血管性痴呆3

Vascular dementia
Vascular dementia, also known as multi-infarct dementia (MID) and vascular cognitive impairment (VCI), is dementia caused by problems in the supply of blood to the brain, typically a series of minor strokes, leading to worsening cognitive decline that occurs step by step. The term refers to a syndrome consisting of a complex interaction of cerebrovascular disease and risk factors that lead to changes in the brain structures due to strokes and lesions, and resulting changes in cognition. The temporal relationship between a stroke and cognitive deficits is needed to make the diagnosis.
血管性痴呆，也称为多梗塞性痴呆(中)和血管认知损伤(VCI)，是由血液供应给大脑的问题引起的痴呆，通常是一系列轻微的中风，导致逐渐恶化的认知能力衰退。

这一术语指的是一种由脑血管疾病和危险因素组成的复杂的相互作用，导致脑结构因中风和病变而发生变化，并导致认知的改变。

中风和认知障碍之间的时间关系是需要进行诊断的。

Differentiating the different dementia syndromes can be challenging, due to the frequently overlapping clinical features and related underlying pathology. In particular, Alzheimer's dementia often co-occurs with vascular dementia.
由于经常重叠的临床特征和相关的基础病理学，区分不同的痴呆综合症是有挑战性的。

特别地，阿尔茨海默痴呆通常与血管性痴呆共同发生。

People with vascular dementia present with progressive cognitive impairment, acutely or subacutely as in mild cognitive impairment, frequently step-wise, after multiple cerebrovascular events (strokes). Some people may appear to improve between events and decline after more silent strokes. A rapidly deteriorating condition may lead to death from a stroke, heart disease, or infection.
患有血管性痴呆的人表现为进行性认知损伤，在轻度认知损伤中，或在轻度认知损伤中，在多次脑血管事件(中风)后，经常发生继发。

一些人在经历了更多的沉默之后，似乎会在事件和衰退之间有所改善。

迅速恶化的状况可能导致中风、心脏病或感染死亡。

Signs and symptoms are cognitive, motor, behavioral, and for a significant proportion of patients also affective. These changes typically occur over a period of 5–10 years. Signs are typically the same as in other dementias, but mainly include cognitive decline and memory impairment of sufficient severity as to interfere with activities of daily living, sometimes with presence of focal neurologic signs, and evidence of features consistent with cerebrovascular disease on brain imaging (CT or MRI).The neurologic signs localizing to certain areas of the brain that can be observed are hemiparesis, bradykinesia, hyperreflexia, extensor plantar reflexes, ataxia, pseudobulbar palsy, as well as gait and swallowing difficulties. People have patchy deficits in terms of cognitive testing. They tend to have better free recall and fewer recall intrusions when compared with patients with Alzheimer's disease. In the more
severely affected patients, or patients affected by infarcts in Wernicke's or Broca's areas, specific problems with speaking called dysarthrias and aphasias may be present.
症状和体征是认知的，运动的，行为的，而且对于相当一部分病人来说也是有情感的。

这些变化通常发生在10-10年的时间内。

症状通常与其他痴呆症状相同，但主要包括认知能力下降和严重程度的记忆损伤，以干扰日常生活活动，有时还会出现病灶神经信号，以及脑成像(CT或MRI)与脑血管疾病相一致的特征。

神经信号在大脑的某些区域可以被观察到，包括偏瘫、慢速运动、超反射、伸肌反射、共济失调、假球性麻痹，以及步态和吞咽困难。

在认知测试方面，人们的缺陷是不完整的。

与阿尔茨海默氏症患者相比，他们的记忆力更好，记忆力也更强。

在受影响更严重的患者中，或在Wernicke或布洛卡的地区受到梗塞的患者，有可能出现的具体问题称为“肌障碍”和“不可能”。

In small vessel disease, the frontal lobes are often affected. Consequently, patients with vascular dementia tend to perform worse than their Alzheimer's disease counterparts in frontal lobe tasks, such as verbal fluency, and may present with frontal lobe problems: apathy, abulia, problems with attention, orientation, and urinary incontinence. They tend to exhibit more perseverative behavior. VaD patients may also present with general slowing of processing ability, difficulty shifting sets, and impairment in abstract thinking. Apathy early in the disease is more suggestive of vascular dementia.
在小血管疾病中，额叶经常受到影响。

因此，患有血管性痴呆的患者在额叶任务中表现得比他们的阿尔茨海默氏症患者表现得更差，例如语言流畅性，并且可能出现额叶问题:冷漠、阿布利亚、注意力问题、定向障碍和尿失禁。

