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Inicio Revista Española de Geriatría y Gerontología Avances en la fisiopatología de la demencia vascular
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Vol. 39. Núm. 1.
Páginas 41-49 (Enero 2004)
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Vol. 39. Núm. 1.
Páginas 41-49 (Enero 2004)
DOI: 10.1016/S0211-139X(04)74930-6
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Avances en la fisiopatología de la demencia vascular
Advances in the physiopathology of vascular dementia
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K.A. Jellinger
Autor para correspondencia
kurt.jellinger@univie.ac.at

Correspondencia: Institute of Clinical Neurobiology. Kenyongasse 18. A-1070 Vienna. Austria.
Institute of Clinical Neurobiology. Viena. Austria
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La prevalencia, morfología y patogenia de la demencia vascular (DV) —que engloba desde muy recientemente los términos deterioro cognitivo de origen vascular (DCV) y demencia mixta (suma de enfermedad de Alzheimer [EA] y encefalopatía vascular)—, continúan siendo tema de controversia, sin que hasta el momento se disponga de criterios neuropatológicos validados para el diagnóstico de estas entidades. En las series recogidas por las distintas Unidades de Memoria de países occidentales, la combinación DV/DCV se sugiere únicamente en un 8-10% de los ancianos referidos por deterioro cognitivo. Su prevalencia en las series de autopsias varía desde el 0,03 al 58%, aunque la mayoría la sitúa entre el 5 y el 15%. La DV, que razonablemente constituye una rareza como entidad nosológica aislada, parece estar muy relacionada con la presencia de microinfartos o lagunas corticales y/o subcorticales, ya sean focales, multifocales o difusos, que afectan a zonas estratégicas (tálamo, sistema frontobasal y límbico), sustancia blanca y, con menor frecuencia, a áreas extensas del córtex. Son el resultado de enfermedades de grandes o pequeños vasos, sean éstas sistémicas, cardíacas o circunscritas al cerebro. El sustrato patológico de la forma «pura» de DV, con predominio de múltiples pequeñas lesiones (subcorticales) debidas a microangiopatía, difiere con claridad de los hallazgos en la demencia mixta (EA + DV), más habitualmente relacionada con infartos más extensos, lo cual sugiere mecanismos patogénicos diferentes para ambos tipos de demencia. En sujetos muy ancianos se puede encontrar esclerosis selectiva del hipocampo en innumerables afecciones de tipo vascular. Las lesiones cerebrales microvasculares —excepto la angiopatía amiloide severa —, no parecen clave para el desarrollo de deterioro cognoscitivo en la EA auténtica; sin embargo, actuarían de forma sinérgica para desenmascarar o desencadenar los síntomas de demencia, tanto en las formas anatomopatológicas de EA leve como en la enfermedad de pequeños vasos. Los hallazgos patológicos de la EA son significativamente menos intensos en presencia de lesiones cerebrovasculares. Para validar los criterios diagnósticos de DV/DCV y aclarar el papel de las lesiones vasculares en la aparición de deterioro cognitivo son necesarios más estudios.

Palabras clave:
Deterioro cognitivo vascular
Demencia vascular
Demencia mixta
Infartos cerebrales
Enfermedad de pequeño vaso
Lesiones vasculares subcorticales
Abstract

The prevalence, morphology, and pathogenesis of vascular dementia (VaD), recently termed vascular cognitive impairment (VCI), and of mixed dementia (Alzheimer disease + vascular encephalopathy) are a matter of dicussion and no validated neuropathologic criteria for these disorders are currently available. In Western memory clinic-based series, VaD/CVI is suggested in 8-10% of cognitively impaired elderly subjects; its prevalence in autopsy series ranges from 0.03 to 58% with reasonable values of 5-15%. Fairly unusual as an isolated nosological entity, VaD appears to correlate with focal, multifocal or diffuse cortical and/or subcortical microinfarcts and lacunes often affecting strategically important brain areas (thalamus, frontobasal and/or limbic systems), hemispheric white matter and, less often, large brain areas. They result from systemic, cardiac or local large or small vessel disease. The lesion pattern in «pure» VaD with predominant multiple small (subcortical) lesions related to microangiopathies differs from that in mixed dementia (AD + VaD), more often associated with large infarcts, suggesting different pathogenesis of both types. In very old subjects selective hippocampal sclerosis may be associated with multiple other vascular pathologies. Minor cerebrovascular lesions, except for severe amyloid angiopathy, appear not essential for cognitive decline in full-blown AD, while both mild AD-type pathology and small vessel disease may interact synergistically in “unmasking” or promoting dementia. AD pathology is significantly less severe in the presence of cerebrovascular lesions. Further studies are neededed to validate diagnostic criteria for VaD/VCI and to clarify the impact of vascular lesions on cognitive impairment.

Key words:
Vascular cognitive impairment
Vascular dementia
Mixed type dementia
Cerebral infarcts
Small vessel disease
Subcortical vascular lesions
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Presentado en el V Congreso Europeo de Gerontología celebrado en Barcelona en julio de 2003.

Manuscrito traducido por Jesús Mora Fernández.

Copyright © 2004. Sociedad Española de Geriatría y Gerontología
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