Cerebral Small Vessel Disease, Hypertension, and Vascular Contributions to Cognitive Impairment and Dementia

From mechanism to classification: Understanding a novel model of cerebral small vessel disease

The studies explored cerebral small vessel disease (cSVD), emphasizing the need for precise classification to improve prevention and intervention strategies. Kang et al. introduced an intra-cisterna-magna bevacizumab injection (ICM-BI) model in mice, which induced tight junction loss, microbleeds, and amyloid deposits. However, bevacizumab's low affinity for murine vascular endothelial growth factor raises questions about its mechanism of action, suggesting potential off-target effects. While most cSVD models mimic arteriolosclerosis (type 1) or genetic variants (types 2 and 3), the ICM-BI model represents a novel approach to studying immune-mediated cSVD (type 4). The complexity and variability of cSVD remain significant research challenges.

Nutrition, cognition and chronic kidney disease: A comprehensive review of interactions and interventions

BACKGROUND

Cognitive impairment is a prevalent complication in chronic kidney disease (CKD), ranging from mild deficits in early stages to more severe conditions, such as mild cognitive impairment and dementia in advanced stages. CKD patients exhibit reduced performance in memory, attention, language, visuospatial abilities and executive functions.

RESULTS AND DISCUSSION

Contributing factors include uraemic toxins, structural brain changes, blood-brain barrier dysfunction, anaemia and comorbidities like diabetes mellitus. Malnutrition, affecting nearly half of CKD patients, exacerbates cognitive decline through inflammation, oxidative stress and protein-energy wasting. Nutritional deficiencies, particularly in protein, vitamin D, B vitamins, omega-3 fatty acids and antioxidants, are linked to impaired cognition. Emerging evidence highlights the role of the gut-brain axis, with gut-derived uraemic toxins and microbiome alterations contributing to cognitive dysfunction. Processed foods and microplastics further compound risks by promoting inflammation and neurotoxicity. Dialysis and kidney transplantation offer opportunities for cognitive recovery, though challenges remain, particularly in haemodialysis patients. Nutritional interventions, including tailored protein intake, micronutrient supplementation and dietary counselling, are critical for mitigating cognitive decline. Addressing CKD comorbidities, such as anaemia and diabetes through targeted nutritional and pharmacological strategies, improves outcomes. Integrating psychological and social support enhances quality of life, given the high prevalence of anxiety and depression in CKD patients.

CONCLUSIONS

Future research should focus on personalized nutrition, gut microbiota modulation and routine cognitive assessments to optimise care. A holistic approach combining medical, nutritional and psychosocial strategies is essential for improving cognitive and overall health in CKD patients.

Manual acupuncture enhanced therapeutic efficacy in vascular dementia rat model: systematic review and network meta-analysis

OBJECTIVE

This study aimed to systematically evaluate the efficacy of electroacupuncture and manual acupuncture for treating vascular dementia and to determine the optimal acupuncture point combination scheme for efficacy.

METHODS

The PubMed, Embase, Web of Science, Cochrane, CNKI, VIP, and Wanfang electronic databases were searched up to July 2024 to identify relevant randomized controlled trials. RevMan 5.4 software and Addis software were used to assess the risk of bias for each study, determine subgroup classifications, and conduct meta-analyses.

RESULTS

A total of 29 RCTs involving 659 animals were ultimately included. The meta-analysis results revealed that acupuncture treatment had a significant effect compared with the vascular dementia model group [mean difference (MD) = - 21.68, 95% confidence interval (CI) (- 25.77, - 17.59), P < 0.00001]. Manual acupuncture demonstrated better efficacy than electroacupuncture did [MD = - 0.42, 95% CI (- 12.72, 12.27)]. Among the different acupuncture point combinations, the Baihui (GV20) + Dazhui (GV14) combination yielded the best efficacy [MD = - 23.03, 95% CI (- 30.02, - 16.04), P < 0.00001]. Compared with other acupuncture protocols, the experiment conducted by Caiyu Peng et al. exhibited superior efficacy [MD = - 24.96, 95% CI (- 92.68, - 40.76)].

CONCLUSION

Acupuncture significantly improves cognitive function in rats with vascular dementia. Manual acupuncture is more effective than electroacupuncture. Among the different acupuncture point combinations, manual acupuncture at GV20 and GV14 yields the best results. Compared with other acupuncture protocols, the best efficacy was observed when the two-vessel occlusion (2VO) model was used in 230 ± 10 g SD rats; when the Mingmen (GV4), Dazhui (GV14), Fengfu (GV16), Baihui (GV20), Shenting (GV24), Shuigou (GV26), Neiguan (PC6), Dalin (PC7), and Laogong (PC8) acupoints were selected; and when manual acupuncture with reinforcing and reducing methods was used for 30 min per day for 14 days.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42024551402.