他们倾向于表现出更有毅力的行为。

VaD患者可能也会出现一般的处理能力下降，困难转移，以及抽象思维的障碍。

早期对这种疾病的冷漠更暗示了血管性痴呆。

Rare genetic disorders which result in vascular lesions in the brain have other patterns of presentation. As a rule, they tend to present earlier in life and have a more aggressive course. In addition, infectious disorders, such as syphilis, can lead to arterial damage, strokes, and bacterial inflammation of the brain.
导致脑部血管病变的罕见遗传性疾病有其他的表现形式。

一般来说，他们更倾向于在生活中出现，并有更积极的方向。

此外，传染性疾病，如梅毒，可能导致动脉损伤、中风和大脑的细菌炎症。

Vascular dementia can be caused by ischemic or hemorrhagic infarcts affecting multiple brain areas, including the anterior cerebral artery territory, the parietal lobes, or the cingulate gyrus. On rare occasion, infarcts in the hippocampus or thalamus are the cause of dementia. Brain vascular lesions can also be the result of diffuse cerebrovascular disease, such as small vessel disease.
血管性痴呆可由缺血性或出血性梗塞引起，包括前脑动脉区域，顶叶，或扣带回。

在极少数情况下，海马体或丘脑的梗塞是引起痴呆的原因。

脑血管病变也可能是弥散性脑血管疾病的结果，如小血管疾病。

Risk factors for vascular dementia include age, hypertension, smoking, hypercholesterolemia, diabetes mellitus, cardiovascular disease, and cerebrovascular disease. Other risk factors include geographic origin, genetic predisposition, and prior strokes.
血管性痴呆的危险因素包括年龄、高血压、吸烟、高胆固醇血症、糖尿病、心血管疾病和脑血管疾病。

其他的危险因素包括地理起源、遗传易感性和之前的中风。

Vascular dementia can sometimes be triggered by cerebral amyloid angiopathy, which involves accumulation of beta amyloid plaques in the walls of the cerebral arteries, leading to breakdown and rupture of the vessels. Since amyloid plaques are a characteristic feature of Alzheimer's Disease, vascular dementia may occur as a consequence. Cerebral amyloid angiopathy can, however, appear in people with no prior dementia condition. Some beta amyloid plaques are often present in cognitively normal elderly persons
血管性痴呆有时是由脑淀粉样血管病引起的，它包括在脑动脉壁上堆积beta淀粉样斑块，导致血管破裂和破裂。

由于淀粉样蛋白斑块是阿尔茨海默病的一个特征，因此血管性痴呆可能会发生。

然而，脑淀粉样血管病可以出现在没有痴呆症状的人群中。

在认知正常的老年人中有一些贝塔淀粉样斑块
Several specific diagnostic criteria can be used to diagnose vascular dementia, including the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, the International Classification of Diseases, Tenth Edition (ICD-10) criteria, the National Institute of Neurological Disorders and Stroke criteria, Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN) criteria, the Alzheimer's Disease Diagnostic and Treatment Center criteria, and the Hachinski Ischemic Score (after Vladimir Hachinski).
几个具体可以用于诊断血管性痴呆诊断标准,包括精神疾病诊断与统计手册第四版(dsm - iv)标准,国际疾病分类第十版(icd - 10)标准,国家神经疾病和中风研究所的标准,协会国际歌倒说是et l 'Enseignement神经科学(NINDS-AIREN)标准,阿尔茨海默病的诊断和治疗中心标准,和Hachinski缺血性分数(Vladimir Hachinski 之后)。

The recommended investigations for cognitive impairment include: blood tests (for anemia, vitamin deficiency, thyrotoxicosis, infection, etc.), chest X-Ray, ECG, and neuroimaging, preferably a scan with a functional or metabolic sensitivity beyond a simple CT or MRI. When available as a diagnostic tool, single photon emission computed tomography (SPECT) and positron emission tomography (PET) neuroimaging may be used to confirm a diagnosis of multi-infarct dementia in conjunction with evaluations involving mental status examination. In a person already having dementia, SPECT appears to be superior in differentiating multi-infarct dementia from Alzheimer's disease, compared to the usual mental testing and medical history analysis. Advances have led to the proposal of new diagnostic criteria.
对认知损伤的推荐调查包括:血检(贫血、维生素缺乏、甲状腺毒症、感染等)、胸部x光片、心电图和神经影像，最好是一种功能或代谢敏感性的扫描，而不是简单的CT或MRI。

