Cerebral Small Vessel Disease Burden in Saudi Arabia: Epidemiology, Risk Determinants, and Neuroimaging Characteristics

Background: Cerebral small vessel disease (CSVD) is a major contributor to stroke, cognitive impairment, and gait disturbance. Data describing its burden and determinants in Middle Eastern populations remain limited. This study aimed to estimate the prevalence, clinical predictors, and neuroimaging characteristics of CSVD among adults undergoing brain MRI in Saudi Arabia and to examine associations with vascular risk factors and antihypertensive therapy. Methods: We conducted a retrospective cross-sectional study of adults aged 40– 70 years who underwent brain MRI at King Abdulaziz Medical City, Riyadh, between January 2018 and January 2019. CSVD markers were identified according to the STandards for ReportIng Vascular changes on nEuroimaging (STRIVE) criteria, and white matter hyperintensities were graded using the Fazekas scale. Multivariable logistic regression models were constructed to identify factors independently associated with CSVD. Results: Among 644 participants undergoing brain MRI, CSVD was identified in 36.5% of patients. Prevalence increased markedly with age, rising from 18.2% in individuals aged 40– 50 years to 54.1% in those aged 60– 70 years (p < 0.001). In the multivariable etiological model, hypertension emerged as the strongest independent vascular predictor of CSVD. White matter hyperintensities were the most frequent imaging manifestation and increased in severity with advancing age. Among hypertensive patients, certain antihypertensive classes, particularly calcium channel blockers and ACE inhibitor/ARB monotherapy, were associated with lower odds of CSVD compared with untreated hypertension. Conclusion: In this MRI-based clinical cohort from Saudi Arabia, CSVD was present in more than one-third of adults aged 40– 70 years undergoing neuroimaging. Disease prevalence increased substantially with advancing age and vascular comorbidities. These findings highlight the importance of vascular risk factor control and provide important regional data on the clinical and imaging profile of CSVD in Middle Eastern populations. Keywords: cerebral small vessel disease, lacunar infarction, white matter hyperintensities, diabetes mellitus, hypertension, stroke prevention, Saudi Arabia