Diagnosis of vascular cognitive impairment: recommendations of the scientific department of cognitive neurology and aging of the Brazilian Academy of Neurology

Barbosa, Breno José Alencar Pires; Siqueira Neto, José Ibiapina; Alves, Gilberto Sousa; Sudo, Felipe Kenji; Suemoto, Claudia Kimie; Tovar-Moll, Fernanda; Smid, Jerusa; Schilling, Lucas Porcello; Balthazar, Marcio Luiz Figueredo; Frota, Norberto Anízio Ferreira; Souza, Leonardo Cruz de; Vale, Francisco Assis Carvalho; Caramelli, Paulo; Bertolucci, Paulo Henrique Ferreira; Brucki, Sonia Maria Dozzi; Nitrini, Ricardo; Engelhardt, Eliasz; Chaves, Márcia Lorena Fagundes

doi:10.1590/1980-5764-DN-2022-S104EN

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Consensus • Dement. neuropsychol. 16 (3 suppl 1) • Sept 2022 • https://doi.org/10.1590/1980-5764-DN-2022-S104EN copy

Diagnosis of vascular cognitive impairment: recommendations of the scientific department of cognitive neurology and aging of the Brazilian Academy of Neurology

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Since the publication of the latest recommendations for the diagnosis and treatment of Vascular Dementia by the Brazilian Academy of Neurology in 2011, significant advances on the terminology and diagnostic criteria have been made. This manuscript is the result of a consensus among experts appointed by the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology (2020-2022). We aimed to update practical recommendations for the identification, classification, and diagnosis of Vascular Cognitive Impairment (VCI). Searches were performed in the MEDLINE, Scopus, Scielo, and LILACS databases. This guideline provides a comprehensive review and then synthesizes the main practical guidelines for the diagnosis of VCI not only for neurologists but also for other professionals involved in the assessment and care of patients with VCI, considering the different levels of health care (primary, secondary and tertiary) in Brazil.

Keywords:
Dementia, Vascular; Cognitive Dysfunction; Cerebral Infarction; Stroke

Criteria	Description
Zhao et al., 2010⁴⁹49. Zhao QL, Zhou Y, Wang YL, Dong KH, Wang YJ. A new diagnostic algorithm for vascular cognitive impairment: the proposed criteria and evaluation of its reliability and validity. Chin Med J (Engl). 2010;123(3):311-9.	VCIND
	Cognitive impairment in ≥ 1 domain.
	ADLs maintained.
	Does not meet accepted criteria for the diagnosis of dementia.
VCCID Gorelick et al., 2011⁹9. Gorelick PB, Scuteri A, Black SE, DeCarli C, Greenberg SM, Iadecola C, et al. Vascular Contributions to Cognitive Impairment and Dementia: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2011;42(9):2672-713. doi:10.1161/STR.0b013e3182299496. https://doi.org/10.1161/STR.0b013e318229...	VMCI
	Includes the 4 proposed subtypes for MCI: amnesic, amnesic + other domains, non-amnestic single domain, and non-amnestic multiple domains.
	The VMCI classification must be based on cognitive tests and at least 4 cognitive domains must be assessed: executive/attention, memory, language, and visuospatial functions.
	Classification should be based on presumed decline in cognitive function compared to a previous baseline and impairment in ≥ 1 cognitive domain.
	IADLs can be normal or mildly compromised (regardless of motor/sensory symptoms).
VASCOG Sachdev et al., 2014¹⁴14. Sachdev P, Kalaria R, O'Brien J, Skoog I, Alladi S, Black SE, et al. Diagnostic Criteria for Vascular Cognitive Disorders: A VASCOG Statement. Alzheimer Dis Assoc Disord. 2014;28(3):206-18. doi:10.1097/WAD.0000000000000034. https://doi.org/10.1097/WAD.000000000000...	Mild VCD
	Evidence of significant cognitive decline in > 1 domain compared to previous level of performance.
	Cognitive impairment between 1 and 2 SD below the mean (or between the 3^rd and 16^th percentile) (compared to individuals of similar age, sex, education and social-cultural profile).
	Fronto-executive deficiencies are more likely to be present.
	Preserved IADLs (the individual, although still independent, performs tasks with greater effort and uses compensation strategies).
VICCCS Skrobot et al., 2018¹1. Skrobot OA, Black SE, Chen C, DeCarli C, Erkinjuntti T, Ford GA, et al. Progress toward standardized diagnosis of vascular cognitive impairment: Guidelines from the Vascular Impairment of Cognition Classification Consensus Study. Alzheimers Dement. 2018;14(3):280-92. doi:10.1016/j.jalz.2017.09.007. https://doi.org/10.1016/j.jalz.2017.09.0...	Mild VCI
	Impairment in ≥ 1 cognitive domain.
	BADLs or IADLs maintained or with mild impairment (regardless of motor/sensory symptoms).
ABN 2021 Consensus Proposal	CCVND
	Cognitive impairment in ≥ 1 cognitive domain.
	Cognitive impairment between 1 and 2 SD below the mean (or between the 3^rd and 16^th percentile).
	BADLs maintained (regardless of motor/sensory symptoms).
	Preserved IADLs (although with greater effort + compensation strategies).

