Understanding and treating vascular cognitive impairment

Abstract

Purpose of review: It is estimated that one in three people will experience a stroke, dementia, or both during their lifetime. The goal of this article is to assist clinicians in the identification and treatment of patients with vascular cognitive impairment (VCI). To that end, we will discuss the scope and definition of VCI; how this definition can be applied in clinical practice; VCI epidemiology and pathogenesis, its clinical features, and assessment; and prevention and treatment of this disorder.

Recent findings: During the past decade, we have gained a more complete understanding of clinical manifestations of VCI (eg, the importance of executive function and memory), what it looks like pathologically (eg, the role of cerebral amyloid angiopathy, microinfarcts, and "silent" strokes), and how VCI relates to other disease processes (eg, co-occurrence with Alzheimer disease). A recent American Heart Association and American Stroke Association guidance statement clarified the construct of VCI, including the severity of cognitive and behavioral dysfunction contained under the definition of VCI and the presence of both "pure" and "mixed" VCI forms. VCI treatments approved by the US Food and Drug Administration are still lacking, and challenges remain regarding how to convert promising observational study findings that link stroke and coronary heart disease risk factors to cognitive impairment and dementia into evidence-based preventive methods.

Summary: VCI is a common contributor to cognitive impairment in later life. Because the risk of Alzheimer disease may be heightened by the same risk factors that make us susceptible to stroke and coronary heart disease, these borderlands merit careful consideration as we strive to preserve cognitive function throughout the aging process.

Figure 8-1.

Cerebral microbleeds. Gradient-echo MRI brain study showing multiple cortical cerebral microbleeds (small, dark, circular areas in both hemispheres) (A) with remnant of macrobleed in frontal area (larger, frontal, dark, circular area) (B). Figure courtesy of Chelsea Kidwell, MD, Georgetown University, Washington, DC.

Figure 8-2.

Diffusion-weighted brain MRI. Note increased signal intensity of periventricular area on the left side.

Figure 8-3.

Brain MRI. Note extensive white matter disease with involvement of external capsule. Other MRI sequences showed slight involvement of the temporal tips bilaterally.