Vascular dementia and subcortical ischemic vascular disease
Diagnostics
Clinical criteria for vascular dementia (Roman et al, 1993)
1) Probable vascular dementia, all diagnostic features must be present
- a. Diagnosis of dementia manifested by impairment of memory and 2+ cognitive domains
- b. Cerebrovascular disease
- i. Focal signs on neurologic examination
- ii. Relevant brain imaging with multiple large vessel infarcts or a single strategically placed infarct or extensive periventricular white matter lesions, or combinations thereof
- c. A relationship between the above two disorders with one or more of the following
- i. Onset of dementia within 3 months following a recognized stroke
- ii. Abrupt deterioration in cognitive functions
- iii. Fluctuating, stepwise progression of cognitive deficits
- d. Exclusion criteria:
- i. Cases with disturbance of consciousness, delirium, psychosis, severe aphasia, or major sensorimotor impairment precluding neuropsychological testing
- ii. Systemic disorders or other brain diseases that in and of themselves could account for deficits
2) Supportive diagnostic features of probable vascular dementia:
- a. Early presence of gait disturbance
- b. History of unsteadiness and frequent, unprovoked falls
- c. Early urinary frequency, urgency, and other urinary symptoms not explained by urologic disease
- d. Pseudobulbar palsy
- e. Personality and mood changes, abulia, depression, emotional incontinence, or other subcortical deficits including psychomotor retardation and abnormal executive function
3) Features associated with an unlikely / uncertain diagnosis of vascular dementia:
- a. Early onset of memory deficit and progressive worsening of memory deficit and other cognitive functions such as language (transcortical sensory aphasia), motor skills (apraxia), and perception (agnosia), in the absence of corresponding focal lesions on brain imaging
- b. Absence of focal neurological signs, other than cognitive disturbance
- c. Absence of cerebrovascular lesions on brain CT or MRI
4) Possible vascular dementia
- a. Presence of dementia with focal neurologic signs in patients in whom brain imaging studies to confirm definite CVD are missing
- b. Absence of clear temporal relationship between dementia and stroke
- c. Patients with subtle onset and variable course (plateau or improvement) of cognitive deficits and evidence of relevant CVD
5) Definite vascular dementia
- a. Clinical criteria for probable vascular dementia
- b. Histopathologic evidence of CVD obtained from biopsy or autopsy
- c. Absence of neurofibrillary tangles and neuritic plaques exceeding those expected for age
- d. Absence of other clinical or pathological disorder capable of producing dementia
6) Classification of vascular dementia for research purposes may be made on the basis of clinical, radiologic, and neuropathological features, for subcategories or defined conditions such as cortical vascular dementia, subcortical vascular dementia, BD, and thalamic dementia
7) The term “AD with CVD” should be reserved to classify patients fulfilling the clinical criteria for possible AD and who also present clinical or brain imaging evidence of relevant CVD. Traditionally, these patients have been included with vascular dementia in epidemiologic studies. The term “mixed dementia,” used hitherto, should be avoided
Imaging
- Coronal and axial FLAIR (A & B) show confluent white matter hyperintensity affecting predominantly corona radiata
- SWI (C) demonstrates hypertensive microbleeds in basal ganglia and thalamus
- Axial T2 (D) shows enlarged perivascular spaces (best seen around putamen)
Treatment
References
Roman, G. et al. Vascular dementia: diagnostic criteria for research studies. Report of the NINDS-AIREN International Workshop. Neurology 43, 250–60 (1993). https://pubmed.ncbi.nlm.nih.gov/8094895/