Criteria	Description
VCCID Gorelick et al., 2011⁹9. Gorelick PB, Scuteri A, Black SE, DeCarli C, Greenberg SM, Iadecola C, et al. Vascular Contributions to Cognitive Impairment and Dementia: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2011;42(9):2672-713. doi:10.1161/STR.0b013e3182299496. https://doi.org/10.1161/STR.0b013e318229...	VD
	The diagnosis of VD should be based on a presumption of decline in cognitive function compared to a previous baseline and impairment in ≥ 2 cognitive domains sufficient to affect activities of daily living.
	The diagnosis of VD must be based on cognitive tests, and at least 4 cognitive domains must be assessed: executive/attention, memory, language, and visuospatial functions.
	Deficits in ADLs must be independent of the motor/sensory sequelae of the vascular event.
VASCOG Sachdev et al., 2014¹⁴14. Sachdev P, Kalaria R, O'Brien J, Skoog I, Alladi S, Black SE, et al. Diagnostic Criteria for Vascular Cognitive Disorders: A VASCOG Statement. Alzheimer Dis Assoc Disord. 2014;28(3):206-18. doi:10.1097/WAD.0000000000000034. https://doi.org/10.1097/WAD.000000000000...	Dementia, major VCD
	Evidence of significant cognitive decline in > 1 domain compared to previous level of performance.
	Cognitive impairment ≥ 2 SD below the average (or below the 3^rd percentile) (compared to individuals of similar age, sex, education and socio-cultural profile)
	Fronto-executive deficiencies are more likely to be present.
	Enough to interfere with independence (at least requires help with IADLs, e.g., complex tasks such as managing finances or medications).
VICCCS Skrobot et al., 2018¹1. Skrobot OA, Black SE, Chen C, DeCarli C, Erkinjuntti T, Ford GA, et al. Progress toward standardized diagnosis of vascular cognitive impairment: Guidelines from the Vascular Impairment of Cognition Classification Consensus Study. Alzheimers Dement. 2018;14(3):280-92. doi:10.1016/j.jalz.2017.09.007. https://doi.org/10.1016/j.jalz.2017.09.0...	Major VCI, VD
	Impairment in ≥ 1 cognitive domain.
	Significant impairment of IADLs or ABVDs (regardless of motor/sensory symptoms).
ABN 2021 Consensus Proposal	Major VCI, VD
	Cognitive impairment in ≥ 1 cognitive domain.
	Cognitive impairment ≥ 2 SD below the mean (or below the 3^rd percentile).
	Significant impairment of IADLs or ADLs (regardless of motor/sensory symptoms).

