Dementia resulting from stroke
Medical condition
Vascular dementia
|
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Other names
| Dementia due to cerebrovascular disease;
[1]
Vascular cognitive impairment
[2]
|
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![](//upload.wikimedia.org/wikipedia/commons/thumb/e/e4/BrainAtrophy%28exvacuo%29.png/300px-BrainAtrophy%28exvacuo%29.png) |
Brain atrophy from vascular dementia
|
Specialty
| Psychiatry
,
neurology
![Edit this on Wikidata](//upload.wikimedia.org/wikipedia/en/thumb/8/8a/OOjs_UI_icon_edit-ltr-progressive.svg/10px-OOjs_UI_icon_edit-ltr-progressive.svg.png) |
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Symptoms
| Cognitive impairment
, short term memory loss
[3]
|
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Complications
| Heart disease, loss of ability to care for self,loss of ability to interact, pneumonia
[4]
|
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Causes
| Conditions that impair blood vessels in the brain and therefore interfere with oxygen delivery to the brain
[3]
|
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Risk factors
| High blood pressure, high cholesterol, atrial fibrillation, diabetes
[3]
|
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Diagnostic method
| Lab test, neuroimaging test, neuropsychological testing
[5]
|
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Differential diagnosis
| Alzheimer disease
[5]
|
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Treatment
| There is no cure (however, symptoms are managed)
[3]
[4]
|
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Frequency
| 15-30% of dementia cases in the United States, Europe, and Asia
[5]
[6]
|
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Vascular dementia
is
dementia
caused by a series of
strokes
.
[2]
[4]
Restricted blood flow due to strokes reduces oxygen and glucose delivery to the brain, causing cell injury and neurological deficits in the affected region.
[6]
Subtypes of vascular dementia include subcortical vascular dementia, multi-infarct dementia, stroke-related dementia, and mixed dementia.
[2]
[5]
Subcortical vascular dementia occurs from
damage to small blood vessels
in the brain. Multi-infarct dementia results from a series of small strokes affecting several brain regions. Stroke-related dementia involving successive small strokes causes a more gradual decline in
cognition
.
[4]
Dementia may occur when neurodegenerative and cerebrovascular pathologies are mixed, as in susceptible elderly people (75 years and older).
[2]
[5]
Cognitive decline can be traced back to occurrence of successive strokes.
[4]
ICD-11
lists vascular dementia as
dementia due to cerebrovascular disease
.
[1]
DSM-5
lists vascular dementia as either
major or mild vascular neurocognitive disorder
.
[7]
Signs and symptoms
[
edit
]
People with vascular dementia present with progressive
cognitive impairment
, acutely or sub-acutely as in
mild cognitive impairment
, frequently step-wise, after multiple strokes.
[5]
The disease is described as both a
mental
and
behavioral disorder
within the
ICD-11
.
[8]
Signs and symptoms are cognitive, motor, behavioral, and for a significant proportion of people, also
affective
. These changes typically occur over a period of 5?10 years. Signs are typically the same as in other dementias, but mainly include cognitive decline and memory impairment of sufficient severity as to interfere with activities of daily living, sometimes with presence of focal neurological signs, and evidence of features consistent with cerebrovascular disease on brain imaging (CT or MRI).
[4]
[5]
The neurological signs localizing to certain areas of the brain that can be observed are
hemiparesis
,
bradykinesia
,
hyperreflexia
, extensor
plantar reflexes
,
ataxia
,
pseudobulbar palsy
, as well as
gait
problems and
swallowing difficulties
. People have patchy deficits in terms of cognitive testing. They tend to have better
free recall
and fewer
recall intrusions
when compared with people having
Alzheimer's disease
.
[9]
In the more severely affected people, or those affected by infarcts in
Wernicke's
or
Broca's
areas, specific problems with speaking called
dysarthria
and
aphasias
may be present.
