Vascular Cognitive Impairment (VCI) PDF

VASCULAR COGNITIVE IMPAIRMENT Joukje Oosterman Neuropsychology and Rehabilitation psychology [email protected] Today 1. What is vascular cognitive impairment? 2. Normal and abnormal blood supply of the brain – Large and small vessel disease 3. Vascular risk factors and SVD: Ag...

VASCULAR COGNITIVE IMPAIRMENT Joukje Oosterman Neuropsychology and Rehabilitation psychology [email protected] Today 1. What is vascular cognitive impairment? 2. Normal and abnormal blood supply of the brain – Large and small vessel disease 3. Vascular risk factors and SVD: Aging 4. Stroke 5. Vascular dementia 1. What is vascular cognitive impairment? COGNITIVE DISORDERS WITH A CEREBROVASCULAR AETIOLOGY Vascular Cognitive Impairment (VCI) All forms of cognitive disorder associated with cerebrovascular disease Aetiology Large vessel disease Small vessel disease VCI covers the entire spectrum from mild cognitive disorders to vascular dementia No impairments Mild cognitive Vascular disorders dementia Severity 2. Normal and abnormal blood supply of the brain From artery to vein Arteries: Carry oxygenated blood from the heart Veins: Carry deoxygenated blood to the heart Small vessels Large vessels 2. Normal and abnormal blood supply of the brain The blood vessels in our brain: https://www.youtube.com/watch?v=uMMMqkVZAhk 2. Normal and abnormal blood supply of the brain Large versus small vessel disease 2. Normal and abnormal blood supply of the brain Large versus small vessel disease Rao et al. Cureus 2018 2. Normal and abnormal blood supply of the brain Large versus small vessel disease Cerebral White matter microbleeds hyperintensities ter Telgte et all., 2018, Wardlaw et al., 2013 Lacunes 3. Vascular risk factors and SVD: Aging Causes: prevalence of vascular risk factors LaPlume et al. Alzheimers Dement 2022 3. Vascular risk factors and SVD: Aging Vascular risk relates to accelerated cognitive decline LaPlume et al. Alzheimers Dement 2022 3. Vascular risk factors and SVD: Aging Causes: vascular risk factors and dementia Kloppenborg et al. Eur J Pharmacol 2008 3. Vascular risk factors and SVD: Aging Global increases in unhealthy lifestyles Obesity Sedentary behavior Agha et al., 2017; López-Valenciano et al. (2020) A 78-year-old man with history of hypertension and type 2 diabetes awoke with inability to move his right side. On examination, his blood pressure was 180/98, his pulse was regular, and he had no carotid bruits. He had a dense right hemiparesis with no other associated neurological deficits. Initial CT of scan of the head did not reveal any acute intracranial abnormalities. Brain MRI (Figure 7-2) showed an acute small subcortical stroke in the posterior limb of the left internal capsule. Carotid ultrasound and cardiac workup were unremarkable. The patient was discharged on antiplatelet therapy, antihypertensives, an adjusted regimen for his diabetes, and a statin. He evolved favorably over the subsequent few months. https://radiologykey.com/small-vessel-disease/ 3. Vascular risk factors and SVD: Aging Modifiable risk factors of dementia Cardiovascular risk factors make aging- related changes more pronounced E.g. hypertension, alcohol usage, obesity, smoking, physical inactivity, diabetes Modifying these might prevent or delay up to nearly half of all dementia cases And generally improve healthy aging Livingstone et al. Lancet 2024 3. Vascular risk factors and SVD: Aging Aging, cerebral blood flow and grey matter loss Chen et al. Neuroimage 2011 Thompson et al.. J Neurosci 2003 3. Vascular risk factors and SVD: Aging Prevelance of SVD in aging Mu et al. Neuropsychiatr Dis Treat 2022 3. Vascular risk factors and SVD: Aging Cognitive profile of aging Executive functioning and (psycho)motor speed are most prominently affected by SVD Levitt et al., Exp Aging Res 2006;32:263-295. 3. Vascular risk factors and SVD: Aging Time to start moving! 3. Vascular risk factors and SVD: Aging Cerebral perfusion Carl-Johan Boraxbekk et al. NeuroImage, Volume 131, 2016, 133–141 3. Vascular risk factors and SVD: Aging The effect of physical activity 9 years later 299 participants Average age: 78 years Minnesota Leisure-Time Activities Questionnaire (duration & frequency physical activity) (4 groups, based on quartiles) MRI-9 years later (grey matter volume) Erickson et al. Neurology 2010;75:1415-1422 3. Vascular risk factors and SVD: Aging Exercise as an intervention 16 older adults (age 72.1) 4 weeks exercise, minimum of 2 to 3x a week, + additional activities at home 16 older control adults (no exercise, age 73.6) Cognitive functioning before and after intervention Executive functioning Psychomotor speed Anderson-Hanley et al. JCEN 2010 4. Cerebrovascular accident (CVA) Stroke CVA = stroke 40 000 people per year 15% between 18 and 50 yrs ±80% ±20%  4. Cerebrovascular accident (CVA) Ischemic stroke – Penumbra: area