What is Vascular Neurocognitive Disorder?

Vascular NCD is cognitive impairment caused by cerebrovascular disease processes — large vessel infarcts, strategic single lesions, or chronic small vessel disease leading to subcortical ischemic changes. Cognitive deficits often affect processing speed, attention and executive function more than episodic memory early in the course.

Subtypes & patterns

• Post-stroke (multi-infarct) cognitive impairment: cognitive decline following one or more cortical infarcts.
• Subcortical ischemic vascular disease (SIVD): diffuse small vessel disease with white matter lesions, lacunes and executive dysfunction.
• Mixed Alzheimer’s and vascular pathology: common in older adults; both pathologies contribute to symptoms.
• Strategic infarct dementia: focal lesion in critical areas (e.g., thalamus, angular gyrus) causing disproportionate cognitive deficits.

Clinical features

• Stepwise or fluctuating decline after vascular events (more typical in multi-infarct patterns).
• Slowed information processing and impaired attention.
• Executive dysfunction — planning, organising, cognitive flexibility deficits.
• Gait disturbance and urinary symptoms may be prominent in subcortical disease.
• Septal onset of mood changes, apathy and emotional lability.
• Memory impairment often retrieval-based rather than classic hippocampal consolidation failure.

Risk factors & contributors

• Vascular risk factors: hypertension, diabetes mellitus, dyslipidaemia, smoking, atrial fibrillation.
• Age, prior stroke or transient ischaemic attack (TIA), chronic kidney disease, sleep apnoea.
• Small vessel disease drivers: chronic hypertension, cerebral amyloid angiopathy, metabolic syndrome.

Assessment — clinical and imaging priorities

1. Thorough history: stroke/TIA events, timeline (stepwise vs insidious), functional impact and collateral information.
2. Examine cognition with screening tests sensitive to executive dysfunction (MoCA preferable to MMSE).
3. Neurological exam focusing on focal signs, gait, reflexes and pyramidal features.
4. Neuroimaging: MRI brain (FLAIR, T2, diffusion) to identify infarcts, lacunes, white matter hyperintensities and microbleeds; CT when MRI contraindicated.
5. Vascular workup: carotid doppler, echocardiography, cardiac rhythm monitoring (for AF), and vascular risk factor evaluation.
6. Consider neuropsychological testing for detailed domain profiling.

Investigations

• MRI brain with sequences for small vessel disease and microbleeds.
• Vascular studies: carotid ultrasound, CT/MR angiography when indicated.
• Cardiac evaluation: ECG, Holter monitoring, echocardiography to detect cardioembolic sources.
• Routine blood tests: glucose, HbA1c, lipids, renal and liver function, thyroid function, B12; inflammatory markers where relevant.

Treatment principles — secondary prevention & symptomatic management

Management aims to prevent further vascular injury, optimise cognition and function, address neurological and psychiatric symptoms, and support caregivers.

Secondary prevention

• Aggressive vascular risk factor control — blood pressure targets (individualised), glycaemic control, lipid lowering (statins), smoking cessation.
• Atrial fibrillation management — anticoagulation when indicated to prevent cardioembolic strokes.
• Antiplatelet therapy for non-cardioembolic stroke prevention (aspirin/clopidogrel as per guidelines).
• Address sleep apnoea and other modifiable contributors.

Symptomatic & cognitive interventions

• Cognitive rehabilitation targeting executive skills and compensatory strategies.
• Occupational therapy, physiotherapy for gait and mobility, and speech therapy when language or swallowing affected.
• Consider cholinesterase inhibitors in selected cases of mixed or probable vascular dementia with cortical involvement — specialist decision advised.

Behavioural and psychiatric management

• Treat depression, apathy and anxiety (SSRIs often first-line; monitor interactions and bleeding risk with anticoagulation).
• Manage agitation or psychosis cautiously with low-dose antipsychotics and regular review for side effects.

Key takeaways

• Vascular NCD includes diverse patterns — post-stroke, small vessel disease, strategic infarcts and mixed pathology.
• Executive dysfunction and slowed processing are hallmark features; MRI is central to diagnosis.
• Primary management is vascular risk reduction and secondary prevention to avoid further brain injury.
• Multidisciplinary rehabilitation and caregiver support improve outcomes and quality of life.