Comparative characterization of vascular cognitive impairment in dyscirculatory encephalopathy

The significant prevalence of cerebrovascular diseases and the high percentage of disability and mortality from them make this problem one of the most important, having not only medical but also national significance.

Chronic cerebrovascular accidents (CVA) are extremely widespread. Patients with these disorders make up a significant portion of the neurological hospital population. In the domestic classification, such conditions are described as cerebrovascular insufficiency (CVI). Cerebrovascular insufficiency is a progressive multifocal disorder of brain function caused by insufficient blood circulation. According to the order of the Ministry of Health of Ukraine dated 17.08.2007 No. 487 ("On approval of clinical protocols for providing medical assistance in the specialty "Neurology""), the diagnosis of cerebrovascular insufficiency requires cognitive and/or emotional-affective disorders confirmed by neuropsychological studies.

Traditionally, the main focus of research has been vascular dementia, which is considered to be the second most common dementia in the population after primary degenerative dementia. Currently, less severe cognitive impairment (CI) is receiving increasing attention.

Cognitive disorders are one of the most important problems of modern neurology and neurogeriatrics, having both medical and social significance. This reflects the general trend in modern neurogeriatrics towards maximum optimization of early diagnostics and therapy of cognitive disorders in order to prevent the development of dementia. Life expectancy and its quality directly depend on the preservation of cognitive functions. Cognitive disorders are obligatory clinical manifestations of all variants of acute and chronic cerebrovascular diseases (CVD). The peculiarities of cognitive disorders against the background of cerebrovascular diseases include their combination with neurological disorders (motor, speech, coordination), which makes this problem especially relevant for neurologists.

The relevance of the problem of chronic cerebrovascular insufficiency is determined not only by its prevalence, but also by its social significance: cognitive and neurological disorders in cerebrovascular insufficiency can cause severe disability of patients. According to the state program "Prevention and treatment of cardiovascular and cerebrovascular diseases for 2006-2010" primary and secondary prevention measures, timely provision of specialized medical care, rehabilitation measures are necessary. Therefore, an important condition for the management of these patients is the early diagnosis of cognitive impairment to identify pre-dementia stages of the process. It is necessary to organize specialized offices to provide assistance to patients with cognitive impairment. In modern neurology, there are opportunities for effective prevention, treatment and rehabilitation of patients with cognitive impairment at the early stages of the evolution of cognitive deficit.

The importance of analyzing the state of cognitive functions in clinical practice is not limited to the need to treat and prevent cognitive disorders themselves. The study of cognitive functions allows us to clarify the localization and severity of brain damage, clarify the cause, diagnose brain damage in neurological and somatic diseases at an earlier stage, clarify the dynamics of development or regression of the pathological process, increase the effectiveness of prevention, treatment, rehabilitation, and accurately formulate a prognosis.

The aim of the study is to optimize early diagnosis and correction of cognitive impairment in patients with cerebrovascular insufficiency by studying the characteristics of clinical, neuropsychological, and MRI studies.

The study included 103 patients diagnosed with stage I and II cerebrovascular insufficiency.

The inclusion criteria were as follows:

• clinically established diagnosis of DE stages I and II, confirmed by neuroimaging methods (MRI);
• absence of pronounced stenotic occlusive process of large vessels of the neck and head (according to ZDG data);
• clinical signs of atherosclerosis using lipidemic profile data;
• absence of signs of severe heart failure;
• absence of concomitant acute and chronic diseases in the decompensation stage that could influence the course of the disease (diabetes mellitus, thyroid pathology, collagenoses, purulent-inflammatory diseases, endogenous intoxication syndromes, etc.);
• absence of acute cardiac causes (myocardial infarction, arrhythmia, artificial heart valves, severe heart failure in coronary heart disease).

Among the causes of the disease, 85% were long-term neuropsychic and physical overstrain at work and at home; 46% - violation of the work and rest regime, 7% - alcohol abuse, 35% - smoking, 68% - irrational ratio of consumption of animal fats, carbohydrates, table salt against the background of low physical activity, 62% - hereditary burden of cardiovascular diseases (ischemic heart disease, atherosclerosis, arterial hypertension, myocardial infarction).

Neurological examination was performed according to the scheme using traditional methods of assessing the functions of the cranial nerves, motor and sensory spheres, assessing the cerebellar functions and pelvic organs. To study higher nervous activity, a brief rating scale of assessment (Mini Mental State Examination - MMSE), a battery of tests of frontal dysfunction (Frontal Assessment Battery - FAB) were used. According to the MMSE scale, the norm was 28-30 points, mild cognitive impairment - 24-27 points, mild dementia - 20-23 points, moderate dementia - 11-19 points, severe dementia - 0-10 points; according to the FAB scale, the norm was in the range of 17-18 points, moderate cognitive impairment - 15-16 points, severe cognitive impairment - 12-15 points, dementia - 0-12 points.

