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Vascular Dementia

Summary

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  • Vascular dementia is cognitive impairment caused by cerebrovascular disease
  • Characterised by stepwise decline in cognitive function
  • Imaging shows multiple infarcts, white matter changes, or strategic single infarcts

Pathophysiology

  • Caused by reduced blood flow to the brain due to:
    • Multiple small vessel infarcts
    • Large vessel occlusions
    • Chronic hypoperfusion
  • Results in neuronal death and cognitive decline
  • Vascular risk factors contribute to endothelial dysfunction and blood-brain barrier disruption

Demographics

  • Second most common cause of dementia after Alzheimer's disease
  • Prevalence increases with age:
    • 1-4% in individuals 65-69 years
    • 14-16% in those over 80 years
  • Higher incidence in men and individuals of African or Asian descent

Diagnosis

  • Clinical presentation:
    • Stepwise cognitive decline
    • Focal neurological signs
    • Gait disturbances
    • Urinary incontinence
  • Neuropsychological testing:
    • Executive function deficits
    • Slowed processing speed
    • Impaired attention and concentration
  • Diagnostic criteria:
    • Evidence of cognitive decline
    • Presence of cerebrovascular disease
    • Temporal relationship between vascular events and cognitive decline

Imaging

  • CT findings:
    • Multiple lacunar infarcts
    • Cortical infarcts
    • White matter hypodensities
  • MRI findings:
    • T2/FLAIR hyperintensities in white matter and deep gray nuclei
    • Microbleeds on susceptibility-weighted imaging
    • Strategic infarcts (e.g., thalamus, angular gyrus)
  • Advanced techniques:
    • DTI: reduced fractional anisotropy in white matter tracts
    • Perfusion imaging: areas of hypoperfusion
    • MR spectroscopy: reduced N-acetylaspartate/creatine ratio

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  • 75-year-old patient with many cardiovascular risk factors presented with impaired memory and depression.
  • There was a severe burden of small vessel disease that invovled the dorsal thalami bilaterally.

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  • A 70-year-old patient with hypertension (now controlled on 3 agents) presented with cognitive impairment affecting mutliple domains.
  • MRI showed Fazekas grade 3 small vessel disease and multiple deep microhaemorrhages.

Treatment

  • Management of vascular risk factors:
    • Hypertension control
    • Diabetes management
    • Smoking cessation
    • Lipid-lowering therapy
  • Antiplatelet therapy for secondary stroke prevention
  • Cognitive rehabilitation and occupational therapy
  • Cholinesterase inhibitors may provide modest cognitive benefit
  • No disease-modifying treatments currently available

Differential diagnosis

Differential Diagnosis Distinguishing Feature
Alzheimer's Disease Hippocampal and entorhinal atrophy on MRI; posterior parietal and precuneus hypometabolism on FDG-PET; lesser burden of white matter hyperintensities and lacunar infarcts
Lewy Body Dementia Occipital hypometabolism on FDG-PET; less prominent white matter disease; midbrain atrophy
Frontotemporal dementia Frontal and anterior temporal atrophy without significant white matter hyperintensities or lacunar infarcts
Creutzfeldt-Jakob disease Cortical ribbon and basal ganglia DWI restriction; pulvinar sign on T2; rapid cortical atrophy on follow-up
CADASIL Anterior temporal pole and external capsule FLAIR hyperintensity; subcortical lacunar infarcts; microbleeds