Vascular cognitive disorder: A new diagnostic category updating vascular cognitive impairment and vascular dementia
Department of Medicine/Neurology, University of Texas HSC at San Antonio and the Audie Murphy Veterans Administration Hospital, Mail Code 7883, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA.Journal of the Neurological Sciences (Impact Factor: 2.47). 11/2004; 226(1-2):81-7. DOI: 10.1016/j.jns.2004.09.016
Vascular cognitive impairment (VCI) was proposed as an umbrella term to include subjects affected with any degree of cognitive impairment resulting from cerebrovascular disease (CVD), ranging from mild cognitive impairment (MCI) to vascular dementia. VCI may or may not exclude the host of "focal" circumscribed impairments of specialized functions such as language (aphasia), intentional gesture (apraxia), or categorical recognition (agnosia), among others, that may result from a stroke. Therefore, there are no universally accepted diagnostic criteria for VCI. We conclude that this concept could be more useful if it were to be limited to cases of vascular MCI without dementia, by analogy with the concept of amnestic MCI, currently considered the earliest clinically diagnosable stage of Alzheimer disease (AD). In agreement with our view,the Canadian Study on Health and Aging successfully implemented a restricted definition of VCI, excluding cases of dementia (i.e., vascular cognitive impairment no dementia, VCI-ND). The Canadian definition and diagnostic criteria could be utilized for future studies of VCI. This definition excludes isolated impairments of specialized cognitive functions. Vascular dementia (VaD): The main problem of this diagnostic category stems from the currently accepted definition of dementia that requires memory loss as the sine qua non for the diagnosis. This may result in over-sampling of patients with AD worsened by stroke (AD+CVD). This problem was minimized in controlled clinical trials of VaD by excluding patients with a prior diagnosis of AD, those with pre-existing memory loss before the index stroke, and those with amnestic MCI. We propose a definition of dementia in VaD based on presence of abnormal executive control function, severe enough to interfere with social or occupational functioning. Vascular cognitive disorder (VCD): This term, proposed by Sachdev [P. Sachdev, Vascular cognitive disorder. Int J Geriat Psychiatry 14 (1999)402-403.] would become the global diagnostic category for cognitive impairment of vascular origin, ranging from VCI to VaD. It would include specific disease entities such as post-stroke VCI, post-stroke VaD, CADASIL, Binswanger disease, and AD plus CVD. This category explicitly excludes isolated cognitive dysfunctions such as those mentioned above.
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- "Patients did not meet the criteria for dementia of the Diagnostic and Statistical Manual for Mental Disorders – Forth Edition – Text Revised (DSM- IV-TR), but fulfilled the neuroradiological criteria for subcortical vascular disease with predominant white matter lesions (WMLs) . They also showed impairment in at least one cognitive domain and normal ability at the activities of daily living . Patients with a history of major neurological disorders (i.e., dementia , stroke, Parkinson's disease, multiple sclerosis, and epilepsy) or major psychiatric illness, head trauma, acute medical illness or organ failure (such as heart failure, liver cirrhosis, kidney failure, respiratory failure, severe metabolic imbalance, and diffuse neoplasm ), alcohol or drug abuse, Mini Mental State Examination (MMSE) < 24 , use of drugs able to modulate cortical excitability (i.e. "
ABSTRACT: Background: An impairment of central cholinergic activity, as evaluated non-invasively by the short-latency afferent inhibition (SAI) of motor responses evoked by transcranial magnetic stimulation (TMS), was observed in patients with Alzheimer's disease (AD) and amnestic Mild Cognitive Impairment. Conversely, the involvement of central cholinergic neurotransmission in vascular dementia (VaD) is still under debate and data on Vascular Cognitive Impairment - No Dementia (VCI-ND) at risk for future VaD are lacking. Objective: To test for the first time SAI in patients with VCI-ND. Methods: Single-pulse TMS measures of cortical excitability and SAI were evaluated in 25 VCI-ND patients with subcortical ischemic lesions and 20 age-matched healthy controls. Functional status, neuropsychological tests evaluating frontal lobe abilities, and white matter lesions (WMLs) load were assessed. Results: A significant difference was found between patients and controls for the mean SAI, although this result did not resist after the Bonferroni correction. In the whole group of patients and controls, SAI showed a correlation with worse scores at the Montreal Cognitive Assessment (r = 0.376, p < 0.01). SAI also positively correlated with the total vascular burden (r = 0.345, p < 0.05) but not with the WML severity. Conclusions: Central cholinergic pathway does not seem to be involved in VCI-ND, and the current results differ from those reported in primary cholinergic forms of dementia, such as AD. SAI might represent a valuable additional tool in the differential diagnosis of the dementing processes and in identifying potential responders to cholinergic agents.