[2]
[5]
In
small vessel disease
, the frontal lobes are often affected. Consequently, people with vascular dementia tend to perform worse than their Alzheimer's disease counterparts in
frontal lobe
tasks, such as verbal fluency, and may present with frontal lobe problems:
apathy
,
abulia
(lack of will or initiative), problems with attention, orientation, and urinary incontinence. They tend to exhibit more
perseverative
behavior. People with vascular dementia may also present with general slowing of processing ability, difficulty
shifting sets
, and impairment in abstract thinking. Apathy early in the disease is more suggestive of vascular dementia.
[2]
[5]
Rare genetic disorders that cause vascular lesions in the brain have other presentation patterns. As a rule, they tend to occur earlier in life and have a more aggressive course. In addition, infectious disorders, such as
syphilis
, can cause arterial damage, strokes, and bacterial inflammation of the brain.
[10]
Causes
[
edit
]
Risk factors and clinical characteristics for vascular dementia
[11]
Vascular dementia can be caused by ischemic or hemorrhagic
infarcts
affecting multiple brain areas, including the
anterior cerebral artery
territory, the
parietal lobes
, or the
cingulate gyrus
.
[5]
On rare occasion, infarcts in the
hippocampus
or
thalamus
are the cause of dementia.
[12]
A history of stroke increases the risk of developing dementia by around 70%, and recent stroke increases the risk by around 120%.
[13]
Brain vascular lesions can also be the result of diffuse
cerebrovascular disease
, such as
small vessel disease
.
[5]
Risk factors
[
edit
]
Risk factors
for vascular dementia include increasing age,
hypertension
, smoking,
hypercholesterolemia
,
diabetes mellitus
,
cardiovascular disease
, and
cerebrovascular disease
.
[2]
[5]
Other risk factors include lifestyle, geographic origin, and
APOE-ε4
genotype
.
[2]
[5]
Vascular dementia can sometimes be triggered by
cerebral amyloid angiopathy
, which involves accumulation of
amyloid beta
plaques in the walls of the cerebral arteries, leading to breakdown and rupture of the vessels.
[2]
[5]
Since amyloid plaques are a characteristic feature of
Alzheimer's disease
, vascular dementia may occur as a consequence.
[2]
[6]
Diagnosis
[
edit
]
Several specific diagnostic criteria can be used to diagnose vascular dementia, including the
Diagnostic and Statistical Manual of Mental Disorders
, Fourth Edition (DSM-IV) criteria, the
International Classification of Diseases
, Tenth Edition (ICD-10) criteria, the
National Institute of Neurological Disorders and Stroke
criteria, Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN) criteria, the Alzheimer's Disease Diagnostic and Treatment Center criteria, and the Hachinski Ischemic Score (after
Vladimir Hachinski
).
[2]
[6]
[14]
The recommended investigations for cognitive impairment include: blood tests (for anemia, vitamin deficiency, thyrotoxicosis, infection, among others), chest xray,
ECG
, and neuroimaging, preferably a scan with a functional or metabolic sensitivity beyond a simple CT or MRI.
[2]
[4]
When available as a diagnostic tool,
single photon emission computed tomography
(SPECT) and
positron emission tomography
(PET) neuroimaging may be used to confirm a diagnosis of multi-infarct dementia in conjunction with evaluations involving
mental status examination
.
[2]
[4]
[6]
In a person already having dementia, SPECT appears to be superior in differentiating multi-infarct dementia from Alzheimer's disease, compared to the usual mental testing and
medical history
analysis.
[15]
[
additional citation(s) needed
]
The screening blood tests typically include
full blood count
,
liver function tests
,
thyroid function tests
, lipid profile,
erythrocyte sedimentation rate
,
C reactive protein
,
syphilis
serology, calcium serum level, fasting glucose,
urea
,
electrolytes
,
vitamin B-12
, and
folate
.
[4]
[6]
Differential diagnosis
[
edit
]
Differentiating dementia syndromes can be challenging, due to the frequently overlapping clinical features and related underlying pathology.
Mixed dementia
, involving two types of dementia, can occur. In particular,
Alzheimer's disease
often co-occurs with vascular dementia.
[2]
[5]
Mixed dementia is diagnosed when people have evidence of
Alzheimer's disease
and cerebrovascular disease, either clinically or based on neuro-imaging evidence of ischemic lesions.
