Vascular Dementia

Cortical VaD (MID) is seen in connection with large vessel disease, cardiac embolic events and also hypoperfusion (see Table 2). It shows predominantly cortical and cortico-subcortical arterial territorial and distal field (watershed) infarcts. Typical clinical features are changes in strength or sensation on one side of the body, with facial problems such as language impairment, comprehension, and abrupt onset of cognitive impairment.

Strategic infarct dementia. Focal, often small, ischemic lesions involving specific sites critical for higher cortical functions are usually classified separately from other types of VaD. A stroke in one specific area, known as angular gyrus can give a syndrome almost indistinguishable from Alzheimer’s disease, except that it has a sudden onset. Subcortical infarcts can also give rise to dementia. Depending on the strategic location in question, the time-course and clinical features vary greatly.

Subcortical VaD. This type of VaD incorporates two entities ‘‘the lacunar state’’ and ‘‘Binswanger disease.’’ It relates to small vessel disease and is characterized by lacunar infarcts, focal and diffuse ischemic white matter lesions, and incomplete ischemic injury.

Ischaemic lesions in substantial VaD affect not only the subcortical areas, but also their link to prefrontal cortex. Indeed, the so called ‘‘subcortical syndrome’’ is its primary clinical manifestation. This syndrome includes several factors, such as weakness without sensory changes, motor difficulties with speech and swallowing, a gait disorder, depression and emotional liability, and, especially, deficits in executive functioning. Patients with subcortical VaD often have multiple lacunes and extensive white matter lesions on neuroimaging often do not give a clinical history characteristic to stroke.