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Etiology, clinical manifestations, and diagnosis of vascular dementia

Clinton B Wright, MD, MS
Section Editors
Steven T DeKosky, MD, FAAN, FACP, FANA
Scott E Kasner, MD
Deputy Editor
April F Eichler, MD, MPH


Vascular dementia (VaD) has a long history. VaD was first described in the late 19th century by Binswanger and Alzheimer who also recognized and described a variety of underlying pathologic mechanisms including the role of multiple infarctions and chronic ischemia. For nearly 50 years this was held to be the predominant form of dementia. Subsequently, pathologic studies demonstrated that the amyloid plaques and neurofibrillary tangles of Alzheimer disease (AD) were much more common in the brains of the demented elderly than previously thought [1]; chronic ischemic injury was thought to be quite rare, and VaD was understood as the sequelae of recurrent strokes or "multi-infarct dementia" (MID) [2]. With the advent of sophisticated neuroimaging techniques, computed tomography (CT) and magnetic resonance imaging (MRI), in the latter part of the twentieth century, the high prevalence of chronic vascular injury in the brain was appreciated, and interest in the role of vascular disease, including the role of progressive ischemic injury, on cognitive decline reemerged.

Despite this surge of interest, certain issues impede progress. There are no pathologic criteria for the diagnosis of VaD, as there are for AD. A number of clinical diagnostic criteria exist but are poorly validated and inconsistently applied.

Even basic terminology requires clarification. As an example, the traditional definition of dementia was originally developed in the context of AD in which memory loss occurs prominently and early on in the disease. However, in patients with cognitive deficits ultimately attributable to VaD, memory impairment appears somewhat later, and these patients may have significant cognitive disability long before they meet criteria for dementia.

This has led to the proposed concept of "vascular cognitive impairment" or VCI [3,4]. The National Institute of Neurological Disorders and Stroke-Canadian Stroke Network Vascular Cognitive Impairment Harmonization Standards, recognizing the limitations of current diagnostic criteria for both AD and VaD, promulgate the use of VCI as "cognitive impairment that is caused by or associated with vascular factors" [5]. Cognitive deficits associated with vascular disease that don't meet criteria for dementia is labelled "vascular cognitive impairment, no dementia" (vCIND). This is somewhat analogous to the more accepted term "mild cognitive impairment" or MCI, also known as "cognitive impairment, no dementia" or CIND [6]. Criteria as to what deficits qualify as cognitive impairment are ill-defined [6]. Use of the term Binswanger's disease to apply to VaD characterized by severe white matter disease associated with longstanding hypertension is no longer accepted; the volume of the white matter damage sufficient to cause VaD is not known and there are no accepted diagnostic criteria for this entity.

At the foundation of some of these problems is the fact that cerebrovascular disease is itself a heterogeneous disorder, with a variety of pathophysiologic mechanisms and clinical manifestations. At present, the entity of VaD is best understood as a heterogeneous syndrome rather than a distinct disorder, in which the underlying cause is cerebrovascular disease in some form and its ultimate manifestation is dementia.

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Literature review current through: Nov 2017. | This topic last updated: May 02, 2017.
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