Diagnosing vascular cognitive impairment: Current challenges and future perspectives

Abstract

Cerebrovascular disease is a major cause of cognitive decline and dementia. This is referred to as vascular cognitive impairment (VCI). Diagnosing VCI is important, among others to optimize treatment to prevent further vascular injury. This narrative review addresses challenges in current diagnostic approaches to VCI and potential future developments. First we summarize how diagnostic criteria for VCI evolved over time. We then highlight challenges in diagnosing VCI in clinical practice: assessment of severity of vascular brain injury on brain imaging is often imprecise and the relation between vascular lesion burden and cognitive functioning shows high intersubject variability. This can make it difficult to establish causality in individual patients. Moreover, because VCI is essentially an umbrella term, it lacks specificity on disease mechanisms, prognosis, and treatment. We see the need for a fundamentally different approach to diagnosing VCI, which should be more dimensional, including multimodal quantitative assessment of injury, with more accurate estimation of cognitive impact, and include biological definitions of disease that can support further development of targeted treatment. Recent developments in the field that can form the basis of such an approach are discussed.

Network impact score is an independent predictor of post-stroke cognitive impairment: A multicenter cohort study in 2341 patients with acute ischemic stroke

“…Clinical predictors and imaging characteristics, in particular infarct location and size, have prognostic value ( Weaver et al, 2021 ), but accurate PSCI risk prediction remains challenging. Improving PSCI risk prediction is considered an important step towards developing and implementing disease-modifying therapies in patients at risk ( Biesbroek, 2022 , Vinciguerra et al, 2020 ).…”

“…A major source of prognostic uncertainty after stroke is the marked heterogeneity in terms of underlying disease mechanisms, premorbid brain function and comorbidity, impact on brain connectomics, and brain plasticity ( Biesbroek, 2022 , Vinciguerra et al, 2020 ). As a consequence, two patients with an infarct that appears similar on routine brain imaging may have different cognitive outcomes.…”

“…As a consequence, two patients with an infarct that appears similar on routine brain imaging may have different cognitive outcomes. Promising approaches to improving prediction of PSCI focus on developing diagnostic and prognostic biomarkers that support biological definitions of disease mechanisms and quantitative, multimodal assessment of vascular brain injury and its impact on brain function ( Biesbroek, 2022 , Vinciguerra et al, 2020 ).…”

Advances in large artery occlusive stroke from COVID-19 to thrombectomy and more

“…Dementia is a major complication of stroke, but the mechanisms underlying this association are not fully understood. 15 Gong et al in this month's issue investigated this question 16 using data from the PROGRESS blood pressure reduction after stroke trial. 17 Over a median follow-up of 4 years, 763 of 5888 participants (of whom 31% were women) developed cognitive decline/dementia.…”

Three major global stroke challenges: Intracranial stenosis, atrial fibrillation, and cerebral small vessel disease

“…11,12 Such imaging markers are providing important insights into the mechanisms of cognitive impairment in individual patient groups, and may allow targeted and more personalized treatment approaches. 9 There is also great interest in their use in predicting future risk of cognitive decline. MR-based studies have shown that scores based on both simple clinical MRI markers of SVD, 13,14 and also more advanced techniques such as diffusion tensor imaging, 15,16 may allow improved detection of which patients with stroke progress to dementia.…”