[16]
Pathology
[
edit
]
Gross examination of the brain may reveal noticeable lesions and damage to blood vessels.
[2]
[6]
Accumulation of various substances such as lipid deposits and clotted blood appear on microscopic views. The
white matter
is substantially affected, with noticeable atrophy (tissue loss), in addition to calcification of the arteries.
[2]
[6]
[17]
Microinfarcts may also be present in the gray matter (cerebral cortex), sometimes in large numbers.
[2]
Although
atheroma
of the major cerebral arteries is typical in vascular dementia, smaller vessels and arterioles are mainly affected.
[2]
[6]
Prevention
[
edit
]
Early detection and accurate diagnosis are important, as vascular dementia is at least partially preventable.
Ischemic changes in the brain
are irreversible, but the person with vascular dementia can demonstrate periods of stability or even mild improvement.
[18]
Since stroke is an essential part of vascular dementia,
[13]
the goal is to prevent new strokes. This is attempted through reduction of stroke risk factors, such as
high blood pressure
,
high blood lipid levels
,
atrial fibrillation
, or
diabetes mellitus
.
[2]
[5]
Medications for high blood pressure are used to prevent pre-stroke dementia.
[19]
These medications include
angiotensin converting enzyme inhibitors
,
diuretics
,
calcium channel blockers
, sympathetic nerve inhibitors,
angiotensin II receptor antagonists
or
adrenergic antagonists
.
[
medical citation needed
]
A 2023 review found that therapy with
statin
drugs was ineffective in treating or preventing stroke or dementia in people without a history of cerebrovascular disease.
[20]
Treatment
[
edit
]
As of 2024, there are no medications used specifically for prevention or treatment of vascular dementia.
[4]
[3]
Prognosis
[
edit
]
Many studies have been conducted to determine average survival of people with dementia. The studies were frequently small and limited, which caused contradictory results in the connection of mortality to the type of dementia and the person's gender. One 2015 study found that the one-year mortality was three to four times higher in people after their first referral to a day clinic for dementia, when compared to the general population.
[21]
If the person was hospitalized for dementia, the mortality was even higher than in people hospitalized for
cardiovascular disease
.
[21]
Vascular dementia was found to have either comparable or worse survival rates when compared to Alzheimer's disease;
[22]
another 2014 study found that the prognosis for people with vascular dementia was worse for male and older people.
[23]
Vascular dementia may be a direct cause of death due to the possibility of a fatal interruption in the brain's blood supply.
[24]
Epidemiology
[
edit
]
Vascular dementia is the second-most-common form of dementia after
Alzheimer's disease
in older adults.
[4]
The
prevalence
of the illness is 1.5% in Western countries and approximately 2.2% in Japan. It accounts for 50% of all dementias in Japan, 20% to 40% in Europe and 15% in Latin America. 25% of people with stroke develop new-onset dementia within one year of their stroke. One study found that in the United States, the prevalence of vascular dementia in all people over the age of 71 is 2.43%, and another found that the prevalence of the dementias doubles with every 5.1 years of age.
[
citation needed
]
The incidence peaks between the fourth and the seventh decades of life and 80% of people have a history of
hypertension
.
[25]
[
additional citation(s) needed
]
A 2018
meta-analysis
identified 36 studies of prevalent stroke (1.9 million participants) and 12 studies of incident stroke (1.3 million participants).
[13]
For prevalent stroke, the pooled hazard ratio for all-cause dementia was 1.69; for incident stroke, the pooled risk ratio was 2.18.
[13]
Study characteristics did not modify these associations, with the exception of sex, which explained 50.2% of between-study heterogeneity for prevalent stroke. These results confirm that stroke is a strong, independent, and potentially modifiable risk factor for all-cause dementia.
[13]
See also
[
edit
]
References
[
edit
]
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b
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Adult personality and behavior
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Neurological and symptomatic
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Physiological and physical behavior
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Delusional
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Psychosis
and
schizophrenia-like
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Schizophrenia
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Other
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Symptoms and uncategorized
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Classification
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External resources
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