The prevalence of dementia is increasing in our aging population at an alarming rate. Because of the heterogeneity of clinical presentation and complexity of disease neuropathology, dementia classifications remain controversial. Recently, the National Plan to address Alzheimer's Disease prioritized Alzheimer's disease-related dementias to include: Alzheimer's disease, dementia with Lewy bodies, frontotemporal dementia, vascular dementia, and mixed dementias. While each of these dementing conditions has their unique pathologic signature, one common etiology shared among all these conditions is cerebrovascular dysfunction at some point during the disease process. The goal of this comprehensive review is to summarize the current findings in the field and address the important contributions of cerebrovascular, physiologic, and cellular alterations to cognitive impairment in these human dementias. Specifically, evidence will be presented in support of small-vessel disease as an underlying neuropathologic hallmark of various dementias, while controversial findings will also be highlighted. Finally, the molecular mechanisms shared among all dementia types including hypoxia, oxidative stress, mitochondrial bioenergetics, neuroinflammation, neurodegeneration, and bloodbrain barrier permeability responsible for disease etiology and progression will be discussed.

The goal of this study was to elucidate the mechanisms of 17␤-estradiol (E 2 ) antioxidant and neuroprotective actions in stroke. The results reveal a novel extranuclear receptor-mediated antioxidant mechanism for E 2 during stroke, as well as a hypersensitivity of the CA3/CA4 region to ischemic injury after prolonged hypoestrogenicity. E 2 neuroprotection was shown to involve a profound attenuation of NADPH oxidase activation and superoxide production in hippocampal CA1 pyramidal neurons after stroke, an effect mediated by extranuclear estrogen receptor ␣ (ER␣)-mediated nongenomic signaling, involving Akt activation and subsequent phosphorylation/ inactivation of Rac1, a factor critical for activation of NOX2 NADPH oxidase. Intriguingly, E 2 nongenomic signaling, antioxidant action, and neuroprotection in the CA1 region were lost after long-term E 2 deprivation, and this loss was tissue specific because the uterus remained responsive to E 2 . Correspondingly, a remarkable loss of ER␣, but not ER␤, was observed in the CA1 after long-term E 2 deprivation, with no change observed in the uterus. As a whole, the study reveals a novel, membrane-mediated antioxidant mechanism in neurons by E 2 provides support and mechanistic insights for a "critical period" of E 2 replacement in the hippocampus and demonstrates a heretofore unknown hypersensitivity of the CA3/CA4 to ischemic injury after prolonged hypoestrogenicity.

Estrogen has multiple actions in the brain to modulate homeostasis, synaptic plasticity/cognition and neuroprotection. While many of these actions undoubtedly involve mediation via the classical genomic mechanism of regulation of transcription of genes via estrogen nuclear receptors, there has been growing interest in the rapid nongenomic effects of estrogen and the role they may play in the neural actions of estrogen. In this review, we will focus on these rapid nongenomic actions of estrogen in the brain and discuss the potential physiological significance of these actions. The evidence for rapid estrogen regulation of cell signaling pathways, including calcium, ion channel and kinase signaling pathways in the brain will be reviewed, as will evidence derived from plasma-membrane impermeable estrogen-peptide conjugates in the regulation of these cell signaling pathways. Evidence supporting classical and nonclassical estrogen receptor localization to the plasma membrane of neurons will also be reviewed, including the putative new membrane estrogen G-protein-coupled receptor, GPR30. Precisely how membrane estrogen receptors couple to kinase signaling pathways is unclear, but we will discuss the latest findings on estrogen receptor-interacting scaffold proteins, such as MNAR/PELP1, striatin and p130Cas, which are capable of linking estrogen receptors and kinases such as Src and PI3K, to potentially mediate estrogen-induced kinase signaling. Finally, we will review the growing evidence that rapid membrane-mediated effects of estrogen play an important physiological role in the neural actions of estrogen in the brain, including estrogen feedback control and modulation of homeostasis, regulation of synaptic plasticity/cognition, and estrogen-mediated neuroprotection.