当可用作诊断工具时，单光子发射计算机断层扫描(SPECT)和正电子发射断层扫描(PET)可用于确认多梗塞性痴呆的诊断与精神状态检查的评估。

在一个已经患有痴呆症的人看来，与通常的精神测试和病史分析相比，SPECT在区分多梗塞性痴呆和阿尔茨海默氏症方面表现得更好。

进步导致了新的诊断标准的提出。

The screening blood tests typically include full blood count, liver function tests, thyroid function tests, lipid profile, erythrocyte sedimentation rate, C reactive protein, syphilis serology, calcium serum level, fasting glucose, urea, electrolytes, vitamin B-12, and folate. In selected patients, HIV serology and certain autoantibody testing may be done.
Mixed dementia is diagnosed when people have evidence of Alzheimer's disease and cerebrovascular disease, either clinically or based on neuro-imaging evidence of ischemic lesions.
筛查血检的典型特征包括:全血细胞计数、肝功能检查、甲状腺功能测试、脂质谱、红细胞沉降率、C反应蛋白、梅毒血清学、钙血清水平、空腹血糖、尿素、电解质、维生素b-12和叶酸。

在选定的患者中，可能会进行艾滋病毒血清学和某些自体抗体检测。

当人们有阿尔茨海默病和脑血管疾病的证据时，就可以诊断出混合性痴呆，这是临床上的或基于脑缺血损伤的神经影像证据。

Pathology
Gross examination of the brain may reveal noticeable lesions and damage to blood vessels. Accumulation of various substances such as lipid deposits and clotted blood appear on microscopic views. The white matter is most affected, with noticeable atrophy (tissue loss), in addition to calcification of the arteries. Microinfarcts may also be present in the gray matter (cerebral cortex), sometimes in large numbers. Although atheroma of the major cerebral arteries is typical in vascular dementia, smaller vessels and arterioles are mainly affected.
对大脑的检查可能会发现明显的损伤和对血管的损害。

各种物质的积累，如脂质沉积和凝结的血液，出现在微观的观点上。

白质受影响最严重，除了动脉钙化外，还有明显的萎缩(组织损失)。

微梗塞也可能出现在灰质(大脑皮层)，有时是大量的。

虽然主要脑动脉的动脉粥样硬化是血管性痴呆的典型症状，但较小的血管和小动脉主要受到影响。

Early detection and accurate diagnosis are important, as vascular dementia is at least partially preventable. Ischemic changes in the brain are irreversible, but the patient with
vascular dementia can demonstrate periods of stability or even mild improvement.Since stroke is an essential part of vascular dementia, the goal is to prevent new strokes. This is attempted through reduction of stroke risk factors, such as high blood pressure, high blood lipid levels, atrial fibrillation, or diabetes mellitus. Meta-analyses have found that medications for high blood pressure are effective at prevention of pre-stroke dementia, which means that high blood pressure treatment should be started early. These medications include angiotensin converting enzyme inhibitors, diuretics, calcium channel blockers, sympathetic nerve inhibitors, angiotensin II receptor antagonists or adrenergic antagonists. Elevated lipid levels, including HDL, were found to increase risk of vascular dementia. However, four large recent reviews showed that therapy with statin drugs was ineffective in treatment or prevention of this dementia. Aspirin is a medication that is commonly prescribed for prevention of strokes and heart attacks; it is also frequently given to patients with dementia. However, its efficacy in slowing progression of dementia or improving cognition has not been supported by studies. Smoking cessation and Mediterranean diet have not been found to help patients with cognitive impairment, however physical activity was consistently the most effective method of preventing cognitive decline.
早期发现和准确诊断是很重要的，因为血管性痴呆至少可以部分预防。

脑缺血的变化是不可逆转的，但是患有血管性痴呆的病人可以表现出稳定的时期，甚至是轻微的改善。

由于中风是血管性痴呆的重要组成部分，所以我们的目标是防止中风。

这是通过减少中风危险因素，如高血压，高血脂，心房纤维颤动，或糖尿病的减少而来的。

元分析发现，治疗高血压的药物对预防中风前的痴呆有效，这意味着高血压的治疗应该尽早开始。

这些药物包括血管紧张素转化酶抑制剂、利尿剂、钙通道阻滞剂、交感神经抑制剂、血管紧张素II受体抑制剂或adrenergic。

高脂水平，包括HDL，被发现会增加血管性痴呆的风险。

然而，最近的四项综述显示，他汀类药物的治疗在治疗或预防痴呆方面效果不明显。

阿司匹林是一种常用的预防中风和心脏病发作的药物;它也经常被给予痴呆患者。

然而，它在减缓痴呆症恶化或提高认知能力方面的功效还没有得到研究的支持。

戒烟和地中海饮食并没有被发现能帮助患有认知障碍的患者，但是体育活动始终是预防认知能力下降最有效的方法。

Currently, there are no medications that have been approved specifically for prevention or treatment of vascular dementia. The use of medications for treatment of Alzheimer's dementia, such as cholinesterase inhibitors and memantine, has shown small improvement of cognition in vascular dementia. This is most likely due to the drugs' actions on co-existing AD-related pathology. Multiple studies found a small benefit in VaD treatment with: memantine, a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist; cholinesterase inhibitors galantamine, donepezil, rivastigmine; and ginkgo biloba extract.
目前，还没有专门用于预防或治疗血管性痴呆的药物。