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- "The current study also found a specific association between cerebral perfusion of the frontal lobe and performance on a test of executive function. This is noteworthy , as executive dysfunction is common in older adults with vascular disease (Roman et al. 2004) and may be a result of reduced oxygenation to the highly plastic frontal lobes subsequent to disrupted cerebral hemodynamics . It is also possible that memory deficits in this sample may involve frontal-subcortical dysfunction (e.g., encoding, organizing) given the current association between frontal lobe perfusion and memory (Bonelli and Cummings 2008). "
ABSTRACT: It is well established that aging and vascular processes interact to disrupt cerebral hemodynamics in older adults. However, the independent effects of cerebral perfusion on neurocognitive function among older adults remain poorly understood. We examined the associations among cerebral perfusion, cognitive function, and brain structure in older adults with varying degrees of vascular disease using perfusion magnetic resonance imaging (MRI) arterial spin labeling (ASL). 52 older adults underwent neuroimaging and were administered the Mini Mental State Examination (MMSE), the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), and measures of attention/executive function. ASL and T1-weighted MRI were used to quantify total brain perfusion, total brain volume (TBV), and cortical thickness. Regression analyses showed reduced total brain perfusion was associated with poorer performance on the MMSE, RBANS total index, immediate and delayed memory composites, and Trail Making Test B. Reduced frontal lobe perfusion was associated with worse executive and memory function. A similar pattern emerged between temporal lobe perfusion and immediate memory. Regression analyses revealed that decreased total brain perfusion was associated with smaller TBV and mean cortical thickness. Regional effects of reduced total cerebral perfusion were found on temporal and parietal lobe volumes and frontal and temporal cortical thickness. Reduced cerebral perfusion is independently associated with poorer cognition, smaller TBV, and reduced cortical thickness in older adults. Prospective studies are needed to clarify patterns of cognitive decline and brain atrophy associated with cerebral hypoperfusion.
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- "Vascular cognitive impairment (VCI) subsumes a wide range of cognitive deficits caused by ischaemic brain lesions.1 White matter hyperintensities (WMHs) on fluid attenuated inversion recovery (FLAIR) and T2 weighted MRI are commonly seen in VCI patients, and the size of the lesions is used to indicate the extent of ischaemia.2–4 However, WMHs are found in a number of neurological disorders and their contribution to VCI symptoms is controversial.5 6 Furthermore, considerable inter-rater variability in the scoring of radiological findings in VCI has been reported7 and, to date, correlations between lesion load and neuropsychological testing results have been shown only for processing speed in one study on cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy.8 "
ABSTRACT: Background White matter hyperintensities (WMHs) are associated with vascular cognitive impairment (VCI) but fail to correlate with neuropsychological measures. As proton MR spectroscopy (1H-MRS) can identify ischaemic tissue, we hypothesised that MRS detectable brain metabolites would be superior to WMHs in predicting performance on neuropsychological tests. Methods 60 patients with suspected VCI underwent clinical, neuropsychological, MRI and CSF studies. They were diagnosed as having subcortical ischaemic vascular disease (SIVD), multiple infarcts, mixed dementia and leukoaraiosis. We measured brain metabolites in a white matter region above the lateral ventricles with 1H-MRS and WMH volume in this region and throughout the brain. Results We found a significant correlation between both total creatine (Cr) and N-acetylaspartyl compounds (NAA) and standardised neuropsychological test scores. Cr levels in white matter correlated significantly with executive function (p=0.001), attention (p=0.03) and overall T score (p=0.007). When lesion volume was added as a covariate, NAA also showed a significant correlation with executive function (p=0.003) and overall T score (p=0.015). Furthermore, while metabolite levels also correlated with total white matter lesion volume, adjusting the Cr levels for lesion volume did not diminish the strength of the association between Cr levels and neuropsychological scores. The lowest metabolite levels and neuropsychological scores were found in the SIVD group. Finally, lesion volume alone did not correlate significantly with any neuropsychological test score. Conclusion These results suggest that estimates of neurometabolite levels provide additional and useful information concerning cognitive function in VCI not obtainable by measurements of lesion load.
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