Brain & Nervous System Stroke What Is a Small Vessel Stroke? Also called a subcortical stroke By Heidi Moawad, MD Updated on April 09, 2022 Medically reviewed by Brigid Dwyer, MD Print Table of Contents View All Table of Contents Types and Causes Arteries Affected Brain Structures Affected A small vessel stroke occurs when a small artery that branches off from a large artery in the brain becomes blocked or leaks. This deprives the brain of oxygen and nutrients, which kills brain cells. Since small vessel strokes occur in the subcortical region—an area deep beneath the surface layers of the brain—they are also called subcortical strokes. Even though a subcortical stroke is generally small in terms of the area it affects, it can cause noticeable signs and symptoms, like weakness or numbness on one side of the body. That said, a small vessel stroke is unlikely to cause life-threatening consequences, such as seizures or brain swelling. Read on to learn about how and where small vessel strokes occur, as well as some of their possible symptoms. Hero Images / Getty Images Types and Causes of Small Vessel Strokes There are two main types of small vessel strokes: Small vessel ischemic stroke: When a small artery deep within the brain becomes narrowed or blocked.Small vessel hemorrhagic stroke: When a small artery deep within the brain leaks or bursts open. Both of these result in decreased blood flow to the brain. Brain cells begin to die right away because they cannot receive the oxygen and nutrients they need to survive. This response to the lack of blood flow is called an infarction. High blood pressure (hypertension) is a major risk factor for all small vessel strokes. The elevated blood pressure can damage the walls of the tiny arteries, causing them to narrow or break open. Small vessel ischemic strokes can also occur as a result of atherosclerosis, a condition in which fatty deposits (plaque) clog the arteries. They can also develop from blood clots that travel to the brain from elsewhere in the body. A traveling blood clot is called an embolus. What Arteries Are Affected? Arteries are blood vessels that carry oxygen-rich blood to vital organs throughout the body, including the brain.Small vessel strokes affect small branches of three large arteries—the middle cerebral artery, anterior cerebral artery, and posterior cerebral artery. These small branches are called penetrating, end arteries because they have no branches and stop within the brain tissue. The anterior and posterior cerebral arteries are part of the Circle of Willis, a network of arteries located at the base of your brain. The middle cerebral artery is not part of the Circle of Willis, but it runs close by, branching off from the internal carotid artery, which runs along the side of your neck What Brain Structures Are Affected? Small vessel strokes occur in structures deep within the brain, such as the thalamus, basal ganglia, internal capsule, and brainstem. Anatomy of the Brain Thalamus The thalamus serves as a critical hub area for collecting and integrating sensory signals (e.g., for taste, vision, and hearing) before relaying them to the outermost portion of the brain called the cerebral cortex. Specifically, the right side of the thalamus transmits sensation from the left side of the body, and the left side of the thalamus transmits sensation from the right side of the body. A small vessel thalamic stroke can cause numbness, tingling, or even complete loss of sensation of the face, arm, and leg. The thalamus also plays a key role in relaying motor (movement) signals, regulating emotion and the sleep-wake cycle, and managing various cognitive processes like attention and memory processing. That said, larger vessel thalamic strokes, not small vessel ones, typically cause impairment in one or more of these higher-order functions. Basal Ganglia The basal ganglia is a group of subcortical nerve cells that is highly connected to several brain areas, including the thalamus, brainstem, and cerebral cortex. The basal ganglia contains multiple structures. One, the substantia nigra, is affected in Parkinson's disease. The basal ganglia controls sophisticated functions that require coordination and muscle movements. A small vessel stroke affecting the basal ganglia can cause symptoms such as writhing, twisting movements, muscle twitching, and/or tremor. Internal Capsule The internal capsule is located very deep within the brain. Its white appearance is a result of myelin, a specialized type of fat that covers brain and nerve cells to protect and insulate them, allowing the electrical signals to travel quickly and efficiently. The internal capsule's function is transmitting signals for movement to more inferior structures. As a result, symptoms of a small vessel stroke in this area may include mild weakness, severe weakness, or complete paralysis of the opposite face, arm, and leg. In addition, the internal capsule is involved in carrying nerve signals related to sensation. Numbness on the opposite side of the body may occur with a small vessel stroke in this area. While the internal capsule also transmits visual and language information, these functions are uncommonly affected by small vessel strokes. Brainstem The brainstem connects your brain to your spinal cord and has many roles, such as helping to control your breathing, heartbeat, and blood pressure. It also helps control your eye movements and swallowing. Motor and sensory nerve pathways course through the brainstem as well. Symptoms of a small vessel stroke in the brainstem may include weakness or sensory loss on the side of the body opposite the stroke. Eye movement problems or problems swallowing (dysphagia) may also occur. Summary A small vessel stroke, also called a subcortical stroke, is caused by the blockage or leaking of a small, deeply located branch of a larger artery in the brain. High blood pressure is a major cause of small vessel strokes. Symptoms of these strokes tend to include issues with movement and/or sensation on one side of the body. More complex functions, like language, vision, and cognitive processes, are not usually affected. A Word From Verywell A small vessel stroke is often the first sign of stroke risk factors, like hypertension, diabetes, or high cholesterol. This means that, in addition to recovering from the stroke itself, you will also need to get a medical workup to see why you experienced a stroke. With rehabilitation and risk factor management, you can achieve maximal recovery and prevent additional strokes. 8 Sources Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. Lau KK, Li L, Simoni et al. Long-Term Premorbid Blood Pressure and Cerebral Small Vessel Disease Burden on Imaging in Transient Ischemic Attack and Ischemic Stroke. Stroke. 2018 Sep;49(9):2053-2060. doi:10.1161/STROKEAHA.118.021578 Li Q, Yang Y, Reis C et al. Cerebral Small Vessel Disease. Cell Transplant. 2018 Dec; 27(12): 1711–1722. doi:10.1177/0963689718795148 Fama R, Sullivan EV. Thalamic structures and associated cognitive functions: Relations with age and aging. Neurosci Biobehav Rev. 2015 Jul; 54: 29–37. doi:10.1016/j.neubiorev.2015.03.008 Chen XY, Wang Q, Wang X, Wong KS. Clinical Features of Thalamic Stroke. Curr Treat Options Neuro. 2017 Feb;19(2):5. doi:10.1007/s11940-017-0441-x Bansil S, Prakash N, Kaye J. Movement Disorders after Stroke in Adults: A Review. Tremor Other Hyperkinet Mov (N Y). 2012; 2: tre-02-42-195-1. doi:10.7916/D86W98TB Stanford Medicine. Internal Capsular Stroke. 2021. Alshahrani AM. Horizontal Gaze Defect as a Result of Subcortical Stroke: Case Report and Review of the Literature. Case Rep Neurol. 2021 Feb 26;13(1):140-144. doi:10.1159/000512405 Wilmskoetter J, Daniels SK, Miller AJ. Cortical and Subcortical Control of Swallowing—Can We Use Information From Lesion Locations to Improve Diagnosis and Treatment for Patients With Stroke? Am J Speech Lang Pathol. 2020 Jul; 29(2 Suppl): 1030–1043. doi:10.1044/2019_AJSLP-19-00068 By Heidi Moawad, MD Dr. Moawad is a neurologist and expert in brain health. She regularly writes and edits health content for medical books and publications. 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