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Panminerva Medica 2004 December;46(4):217-26


lingua: Inglese

Pathology and pathophysiology of vascular cognitive impairment. A critical update

Jellinger K. A.

Institute of Clinical Neurobiology, Vienna, Austria


The prev­a­lence, mor­phol­o­gy, and path­o­gen­e­sis of vas­cu­lar demen­tia (VaD), recent­ly ­termed vas­cu­lar cog­ni­tive impair­ment (VCI), and of ­mixed demen­tia (Alzheimer dis­ease asso­ciat­ed ­with vas­cu­lar enceph­a­lop­a­thy) are a mat­ter of dis­cus­sion and clinical diagnostic cri­te­ria for ­these dis­or­ders slow low sensitivity and variable specificty. In Western mem­o­ry clin­ic-­based ­series, VaD/VCI is sug­gest­ed in 8-10% of cog­ni­tive­ly ­impaired eld­er­ly sub­jects. Its prev­a­lence in autop­sy ­series rang­es ­from 0.03% to 58% ­with rea­son­able val­ues of 4-10%. It has ­been relat­ed to ­focal, mul­ti­fo­cal or dif­fuse cor­ti­cal and/or sub­cor­ti­cal micro­in­farcts and ­lacunes ­often affect­ing stra­te­gi­cal­ly impor­tant ­brain are­as (thal­a­mus, fron­tob­a­sal and/or lim­bic ­systems), hem­i­spher­ic ­white mat­ter ­lesions and, ­less ­often, ­large ­brain ­infarcts. They ­result ­from system­ic, car­diac or ­local ­large or ­small ves­sel dis­ease. The path­o­gen­e­sis of cereb­ro­vas­cu­lar ­lesions is mul­ti­fac­to­ri­al and ­their pathoph­y­sio­lo­gy ­affects neu­ro­nal ­systems ­involved in cog­ni­tion, mem­o­ry, and behav­ior. Vascular pathol­o­gy ­often coex­ists ­with Alzheimer dis­ease (AD) and oth­er dement­ing dis­or­ders; 25-60% of demen­tia cas­es ­show ­both AD and vas­cu­lar ­lesions. The ­lesion pat­terns in “­pure” VCI ­with pre­dom­i­nant mul­ti­ple ­small (sub­cor­ti­cal) ­lesions relat­ed to arte­rio­scle­ro­sis and micro­an­gio­pa­thies and in ­mixed demen­tia (AD asso­ciat­ed ­with vas­cu­lar enceph­a­lop­a­thy), ­more ­often show­ing ­large ­infarcts, sug­gest dif­fer­ent path­o­gen­e­sis of ­both ­types of ­lesions. Due to the ­high var­i­abil­ity of cereb­ro­vas­cu­lar pathol­o­gy and its caus­a­tive fac­tors no val­i­dat­ed neu­ro­path­o­log­i­cal cri­te­ria ­exist for VCI and ­mixed demen­tia. In ­very old sub­jects selec­tive hip­po­cam­pal scler­o­sis may be asso­ciat­ed ­with mul­ti­ple oth­er vas­cu­lar pathol­o­gies. Minor cereb­ro­vas­cu­lar ­lesions, ­except for ­severe amy­loid angio­pa­thy, ­appear not essen­tial for cog­ni­tive ­decline in ­full-­blown AD, ­while ­both ­mild AD-­type pathol­o­gy and ­small ves­sel dis­ease may inter­act syn­er­gis­ti­cal­ly in “unmask­ing” or pro­mot­ing demen­tia. AD pathol­o­gy is sig­nif­i­cant­ly ­less ­severe in the pres­ence of cereb­ro­vas­cu­lar ­lesions. Further stud­ies are need­ed to val­i­date diag­nos­tic cri­te­ria for VaD/VCI and to clar­i­fy the ­impact of vas­cu­lar ­lesions on cog­ni­tive impair­ment as a ­basis for ­more pre­cise clin­i­cal diag­no­sis, ear­ly pre­ven­tion and man­age­ment.

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