Vascular Cognitive Impairment Flashcards
Vascular dementia diagnostic criteria
- Dementia, characterized by the presence of memory impairment and impairment in at least two additional cognitive domains
- Interference in ADLs not attributable to stroke alone, delirium, major psychiatric disorders, or other dementias
- Evidence of cardiovascular disease (CVD: ischemic and/or hemorrhagic)), as manifest in focal neurologic signs consistent with stroke and neuroimaging evidence of CVD.
- Presumed causal relationship between dementia and CVD, as suggested by:
onset of dementia within 3 months of recognized stroke event and/or abrupt deterioration of, or stepwise progression of, cognitive impairment.
Underlying pathophysiology of vascular cognitive impairment
cardioembolic, atherosclerotic, ischemic (>70% of elderly), hemorrhagic or genetic processes resulting in:
- multiple small vessel disease resulting in microinfarction, leukoencephalopathy and/or lacunar infarctions
- large-vessel occlusive disease
- microhemorrhagic lesions
- macrohemorrhagic lesions
Vascular cognitive impairment subtypes
Leukoaraiosis - refers to nonspecific loss of density of subcortical white matter, presumably due to diffuse microvascular ischemia and is generally synonymous with periventricular white matter disease
Multi-Infarct Dementia (MID) - cases involving dementia in the context of multiple cerebral infarctions with subsequent cerebral volume loss and a temporally concurrent, stepwise progression of cognitive impairment.
Strategic Infarct - vascular dementia occurring from one infarct, particularly in left angular gyrus region, the caudate nucleus, the globus pallidus, and the thalamus
Lacunar Infarcts - small noncortical infarcts caused by occlusion of a single penetrating branch of a large cerebral artery (usually causing infarct to thalamus or brainstem)
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) - rare hereditary arteriopathy affecting the cerebral small vessels and resulting in diffuse white matter disease and small lacunar infarctions.
- often present with migraine, seizures, depression, recurrent transient ischemic attacks (TIA), and stroke
- onset is typically early to middle adulthood
Mixed Dementia - term is applied to cases in which coexisting pathophysiology of CVD and another dementing disorder (most commonly AD or Lewy body disease) is observed
Strategic infarcts of left angular gyrus can lead to what deficits?
Characteristic symptoms of Gerstmann syndrome (L/R disorientation, finger agnosia, acalculia, agraphia), as well as constructional dysfunction (i.e., difficulty drawing or copying figures due to visuospatial deficits)
Strategic infarcts of thalamus can lead to what deficits?
A broad range of cognitive and behavioral disturbances that manifest as executive dysfunction, language impairment, memory dysfunction, and/or disorders of initiation, inhibition and modulation of mood, and emotional behavior
Vascular cognitive impairment neuropsychological expectations
usually deficits in executive functions, attention, slowing of processing speed early on
hold tests of intellect and achievement (such as Information and Vocabulary, or Spelling and Word Reading) generally spared UNLESS strategic infarct affects left perisylvian regions or thalamic nuclei
Language usually preserved early on (as opposed to Alzheimer’s) though processing speed/EF deficits may affect word list generation - frank aphasia is uncommon
Visuoconstructional task performance is often affected, with deficits to be expected on figure copy tasks or clock drawing.
Patients who have a primarily subcortical focus of pathology, sensorimotor deficits, gait disturbance, dysarthria, extrapyramidal signs, and urinary incontinence are common.
A stepwise decline in cognitive functioning associated with temporally concurrent vascular brain injury is…
a relatively uncommon finding in VCI because:
longitudinal studies cannot determine whether cognitive decline observed at follow-up occurred in a stepwise or smoothly progressive manner
vascular dementia frequently occurs in the context of mixed dementia, combining the pathology of AD and VaD, therefore obscuring a possible temporal association between cerebrovascular events and onset of greater cognitive decline.
A relatively rare phenomenon leading to vascular dementia is
CADASIL
Are periventricular hyperintensities and isolated subcortical lacunar infarctions commonly found in cognitively normal aged adults?
Yes - these alone do not indicate vascular causation of cognitive decline
What symptoms are more common in vascular dementia than Alzheimer’s?
Motor and psychomotor slowing and depression
motor and verbal processing speed deficits are hallmark in vascular dementia
memory impairment and dysnomia (word finding difficulties) are very common presenting symptoms in Alzheimer’s
Diffuse Lewy body disease is more often characterized by fluctuations in cognition, visual hallucinations, and motor symptoms.
Frontotemporal disease is more often characterized by early and pronounced behavioral change
Hallmark symptoms in each dementia subtype
processing speed deficits are hallmark in vascular dementia
memory impairment and dysnomia (word finding difficulties) are very common presenting symptoms in Alzheimer’s
Diffuse Lewy body disease is more often characterized by fluctuations in cognition, visual hallucinations, and motor symptoms.
Frontotemporal disease is more often characterized by early and pronounced behavioral change
What percent of vascular cognitive impairment without dementia progresses to dementia within 1 year?
~12%
Describe occurrence of delusions and visual hallucinations in vascular dementia
they occur in a sizable minority of patients
embolic shower
Kind of stroke. Coronary artery bypass grafting and cardiac valve replacement surgery have been associated with embolic shower
Protective factors for vascular cognitive impairment does NOT include:
antioxidant and B vitamin supplementation
