血管性认知障碍的诊治新进展

1VCI的诊治新进展VCI的定义/诊断标准VCI的神经心理学评估VCI的影像学诊断如何确定影像学与认知损害的关系VCI的治疗进展小结2VCI的诊治新进展VCI的定义/诊断标准VCI的神经心理学评估VCI的影像学诊断如何确定影像学与认知损害的关系VCI的治疗进展小结3VCI的发展历史1899年1969年1974年动脉硬化性和老年性痴呆被认为是不同的综合征Mayer-Gross描述血管性痴呆(VaD)以便于与老年性精神病相鉴别Hachinski等提出多发梗死性痴呆（MID)和Hachinski缺血量表(HIS)1985年Loeb提出适用广泛的VaD概念1993年1997年Petersen提出VCI新概念Bowler和Hachinski提出血管性认知功能损害(VCI),又称血管性认知功能障碍42011年7月AHA/ASA联合发表科学声明-专门针对VCI定义：VCI指存在临床卒中或亚临床脑血管损伤，引起至少一个认知功能区认知功能受损的一组综合征，其中最严重的形式为VaD。Stroke,2011;42(9):2672-713.5AHA/ASA联合声明-VaD的诊断Thediagnosisofdementiashouldbebasedonadeclineincognitivefunctionfromapriorbaselineandadeficitinperformancein≥2cognitivedomainsthatareofsufficientseveritytoaffectthesubject’sactivitiesofdailyliving.Thediagnosisofdementiamustbebasedoncognitivetesting,andaminimumof4cognitivedomainsshouldbeassessed:executive/attention,memory,language,andvisuospatialfunctions.Stroke,2011;42(9):2672-713.6AHA/ASA联合声明-VaD的诊断Thedeficitsinactivitiesofdailylivingareindependentofthemotor/sensorysequelaeofthevascularevent.Stroke,2011;42(9):2672-713.7AHA/ASA联合声明-很可能VaD的诊断Thereiscognitiveimpairmentandimagingevidenceofcerebrovasculardiseaseand–a.Thereisacleartemporalrelationshipbetweenavascularevent(eg,clinicalstroke)andonsetofcognitivedeficits,or–b.Thereisaclearrelationshipintheseverityandpatternofcognitiveimpairmentandthepresenceofdiffuse,subcorticalcerebrovasculardiseasepathology(eg,asinCADASIL).Thereisnohistoryofgraduallyprogressivecognitivedeficitsbeforeorafterthestrokethatsuggeststhepresenceofanonvascularneurodegenerativedisorder.Stroke,2011;42(9):2672-713.8AHA/ASA联合声明-可能VaD的诊断Thereiscognitiveimpairmentandimagingevidenceofcerebrovasculardiseasebut–1.Thereisnoclearrelationship(temporal,severity,orcognitivepattern)betweenthevasculardisease(eg,silentinfarcts,subcorticalsmall-vesseldisease)andthecognitiveimpairment.–2.ThereisinsufficientinformationforthediagnosisofVaD(eg,clinicalsymptomssuggestthepresenceofvasculardisease,butnoCT/MRIstudiesareavailable).–3.Severityofaphasiaprecludespropercognitiveassessment.However,patientswithdocumentedevidenceofnormalcognitivefunction(eg,annualcognitiveevaluations)beforetheclinicaleventthatcausedaphasiacouldbeclassifiedashavingprobableVaD.Stroke,2011;42(9):2672-713.9AHA/ASA联合声明-可能VaD的诊断Thereiscognitiveimpairmentandimagingevidenceofcerebrovasculardiseasebut–4.Thereisevidenceofotherneurodegenerativediseasesorconditionsinadditiontocerebrovasculardiseasethatmayaffectcognition,suchas•a.Ahistoryofotherneurodegenerativedisorders(eg,Parkinsondisease,progressivesupranuclearpalsy,dementiawithLewybodies);•b.ThepresenceofAlzheimerdiseasebiologyisconfirmedbybiomarkers(eg,PET,CSF,amyloidligands)orgeneticstudies(eg,PS1mutation);or•c.Ahistoryofactivecancerorpsychiatricormetabolicdisordersthatmayaffectcognitivefunction.Stroke,2011;42(9):2672-713.10AHA/ASA联合声明-VaMCI的诊断VaMCIincludesthe4subtypesproposedfortheclassificationofMCI:amnestic,amnesticplusotherdomains,nonamnesticsingledomain,andnonamnesticmultipledomain.TheclassificationofVaMCImustbebasedoncognitivetesting,andaminimumof4cognitivedomainsshouldbeassessed:executive/attention,memory,language,andvisuospatialfunctions.VaMCI,vascularmildcognitiveimpairment.Stroke,2011;42(9):2672-713.11AHA/ASA联合声明-VaMCI的诊断Theclassificationshouldbebasedonanassumptionofdeclineincognitivefunctionfromapriorbaselineandimpairmentinatleast1cognitivedomain.Instrumentalactivitiesofdailylivingcouldbenormalormildlyimpaired,independentofthepresenceofmotor/sensorysymptoms.Stroke,2011;42(9):2672-713.12AHA/ASA联合声明-UnstableVaMCISubjectswiththediagnosisofprobableorpossibleVaMCIwhosesymptomsreverttonormalshouldbeclassifiedashaving“unstableVaMCI.”Stroke,2011;42(9):2672-713.13VCI概念简单，组成广泛VCI的组成轻度认知功能损害（MCI）患者所有脑血管疾病相关的认知损害所有已知的VaD类型和混合型痴呆最常见的认知功能损害类型，患病率超过AD14VCI诊断核心要素认知损害血管因素两者有因果关系主诉或知情者报告有认知损害，而且客观检查也有认知损害的证据，和(或)客观检查证实认知功能较以往减退包括血管危险因素、卒中病史、神经系统局灶体征、影像学显示的脑血管病证据，以上各项不一定同时具备通过病史、体格检查、实验室和影像学检查确定认知损害与血管因素有因果关系，并能排除其他原因应用合适的诊断工具筛查认知功能损害，确定核心要素中华神经科杂志.2011;44(2):142-147.15VCI的诊治新进展VCI的定义/诊断标准VCI的神经心理学评估VCI的影像学诊断如何确定影像学与认知损害的关系VCI的治疗进展小结16VCI的神经心理学评估对VCI的神经心理学评估需要一套综合认知测验。执行功能早已被认为是VCI患者的突出特征，故应包含在神经心理成套测验中。但执行功能障碍并非特别地指向脑血管病。对认知损害的操作性定义（如低于类似人群的1个或1.5个标准差）优于对症状的定性描述。17VCI神经心理学评估方案NINDS-CSN推荐方案–60分钟方案–30分钟方案–5分钟方案Stroke.2006Sep;37(9):2220-41.18VCI神经心理学评估方案Executive/Activation–AnimalNaming(semanticfluency);ControlledOralWordAssociationTest;WAIS-IIIDigitSymbol-Coding;TrailmakingTest–ListLearningTestStrategies–FutureUse:SimpleandChoiceReactionTimeLanguage/LexicalRetrieval–BostonNamingTest2ndEdition,ShortFormVisuospatial–Rey-OsterriethComplexFigureCopy–Supplemental:ComplexFigureMemory60分钟方案Stroke.2006Sep;37(9):2220-41.19VCI神经心理学评估方案60分钟方案Memory–HopkinsVerbalLearningTest-Revised–Alternate:CaliforniaVerbalLearningTest–2–Supplemental:BostonNamingTestRecognition–Supplemental:DigitSymbol-CodingIncidentalLearningNeuropsychiatric/DepressiveSymptoms–NeuropsychiatricInventoryQuestionnaireVersion–CenterforEpidemiologicalStudies-DepressionScalePremorbidStatus–InformantQuestionnaireforCognitiveDeclineintheEld