1、VCI的诊治新进展的诊治新进展 章军建章军建 刘汉兴刘汉兴 武汉大学中南医院神经科武汉大学中南医院神经科 湖北省痴呆与认知障碍医学临床研究中心湖北省痴呆与认知障碍医学临床研究中心 2 VCI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 如何确定影像学不认知损害的关系 VCI的治疗进展 小结 3 VCI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 如何确定影像学不认知损害的关系 VCI的治疗进展 小结 4 VCI的发展历史 1899年年 1969年年 1974年年 动脉硬化性和老年性痴呆动脉硬化性和老年性痴呆 被认为是不同的
2、综合征被认为是不同的综合征 Mayer-Gross描述血管性痴呆描述血管性痴呆(VaD)以便于与老年性精神病相鉴别以便于与老年性精神病相鉴别 Hachinski 等提出多发梗死性痴呆（等提出多发梗死性痴呆（MID)和和Hachinski缺血量表缺血量表(HIS)1985年年 Loeb 提出适用广泛的提出适用广泛的VaD概念概念 1993年年 1997年年 Petersen提出提出VCI新概念新概念 Bowler和和Hachinski提出血管性认知功能提出血管性认知功能 损害损害(VCI),又称血管性认知功能障碍又称血管性认知功能障碍 5 2011年7月AHA/ASA联合发表科学声明-丏门针对V
3、CI 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):2672-713.6 AHA/ASA联合声明-VaD的诊断 The diagnosis of dementia should be based on a decline in cognitive function from a prior baseline and a deficit in performance in 2 cognitive domains that are of sufficient severity to aff
4、ect the subjects activities of daily living.The diagnosis of dementia must be based on cognitive testing,and a minimum of 4 cognitive domains should be assessed:executive/attention,memory,language,and visuospatial functions.Stroke,2011;42(9):2672-713.7 AHA/ASA联合声明-VaD的诊断 The deficits in activities o
5、f daily living are independent of the motor/sensory sequelae of the vascular event.Stroke,2011;42(9):2672-713.8 AHA/ASA联合声明-很可能VaD的诊断 There is cognitive impairment and imaging evidence of cerebrovascular disease and a.There is a clear temporal relationship between a vascular event(eg,clinical stroke
6、)and onset of cognitive deficits,or b.There is a clear relationship in the severity and pattern of cognitive impairment and the presence of diffuse,subcortical cerebrovascular disease pathology(eg,as in CADASIL).There is no history of gradually progressive cognitive deficits before or after the stro
7、ke that suggests the presence of a nonvascular neurodegenerative disorder.Stroke,2011;42(9):2672-713.9 AHA/ASA联合声明-可能VaD的诊断 There is cognitive impairment and imaging evidence of cerebrovascular disease but 1.There is no clear relationship(temporal,severity,or cognitive pattern)between the vascular d
8、isease(eg,silent infarcts,subcortical small-vessel disease)and the cognitive impairment.2.There is insufficient information for the diagnosis of VaD(eg,clinical symptoms suggest the presence of vascular disease,but no CT/MRI studies are available).3.Severity of aphasia precludes proper cognitive ass
9、essment.However,patients with documented evidence of normal cognitive function(eg,annual cognitive evaluations)before the clinical event that caused aphasia could be classified as having probable VaD.Stroke,2011;42(9):2672-713.10 AHA/ASA联合声明-可能VaD的诊断 There is cognitive impairment and imaging evidenc
10、e of cerebrovascular disease but 4.There is evidence of other neurodegenerative diseases or conditions in addition to cerebrovascular disease that may affect cognition,such as a.A history of other neurodegenerative disorders(eg,Parkinson disease,progressive supranuclear palsy,dementia with Lewy bodi
11、es);b.The presence of Alzheimer disease biology is confirmed by biomarkers(eg,PET,CSF,amyloid ligands)or genetic studies(eg,PS1 mutation);or c.A history of active cancer or psychiatric or metabolic disorders that may affect cognitive function.Stroke,2011;42(9):2672-713.11 AHA/ASA联合声明-VaMCI的诊断 VaMCI
12、includes the 4 subtypes proposed for the classification of MCI:amnestic,amnestic plus other domains,nonamnestic single domain,and nonamnestic multiple domain.The classification of VaMCI must be based on cognitive testing,and a minimum of 4 cognitive domains should be assessed:executive/attention,mem
13、ory,language,and visuospatial functions.VaMCI,vascular mild cognitive impairment.Stroke,2011;42(9):2672-713.12 AHA/ASA联合声明-VaMCI的诊断 The classification should be based on an assumption of decline in cognitive function from a prior baseline and impairment in at least 1 cognitive domain.Instrumental ac
14、tivities of daily living could be normal or mildly impaired,independent of the presence of motor/sensory symptoms.Stroke,2011;42(9):2672-713.13 AHA/ASA联合声明-Unstable VaMCI Subjects with the diagnosis of probable or possible VaMCI whose symptoms revert to normal should be classified as having“unstable
15、 VaMCI.”Stroke,2011;42(9):2672-713.14 VCI概念简单，组成广泛 VCI 的组成的组成 轻度认知功能损害轻度认知功能损害（MCI）患者）患者 所有脑血管疾病所有脑血管疾病相关的认知损害相关的认知损害 所有已知的所有已知的VaD类类型和混合型痴呆型和混合型痴呆 最常见的认知功最常见的认知功能损害类型，患能损害类型，患病率超过病率超过AD 15 VCI诊断核心要素 认知损害认知损害 血管因素血管因素 两者有因果关系两者有因果关系 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
16、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):142-147.16 VCI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 如何确定影像学不认知损害的关系 VCI的治疗进展 小结 17 VCI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。但执行功能障碍幵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。18 VCI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.2006 Sep;37(9):2220-41.19 VCI神经心理学评估方案 Executive/Activation Animal Naming(semanti