Criteria for the diagnosis of vascular dementia (VaD) that are reliable, valid, and readily applicable in a variety of settings are urgently needed for both clinical and research purposes. To address this need, the Neuroepidemiology Branch of the National Institute of Neurological Disorders and Stroke (NINDS) convened an International Workshop with support from the Association Internationale pour la Recherche et l'Enseignement en Neurosciences (AIREN), resulting in research criteria for the diagnosis of VaD. Compared with other current criteria, these guidelines emphasize (1) the heterogeneity of vascular dementia syndromes and pathologic subtypes including ischemic and hemorrhagic strokes, cerebral hypoxic-ischemic events, and senile leukoencephalopathic lesions; (2) the variability in clinical course, which may be static, remitting, or progressive; (3) specific clinical findings early in the course (eg, gait disorder, incontinence, or mood and personality changes) that support a vascular rather than a degenerative cause; (4) the need to establish a temporal relationship between stroke and dementia onset for a secure diagnosis; (5) the importance of brain imaging to support clinical findings; (6) the value of neuropsychological testing to document impairments in multiple cognitive domains; and (7) a protocol for neuropathologic evaluations and correlative studies of clinical, radiologic, and neuropsychological features. These criteria are intended as a guide for case definition in neuroepidemiologic studies, stratified by levels of certainty (definite, probable, and possible). They await testing and validation and will be revised as more information becomes available.

Cognitive function was examined in 227 patients three months after admission to hospital for ischaemic stroke, and in 240 stroke-free controls, using 17 scored items that assessed memory, orientation, verbal skills, visuospatial ability, abstract reasoning, and attentional skills. After adjusting for demographic factors with standardised residual scores in all subjects, the fifth percentile was used for controls as the criterion for failure on each item. The mean (SD) number of failed items was 3-4 (3.6) for patients with stroke and 0-8 (1.3) for controls (p < 0-001).Cognitive impairment, defined as failure on any four or more items, occurred in 35-2% of patients with stroke and 3-8% of controls (p < 0-001). Cognitive domains most likely to be defective in stroke compared with control subjects were memory, orientation, language, and attention. Among patients with stroke, cognitive impairment was most frequently associated with major cortical syndromes and with infarctions in the left anterior and posterior cerebral artery territories. Functional impairment was greater with cognitive impairment, and dependent living after discharge either at home or nursing home was more likely (55.0% with, v 32-7% without cognitive impairment, p = 0-001). In a logistic model examining the risks related to dependent living after stroke, cognitive impairment was a significant independent correlate (odds ratio, OR = 2-4), after adjusting for age (OR = 5'2, 80 + v 60-70 years) and physical impairment (OR = 3.7, Barthel index < 40 v > 40). It is concluded that cognitive impairment occurs frequently after stroke, commonly involving memory, orientation, language, and attention. The presence of cognitive impairment in patients with stroke has important functional consequences, independent of the effects of physical impairment. Studies of stroke outcome and intervention should take into account both cognitive and physical impairments. (7 Neurol Neurosurg Psychiatry 1994;57:202-207) Cerebrovascular disease is an important cause of morbidity in the elderly, resulting not only in physical disability, but also significant cognitive impairment. Most studies of stroke outcome have focused on physical consequences;' few have examined intellectual deficits.2 In a previous study, we found dementia in 66 (26.3%) of 251 elderly patients examined with neuropsychological tests three months after hospital admission for ischaemic stroke.3 Excluding subjects with functional impairment preceding stroke onset who may have had coexisting Alzheimer's disease, the frequency of dementia in this sample was 16-3% (37 of 227 patients with stroke). Our research criteria for dementia required the presence of memory impairment combined with deficits in two additional cognitive domains. Because the frequency of dementia will depend in part on the diagnostic criteria used,4 the frequency of intellectual decline may be over-represented or underrepresented by focusing on dementia as a diagnosis.An alternative approach to characterising the cognitive conse...

