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DMV burden was assessed using a semiquantitative scoring system (0\u20133 points per region), based on the visibility of DMVs in six anatomical regions on susceptibility-weighted imaging, yielding a total score ranging from 0 to 18. Glymphatic system function was evaluated using the diffusion tensor image analysis along the perivascular space (DTI-ALPS) index. Global cognitive function was assessed with the Montreal Cognitive Assessment (MoCA). Spearman correlation analysis, general linear modeling, and mediation analysis were conducted to examine the relationships among the variables.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      DMV scores(which higher scores indicate poorer venous visibility)were significantly negatively correlated with MoCA scores (\n                      <jats:italic>r<\/jats:italic>\n                      = -0.48,\n                      <jats:italic>p<\/jats:italic>\n                      &lt; 0.001) and with the DTI-ALPS index (\n                      <jats:italic>r<\/jats:italic>\n                      = -0.28,\n                      <jats:italic>p<\/jats:italic>\n                      &lt; 0.001), while the DTI-ALPS index was positively correlated with MoCA scores (\n                      <jats:italic>r<\/jats:italic>\n                      = 0.35,\n                      <jats:italic>p<\/jats:italic>\n                      &lt; 0.05). Mediation analysis indicated that the DTI-ALPS index partially mediated the effect of DMV burden on cognitive performance, accounting for 14.08% of the total effect.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>This study suggests that DMV structural abnormalities may exacerbate CSVD-related cognitive impairment by disrupting glymphatic function. DMV scoring may serve as a potential imaging biomarker, providing a foundation for early identification and intervention.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12883-025-04535-4","type":"journal-article","created":{"date-parts":[[2025,12,17]],"date-time":"2025-12-17T14:06:12Z","timestamp":1765980372000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Glymphatic system dysfunction mediates the relationship between deep medullary vein alterations and cognitive impairment in cerebral small vessel disease"],"prefix":"10.1186","volume":"26","author":[{"ORCID":"https:\/\/orcid.org\/0009-0008-4418-4418","authenticated-orcid":false,"given":"Wenli","family":"Lu","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shengnan","family":"Zhu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ran","family":"Chen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Li","family":"Yang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jing","family":"Qiang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Liya","family":"Ji","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cheng","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8961-5276","authenticated-orcid":false,"given":"Dan","family":"Zhou","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,12,17]]},"reference":[{"issue":"8","key":"4535_CR1","doi-asserted-by":"publisher","first-page":"822","DOI":"10.1016\/S1474-4422(13)70124-8","volume":"12","author":"JM Wardlaw","year":"2013","unstructured":"Wardlaw JM, Smith EE, Biessels GJ, Cordonnier C, Fazekas F, Frayne R, et al. 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The research protocol was approved by the Ethics Committee of Affiliated BenQ Hospital of Nanjing Medical University (No. R2024-KL022). All participants provided written informed consent. In cases where participants lacked decision-making capacity due to cognitive impairment, written informed consent was obtained from their legally authorized representatives (legal guardians or healthcare proxies).","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}},{"value":"The authors declare no conflict of interest.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}}],"article-number":"40"}}