Review articleVascular dementia revisited: Diagnosis, pathogenesis, treatment, and prevention
Section snippets
History
Thomas Willis first described postapoplectic dementia in the seventeenth century [4]. In 1894, Otto Binswanger and Alois Alzheimer separated VaD from dementia paralytica (neurosyphilis), a common cause of dementia at that time, and identified at least four different clinicopathologic forms of VaD [5]. Based on their work, Kraepelin concluded in 1910 that arteriosclerotic insanity, also known as cerebral arteriosclerosis, was the most frequent form of senile dementia [4]. This unwarranted
Pathogenesis
VaD may be caused by a number of vascular lesions and pathogenetic mechanisms as listed in Table 1 [8]. Of particular importance in the elderly is small vessel disease, which causes lacunes and white matter ischemic lesions. These ischemic lesions may interrupt the recently described frontal cortical-subcortical circuits that underlie executive functions, motivation, and socially responsive behaviors [9], [10].
There are five parallel anatomic circuits that link regions of the frontal cortex to
Epidemiology
AD and VaD are the most common causes of senile dementia, with VaD ranking second after AD [3], [38], [39], [40]. Cerebrovascular pathologic findings and heart disease are common in the elderly, and their prevalences increase with age; as a result, histologic changes of AD in the elderly often coexist with stroke and vascular pathologic changes [41], [42]. Somewhat more unexpected was the observation of the adjuvant role of cerebral infarction in AD [43], whereby elderly subjects with the
Risk factors for vascular dementia
One of the long-time paradoxes of VaD has been why it is that some patients develop dementia after a single stroke, whereas others seem to tolerate large or recurrent strokes without decline of intellectual function.
Risk factor quantification in case-control studies of poststroke dementia have begun to provide an answer [54], [55]. Pohjasvaara and colleagues [50] confirmed that the most important risk factors for poststroke VaD are older age, lower educational level, recurrent stroke, and left
Clinical forms of vascular dementia
Román [62] has simplified the clinical syndromes of VaD into two main groups, acute and subacute, according to the temporal profile of clinical presentation.
Diagnosis of vascular dementia
Although a number of diagnostic criteria for VaD have been proposed, the National Institute of Neurologic Disorders and Stroke-Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN) criteria [94] (Table 4) offer an operative approach to the three basic elements needed to reach a diagnosis of VaD: cognitive loss, frequently a subcortical form of dementia; cerebrovascular lesions demonstrated by brain imaging (CT, MRI); and exclusion of other causes of
Secondary prevention
Patients with VaD have higher morbidity and mortality than age-matched control subjects and patients with AD [52]. Coronary artery disease and recurrent strokes are among the common complications in these patients. Secondary prevention of recurrent stroke must be undertaken in patients with poststroke VaD. Although age, gender, ethnicity, and genetic factors are nonmodifiable stroke risk factors, there is clear class I evidence that treatment of hypertension reduces the risk of recurrent stroke
Summary
VaD is the second most common cause of dementia in the elderly after AD. VaD is defined as the loss of cognitive function resulting from ischemic, ischemic-hypoxic, or hemorrhagic brain lesions as a result of CVD and cardiovascular pathologic changes. Diagnosis requires (1) cognitive loss (often predominantly subcortical), (2) vascular brain lesions demonstrated by imaging, and (3) exclusion of other causes of dementia, such as AD. VaD is excluded by brain imaging showing no evidence of
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2019, Neurobiology of DiseaseCitation Excerpt :VaD is a common type of dementia in older people, characterized by gradually worsening memory and other cognitive actions resulting from chronic reduced blood flow in the brain (Sekhon et al., 1997). VaD is a clinical mental condition, caused by cardiovascular pathological modifications and cerebrovascular disease, which can determine ischemic or hemorrhagic brain tissue lesions (Roman, 2002; Seitz et al., 2011). The increased incidence of VaD imposes a heavy economic and social burden on individuals, families, communities, and countries.
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