In a prospective study of 1,805 hospitalized patients in the Stroke Data Bank of the National Institute of Neurological and Communicative Disorders and Stroke, the 1,273 with infarction were classified into diagnostic subtypes. Diagnosis was based on the clinical history, examination, and laboratory tests including computed tomography, noninvasive vascular imaging, and where safe and relevant, angiography. Five hundred and eight cases (fully 40%) were labeled as infarcts of undetermined cause (IUC), of which 138 (27%) were evaluated with both computed tomography and angiography. The clinical syndrome and computed tomographic and angiographic findings in 91 (65.9%) of these 138 IUC cases were clearly not attributable to large-artery thrombosis and could permit reclassification of the infarct as due to some form of embolism. Failure to define a source of embolus kept them in the category of IUC. Thirty-one cases (22.5%) could be reclassified as due to stenosis or thrombosis of a large artery, and 16 (11.6%) as lacunar infarction. To determine if those selected for angiography among the IUC patients differed from those with other final diagnoses, a stepwise multiple logistic model was used. The most important characteristics were young age, presence of a superficial infarct, prior transient ischemic attack, low weakness score, and presentation with a nonlacunar syndrome. The results of the model suggest that angiography use was determined by clinical characteristics uniformly across centers and not by final diagnosis. Continued use of the category IUC may help clarify risk factors and stroke subtypes, allow new mechanisms of ischemic stroke to be uncovered, and prevent classification categories of stroke used in clinical trials from becoming too broad.

Objective.\p=m-\Several cross-sectional studies have found an association between Alzheimer's disease (AD) and limited educational experience. It has been difficult to establish whether educational experience is a risk factor for AD because educational attainment can influence performance on diagnostic tests. This study was designed to determine whether limited educational level and occupational attainment are risk factors for incident dementia. Design.\p=m-\Cohort incidence study. Setting.\p=m-\Generalcommunity. Participants.\p=m-\A total of 593 nondemented individuals aged 60 years or older who were listed in a registry of individuals at risk for dementia in North Manhattan, NY, were identified and followed up.Interventions.\p=m-\Wereexamined subjects 1 to 4 years later with the identical standardized neurological and neuropsychological measures.Main Outcome Measure.\p=m-\Incidentdementia.Results.\p=m-\Weused Cox proportional hazards models, adjusting for age and gender, to estimate the relative risk (RR) of incident dementia associated with low educational and occupational attainment. Of the 593 subjects, 106 became demented; all but five of these met research criteria for AD. The risk of dementia was increased in subjects with either low education (RR, 2.02; 95% confidence interval [CI], 1.33 to 3.06) or low lifetime occupational attainment (RR, 2.25; 95% CI, 1.32 to 3.84). Risk was greatest for subjects with both low education and low l i f e\ x=r eq-\ time occupational attainment (RR, 2.87; 95% CI, 1.32 to 3.84).Conclusions.\p=m-\Thedata suggest that increased educational and occupational attainment may reduce the risk of incident AD, either by decreasing ease of clinical detection of AD or by imparting a reserve that delays the onset of clinical manifestations.

Among 251 patients examined 3 months after the onset of acute ischemic stroke, we diagnosed dementia in 66 (26.3%) by using modified DSM-III-R criteria based on neuropsychological, neurological, functional, and psychiatric examinations. We used a logistic regression model to derive odds ratios (ORs) for clinical factors independently related to dementia in this cross-sectional sample. Dementia was significantly associated with age, education, and race. A history of prior stroke (OR = 2.7) and diabetes mellitus (OR = 2.6) was also independently related to dementia, but hypertension and cardiac disease were not. Stroke features associated with dementia included lacunar infarction compared with all other subtypes combined (OR = 2.7) and hemispheric laterality in relation to brainstem or cerebellar location. There was a predominance of dementia in patients with left-sided lesions (OR = 4.7), an effect not explained by aphasia. Dementia was especially common with infarctions in the left posterior cerebral and anterior cerebral artery territories. A major dominant hemispheral syndrome (reflecting size and laterality) was also independently associated with dementia (OR = 3.9). We suggest that dementia after ischemic stroke is a result of multiple independent factors, including both small subcortical and large cortical infarcts especially involving the left medial frontal and temporal regions, with additional contributions by demographic and vascular risk factors.