Classification	Description
Post-stroke dementia	Presence of new, sudden or subacute cognitive deficit up to 6 months after ischemic or hemorrhagic stroke. It may be due to different cerebrovascular patterns (e.g., multiple cortico-subcortical infarctions, strategic lesions, subcortical vascular dementia, etc.). The temporal relationship between the vascular event and cognitive decline differentiates this form from VD.
Mixed dementias	Broad term that encompasses cognitive decline phenotypes combined between VCI and neurodegenerative diseases (e.g. VCI-AD, VCI-LBD etc). It is recommended to specify which underlying pathology is suspected, avoiding the less specific term “mixed dementia.”
Subcortical ischemic vascular dementia	Small vessel cerebrovascular disease is the main cause in this group, mainly due to lacunar infarcts and white matter lesions. It encompasses the phenotypes described as Binswanger’s Disease and the lacunar state.
Cortical multiple infarct dementia	A group characterized by the presence of multiple cortical infarcts and their likely contribution to dementia.
Level of certainty	Possible - more appropriate term if neuroimaging is unavailable. Probable - in the presence of compatible CT or MR. MR is the method of choice.

Health level	Cognitive screening recommendation for CCV
Primary attention	General practitioners and professionals from the Family Health Strategy can use screening instruments such as MoCA, or alternatively the MMSE associated with the clock drawing test and semantic verbal fluency (animals) and screening for depressive symptoms.
Secondary Care	Specialist physicians (neurologists, geriatricians, and psychiatrists) who receive patients referred from primary care can use a broader protocol that includes global function tests (MoCA or MMSE) associated with CAMCOG subscales, or Addenbrooke battery (ACE-R) and screening for depressive symptoms.
Tertiary care	Specialist physicians at referral centers can use expanded assessment including, in addition to a cognitive protocol, the assessment of neuropsychiatric symptoms (NPI-Q), assessment of severity of dementia (CDR), and screening for depressive symptoms (CES-D or GDS).

Scale [reference]	Brain region [indication]	Method [scores]
Fazekas et al. ⁽¹¹⁴114. Havakuk O, King KS, Grazette L, Yoon AJ, Fong M, Bregman N, et al. Heart Failure-Induced Brain Injury. J Am Coll Cardiol. 2017;69(12):1609-16. doi:10.1016/j.jacc.2017.01.022. https://doi.org/10.1016/j.jacc.2017.01.0...		Periventricular hyperintensities:
		0=absent
		1= “hoods” or thin coat
		2=smooth halo
	White matter hyperintensities	3=periventricular hyperintensities extending into deep white matter
	periventricular and deep	Deep white substance:
		0=absent
		1=point-like foci
		2=initial confluence
		3=large confluent areas
Modified Fazekas (LADIS) ⁽¹¹⁵115. Doehner W, Ural D, Haeusler KG, Celutkien J, Bestetti R, Cavusoglu Y, et al. Heart and brain interaction in patients with heart failure: overview and proposal for a taxonomy. A position paper from the Study Group on Heart and Brain Interaction of the Heart Failure Association: Heart and brain interaction in heart failure. Eur J Heart Fail. 2018;20(2):199-215. doi:10.1002/ejhf.1100. https://doi.org/10.1002/ejhf.1100...	Deep white matter and subcortical lesions (DSWM)	0=absent
		1=[mild] punctiform lesions with maximum unit diameter below 10 mm and areas of clustered lesions smaller than 20 mm
		2=[moderate] single lesions between 10-20 mm in diameter, areas of clustered lesions greater than 20 mm in diameter, no more than connecting bridges between individual lesions 3=[severe] single lesions or confluent areas of hyperintensities 20 mm or more in diameter
Scheltens et al. ⁽¹¹⁶116. Passiak BS, Liu D, Kresge HA, Cambronero FE, Pechman KR, Osborn KE, et al. Perivascular spaces contribute to cognition beyond other small vessel disease markers. Neurology. 2019;92(12):e1309-21. doi:10.1212/WNL.0000000000007124. https://doi.org/10.1212/WNL.000000000000...	PVH, DWMH, basal and infratentorial ganglia hyperintensities	PVH (0-6), WMH (0-24), basal and infratentorial ganglia (both 0-24)
		Total=0 to 84
ARWMC scale¹¹⁷117. Teixeira MM, Passos VMA, Barreto SM, Schmidt MI, Duncan BB, Beleigoli AMR, et al. Association between diabetes and cognitive function at baseline in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Sci Rep. 2020;10(1):1596. doi: 10.1038/s41598-020-58332-9. https://doi.org/10.1038/s41598-020-58332...	Hyperintensities of hemispheres and basal ganglia	White matter lesions:
		0 = absence
		1= focal lesions
		2=initial confluent lesions
		3= diffuse involvement of the entire region
		Basal ganglia:
		0=absence
		1=focal lesions (≥5 mm)
		2= >1 focal lesion
		3=confluent lesions
		Total = 0 to 30

