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Vascular Dementia

by Juebin Huang, MD, PhD

Vascular dementia is acute or chronic cognitive deterioration due to diffuse or focal cerebral infarction that is most often related to cerebrovascular disease.

Vascular dementia is the 2nd most common cause of dementia among the elderly. It is more common among men and usually begins after age 70. It occurs more often in people who have vascular risk factors (eg, hypertension, diabetes mellitus, hyperlipidemia, smoking) and in those who have had several strokes. Many people have both vascular dementia and Alzheimer disease.

Vascular dementia typically occurs when multiple small cerebral infarcts (or sometimes hemorrhages) cause enough neuronal or axonal loss to impair brain function. Vascular dementias include the following:

  • Multiple lacunar infarction: Small blood vessels are affected. Multiple lacunar infarcts occur deep within hemispheric white and gray matter.

  • Multi-infarct dementia: Medium-sized blood vessels are affected.

  • Strategic single-infarct dementia: A single infarct occurs in a crucial area of the brain (eg, angular gyrus, thalamus).

  • Binswanger dementia (subcortical arteriosclerotic encephalopathy): This uncommon variant of small-vessel dementia is associated with severe, poorly controlled hypertension and systemic vascular disease. It causes diffuse and irregular loss of axons and myelin with widespread gliosis, tissue death due to an infarction, or loss of blood supply to the white matter of the brain.

Symptoms and Signs

Symptoms and signs are similar to those of other dementias (see Dementia : Symptoms and Signs). However, multiple-infarct dementia tends to progress in discrete steps; each episode is accompanied by intellectual decline, sometimes followed by modest recovery. Subcortical vascular dementia caused by small-vessel ischemic damage (which includes multiple lacunar infarction and Binswanger dementia) tends to cause small, incremental deficits; thus, the decline appears to be gradual.

As the disease progresses, focal neurologic deficits often develop:

  • Exaggeration of deep tendon reflexes

  • Extensor plantar response

  • Gait abnormalities

  • Weakness of an extremity

  • Hemiplegias

  • Pseudobulbar palsy with pathologic laughing and crying

  • Other signs of extrapyramidal dysfunction

Cognitive loss may be focal. For example, short-term memory may be less affected than in other dementias. Patients with partial aphasia may be more aware of their deficits; thus, depression may be more common than in other dementias.

Diagnosis

  • Generally similar to diagnosis of other dementias

Diagnosis is similar to that of other dementias (see Dementia : Diagnosis). As in other dementias, cognitive impairment must be severe enough to interfere with daily activities. In addition, confirmation of vascular dementia requires a history of stroke or evidence of a vascular cause for dementia detected by neuroimaging. If focal neurologic signs or evidence of cerebrovascular disease is present, a thorough evaluation for stroke should be done (see Overview of Stroke : Evaluation).

CT and MRI may show bilateral multiple infarcts in the dominant hemisphere and limbic structures, multiple lacunar strokes, or periventricular white-matter lesions extending into the deep white matter. In Binswanger dementia, imaging shows leukoencephalopathy in the cerebrum semiovale adjacent to the cortex, often with multiple lacunae affecting structures deep in the gray matter (eg, basal ganglia, thalamic nuclei).

The Hachinski Ischemic Score is sometimes used to help differentiate vascular dementia from Alzheimer disease (see Modified Hachinski Ischemic Score).

Prognosis

The 5-yr mortality rate is 61%, which is higher than that for most forms of dementia, presumably because other atherosclerotic disorders coexist.

Treatment

  • Generally similar to treatment of other dementias

Generally, treatment is the same as that of other dementias (see Dementia : Treatment). However, vascular dementia may be preventable, and its progression may be slowed by BP control, cholesterol-lowering therapy, regulation of plasma glucose (90 to 150 mg/dL), and smoking cessation.

Efficacy of cholinesterase inhibitors and memantine is uncertain in vascular dementia. However, these drugs are commonly used, partly because elderly patients with vascular dementia may also have Alzheimer disease. Adjunctive drugs for depression, psychosis, and sleep disorders are useful.

Key Points

  • Vascular dementia can occur as a series of discrete episodes (which may seem like a gradual decline) or in a single episode.

  • Focal neurologic signs may help differentiate vascular dementia from other dementias.

  • Confirm that dementia is vascular based on a history of stroke or neuroimaging findings that suggest a vascular cause.

  • Control vascular risk factors, and if Alzheimer disease could also be present, treat with cholinesterase inhibitors and memantine.

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