Vascular cognitive impairment
Vascular cognitive impairment
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DOI：
10.1136/jnnp.2005.082313
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发表时间：
2005-12-01
影响因子：
11
通讯作者：
Bowler, JV
中科院分区：
文献类型：
--
作者：
Bowler, JV
在20世纪的大部分时间里，痴呆症通常被归因于动脉硬化和随之而来的慢性脑缺血。这种观点随着对阿尔茨海默病（AD）认识的增加以及证明梗死而非慢性缺血是后来被称为多发性梗死性痴呆（MID）的基础而改变。“血管性痴呆”一词随后取代了MID，因为人们认识到除了多发性梗死外还有许多不同的病因。然而，到20世纪末，越来越多的人认识到AD掩盖了VaD，以至于一些作者报道MID是罕见的。因为阿尔茨海默氏症被认为是痴呆的主要原因，它的诊断标准适用于所有痴呆。AD与VaD的分离使用临床特征来反映血管危险因素、血管事件以及全身性和脑血管疾病的表现，通常使用缺血评分进行编码（表1）。该定义的基础导致了VaD的标准，强调记忆丧失，通常是认知能力下降的进展和不可逆性，但事实并非如此。此外，他们还将痴呆症定义为正常日常功能受损的认知障碍水平，因此只会识别晚期病例，因此低估了血管疾病引起的认知障碍的患病率，并剥夺了患者早期预防性治疗的好处。监管机构越来越多地决定可以做什么和对谁做，它们倾向于严格遵守已公布的数据。如果数据只存在于晚期疾病，那么昂贵的药物可能只适用于晚期疾病，至少在指南范围内。这个重要的早期阶段被称为血管性认知障碍（VCI）。VCI的重要性在于，血管疾病是除年龄外痴呆最大的单一可识别风险因素，也是目前唯一可治疗的风险因素。事实上，这个概念还可以进一步发展；虽然预防VCI进展类似于二级预防，但一级预防需要识别易感宿主中存在的风险因素，称为“脑危”（图1）。在过去的五年里，这个领域的工作人员已经认识到VCI是一个比VaD更合适的概念，尽管还没有为VCI制定标准。由于最近的认识和缺乏标准，目前关于VCI的数据很少；许多已有的知识都来自于VaD的旧概念。在本文中，VaD指的是基于旧概念和标准的数据，我们将对这些标准进行批判性评价，以便了解基于它们的数据的局限性。对VCI的认识并不是唯一的新发展。我们对VCI的理解已经从MID发展到包括一系列病因，最近认识到皮层下VCI是最常见和最容易表征的。皮层下VCI占所有VCI的40%以上，是Binswanger病的自然后继者，就像VCI是VaD的后继者一样。在过去的十年中，随着对混合性痴呆的认识的增加，还有另一个重大的变化，即VaD与其他痴呆原因共存，特别是ad，现在这种情况很常见。皮层下血管性认知障碍皮层下血管性认知障碍有其自身的历史，可以追溯到Binswanger病的概念，这是一个过时的概念，Olszewski已经对其进行了回顾。宾斯旺格的病很少被报道。
For the greater part of the 20th century dementia was routinely attributed to arteriosclerosis and consequent chronic cerebral ischaemia. This view changed with the increasing recognition of Alzheimer’s disease (AD) and the demonstration that infarcts and not chronic ischaemia were the basis of what came to be termed multi-infarct dementia (MID). The term ‘‘vascular dementia’’subsequently replaced MID as it was recognised that there were many different aetiologies apart from multiple infarcts. However, by the end of the 20th century, the increasingly recognised AD overshadowed VaD to the extent that some authors reported that MID was rare. Because AD was thought to be the major cause of dementia, its criteria became those applied to all dementia. AD was separated from VaD using clinical features thought to reflect vascular risk factors, vascular events, and the manifestations of systemic and cerebral vascular disease, typically codified using the ischaemic score (table 1). The basis of the definition has resulted in the criteria for VaD emphasising memory loss and usually the progression and irreversibility of cognitive decline, none of which are necessarily the case. In addition, they also define dementia as the level of cognitive impairment at which normal daily functions are impaired and therefore will identify only late cases, so underestimating the prevalence of cognitive impairment caused by vascular disease and denying patients the benefit of early preventative treatment. Regulatory bodies, which increasingly determine what may be done and to whom, have a tendency to adhere rigidly to published data. If data exist only for advanced disease, then expensive drugs may only be available for advanced disease, at least within guidelines. This important early stage is termed vascular cognitive impairment (VCI). The importance of VCI lies in the fact that vascular disease is the largest single identifiable risk factor for dementia apart from age and the only one currently treatable. Indeed, the concept can be taken further; while the prevention of progression of VCI is analogous to secondary prevention, primary prevention requires the recognition of the presence of risk factors in a susceptible host, termed ‘‘brain-at-risk’’(fig 1). In the past five years, those working in this field have come to recognise that VCI is a far more appropriate concept than VaD, although as yet no criteria have been developed for VCI. As a result of this very recent recognition and lack of criteria there are currently few data concerning VCI; much of the established knowledge is derived from the old concept of VaD. In this paper, VaD refers to data based on the old concept and criteria, and these criteria will be critically appraised in order that the limitations of data based upon them can be appreciated. Awareness of VCI has not been the only new development. Our understanding of VCI has advanced from MID to encompass a range of aetiologies and to the more recent realisation that it is subcortical VCI that is the most common and the most readily characterised. Subcortical VCI accounts for over 40% of all VCI and is the natural successor to Binswanger’s disease in much the same way that VCI is the successor to VaD. There has been another major change in the past decade with the increasing recognition of mixed dementia—that is, where VaD coexists with other causes of dementia, particularly AD—and this is now known to be common.SUBCORTICAL VASCULAR COGNITIVE IMPAIRMENT Subcortical VCI has its own history which dates back to the notion of Binswanger’s disease, an outdated concept which has been reviewed by Olszewski. Binswanger’s disease was rarely reported …