LADIS Battery
	MEEM	ADAS-Cog	COMMANDER					Trails A B	Stroop
			Digit-symbol	Digit span	Maze	Cancellation	Verbal Fluency
			Digit-symbol	WAIS-III	Maze	Digits	Verbal Fluency
Global Mental Functioning	+	+
Orientation		+
Memory		+		+
Attention			+	+		+		+
Language		+
Constructional abilities		+
Executive function			+				+	+	+
Praxis		+
Speed and motor control					+	+		+
MCIV-Tuscany Battery
	MEEM	MoCA	Digit-symbol	Rey Test	Short story	Rey-Osterrieth	Verbal Fluency	Trails A B	Stroop	Visual search
				(RAVL)		Copy Figure - Retrieval
				immed - late		Copy Figure - Retrieval
Global Mental Functioning	+	+
Orientation
Memory				+ +	+	+
Attention + Executive function			+					+ +	+	+
Language							+
Constructional abilities						+
VCI-VICCCS criteria
	MEEM	Boston Naming	Digit-symbol	Hopkins Verbal Learning Test	Simple reaction time with choice	Rey-Osterrieth	Verbal Fluency	NPI-Q	CES-D
	MEEM	Boston Naming	Digit-symbol	Hopkins Verbal Learning Test	Simple reaction time with choice	Copy Figure- Retrieval	Verbal Fluency	NPI-Q	CES-D
Global Mental Functioning	+
Orientation
Memory				+
Attention			+			+
Language		+					+
Constructional abilities						+
Executive function			+	+			+
Speed and motor control					+
Depressive symptoms									+
Neuropsychiatric symptoms								+
Consensus Protocol A/ABN 2011
	MEEM	Clock Drawing Test					Verbal Fluency
Global Mental Functioning	+
Language							+
Constructional abilities		+
Executive function							+
Protocol B of consensus/ABN 2011
	MEEM	CAMCOG (global and subscales)	Digit span	Trails A B	Boston Naming	Verbal Fluency	Word List - CERAD	CLOX	NPI	Cornell Depression Scale	CDR
	MEEM	CAMCOG (global and subscales)	WAIS-III	Trails A B	Boston Naming	Verbal Fluency	Word List - CERAD	CLOX	NPI	Cornell Depression Scale	CDR
Global Mental Functioning	+	+
Orientation	+	+
Memory							+
Attention		+	+	+
Language		+			+	+
Constructional abilities		+
Executive function			+	+		+		+
Praxis		+
Gnosia		+
Abstract reasoning		+
Depressive symptoms										+
Neuropsychiatric symptoms									+
Severity											+
NINDS - Canadian Stroke Network Vascular Cognitive Impairment (Hachinski et al., 2006)
30-minute Protocol
	MEEM	Hopkins Verbal Learning test	Digit-symbol	Trails A B	Verbal Fluency	NPI-Q	CES-D
Global Mental Functioning	+
Orientation
Memory		+
Attention			+	+
Language					+
Constructional abilities
Executive function			+	+	+
Speed and motor control
Depressive symptoms							+
Neuropsychiatric symptoms						+
5-minute Protocol - MoCA Subtests
	Memory task with words	Orientation	Phonemic Verbal Fluency
Orientation		+
Memory	+
Attention	+		+
Executive function			+