In the diagnosis of dementia with predominant damage to the frontal lobes, a comparison of the FAB and MMSE results is important: frontal dementia is indicated by an extremely low FAB result (less than 11 points) with a relatively high MMSE result (24 points or more).

In mild Alzheimer's dementia, on the contrary, the MMSE index decreases first (20-24 points), while the EAB index remains at its maximum or decreases slightly (more than 11 points). Finally, in moderate and severe Alzheimer's dementia, both the MMSE index and the EAB index decrease.

The choice of these scales is due to the fact that cognitive impairments of vascular genesis are often combined with degenerative processes.

The study included 21 (20.4%) patients with stage I cerebrovascular insufficiency (first group) and 82 (79.6%) patients with stage II cerebrovascular insufficiency (second group).

Clinical and neurological disorders in stage I-II cerebrovascular insufficiency are manifested by cephalgic (97.9%), vestibulo-ataxic (62.6%), cerebrospinal fluid-hypertensive (43.9%), asthenic (32%), pseudobulbar (11%) syndromes, autonomic dysfunction in the form of panic attacks, mixed paroxysms (27%), emotional dysfunction (12%), sensory disturbances (13.9%), pyramidal insufficiency (41.2%).

In a neuropsychological study using the MMSE scale, the average score in the first group was 28.8±1.2 points, in the second group in patients aged 51-60 years - 24.5-27.8 points; at the age of 61-85 years - 23.5-26.8 points.

The results were reduced in the following parameters: orientation in place and time, fixation in memory, concentration of attention, copying a picture, repetition of simple proverbs.

The number of patients with values bordering on dementia in the first group was 2.7%, in the second - 6%. The assessment bordering on dementia (23.5 points) was expressed by a decrease in indicators for all items of the MMSE scale.

In the first group, the test result was reduced due to incorrect copying of the drawing or a decrease in memory (words were recorded in memory, but during subsequent testing of 3 words in 15% of cases, patients either did not name a single word, or named words in the wrong order, replacing forgotten ones).

In the second group, the test result decreased due to incorrect copying in 75% of cases. Patients had difficulty repeating a complex phrase, and serial counting was impaired in more than 60%. In patients aged 51-60, the test results for memory decreased in 74%; for orientation in time and writing a sentence - in 24%.

In patients aged 61-70 years - orientation on the spot - in 43.1%, perception - in 58.7%, memory - in 74% of cases. At the age of 71-85 years, difficulties were found in naming objects, performing a three-stage command, in 81% of patients a sharp decrease in memory indicators was observed.

Neuropsychological testing according to EAB in the first group showed a result of 17.1 ± 0.9 points, in the second group - 15.4 + 0.18 points (51-60 years), 12-15 points (61-85 years).
Patients in the second group had difficulties with speech fluency (1.66-1.85, p < 0.05) and choice reaction (1.75-1.88, p < 0.05). When performing a three-stage motor program, 15% experienced difficulties or dynamic apraxia.

Thus, the results on the MMSE and FAB scales were not identical. 34% of patients with normal MMSE cognitive function indices had FAB symptoms (conceptualization, verbal fluency, praxis, choice reaction). The obtained results emphasize the need to determine sensitive test scales, the use of which allows detecting mild cognitive impairments related to individual cognitive functions.

In the first group, the quality of tests for praxis, choice reaction, speech functions, and optical-spatial activity decreased. In the second group, moderate cognitive impairments were observed in the form of a decrease and impairment of regulatory components (control over activity, its programming, and voluntary regulation), operational components (praxis, speech function, optical-spatial activity).

According to MRI data, the lesions are symmetrical, hyperintense on T2-weighted images, localized mainly in the white matter, less often in the basal ganglia. External and/or internal hydrocephalus with signs of cortical atrophy is revealed.

The absence of identity of the indicators in assessing the cognitive status using scales indicates the need for a combined use of screening scales to detect cognitive impairment. In patients with stage I and II cerebrovascular insufficiency, cognitive impairment should be recognized as the core of the clinical picture. Management of patients with cognitive impairment should be based on a number of general provisions: early detection of cognitive impairment; determination of its severity during dynamic observation of patients; clarification of the nature and pathophysiology of cognitive impairment; early initiation with the use of symptomatic and, if possible, etiopathogenetic drug and non-drug therapy with its long duration and continuity; treatment of concomitant neurological, neuropsychiatric and somatic disorders; medical, professional and everyday rehabilitation; in case of severe cognitive impairment - medical and social assistance to family members of patients.

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