Imaging biomarkers of vascular cognitive impairment: Lessons from structural progression in cerebral small vessel disease

The study by Lu et al. highlights progressive structural changes in cerebral small vessel disease, spanning subcortical vascular mild cognitive impairment to vascular dementia. Using voxel-based morphometry, diffusion tensor imaging, and fixel-based analysis, the authors demonstrate converging gray and white matter alterations associated with both cognitive and motor decline. This commentary discusses the significance of their multimodal approach, its clinical implications for early diagnosis and disease monitoring, and the methodological challenges of generalizability and mixed pathology. We situate these findings within the broader literature on vascular cognitive impairment and emphasize directions for biomarker-driven translational research.