Bateria LADIS
	MEEM	ADAS-Mod	VADAS					Trilhas A B	Stroop
			Digito-simbolo	Span digitos	Labirinto	Cancelamento	Fluência Verbal
			Digito-simbolo	WAIS-III	Labirinto	Digitos	Fluência Verbal
Funcionamento Mental Global	+	+
Orientação		+
Memória		+		+
Atenção			+	+		+		+
Linguagem		+
Habilidades construcionais		+
Função executiva			+				+	+	+
Praxias		+
Velocidade e controle motor					+	+		+
Bateria CCV-TOSCANA
	MEEM	MoCA	Digito-simbolo	Teste de Rey	Pequena história	Figura de Rey-Osterrieth	Fluência Verbal	Trilhas A B	Stroop	Busca visual
				(RAVL)		Cópia - Evoc
				imed - tardio		Cópia - Evoc
Funcionamento Mental Global	+	+
Orientação
Memória				+ +	+	+
Atenção + Funções executivas			+					+ +	+	+
Linguagem							+
Habilidades construcionais						+
VCI-VICCCS criteria
	MEEM	Boston Naming	Digito-simbolo	Teste Aprendizado Verbal Hopkins	Tempo de reação simples e com escolha	Figura de Rey-Osterrieth	Fluência Verbal	NPI-Q	CES-D
	MEEM	Boston Naming	Digito-simbolo	Teste Aprendizado Verbal Hopkins	Tempo de reação simples e com escolha	Cópia - Evoc	Fluência Verbal	NPI-Q	CES-D
Funcionamento Mental Global	+
Orientação
Memória				+
Atenção			+			+
Linguagem		+					+
Habilidades construcionais						+
Função executiva			+	+			+
Velocidade e controle motor					+
Sintomas depressivos									+
Sintomas neuropsiquiátricos								+
Protocolo A do Consenso/ABN 2011
	MEEM	Teste Desenho Relógio					Fluência Verbal
Funcionamento Mental Global	+
Linguagem							+
Habilidades construcionais		+
Função executiva							+
Protocolo B do Consenso/ABN 2011
	MEEM	CAMCOG (global e subescalas)	Span digitos WAIS-III	Trilhas A B	Boston Naming	Fluência Verbal	Lista de Palavras - CERAD	CLOX	NPI	Escala Cornell Depressão	CDR
Funcionamento Mental Global	+	+
Orientação	+	+
Memória							+
Atenção		+	+	+
Linguagem		+			+	+
Habilidades construcionais		+
Função executiva			+	+		+		+
Praxias		+
Gnosias		+
Raciocínio abstrato		+
Sintomas depressivos										+
Sintomas neuropsiquiátricos									+
Gravidade											+
NINDS - Canadian Stroke Network Vascular Cognitive Impairment (Hachinski et al., 2006)
Protocolo 30 min
	MEEM	Hopkins Verbal Learning test	Digito-simbolo	Trilhas A B	Fluência Verbal	NPI-Q	CES-D
Funcionamento Mental Global	+
Orientação
Memória		+
Atenção			+	+
Linguagem					+
Habilidades construcionais
Função executiva			+	+	+
Velocidade e controle motor
Sintomas depressivos							+
Sintomas neuropsiquiátricos						+
Protocolo 5 min - Subtestes do MoCA
	Tarefa de Memória com palavras	Orientação	Fluência Verbal Fonêmica
Orientação		+
Memória	+
Atenção	+		+
Função executiva			+

Academia Brasileira de Neurologia, Departamento de Neurologia Cognitiva e Envelhecimento R. Vergueiro, 1353 sl.1404 - Ed. Top Towers Offices, Torre Norte, São Paulo, SP, Brazil, CEP 04101-000, Tel.: +55 11 5084-9463 | +55 11 5083-3876 - São Paulo - SP - Brazil
E-mail: revistadementia@abneuro.org.br | demneuropsy@uol.com.br

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[1] Correspondence: Breno José Alencar Pires Barbosa; Email: brenojb@gmail.com.