD etiologies. Future longitudinal studies and the standardization of advanced techniques (e.g., left atrial strain, carotid wall shear stress) are necessary to translate these ultrasound biomarkers into routine clinical practice and to test whether interventions aimed at improving cardiac or carotid function can slow the progression of CSVD.