Cerebrovascular disease in patients with cognitive impairment: A white paper from the ESO dementia committee – A practical point of view with suggestions for the management of cerebrovascular diseases in memory clinics

Abstract

Purpose Practical suggestions on clinical decisions about vascular disease management in patients with cognitive impairment are proposed. Methods The document was produced by the Dementia Committee of the European Stroke Organisation (ESO) based on the evidence from the literature where available and on the clinical experience of the Committee members. This paper was endorsed by the ESO. Findings Vascular risk factors and cerebrovascular disease are frequent in patients with cognitive impairment. While acute stroke treatment has evolved substantially in last decades, evidence of management of cerebrovascular pathology beyond stroke in patients with cognitive impairment and dementia is quite limited. Additionally, trials to test some daily-life clinical decisions are likely to be complex, difficult to undertake and take many years to provide sufficient evidence to produce recommendations. This document was conceived to provide some suggestions until data from field trials are available. It was conceived for the use of clinicians from memory clinics or involved specifically in cognitive disorders, addressing practical aspects on diagnostic tools, vascular risk management and suggestions on some therapeutic options. Discussion and conclusions The authors did not aim to do an exhaustive or systematic review or to cover all current evidence. The document approach in a very practical way frequent issues concerning cerebrovascular disease in patients with known cognitive impairment.

ESO Guideline on covert cerebral small vessel disease

“…145 We also refer to current hypertension, 32 diabetes, 137 or dementia guidelines 145 and white papers. 156,157 We expected that there could be limited evidence on ccSVD and clinical outcomes. Not only was the amount of evidence limited, but the quality of evidence was generally low reflecting primarily the small sample sizes and methodologies including randomisation procedures.…”

Outcome of Magnetic Resonance Imaging (MRI) Technique on Vascular Cognitive Impairment (VCI): Meta-Analysis

“…To measure the severity and ascertain the state of vascular brain injury, imaging of the brain becomes paramount. Detection of small brain lesions, WMH, microbleed and superficial siderosis, MRI is selected over computed tomography due its sensitivity [11,12]. Patient's age should be considered when weighing the burden of brain atrophy and vascular brain lesions, because the occurrence of WMH increase from 50% to 95% at 45 and 80 years respectively in the overall populace [13,14].…”

Diagnosing vascular cognitive impairment: Current challenges and future perspectives

“…Modifiable vascular risk factors (i.e. hypertension, diabetes mellitus, smoking, hyperlipidemia, obesity, excessive alcohol consumption, poor diet, inadequate exercise) 12 should be systematically recorded.…”

“…subdural hematoma, brain tumor) and for demonstrating large infarcts, most lacunes, severe white matter lesions, and brain atrophy. 12 , 16 The burden of brain atrophy and vascular brain lesions should be weighted according to the patient’s age. In the general population, the prevalence of WMH increases from 50% at 45 years to 95% at 80 years of age.…”

“… 17 , 18 Silent brain infarcts, lacunes, microbleeds, pronounced perivascular spaces, and brain atrophy are also commonly found in asymptomatic individuals. 12 , 18 A known dilemma in assessing the burden of vascular brain injury, particularly for small vessel disease, is that normative data are not routinely available in a clinical setting and generally not part of radiology reports.…”