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Vascular Dementia


KEY FACTS

Terminology

  • Vascular dementia (VaD), multiinfarct dementia (MID)

  • Stepwise progressive ↓ in cognitive function

  • Heterogeneous group of disorders with varying etiologies, pathologic subtypes

    • VaD often mixed etiology

    • Can occur alone or in association with Alzheimer disease (AD)

    • MID secondary to repeated cerebral infarctions

Imaging

  • General features

    • Multifocal infarcts [cortical gray matter, subcortical white matter (WM)]

    • Basal ganglia, pons

    • Territorial as well as lacunar lesions

    • Coexisting microvascular WM disease common

    • Multiple remote microhemorrhage

  • CT

    • Multifocal infarcts

    • Single or multiple, lacunar to territorial

    • WM hypointensities (discrete to confluent)

  • FDG PET

    • Multifocal regions ↓ metabolism in cortex, WM

Top Differential Diagnoses

  • AD

  • Frontotemporal lobar degeneration

  • CADASIL

  • Dementia with Lewy bodies

Clinical Issues

  • 2nd most common dementia (after AD)

  • Mood and behavioral changes more typical than memory loss

Diagnostic Checklist

  • Report strategically placed infarcts

  • Look for hemorrhage, DWI abnormalities

Axial diagram of vascular dementia shows diffuse cerebral atrophy, focal volume loss due to multiple chronic infarcts
, an acute left occipital lobe infarct
, and small lacunar infarcts in the basal ganglia/thalami
.

Axial NECT demonstrates periventricular white matter hypodensity
, as well as bilateral MCA
and right PCA
infarcts, in a patient with vascular dementia. The clinical history plus findings of infarcts in multiple separate vascular distributions are consistent with vascular dementia.

Axial FDG PET in a patient with multiinfarct dementia demonstrates multiple wedge-shaped areas of hypometabolism
due to chronic infarcts.

(Courtesy A. Ali, MD.)

Axial FLAIR MR in a 72-year-old man with chronic hypertension and diabetes presenting with mood and behavioral changes shows confluent white matter hyperintensities
in the periventricular regions. Note the multiple chronic lacunar infarcts in the basal ganglia
as well as enlargement of the ventricles and cortical sulci.

TERMINOLOGY

Abbreviations

  • Vascular dementia (VaD)

Synonyms

  • Multi-infarct dementia (MID)

  • Vascular cognitive disorder (VCD)

  • Vascular cognitive impairment (VCI)

  • Subcortical ischemic vascular dementia

  • Poststroke dementia

Definitions

  • Stepwise progressive deterioration of cognitive function

    • VaD: Heterogeneous group of disorders with varying etiologies, pathologic subtypes

      • –

        Often mixed etiology

    • Can occur alone or in association with Alzheimer disease (AD)

    • MID secondary to repeated cerebral infarctions

IMAGING

General Features

  • Best diagnostic clue

    • Multifocal infarcts

      • –

        Cortical gray matter (GM), subcortical white matter (WM)

      • –

        Basal ganglia (BG), pons

      • –

        Territorial as well as lacunar infarcts

      • –

        Changes of microvascular WM ischemia common

  • Location

    • Typically involve cerebral hemispheres and BG

    • Usually bilateral but may be unilateral

  • Size

    • Vary from single to multiple, punctate to large/confluent

  • Morphology

    • Small infarcts are rounded or oval; large confluent abnormalities are ill defined

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