Cerebral small vessel disease (CSVD) is a heterogeneous disease of the microcirculatory vessel bed, leading to the development of cognitive impairments, lacunar strokes, and intracerebral hemorrhages. The pathogenesis of CSVD is characterized by disturbances in the structure of the intercellular matrix of the vessel wall, resulting in the accumulation of pathological proteins, hyalinosis, necrosis, and increased permeability of the blood-brain barrier. Disease progression is associated with a decrease in the area of the microvascular bed, inflammatory processes, atrophy, and demyelination. The article presents a pathogenetic classification of CSVD, discusses principles of diagnosis and treatment. Special attention is given to promising approaches for managing patients with chronic small artery pathology. Principles for the use of vasodilators from various pharmaceutical groups are proposed and justified, along with discussions on the prospects of using systemic proteolytic enzymes and platelet anti-aggregants.