Objective: To characterize the relationship between composite cerebral small vessel disease (CSVD) burden and motor phenotype severity across a clinically heterogeneous cohort of patients with parkinsonian syndromes.

Background: Vascular contributions to parkinsonism have gained substantial mechanistic attention, yet their phenotypic consequences remain inadequately quantified. Cerebral small vessel disease disrupts the structural integrity of basal ganglia–thalamocortical circuitry, plausibly conferring selective vulnerability to axial motor dysfunction — particularly postural instability and gait impairment. Elucidating these associations may refine prognostic stratification and identify modifiable disease contributors.

Method: study was conducted at a tertiary neurology referral center, enrolling 118 patients with clinically established parkinsonian syndromes who underwent brain MRI between 2021 and 2025. CSVD burden was quantified using a composite neuroimaging score incorporating white matter hyperintensity load (Fazekas scale), lacunar infarct count, and cerebral microbleed burden. Motor severity was evaluated using the Unified Parkinson’s Disease Rating Scale Part III (UPDRS-III), with phenotypic classification into tremor-dominant (TD) and postural instability/gait disorder (PIGD) subtypes. Multivariable linear regression models examined associations between CSVD burden and motor outcomes, adjusting for age, disease duration, and cumulative vascular risk factor load.

Results: Elevated CSVD burden independently predicted greater motor impairment across the cohort (β = 0.34, p < 0.01). PIGD-phenotype patients exhibited significantly higher composite CSVD scores relative to their TD counterparts (2.6 ± 1.1 vs. 1.5 ± 0.8; p < 0.001). Among individual CSVD components, white matter hyperintensity volume demonstrated the strongest and most spatially specific association with gait disturbance and postural instability subscores.

Conclusion: These findings provide neuroimaging-level support for a vascular contribution to motor circuit disruption and underscore the clinical rationale for proactive vascular risk factor management as a potential disease-modifying strategy in parkinsonism.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/cerebral-small-vessel-disease-burden-and-motor-phenotype-expression-in-parkinsonian-syndromes-a-quantitative-neuroimaging-analysis/