Guideline sources The following summarized guidelines for the evaluation and management of vascular cognitive impairment (VCI) are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2023), the Canadian Consensus Conference on Diagnosis and Treatment of Dementia (CCCDTD 2020), the European Federation of Neurological Societies (EFNS 2012), and the American Heart Association (AHA/ASA 2011). 1 2 3 4 Guidelines 1. Screening and diagnosis Diagnostic criteria: use standardized criteria (the VASCOG criteria, DSM-5, VICCCS, or the AHA consensus statement) for the diagnosis of vascular mild cognitive impairment and vascular dementia. B 2. Diagnostic investigations Brain imaging: As per CCCDTD 2020 guidelines, obtain MRI over CT for investigating VCI. B https://web.pathway.md/diseases/reclxjH2j1OkP5AJ6 1/4 6/29/23, 3:24 AM Vascular cognitive impairment Pathway As per EFNS 2012 guidelines, obtain structural imaging at least once in the diagnostic work- up of patients with cognitive impairment for at least 3 purposes: to exclude other potentially treatable diseases, to recognize vascular lesions, and to identify specific findings to help distinguish different forms of neurodegenerative types of dementia. E Show 4 more As per AHA 2011 guidelines: Consider obtaining brain CT or MRI in making a diagnosis of VCI. C Consider obtaining MRI with T2-weighted gradient-echo sequences in patients with progressive cognitive impairment for detection of multiple strictly lobar hemorrhagic lesions characteristic of probable cerebral amyloid angiopathy. C Genetic testing: Consider obtaining genetic testing for cysteine-altering mutations in NOTCH3 in patients with progressive cognitive impairment, characteristic imaging findings, and family history suggestive of autosomal dominant inheritance. B Consider obtaining NOTCH3 genetic testing in sporadic patients with suggestive clinical and imaging findings, particularly in the absence of strong cardiovascular risk factors. C 3. Diagnostic procedures Skin or muscle biopsy: consider obtaining an ultrastructural examination of the skin or muscle biopsy specimen for granular osmiophilic deposits as an alternative or complementary procedure if genetic testing is either unavailable or demonstrates NOTCH3 mutations of unclear significance. C 4. Medical management Management of cardiovascular risk factors: As per CCCDTD 2020 guidelines: Consider initiating antihypertensive therapy for average diastolic BP readings 90 mmHg and for average systolic BP readings 140 mmHg in patients with cognitive disorders if a vascular contribution is known or suspected. B Initiate guideline-recommended treatments to prevent first-ever or recurrent stroke as appropriate in all patients with cognitive symptoms or impairment. B As per AHA 2011 guidelines, consider managing cardiovascular risk factors in patients with suspected cerebral amyloid angiopathy or cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. C Cholinesterase inhibitors: As per CCCDTD 2020 guidelines, consider offering cholinesterase inhibitors (donepezil, galantamine, or rivastigmine) for the treatment of VCI in selected patients. C As per AHA 2011 guidelines, consider offering donepezil for cognitive enhancement in patients with vascular dementia. B Show 2 more https://web.pathway.md/diseases/reclxjH2j1OkP5AJ6 2/4 6/29/23, 3:24 AM Vascular cognitive impairment Pathway NMDA antagonists: As per CCCDTD 2020 guidelines, consider offering memantine for the treatment of VCI in selected patients. C As per AHA 2011 guidelines, insufficient evidence to support the use of memantine in patients with vascular dementia. I Antiplatelet therapy: As per CCCDTD 2020 guidelines: Do not use aspirin in patients with mild cognitive impairment or dementia having brain imaging evidence of covert white matter lesions of presumed vascular origin without history of stroke or brain infarcts. D Insufficient evidence regarding the effects of aspirin on cognitive decline in patients with mild cognitive impairment or dementia having covert brain infarcts detected on neuroimaging without history of stroke. I As per AHA 2011 guidelines, insufficient evidence to support the use of antiplatelet therapy in patients with VCI. I Immunosuppressive therapy: administer a course of immunosuppressive therapy, such as corticosteroids or cyclophosphamide, in patients with subacute cognitive decline and evidence of cerebral amyloid angiopathy-related inflammation. B 5. Nonpharmacologic interventions Vitamin supplements: insufficient evidence to support the use of vitamin supplements for improving cognitive function. I 6. Preventative measures Primary prevention (lifestyle modifications): consider advising moderation of alcohol intake, weight control, physical activity, a Mediterranean-type dietary pattern, C and smoking cessation in patients at risk for VCI. B Primary prevention, cardiovascular conditions: As per CCCDTD 2020 guidelines: Assess, diagnose and treat hypertension according to current evidence-based guidelines as treatment of hypertension may reduce the risk of dementia. B Consider targeting a systolic BP of < 120 mmHg in middle-aged and older patients being treated for hypertension and having associated vascular risk factors as it may be associated with a decreased risk of developing mild cognitive impairment. C As per AHA/ASA 2011 guidelines, treat hypertension in patients at risk for VCI. A Show 6 more Primary prevention (carotid interventions): do not perform carotid interventions for the prevention of cognitive impairment in patients with a 70-99% asymptomatic carotid artery stenosis unless a causal association between severe asymptomatic carotid artery stenosis and cognitive decline has been established. D https://web.pathway.md/diseases/reclxjH2j1OkP5AJ6 3/4 6/29/23, 3:24 AM Vascular cognitive impairment Pathway Clinical findings Patient demographics Symptoms Elderly age Memory impairment Mood changes Past medical history Social history Alzheimer's disease Atherosclerotic disease Physical inactivity CVD Tobacco use Cerebral amyloid angiopathy Coronary artery disease Depression Dyslipidemia Hypertension Intracerebral hemorrhage Obesity PAD Stroke Neurological exam Cognitive impairment References 1. Philip B Gorelick, Angelo Scuteri, Sandra E Black et al. Vascular Contributions to Cognitive Impairment and Dementia: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2011 Sep;42 9 2672 713. Open 2. Eric E Smith, Philip Barber, Thalia S Field et al. Canadian Consensus Conference on Diagnosis and Treatment of Dementia CCCDTD 5 Guidelines for management of vascular cognitive impairment. Alzheimers Dement N Y . 2020 Nov 11;6 1):e12056. Open 3. Ross Naylor, Barbara Rantner, Stefano Ancetti et al. Editor's Choice European Society for Vascular Surgery ESVS 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg. 2023 Jan;65 1 7 111. Open 4. M Filippi, F Agosta, F Barkhof et al. EFNS task force: the use of neuroimaging in the diagnosis of dementia. Eur J Neurol. 2012 Dec;19 12):e131 40, 1487 501. Open https://web.pathway.md/diseases/reclxjH2j1OkP5AJ6 4/4