Aging, mitochondrial dysfunction, and cerebral microhemorrhages: a preclinical evaluation of SS-31 (elamipretide) and development of a high-throughput machine learning-driven imaging pipeline for cerebromicrovascular protection therapeutic screening

Cerebral microhemorrhages (CMHs, also known as cerebral microbleeds) contribute to vascular cognitive impairment and dementia (VCID), with aging and hypertension being key risk factors. Mitochondrial oxidative stress is a hallmark of cerebrovascular aging, leading to endothelial dysfunction. This study tests the hypothesis that increased mitochondrial oxidative stress contributes to age-related CMH susceptibility and evaluates the mitochondrial-targeted antioxidative peptide SS-31 (elamipretide) as a potential protective agent in an aged, hypertensive mouse model. Concurrently, we developed a high-throughput, machine learning-driven imaging pipeline to enhance CMH quantification and facilitate the screening of anti-aging vasoprotective interventions. To detect CMHs, brain sections were labeled with diaminobenzidine (DAB) and digitized using a slide scanner-based imaging platform. We developed multiple quantification tools, including color space transformation for enhanced contrast separation and a supervised machine-learning approach utilizing a random forest algorithm to generate whole-brain 3D reconstructions and precisely localize CMHs. We optimized a semi-automated detection method integrating color space transformation and machine learning, benchmarking it against traditional manual counting and color deconvolution-based approaches. While SS-31 treatment did not significantly mitigate hypertension-induced CMH burden in aged mice, our high-throughput imaging pipeline provided a reliable, scalable, and unbiased approach to CMH detection, reducing processing time while improving accuracy. This methodological advancement paves the way for future preclinical studies evaluating therapeutic strategies for cerebrovascular protection in aging. Our findings underscore the need for multi-targeted interventions to mitigate CMH-related neurovascular impairments and prevent VCID.

White matter hyperintensity spatial patterns: Risk factors and clinical correlates

INTRODUCTION

White matter hyperintensities (WMHs), a major cerebral small vessel disease (cSVD) marker, may arise from different pathologies depending on their location. We explored clinical and genetic correlates of agnostically derived spatial WMH patterns in two longitudinal population-based cohorts (Three-City Study [3C]-Dijon, LIFE-Adult).

METHODS

We derived seven WMH spatial patterns using Bullseye segmentation in 2878 individuals aged 65+ and explored their associations with vascular and genetic risk factors, cognitive performance, dementia and stroke incidence.

RESULTS

WMHs in the frontoparietal and anterior periventricular region were associated with blood pressure traits, WMH genetic risk score (GRS), baseline and decline in general cognitive performance, incident all-cause dementia, and ischemic stroke. Juxtacortical-deep occipital WMHs were not associated with vascular risk factors and WMH GRS, but with incident all-cause dementia and intracerebral hemorrhage.

DISCUSSION

Accounting for WMH spatial distribution is key to deciphering mechanisms underlying cSVD subtypes, an essential step towards personalized therapeutic approaches.

HIGHLIGHTS

We studied spatial patterns of WMHs in 2878 participants. Blood pressure was associated with frontoparietal and anterior PV WMHs. Anterior PV WMHs predicted dementia and stroke risk. Juxtacortical-deep occipital WMH burden was not associated with blood pressure or WMH genetic risk. Juxtacortical-deep occipital WMH burden predicted dementia and intracerebral hemorrhage.

Effects of repetitive transcranial magnetic stimulation on learning and memory cognitive function in rats with vascular cognitive impairment and its neural induction mechanism

BACKGROUND

The treatment of vascular cognitive impairment (VCI) is challenging, and its neurological mechanisms are not yet fully understood. Repetitive transcranial magnetic stimulation (rTMS) offers a new non-invasive treatment approach.

METHODS

One hundred male SD rats were grouped: intervention group (IG), model group (MG), sham group (SG), and control group (CG), to prepare the rat model of VCI. The Morris water maze (MWM) test was conducted, and oxidative stress (OS) markers, neurotrophic factors, apoptosis factors, and the amplitude of postsynaptic potential (PSP) in the hippocampus of rats were measured.

