Vascular dementia (VaD) is the second most common cause of dementia and its prevalence increases after the sixth decade of life [1] [2]. It is defined as a condition characterized by features of stroke or subclinical vascular brain injury which involves malfunction of at least two cognitive domains leading to a decrease in the ability to perform activities of daily living [3]. The cognitive features of VaD depend on the anatomical location of the vascular injury and this has led to the classification of VaD into different subtypes: small, large, or mixed vessel disease [4] [5]. Patients with small vessel disease present with a higher incidence of executive dysfunction whereas dysfunctional language and visuospatial perception are noticed more often in patients with large vessel VaD [6]. Clinical presentation of VaD in cortical injury includes speech abnormalities and neglect while a subcortical injury is associated with cognitive, emotional and behavioral difficulties, psychomotor retardation, pseudobulbar palsy, and gait dysfunction [1] [3]. Other features of VaD are restlessness, agitation, aggressive behavior, hallucinations, delusions, paranoia, circadian mood disturbances (sundowning), disorientation, and depression. As the brain injury is variable in VaD, memory disturbances may also be variable or may be completely absent [1]. The intellectual decline in VaD is classically described as "step-wise" (multi-infarct dementia) but can be continuous (lacunar infarcts) too.

Clinical presentation of VaD may resemble that of Alzheimer's disease (AD) although the following features help to differentiate between the two conditions:

• major depression is more commonly seen in patients with VaD
• apathy is seen in the early stages of VaD while it occurs in the late stages of AD
• VaD patients have diminished language fluency compared to AD patients
• Long-term memory deficits are more prevalent in AD patients

• Carotid Bruit

  The cardiovascular examination is crucial in patients with suspected vascular dementia, as the identification of specific treatable causes, such as hypertension, atrial fibrillation, or a carotid bruit, will help direct therapy appropriately. [web.archive.org]

• Vertical Gaze Palsy

  On examination, the patient had a supranuclear vertical gaze palsy. A CT scan of the brain performed ten days after admission showed enhancing bilateral medial thalamic infarctions. [web.archive.org]

• Memory Impairment

  impairment and other deficits to meet operationalized criteria for dementia, and (3) the use of limited test batteries whose psychometric properties are incompletely understood. [ncbi.nlm.nih.gov]

  The development of multiple cognitive deficits manifested by both: Memory impairment (impaired ability to learn new information or to recall previously learned information) One or more of the following cognitive disturbances: (a) aphasia (language disturbance [strokecenter.org]

  Symptoms of vascular dementia include the following: Memory impairment Impairment in at least 1 other cognitive domain (eg, orientation, language, praxis, executive functions, visuospatial abilities) Worsening of cognitive abnormalities Impact on activities [emedicine.medscape.com]

• Aphasia

  Transcortical sensory and motor aphasia was observed in four patients with thalamic hemorrhages and infarcts. In these patients SPECT detected hypoperfusion in adjacent cortical areas. [ncbi.nlm.nih.gov]

  Exclusion criteria : cases with disturbance of consciousness, delirium, psychosis, severe aphasia, or major sensorimotor impairment precluding neuropsychological testing. [strokecenter.org]

  […] neurologic deficits often develop: Exaggeration of deep tendon reflexes Extensor plantar response Gait abnormalities Weakness of an extremity Hemiplegias Pseudobulbar palsy with pathologic laughing and crying Other signs of extrapyramidal dysfunction Aphasias [merckmanuals.com]

  Those symptoms include confusion; memory loss; struggles with word recall, or aphasia; difficulty paying attention, or following a conversation; impaired motor skills, and vision loss. [lcbseniorliving.com]

• Apraxia

  Visual constructive apraxia is very common in dementia and impairment in these abilities can provide clinical information for differential diagnosis. [ncbi.nlm.nih.gov]

  […] of multiple cognitive deficits manifested by both: Memory impairment (impaired ability to learn new information or to recall previously learned information) One or more of the following cognitive disturbances: (a) aphasia (language disturbance) (b) apraxia [strokecenter.org]

  In addition, the person must have one or more of the following symptoms: Aphasia - A deterioration of language abilities Apraxia - Difficulty executing motor activities Agnosia - An impaired ability to recognize or identify objects Problems with executive [mentalhelp.net]

  Apraxia: It is an inability to carry out simple or complex movements. Attention Deficit: Moderate or severe distraction. Fluctuating course: The person with vascular dementia does not remain stable throughout. [blog.cognifit.com]