located around the ischaemic core – Embolic stroke: clotted material that breaks off from elsewhere in the body (eg lungs) – Atherothrombosis: formation of blood clot (thrombotic stroke) in brain artery 4. Cerebrovascular accident (CVA) Haemorrhagic stroke Intracerebral haemorrhage (within brain) – Lobar: located in one of the cerebral lobes – Non-lobar: located in basal ganglia, thalamus, cerebellum or brain stem Subarachnoid haemorrhage (not within brain) – Bleeding in the subarachnoid space  4. Cerebrovascular accident (CVA) Perfusion areas of the major arteries – Supratentorial: in the cerebrum – Infratentorial: in the brainstem or cerebellum 4. Cerebrovascular accident (CVA) Type of motor or cognitive dysfunction depends on location of stroke: Supply area of anterior cerebral artery Supplies blood to the dorsal and medial parts of the frontal and parietal lobes. Impairments are found in: Neurological Language symptoms Executive function Behavioural Emotional Social cognition disorders disorders Behaviour and emotions Personality … changes Cognitive disorders 4. Cerebrovascular accident (CVA) Type of motor or cognitive dysfunction depends on location of stroke: Supply area of middle cerebral artery Supplies blood to the frontal, temporal and parietal lobes, and deep brain structures (eg thalamus). Accounts for approximately 80% of all stroke cases. Common consequences: Memory disorders Aphasia Apraxia Hemispatial neglect Extinction 4. Cerebrovascular accident (CVA) Type of motor or cognitive dysfunction depends on location of stroke: Supply area of posterior cerebral artery Supplies blood to the occipital and temporal lobes. Common consequences: Hemianopsia or quandrantanopsia Visual agnosia (e.g., object agnosia, proposagnosia) 4. Cerebrovascular accident (CVA) Transient Ischaemic Attack (TIA) Recovery < 24 hours. TIA: Brief ischaemic event Focal symptoms: Problem is specific to a certain area of the brain Abnormalities often also appear on acute brain scan Increased risk of having a stroke 4. Cerebrovascular accident (CVA) Transient Ischaemic Attack (TIA) Many people still report cognitive problems three months after a TIA Impairments on neuropsychological assessment Van Rooij et al. Stroke 2014  Video: life after stroke 4. Cerebrovascular accident (CVA) Cognitive recovery 8 days post-stroke 6-10 months after first assessment Baseline Follow-up 35 30 Prevalence (%) 25 20 15 10 5 0 Perception/ Executive Reasoning Verbal Language Visual construction function memory memory 49% cognitive impairments in acute phase → 31% at follow-up  4. Cerebrovascular accident (CVA) Cognitive recovery ▪ ‘Unimpaired’ patients still unimpaired after six months ▪ Other group generally shows progress ▪ Dynamic recovery and not ‘demented’ ▪ Dependent on affected domain ▪ May be linked to location of recovery ▪ Determinants ▪ Schooling/age → ‘cognitive reserve’? (Stern et al., 2003; Robertson & Murre, 1999) ▪ Lesion volume less important than location → small strategic infarcts sometimes accompanied by dementia (see Auchus et al., 2002)  4. Cerebrovascular accident (CVA) Mood disorders post-stroke Depressive symptoms occur in one third of stroke survivors Frequency is highest within the first year after stroke event Associated with poor recovery and long-term outcomes Suggested underlying mechanisms: Biological hypothesis Reactive hypothesis Vascular depression hypothesis (Robinson et al.) (Gainotti et al.) (Alexopoulus et al.) Towfighi et al. Stroke 2017 Video: rehabilitation 5:10 e.v. 11:50 e.v. 14.15 e.v. systeem 5. Vascular dementia Dementia subtypes Dementia 5. Vascular dementia Dementia Cortical v. subcortical profile No specific neuropsychological pattern Course often fluctuates Strategic infarct or multi-infarct may contribute Roman, J Am Geriatr Soc 2003 5. Vascular dementia Most important cognitive deficits Dementia Executive deficits (at the level of thought, behaviour, emotion) Additional deficits: Mental processing speed Memory Visuoconstruction Language Roman, J Am Geriatr Soc 2003 5. Vascular dementia AD versus sVAD Dementia Strategic retrieval VanderPloeg et al., 2001 JINS LEARNING OBJECTIVES Knowledge of the circulatory system of the brain and the supply and perfusion area Knowledge of small and large vessel disease Knowledge of the neurocognitive profile of normal aging Knowledge of the importance of vascular risk factors and physical activity Knowing the differences between a brain infarct, a brain haemorrhage and TIA Insight in cognitive disorders after a stroke Insight in predictors of recovery after a stroke Being able to explain the relationship between localisation of the lesion and function loss Being able to explain what stroke is, along with its typical cognitive profile Knowing terms such as penumbra, diaschisis, embolism and thrombosis Knowing the criteria for vascular dementia and differences between subtypes