用于治疗阿尔茨海默病的药物，如胆碱酯酶抑制剂和美金刚胺，在血管性痴呆方面的认知能力有所改善。

这很可能是由于药物在与现有的ad相关性病理学上的作用。

多项研究发现VaD 治疗有一个小的好处:美金刚胺，一种非竞争性的n-甲基-d-aspartate(NMDA)受体抑制剂;胆碱酯酶抑制剂galant胺，donepezil，rivastigmine;和银杏叶提取物。

The general management of dementia includes referral to community services, aid with judgment and decision-making regarding legal and ethical issues (e.g., driving, capacity, advance directives), and consideration of caregiver stress.
痴呆症的一般管理包括对社区服务的介绍、对法律和伦理问题的判断和决策(如开车、能力、超前指示)和照顾照顾者的压力。

Behavioral and affective symptoms deserve special consideration in this patient group. These problems tend to be resistant to conventional psychopharmacological treatment and often lead to hospital admission and placement in permanent care.
在这个患者群体中，行为和情感症状值得特别考虑。

这些问题往往会对传统的精神药物治疗产生耐药性，而且往往会导致住院治疗和永久护理。

Many studies have been conducted to determine average survival of patients with dementia. The studies were frequently small and limited, which caused contradictory results in the connection of mortality to the type of dementia and the patient's gender. A very large study conducted in Netherlands in 2015 found that the one-year mortality was three to four times higher in patients after their first referral to a day clinic for dementia, when compared to the general population. If the patient was hospitalized for dementia, the mortality was even higher than in patients hospitalized for cardiovascular disease. Vascular dementia was found to have either comparable or worse survival rates when compared to Alzheimer's Disease, however another very large 2014 Swedish study found that prognosis was worse for male and older patients.
Unlike Alzheimer's Disease, which weakens the patient, causing them to succumb to bacterial infections like pneumonia, vascular dementia can be a direct cause of death due to the possibility of a fatal interruption in the brain's blood supply.
许多研究已经进行，以确定痴呆症患者的平均存活率。

这些研究常常是小而有限的，这在死亡率与痴呆类型和病人的性别之间产生了矛盾的结果。

2015年在荷兰进行的一项非常大的研究发现，与普通人群相比，在首次转介到某天的痴呆患者诊所后，患者的1年死亡率要高出3至4倍。

如果病人因痴呆而住院，死亡率甚至比住院治疗心血管疾病的病人还要高。

与阿尔茨海默氏症相比，血管性痴呆在与阿尔茨海默氏症的比较中有相当或更低的生存率。

然而，另一项2014年瑞典的研究发现，男性和老年患者的预后更差。

与阿尔茨海默氏病不同的是，这种疾病会削弱病人的身体，使他们屈服于像肺炎这样的细菌感染，而血管性痴呆则是导致大脑血液供应中断的直接原因。

Epidemiology
Vascular dementia is the second-most-common form of dementia after Alzheimer's disease (AD) in older adults.[22][23] The prevalence of the illness is 1.5% in Western countries and approximately 2.2% in Japan. It accounts for 50% of all dementias in Japan, 20% to 40% in Europe and 15% in Latin America. The incidence of dementia is nine times higher in patients who have had a stroke than in controls. 25% of stroke patients develop new-onset dementia within 1 year of their stroke. The relative risk of incident dementia is 5.5% within four years of suffering a stroke.
血管性痴呆是老年痴呆(AD)在老年人中仅次于老年痴呆症的第二常见形式。

在西方国家，这种疾病的流行率为1.5%，在日本约为2.2%。

在日本，这一比例为50%，在欧洲是20%到40%，在拉丁美洲则是15%。

在患中风的病人中，患中风的几率是对照组的9倍。

25%的中风患者在中风后的1年内就会出现新的痴呆症。

在中风的4年内，发生痴呆症的相对风险是5.5%。

One study found that in the United States specifically, the prevalence of vascular dementia in all individuals over the age of 71 is 2.43%, and another found that the prevalence of the dementias doubles with every 5.1 years of age.
一项研究发现，在美国，在71岁以上的所有个体中，血管性痴呆的流行率为2.43%，另一项研究发现，痴呆症的发病率每5.1年就翻一番。

The incidence peaks between the fourth and the seventh decades of life and 80% of patients have a history of hypertension.
在生命的第四和七十年之间的发病率达到顶峰，80%的病人有高血压病史。