The diagnosis and treatment of vascular cognitive impairment, a summary of the article

Cerebrovascular diseases represented by stroke, in addition to causing movement, sensation, vision and swallowing disorders, can also cause anxiety, depression, emotional incontinence, apathy, insomnia, fatigue, lack of willpower and other personality behavior changes, as well as decreased attention , Unresponsiveness, memory decline, aphasia, executive function decline and other vascular cognitive disorders.

Vascular cognitive impairment can occur at any age and any type of cerebrovascular disease, but the elderly are more susceptible, and the cause is more common with stroke.

Clinical features Vascular cognitive impairment can start acutely after severe cerebrovascular disease, or slowly appear after several minor strokes.

According to the severity of cognitive impairment and whether it affects the independence of activities of daily living, vascular cognitive impairment can be divided into vascular dementia, vascular mild cognitive impairment and focal high cortical dysfunction.

Abnormal personality behaviors can occur independently or accompanied by vascular cognitive impairment.

 Focal high-grade cortical dysfunction When cerebrovascular disease involves special functional areas of the cerebral cortex, the clinical manifestations are classic cortical syndromes.

The following types are common: ① motor aphasia: damage to the cortex or subcortex of the Broca area of ​​the subfrontal gyrus and the triangle in the dominant hemisphere, and the pronunciation muscles move normally and cannot speak in a coordinated manner.

② Sensory aphasia: One third of the Wernicke center in the superior superior temporal gyrus of the dominant hemisphere is damaged, and the hearing is normal but the language cannot be understood.

③ Dyslexia: The dominant hemisphere angular gyrus and its vicinity are damaged, with normal vision but unable to read text.

④Agraphia: damage to the posterior middle frontal gyrus in the dominant hemisphere, normal hand movement and unable to write words in a coordinated manner.

⑤ Naming aphasia: damage to the lower part of the parietal lobe and posterior temporal lobe in the dominant hemisphere, know the function of the object, and cannot tell the name of the object.

⑥Apraxia: damage to the upper margin of parietal lobe, inferior parietal lobule, and superior lobule, movement, mutual aid, and feeling normal, but unable to perform purposeful actions, unable or unable to use objects correctly, or unable to imitate others' action.

⑦Gerstmann syndrome: It is more common at the junction of the posterior lower parietal lobe and the temporal roof in the dominant hemisphere, manifested as finger agnosia, left-right disorientation, aphasia, and miscalculation.

⑧ Geographical barriers: parieto-occipital area lesions, unfamiliar with the familiar environment, and unable to reproduce or reconstruct the familiar place visually.

 The clinical features of post-stroke vascular cognitive impairment include: ①Have a history of stroke and localized symptoms and signs such as weakness, numbness, pseudobulbar palsy, tendon hyperreflexia, and positive pathological signs on one side of the limb caused by the stroke.

②The onset of cognitive impairment is sudden, with acute or subacute onset, dementia soon after multiple strokes (including transient ischemic attack) or a large-area cerebral infarction or cerebral hemorrhage, or after several small episodes Dementia gradually occurred after cerebral infarction (within 6 months).

③The impairment of advanced cognitive function is related to the lesion site, which may be patchy, memory impairment may be mild, and aphasia or executive function impairment may be severe.

④ It may be accompanied by emotional behavior symptoms such as strong crying and strong laughter, anxiety, depression, emotional instability, impulsivity, and indifference.

⑤Images can show signs of multiple cerebral infarction or single key site infarction, cerebral parenchymal hemorrhage, and convex brain subarachnoid hemorrhage consistent with clinical features.

 The clinical features of vascular cognitive impairment due to cerebral small vessel disease include: ① There is no history of stroke, or there is a short stroke but a quick recovery.

Cognitive impairment starts gradually and progresses slowly.

②Clinical manifestations include slow response, slow speech, delayed thinking and activation, decreased executive functions such as planning, organization, and abstract thinking, and decreased concentration.

③ Early gait changes, such as unstable gait, dragging gait or broken steps, physical examination shows signs of vascular Parkinson's syndrome such as slow movement, mild increase in muscle tone, or early frequent urination, urgency, and other inability to use urinary Urinary tract symptoms explained by system or other neurological diseases.

