• Exosomal miRNAs are crucial regulators in the pathogenesis of cerebral small vessel disease, influencing blood-brain barrier integrity, chronic cerebral hypoperfusion, inflammation, and apoptosis.
• Specific exosomal miRNAs show differential expression in body fluids of CSVD patients, offering potential as non-invasive early diagnostic biomarkers.
• Targeting exosomal miRNAs with mimics or antagonists represents a promising therapeutic strategy for CSVD, though optimization is needed.
• Combined use of multiple exosomal miRNAs and construction of miRNA interaction networks may enhance therapeutic efficacy and disease management.