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Heterogeneity of vascular dementia: mechanisms and subgroups
1Department of Psychiatry and Neurochemistry, University of Göteborg, St Jörgen Hospital, Hisings Backa, Sweden.
Insights
Multi-infarct dementia (MID) is not the only cause of vascular dementia (VAD). Other pathways, including subcortical white-matter dementia, also contribute significantly to VAD, highlighting diverse cerebrovascular mechanisms.
Area of Science:
- Neurology
- Neuroscience
- Pathology
Background:
- Vascular dementia (VAD) is often attributed to multiple, thromboembolically generated cerebral infarcts, clinically presenting as multi-infarct dementia (MID).
- However, a broader spectrum of vascular mechanisms beyond large artery infarcts contribute to VAD.
- These include vessel-wall damage, cerebrovascular insufficiency, and hyperviscosity.
Purpose of the Study:
- To differentiate multi-infarct dementia (MID) from other forms of vascular dementia (VAD).
- To highlight the distinct pathogenetic pathways and clinical presentations of various VAD subtypes.
Main Methods:
- Review of existing literature on vascular dementia and its subtypes.
- Analysis of pathogenetic mechanisms including thromboembolism, vessel-wall damage, cerebrovascular insufficiency, and hyperviscosity.
- Clinical and pathological characterization of multi-infarct dementia and subcortical white-matter dementia.
Main Results:
- Multi-infarct dementia (MID) diagnosis should be reserved for dementia linked to large cerebral artery infarcts.
- Subcortical white-matter dementia, involving small-vessel disease and white-matter lesions, represents another significant VAD category.
- Other vascular factors like atherosclerosis, cerebral amyloid angiopathy, and impaired autoregulation also play roles in VAD pathogenesis.
Conclusions:
- Vascular dementia (VAD) encompasses more than just multi-infarct dementia (MID).
- Subcortical white-matter dementia is a distinct and important VAD subtype.
- Understanding diverse cerebrovascular mechanisms is crucial for accurate VAD diagnosis and classification.
Abstract:
Today, multiple, thromboembolically generated cerebral infarcts are regarded as the main pathogenetic pathway of vascular dementia (VAD), with multi-infarct dementia (MID) as its clinical counterpart. However, taking into account other vascular mechanisms that may influence the brain, such as vessel-wall damage (atherosclerosis, hyalinosis, amyloid angiopathy, or blood-brain barrier dysfunction), cerebrovascular insufficiency (disturbance of systemic circulation, perfusion vulnerability related to the vascular anatomy of the brain, or disturbance of autoregulation), and hyperviscosity, it is evident that MID is not the only VAD category. The diagnosis of MID ought to be reserved for the combination of progressive dementia associated with cerebral ischemic events and evidence of infarction that is mainly associated with the large cerebral arteries. Subcortical white-matter dementia characterized by frontosubcortical symptomatology, white-matter lesions, and small-vessel involvement with or without lacunes/infarcts--a combination of lacunar dementia and Binswanger's disease--appears to be another important VAD disease.