④ It may be accompanied by emotional behavior symptoms such as depression, apathy, lack of initiative, withdrawal from social activities, changes in personality characteristics, and emotional instability.

⑤Imageology can show signs of diffuse white matter changes in the periventricular and deep white matter and/or multiple lacunar infarction, multiple cortical/subcortical microhemorrhage, and hemosiderin deposits on the cortical surface consistent with clinical features.

Abnormal personality and behavior related to cerebrovascular disease Patients with cerebrovascular disease have a variety of abnormal personality behaviors, including depression, lack of pleasure, loss of interest, restlessness, emotional instability, irritability and other depression and anxiety manifestations, indifference, lack of initiative, hesitation Absence of volitional activity such as indecision, or personality changes such as agitation, strong crying, strong laughter, repetition, impulsivity, etc.

Elderly patients are more prone to social withdrawal, less activity, slow response, emotional sensibility, lack of interest in rehabilitation training, many negative concepts about the disease, poor compliance with treatment or even refusal to treat, resulting in recurring or persistent disease.

Diagnosis ① Through cognitive function assessment, it is clear that there is cognitive impairment (reaching the threshold of vascular dementia or VaMCI, or focal cortical dysfunction).

 ②There is an association between cerebrovascular disease and cognitive impairment, that is, the sudden onset.
The time of cognitive impairment is usually related to ≥1 cerebrovascular event, and it shows a fluctuating or step-like course under multiple cerebrovascular events.
Or in the absence of a history of stroke or transient ischemic attack, the disease gradually onset, slowly progressing in the course of the disease, there is evidence of information processing speed, complex attention and/or prominent frontal lobe-executive function damage, and one of the following characteristics : Early gait abnormalities; early frequent urination, urgency, other urinary tract symptoms that cannot be explained by urinary system or other neurological diseases; personality and personality changes, or other subcortical damage manifestations.

 ③There is brain imaging evidence consistent with the pattern of cerebrovascular disease and cognitive impairment in brain imaging examination, that is, there is an imaging change that is consistent with the location of cerebrovascular disease, conforms to the pattern of cognitive impairment, and is sufficient to cause cognitive severity.

 At the same time, satisfying ② or ③ can diagnose a likely vascular cognitive impairment; satisfying ② but no imaging examination, or imaging changes are not sufficient to fully explain the cognitive impairment, then the diagnosis of possible vascular cognitive impairment; if imaging If there is no abnormality, the possible vascular cognitive impairment cannot be diagnosed.

After the diagnosis of vascular cognitive impairment, the etiology of cerebrovascular disease should be diagnosed.

 Treatment principles and commonly used drugs ➤Vascular dementia can be given non-drug treatments such as cognitive medication and cognitive training.

Cholinesterase inhibitors such as donepezil hydrochloride and rivastigmine, and memantine can be used for the treatment of vascular dementia.

 ➤VaMCI drug treatment is not supported by evidence-based medicine, and non-drug treatment methods such as cognitive training are mainly adopted.

 ➤Conventional psychiatric treatment measures can also be used for symptomatic treatment of abnormal personality behavior after stroke.

 ➤Treat and manage cerebrovascular disease and its risk factors.

 Disease management The management of vascular cognitive impairment is the comprehensive management of cerebrovascular disease, cognitive function and emotional behavior.

Patients with vascular cognitive impairment integrate disability, dementia, and personality and behavior changes.
They have many needs for nursing care and are highly dependent.
They need to cooperate with patients and their caregivers through multiple channels such as medical treatment, nursing and social services to provide full management for patients and their caregivers .

People with multiple vascular risk factors such as hypertension, diabetes, hyperlipidemia, obesity, smoking, alcoholism, and people with mild cognitive impairment are the key prevention and control groups.
Active prevention of cerebrovascular disease can significantly reduce the risk of dementia.

 Yimaitong is compiled from: General Office of the National Health Commission.
Standards for diagnosis and treatment of vascular cognitive impairment (2020 edition)[J].
General Practice Clinical and Education, 2021,19(3):197-199.