Diagnosis and treatment of vascular dementia

Diagnostic criteria for vascular dementia

Vascular dementia is a complex disease caused by ischemic stroke, hemorrhagic stroke, or ischemic-hypoxic brain damage.

The diagnosis is divided into three levels: possible, probable, and definite, as follows:

1. Clinical diagnosis criteria for possible vascular dementia

(1) Dementia

Cognitive function is reduced compared to the past, manifested as memory impairment and functional impairment in two or more cognitive domains (orientation, attention, language, visual-spatial function, executive function, motor control, and implementation function). It is best determined by clinical and neuropsychological testing. These functional deficits are sufficient to affect the patient's daily life and are not simply caused by physical impairment caused by stroke.

Exclusion criteria: cases with impaired consciousness, delirium, psychosis, severe aphasia, obvious sensory and motor impairment, but no evidence from neuropsychological tests. Other systemic diseases and other brain diseases that can cause memory and cognitive dysfunction are also excluded.

(2) Cerebrovascular disease

Neurological examinations show focal signs, such as hemiparesis, lower facial paralysis, Babinski sign, sensory loss, hemianopsia, and dysarthria, consistent with stroke (regardless of the history of stroke). Brain imaging (CT or MRI) shows evidence of related cerebrovascular disease, including multiple large vessel strokes, or single infarcts in important areas (angular gyrus, thalamus, base of the forebrain, and the territories supplied by the anterior and posterior cerebral arteries), multiple lacunar lesions in the basal ganglia and white matter, and extensive periventricular ischemic white matter damage, or both.

(3) The above two disease diagnoses are related

At least one or more of the following manifestations are present: ① Dementia symptoms occur 3 months after stroke; ② There is a sudden deterioration of cognitive function, or fluctuating or staged cognitive impairment.

2. Clinical features consistent with possible vascular dementia include:

(1) Early gait instability (brachygait, ataxic gait, or parkinsonian gait);

(2) unstable, frequent, and unexplained falls;

(3) Early onset of urinary frequency, urgency, and other urinary symptoms that cannot be explained by urinary system diseases;

(4) Pseudobulbar palsy;

(5) Personality changes, apathy, depression, emotional incontinence, and other subcortical deficit symptoms such as psychomotor retardation and executive function abnormalities.

3. Features that exclude the diagnosis of vascular dementia include:

(1) Early manifestations include memory impairment, which gradually worsens, accompanied by impairment of other cognitive functions such as language (transcortical sensory aphasia), motor skills (apraxia), and sensory perception (agnosia), and there is no focal damage on related brain imaging examinations;

(2) no focal neurological signs other than cognitive impairment;

(3) No vascular lesions on brain CT or MRI.

4. Vascular dementia may be considered:

There is dementia and focal neurological signs, but no cerebrovascular disease is found on brain imaging examinations; or there is a lack of obvious temporal connection between dementia and stroke; or although cerebrovascular disease exists, it has a slow onset and the course of the disease is inconsistent (there is no plateau period or improvement period).

5. Confirm the diagnostic criteria for vascular dementia:

(1) Clinically consistent with possible vascular esophageal carcinoma;

(2) vascular dementia confirmed by histopathological examination (biopsy or autopsy);

(3) absence of neurofibrillary tangles and senile plaques exceeding the age-limited number;

(4) There are no other clinical and pathological diseases that cause dementia.

For research purposes, classification of vascular dementia can be based on clinical findings, radiological findings, and neuropathology, such as cortical vascular dementia, subcortical vascular dementia, and thalamic dementia.

Differential Diagnosis

1. Alzheimer’s disease (AD)

AD has an insidious onset and slow progression, with prominent cognitive dysfunctions such as memory. Most patients do not have focal neurological signs such as hemiplegia. Neuroimaging shows significant cortical atrophy, and a Hachacinski Ischemia Scale ≤ 4 points (modified Hachacinski Ischemia Scale ≤ 2 points) supports the diagnosis of AD.

2. Pick disease

The onset is early, with progressive dementia, with obvious personality changes and social behavior disorders, language impairment, and memory and other cognitive impairments occurring relatively late. CT or MRI mainly shows significant frontal and/or temporal lobe atrophy.

3. Dementia with Lewy Bodies (DLB)

The three core symptoms are fluctuating cognitive impairment, recurrent vivid visual hallucinations, and extrapyramidal symptoms. DLB with transient loss of consciousness, repeated falls, and syncope can be misdiagnosed as VaD, but there is no infarction in imaging and no localizing signs in neurological examination.

4. Parkinson's disease dementia

In the early stage of Parkinson's disease dementia, symptoms of extrapyramidal involvement such as resting tremor and muscle rigidity appear. Cognitive impairment usually occurs in the late stage, and is mainly characterized by impairment of attention, calculation, visual space, memory, etc. Generally, there is no history of stroke, no focal neurological localization signs, and no infarction, hemorrhage, or white matter lesions on imaging.

treat

1. Etiological treatment: Prevention and treatment of cerebrovascular disease and its risk factors.

2. Treatment of cognitive symptoms: The cholinesterase inhibitor donepezil and the non-competitive NMDA receptor antagonist memantine may improve the cognitive function of vascular dementia.

3. Symptomatic treatment: Symptomatic treatment of depression and mental symptoms.