silent strokes - causes and how to avoid

I am a 41 year old female with a history of hard to control hypertension (currently on four meds for this).  I also have type II diabetes, although it is under control with metformin.  

I have recently been diagnosed with silent strokes, according to an MRI.  There appear to be about 5-6 white matter lesions that the neurologist believes is related to this. A VEP was normal.  He also dx me with complicated migraines and periphreal neuropathy (balance problems).  Here are my questions:

1) Can they tell, from the MRI, how old the silent strokes are?

2) How low does my BP need to be in order to avoid future silent strokes?

3) My BP does not run sky high, but marginally high.  Could this cause silent strokes?  

4) Does the brain "recover" from silent strokes? Will the white matter lesions go away?

5) Aren't I quite young to have had this number of silent strokes?  What should I expect in the future?  

6) I have had some episodes of mental confusion and my cognitive abilities seem to be a bit diminished (my typing speed and accuracy have dropped, for example). Could this be from the silent strokes? Can this come and go, or will it only get worse?

7) The doctor put me on 325 mg of aspirin to avoid future silent strokes. The aspirin causes great problems with already heavy menstrual periods.  Are there any other ways to help avoid future silent strokes?

8)In the future, when I fill out medical forms, do I indicate that I have had a stroke?  Or not?  Are silent strokes considered actual strokes?

Thank you very much for your time,
Ramona

[CCF-Neuro-M.D.-JT]

It's extremely difficult to comment on an MRI that I have never seen personally.  But I'm guessing that these lesions represent "small vessel ischemic disease" which appear on MRI as nonspecific white matter abnormalities seen in the brain. Well what does this all mean? Usually when we see something like that, it typically means that very very tiny blood vessels in the brain get clogged up due to atherosclerotic risk factors such as diabetes and high blood pressure. The very tiny area of brain that these blood vessels supply then loses oxygen and nutrients and is "infarcted" or damaged.  Many times, these little areas of brain damage (permanent) are in silent parts of the brain and don't cause any clinical changes, meaning you remain asymptomatic. It's a matter of semantics.  Technically, these areas do represent parts of the brain that did not get adequate blood supply and "stroked out".  But I would NOT count this as a real stroke.


1.Roughly yes.  If they appear to be cavitations or little holes, then these are probably very old (years).
2.Short answer: AHA recommends under 140/90.  Long answer:But it's very tricky if you have already have clogged arteries in your neck or brain which would lead to compensatory high blood pressure to adequately push through the clog and supply the brain. Have to talk to our doc about this.
3.yes as does the diabetes which is a big risk factor.
4.no
5.yes, but you're also young to have hypertension and diabetes which probably led to it.  If you can control these risk factors, then theoretically you should remain stable.
6.If there is a significant number of "silent strokes" that start to become confluent (or mesh together due to increased size of damaged tissue) then cognitive issues may become a problem.  BUt with just a few areas, it's hard to say. Without personally examining you, it's difficult to say what this could be from.
7.Diet and exercise as well as controlling your other risk factors.  Tell your docs about the problem with your periods.  A baby aspirin may be better for you.
8.NO, see above.
Good luck.