Objective: To determine the association of conventional cardiovascular risk factors, markers of platelet activation, and thrombogenic blood-borne microvesicles with white matter hyperintensity (WMH) load and progression in recently menopausal women.Methods: Women (n 5 95) enrolled in the Mayo Clinic Kronos Early Estrogen Prevention Study underwent MRI at baseline and at 18, 36, and 48 months after randomization to hormone treatments. Conventional cardiovascular risk factors, carotid intima-medial thickness, coronary arterial calcification, plasma lipids, markers of platelet activation, and thrombogenic microvesicles were measured at baseline. WMH volumes were calculated using a semiautomated segmentation algorithm based on fluid-attenuated inversion recovery MRI. Correlations of those parameters with baseline WMH and longitudinal change in WMH were adjusted for age, months past menopause, and APOE e4 status in linear regression analysis.Results: At baseline, WMH were present in all women. The WMH to white matter volume fraction at baseline was 0.88% (0.69%, 1.16%). WMH volume increased by 122.1 mm 3 (95% confidence interval: 2164.3, 539.5) at 36 months (p 5 0.003) and 155.4 mm 3 (95% confidence interval: 292.13, 599.4) at 48 months (p , 0.001). These increases correlated with numbers of platelet-derived and total thrombogenic microvesicles at baseline (p 5 0.03). White matter hyperintensities (WMH) observed in the aging brain are associated with small-vessel disease. Conclusion:1,2 Although high WMH load may lead to mild cognitive impairment 3-6 and increase the risk of stroke, 7,8 little is known regarding the source or nature of cellular factors mediating their formation. 9Conventional cardiovascular risk factors such as hypertension, increasing age, smoking, hypercholesterolemia, and a history of cerebrovascular disease are the most consistent risk factors for the load and progression of WMH in elderly persons. 2,[10][11][12] In addition, thrombogenic risk factors including activated cell-derived microvesicles may contribute to formation of WMH, ischemic brain disease, and cognitive decline. [13][14][15][16] In recently menopausal women enrolled in the Kronos Early Estrogen Prevention Study (KEEPS), numbers of platelet-derived and thrombogenic (annexin V-positive) microvesicles correlated with carotid artery intima-medial thickness (CIMT). 17,18 Furthermore, CIMT correlated positively with the prevalence of WMH and poor cognitive performance. 19 Taken together, these studies suggest that cardiovascular risk factors, which may activate platelets to shed thrombogenic microvesicles, affect brain microstructure.

Vascular cognitive impairment is a major cause of dementia caused by chronic hypoxia, producing progressive damage to white matter (WM) secondary to blood-brain barrier (BBB) opening and vascular dysfunction. Tight junction proteins (TJPs), which maintain BBB integrity, are lost in acute ischemia. Although angiogenesis is critical for neurovascular remodeling, less is known about its role in chronic hypoxia. To study the impact of TJP degradation and angiogenesis during pathological progression of WM damage, we used the spontaneously hypertensive/stroke prone rats with unilateral carotid artery occlusion and Japanese permissive diet to model WM damage. MRI and IgG immunostaining showed regions with BBB damage, which corresponded with decreased endothelial TJPs, claudin-5, occludin, and ZO-1. Affected WM had increased expression of angiogenic factors, Ki67, NG2, VEGF-A, and MMP-3 in vascular endothelial cells and pericytes. To facilitate the study of angiogenesis, we treated rats with minocycline to block BBB disruption, reduce WM lesion size, and extend survival. Minocycline-treated rats showed increased VEGF-A protein, TJP formation, and oligodendrocyte proliferation. We propose that chronic hypoxia disrupts TJPs, increasing vascular permeability, and initiating angiogenesis in WM. Minocycline facilitated WM repair by reducing BBB damage and enhancing expression of TJPs and angiogenesis, ultimately preserving oligodendrocytes.