• Neglect

  Common dementia signs and symptoms include: Memory loss Impaired judgement Difficulties with abstract thinking Faulty reasoning Inappropriate behavior Loss of communication skills Disorientation to time and place Gait, motor, and balance problems Neglect [helpguide.org]

  Caring for people with dementia is stressful and demanding, and caregivers may become depressed and exhausted, often neglecting their own mental and physical health. [msdmanuals.com]

  Clinical presentation of VaD in cortical injury includes speech abnormalities and neglect while a subcortical injury is associated with cognitive, emotional and behavioral difficulties, psychomotor retardation, pseudobulbar palsy, and gait dysfunction [symptoma.com]

  […] cardioembolism, vasculitis Chronic: atherosclerosis, CADASIL Hemorrhage Hypertension Vascular malformation: AVM, aneurysm Cerebral amyloid angiopathy: sporadic, hereditary Treatment of established symptoms (Tertiary amelioration) Cognitive: amnesia, aphasia, neglect [web.archive.org]

• Amnesia

  In 2012, he developed gait disturbance and mild amnesia. One year later, his gait disturbance worsened, and he developed urinary incontinence. [ncbi.nlm.nih.gov]

  Her last neuropsychological testing revealed a stable pattern of amnesia. Figure 1. MRI showing bilateral thalamic infarctions. [web.archive.org]

  ‘Severe amnesia’ was previously an exclusion criteria for bvFTD; however, 10% of pathologically confirmed cases have reported memory symptoms at the time of the initial clinical evaluation, with some showing severe amnesia. [doi.org]

A physician should suspect VaD in a patient with cognitive dysfunction which follows a neurologic episode/deficit. The workup should commence with a detailed history eliciting onset and progression of cognitive and neuropsychiatric symptoms as well as a history of atherosclerotic conditions like angina pectoris. A detailed neurological and psychiatric assessment is essential. The Mini-Mental Status Exam (MMSE) is likely to reveal patchy cognitive deficits in VaD compared to global deficits in AD [7]. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria provide the guidelines to help in the diagnosis of VaD [8].

Laboratory tests are performed to exclude other etiologies of dementia. They include a complete blood count (CBC), erythrocyte sedimentation rate (ESR), blood glucose levels, thyroid, liver, and kidney function tests, vitamin B12 levels, and Venereal Disease Research Laboratory (VDRL) test for syphilis. In addition, other tests like human immunodeficiency virus (HIV) testing, and tests to rule out autoimmune diseases should be ordered.

Neuroimaging with computed tomography (CT) and magnetic resonance imaging (MRI) help to confirm the diagnosis with MRI being considered the gold standard. A vascular cause of dementia mainly can be excluded if CT and MRI do not demonstrate any cerebrovascular pathology. MRI findings in VaD include multiple white matter infarcts or lesions in the periventricular white matter, lacunar infarcts, and atrophy of the hippocampal or entorhinal cortical areas. Positron emission tomography (PET) helps in the identification of VaD and differentiates it from AD [9]. Cerebral angiography is only indicated prior to carotid endarterectomy and is likely to show beading of the cortical blood vessels. Other tests which may be performed include an electrocardiogram, echocardiography, Holter monitoring, and carotid Doppler studies.

1. Ramos AR, Dib SI, Wright CB. Vascular Dementia. Curr Transl Geriatr Exp Gerontol Rep. 2013;2(3): 188-195.
2. Kalaria RN. Cerebrovascular disease and mechanisms of cognitive impairment: evidence from clinicopathological studies in humans. Stroke. 2012;43:2526–2534.
3. Gorelick PB, Scuteri A, Black SE, et al. Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the American heart association/American stroke association. Stroke. 2011;42:2672–2713.
4. van Straaten ECW, Scheltens P, Knol DL, et al. Operational definitions for the NINDS-AIREN criteria for vascular dementia: an interobserver study. Stroke. 2003;34:1907–1912.
5. Jellinger KA. Morphologic diagnosis of “vascular dementia” – a critical update. J Neurol Sci. 2008;270:1–12
6. Ying H, Jianping C, Jianquing Y, et al. Cognitive variations among vascular dementia subtypes caused by small, large or mixed vessel disease. Arch Med Sci. 2016;12(4):747-753.
7. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-198.
8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental disorders (5th ed.). Washington, DC. American Psychiatric Association; 2013.
9. Nagata K, Maruya H, Yuya H, et al. Can PET data differentiate Alzheimer's disease from vascular dementia?. Ann N Y Acad Sci. 2000;903:252-261.