Mild cognitive impairment    Mild cognitive impairment of the vascular type

Diagnostic criteria for mild cognitive impairment
(modified by Petersen et al. Arch Neurol.1999;56:303-308)
1. Memory disturbance referred at least by one of following:
- by patient
- by family members
- by personal physicians

2. Presence of all of this characteristics:
- normal activities of daily living
- normal general cognitive functions (within 0.5 standard deviations of age- and education-matched control subjects)
- abnormal memory for age (1.5 standard deviations below age- and education-matched control subjects)
- absence of dementia

3. Diagnosis is made by consensus committee involving neurologist, geriatrician, neuropsychologist, nurse and other study personnel who had evaluated the patient usig the following diagnostic tool:
- clinical assessment
   Clinical history (with both patient and families)
   Objective neurological examination
   Short Test of Mental Status
   Geriatric Depression Scale di Yesavage
   Hachinski Ischemic Score
   Record of Indipendent Living
- neuropsychological assessment Wechsler Adult Intelligence Scale-Revised
   Wechsler Memory Scale-Revised
   Auditory Verbal Learning Test
   Wide-Range Achievement Test-III
- laboratory assessment:
   haemachrome
   sedimentation rate
   vitamin B12 and folic acid
   thyroid function
   syphilis serologic testing
- instrumental assessment
   Brain computer tomography or magnetic resonance
   If clinically indicated: lumbar puncture, EEG, SPECT





Mild cognitive impairment    Mild cognitive impairment of the vascular type

Diagnostic criteria for mild cognitive impairment of the vascular type (modified from Erkinjuntti et al. J Neural Transmit Suppl.2000;59:23-30)

I.             The criteria for the clinical diagnosis of mild cognitive impairment of the vascular type include all of the following:
A. COGNITIVE SYNDROME including both
        A1. DYSEXECUTIVE SYNDROME: Impairment in goal formulation, initiation, planning, organizing, sequencing, executing, set-shifting and -maintenace, abstracting
        A2. MEMORY DEFICIT (may be mild): Impaired recall, relative intact recognition, less severe forgetting, benefit from cues.
        A3. ROGRESSION: deterioration of A1 and A2 from a previous higher level of functioning, that are not per se interfering with complex (executive) occupational and social activities.

B. CEREBROVASCULAR DISEASE including both B1 and B2
        B1. EVIDENCE OF RELEVANT CEREBROVASCULAR DISEASE BY BRAIN IMAGING
        B2. PRESENCE OR A HISTORY OF NEUROLOGIC SIGNS as evidence for cerebrovascular disease such as hemiparesis, lower facial weakness, Babinski sign, sensory deficit, dysarthria, gait disorder, extrapyramidal signs consistent with subcortical brain lesion (s).

II.           Clinical features supporting the diagnosis of mild cognitive impairment of the vascular type include the following:

a.            Episodes of mild upper motor neuron involvement such as drift, reflex asymmetry, incordination.
b.            Early presence of a gait disturbance (small-step gait or marche a petits-pa magnetic, apraxic-ataxic or Parkinsonian gait).
c.             History of unsteadiness and frequent, unprovoked falls.
d.            Early urinary frequency, urgency, and other urinary symptoms not explained by urologic disease.
e.             Dysarthria, dysphagia, extrapyramidal signs (hypokinesia, rigidity).
d.             Behavioral and psychological symptoms such as depression, personality change, emotional incontinence, psychomotor retardation.

III.           Features that make the diagnosis of mild cognitive impairment of the vascular type uncertain or unlikely include:

a.  Early onset of memory deficit and progressive worsening of memory and other cognitive functions such as language (transcortical sensory aphasia), motor skills (apraxia), and perception (agnosia), in the absence of corresponding focal lesions on brain imaging.
b.  Absence of relevant cerebrovascular disease lesions on brain CT or MRI

 
BRAIN MAGING CRITERIA FOR MILD COGNITIVE IMPAIRMENT OF THE VASCULAR TYPE

COMPUTED TOMOGRAPHY

                extensive periventricular and deep white matter lesions: patchy areas of low attenuation (intermediate density between that of normal white matter and that of intraventricular cerebro-spinal fluid) or diffuse symmetrical areas of low attenuation with ill defined margins extending to the centrum semiovale plus at least one lacunar infarct

AND

                absence of cortical and/or cortico-subcortical non-lacunar territorial infarcts and watershed infarcts, haemorrhages indicating large vessel disease, signs of normal pressure hydrocephalus, and specific causes of white matter lesions (e.g. multiple sclerosis, sarcoidosis, brain irradiation).

MAGNETIC RESONANCE CRITERIA FOR MILD COGNITIVE IMPAIRMENT OF THE VASCULAR TYPE HAVE NOT YET BEEN DEVELOPED.

 
ETIOLOGY AND BRAIN CHANGES OF MILD COGNITIVE IMPAIRMENT OF THE VASCULAR TYPE

ETIOLOGY
PRIMARY VASCULAR MECHANISMS
         SMALL VESSEL DISEASE: Obliteration and occlusion, increased resistance, decreased autoregulation, cerebral
         blood flow fluctuation, endothelia changes, -blood-brain-barrier and -carrier changes, perivascular changes
PRIMARY RISK FACTORS
         AGE, ARTERIAL HYPERTENSION
SECONDARY VASCULAR MECHANISMS
         HEMODYNAMIC CHANGES OF SYSTEMIC VASCULAR, CARDIAC AND CAROTID ORIGIN
SECONDARY RISK FACTORS
         ARTERIAL HYPOTENSION, HYPOXIC-ISCHEMIC EVENTS, BLOOD PRESSURE FLUCTUATIONS,
         HYPERLIPIDEMIA, LOW EDUCATION


BRAIN CHANGES
PRIMARY TYPE
         ISCHEMIC WHITE MATTER LESIONS (WMLs): -Araiosis, état crible, demyelination, axonal loss, changes in
         oligodendrocytes and glial cells, incomplete infarcs.
         LACUNAR INFARCTS
         INCOMPLETE ISCHEMIC INJURY: -Laminar necrosis, focal gliosis, granular atrophy, incomplete white matter
         infarcts.
PRIMARY LOCATION
         WMLs: Extending periventricular and deep WMLs affecting especially the genu or anterior limb of the internal
         capsule, anterior corona radiata and anterior centrum semiovale.
         LACUNES: Lacunes in the caudate, globus pallidus, thalamus, internal capsule, corona radiata, frontal white
         matter.

CLINICAL SYNDROME
COGNITIVE SYNDROME
          DYSEXECUTIVE SYNDROME: Impairment in goal formulation, initiation, planning, organizing, sequencing,
          executing, set-sifting and -maintenance, abstracting.
          MEMORY DEFICIT (may be mild): Impaired recall, relative intact recognition, less severe forgetting, benefit
          from cues.
          WHICH INDICATE DETERIORATION FROM A PREVIOUS HIGHER LEVEL OF FUNCTIONING THAT IS
          NOT PER SE INTERFERING WITH COMPLEX (EXECUTIVE) OCCUPATIONAL AND SOCIAL ACTIVITIES

BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS
          DEPRESSION, PERSONALITY CHANGE, EMOTIONAL INCONTINENCE,
          PSYCHOMOTOR RETARDATION