2024-01-21 11:15:33
Recently, an article published in Stroke magazine pointed out ten things to remember (and not forget) about vascular cognitive impairment.
The article points out that the clock drawing test, as an independent screening tool for vascular cognitive impairment, has the highest sensitivity and reasonable accuracy.
bell (pixabay)
Vascular cognitive impairment is a broad term used to describe cognitive impairment caused by or associated with vascular risk factors or vascular injury (ischemic or hemorrhagic). It can occur alone or in association with Alzheimer’s disease and other pathologies.
Vascular cognitive impairment is considered the second most common cause of dementia worldwide, accounting for approximately 20% to 40% of dementia cases. The true prevalence of purely vascular cognitive impairment in autopsy studies is difficult to determine (median 11%) due to the lack of well-validated and accepted neuropathological criteria, heterogeneity, and overlapping definitions of cerebrovascular pathology.
Neuropathological studies show that in most cases there is evidence of mixed pathology. One study showed that only 9% of autopsy specimens had Alzheimer’s disease alone, 40% had Alzheimer’s disease + overt vascular co-pathology (macro-infarction, cerebral amyloid angiopathy, atherosclerosis or arteriosclerosis), and 44% had Alzheimer’s disease alone. There is Alzheimer’s + vascular and another neurodegenerative pathology.
Alzheimer’s disease (photoAC)
Vascular cognitive impairment is a heterogeneous disorder that can be divided according to the predominant pathophysiological mechanisms.
(1) Macrovascular diseases:Multiple strokes and infarcts in key areas.
(2) Small vessel disease (the most common neuropathology in the aging process):White matter high signal intensity, lacunar infarcts, microinfarcts, and microhemorrhages.
(3) Bleeding:Vascular cognitive impairment occurs in 19% to 62% of patients after subarachnoid hemorrhage. Cerebral amyloid angiopathy, venous malformations, hypertension, and bleeding associated with anticoagulants and antiplatelet drugs can also cause vascular cognitive impairment.
(4) Insufficient perfusion:This may play a role in hippocampal sclerosis.
(5) Genetic factors:Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, Cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy, Trex1-related microangiopathy, Cathepsin A-related arteriopathy with stroke and leukoencephalopathy, Familial forms of cerebral amyloid angiopathy, etc.
Smoking (photoAC)
Older age (prevalence doubles for every 5 years above 65 years), low education, previous cognitive impairment, and presence of certain cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, smoking, obesity, and deficiency) Patients with hemorrhagic heart disease are at the highest risk of developing vascular cognitive impairment.
When a stroke is confirmed, the stroke is more severe (National Institutes of Health Stroke Scale score >10 points), the stroke is larger, and the key locations are such as the left frontotemporal region, left basal ganglia, left angular gyrus, and right parietal region, Involvement of the anteromedial nucleus of the left dorsal thalamus greatly increases the risk of vascular cognitive impairment. In addition, previous infarction or cerebral hemorrhage also increases the risk of vascular cognitive impairment.
Cognitive deficits are heterogeneous and depend on the location and size of the infarct, the extent of small vessel disease, or all of the above. In contrast to Alzheimer’s disease, pure amnestic syndrome is not the chief complaint of vascular cognitive impairment. Infarction of critical sites can lead to acute cognitive deficits such as neglect or aphasia, depending on which cerebral hemisphere and specific brain lobes are affected.
Small vessel disease, with its insidious but progressive onset of attentional deficits, executive dysfunction, memory retrieval (particularly when cholinergic pathways are involved), and slowed processing speed, known as frontosubcortical dementia, also often occurs Additional clinical and examination features such as dysarthria, parkinsonism, or other gait disorders. Neuropsychiatric manifestations are more common in patients with Alzheimer’s disease than in those with Alzheimer’s disease. Depression was reported in as many as 21.6% of patients, while apathy ranged from 22.5% to 56%.
Brain magnetic resonance imaging (pixabay)
Brain MRI is the cornerstone of diagnosis because major biomarkers of vascular cognitive impairment are found on neuroimaging studies and include white matter hyperintensity, lacunar infarcts, microinfarcts, perivascular spaces, and hemorrhage It is more obvious on MRI, whereas larger regional strokes and cavities can also be seen on CT.
Other functional imaging techniques such as PET and SPECT can reveal hypometabolism or hypoperfusion in areas corresponding to damage to vascular territories, and some findings may aid in the differential diagnosis of other neurodegenerative diseases.
Several diagnostic criteria have been published, the most recently published criteria being from VICCCS-2.
These criteria classify vascular cognitive impairment into mild and pronounced neurocognitive syndromes based on the patient’s degree of independence in daily living.
Overt vascular cognitive impairment is also divided into 4 subtypes based on etiology and underlying pathology: poststroke, subcortical, multiple infarction, and mixed dementia. This also reminds us that the combination of mixed phenotypes with other neurodegenerative causes is by far the most common presentation observed in clinical practice.
First-line treatment includes the use of pharmacological and non-pharmacological methods to control cardiovascular risk factors, such as weight loss, dietary modification, and salt reduction, as well as the use of pharmacological treatment of cardiovascular risk factors for primary and secondary prevention/treatment, such as antihypertensive drugs, hypoglycemic drugs medications and lipid-lowering drugs.
Second-line treatment includes symptom management with cholinesterase inhibitors. Although donepezil is the most studied drug, galantamine and memantine have also been studied. A larger study showed the effectiveness of these drugs in patients with pure vascular cognitive impairment and post-stroke cognitive impairment, and because many older adults may have other neurodegenerative diseases (especially Alzheimer’s disease) , treatment with cholinesterase inhibitors may be reasonable.
weight loss (pixabay)
Patients with vascular cognitive impairment are generally older and have more comorbidities than patients with other types of dementia, and therefore have lower survival rates than those with Alzheimer’s disease alone. After diagnosis, the average survival time for Alzheimer’s disease patients is 7 to 10 years, while the average survival time for vascular cognitive impairment patients is 4 to 7 years.
There is currently no consensus on the optimal cognitive screening tool for vascular cognitive impairment. Recent studies have shown that the Montreal Cognitive Assessment (MoCA) is the most accurate compared to other screening tools and has also shown good reliability and internal consistency. When vascular cognitive impairment is suspected, a useful cutoff for the Montreal Cognitive Assessment is below the established cutoff of <26 points (preferably 30 points), that is, between 16 and 21 points.
As an independent screening tool for vascular cognitive impairment, the clock drawing test has the highest sensitivity (93.3%) and reasonable accuracy (AUC=0.74), helping to distinguish vascular cognitive impairment from Alzheimer’s disease.
The specific method of the clock drawing test is to ask the patient to draw a dial surface and write the numbers indicating the time in the correct position. After the patient draws a circle and adds the numbers, the patient is then asked to draw the big and small or minute hands, such as writing the time. Wait until 7:11.
When drawing time, the hour and minute hands should be distinct, and there should also be intersection points. Each of the above four steps is worth one point, and the total score is four points. If not, you should see a doctor as soon as possible.
来源：Ten Things to Remember (and Not Forget) About Vascular Cognitive Impairment. Stroke, 12 Jan 2024
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