RESULTS

Post-intervention, IG's escape latency was lower than MG but higher than SG and CG. IG's hippocampal malondialdehyde (MDA) content, Bax, and Caspase-3 (Cas-3) were lower than MG but higher than SG and CG, while the tendency was opposite for Bcl-2 expression and the content of glutathione (GSH) and superoxide dismutase (SOD). IG's brain-derived neurotrophic factor (BDNF), glial cell line-derived neurotrophic factor (GDNF), and N-methyl-D-aspartate receptor 1 (NMDAR1) in the hippocampus were higher than MG but lower than SG and CG; The changes in the amplitude of PSP in the hippocampal region of IG at 10, 30, and 60 min were all higher than those in MG but lower than those in SG and CG (P < 0.05).

CONCLUSION

Low-frequency rTMS visibly improved the learning and memory abilities of VCI rats and reduced OS levels.

Predictive value of heart rate for prognosis in patients with cerebral infarction without atrial fibrillation comorbidity analyzed according to the MIMIC-IV database

Objective

This study focused on the relationship between heart rate and the likelihood of death within 28 days in patients with cerebral infarction without the comorbidity of atrial fibrillation, using patient data extracted from the MIMIC-IV database.

Method

This study involved a retrospective analysis of clinical data from 1,643 individuals with cerebral infarction who were admitted to the ICU. To investigate the role of heart rate in determining patient survival, we applied a variety of statistical techniques such as Cox regression models, survival analysis using Kaplan-Meier plots, and spline-based models. In addition, we performed analyses by patient subgroups to identify any potential variables that could influence the association between HR and 28-day mortality.

Result

In univariate and multivariate analyses, elevated heart rate was strongly associated with higher 28-day mortality, even after adjusting for confounders such as age, sex, comorbidities, and clinical scores.(HR:1.01, 95%,CI:1.01 ~ 1.02, p = 0.019) Kaplan-Meier survival analysis showed that patients with heart rate > 90 beats/min had a significantly lower probability of survival. Restricted cubic spline (RCS) analysis confirmed a nonlinear relationship between heart rate and mortality. Subgroup analyses demonstrated an interaction between heart rate and factors such as hypertension and mechanical ventilation status.

Conclusion

This study highlights the prognostic significance of heart rate as an independent predictor of 28-day mortality in patients with cerebral infarction who do not have atrial fibrillation.

White matter injuries mediate brain age effects on cognitive function in cerebral small vessel disease

PURPOSE

This study aims to investigate the potential effect of compromised structural integrity on cerebral aging and cognitive function in cerebral small vessel disease (CSVD).

METHODS

Fifty-five CSVD patients and 42 controls underwent three-dimensional T1-weighted imaging and diffusion tensor imaging. Relative brain age (RBA) was computed to assess cerebral aging. Variables of structural integrity included cortical thickness, cortical volume, white matter hyperintensity (WMH) volume, peak width of skeletonized mean diffusivity (PSMD), ventricular volume, and choroid plexus volume. Mini-Mental State Examination (MMSE) was conducted to assess general cognition. Trail Making Test (TMT) and Auditory Verbal Learning Test were administered to evaluate executive function and episodic memory, respectively. Mediation analysis and multivariate linear regression with interaction terms were performed to explore the differential impacts of RBA on cognitive function and structural integrity between CSVD patients and controls.

RESULTS

RBA was significantly increased in CSVD patients compared to controls (p < 0.001). White matter injuries as assessed with PSMD (mediation magnitude: 41.1%) and WMH volume (mediation magnitude: 56.9%) significantly mediated the relationship between CSVD pathologies and RBA (p < 0.001). Higher RBA was significantly correlated with poorer scores of MMSE, TMT-A, and TMT-B in CSVD patients (p < 0.01). Additionally, PSMD (mediation magnitude: 57.8% in MMSE, 48.3% in TMT-A, and 28.8% in TMT-B) and WMH volume (mediation magnitude: 55.1% in MMSE) significantly mediated the relationship between RBA and cognitive function (p < 0.05).

CONCLUSION

White matter injuries play a critical role in the cerebral aging and cognitive decline in CSVD patients.

Association between healthy lifestyle and cognitive decline, all-cause mortality, and mortality from cardiovascular and cerebrovascular diseases: a 10-year population-based prospective cohort study

INTRODUCTION

The association between cognitive function, healthy lifestyle, and mortality remains understudied in large Chinese cohorts.

METHODS

In this nationwide 10-year prospective study of 24,657 older adults, we assessed Mini-Mental State Examination (MMSE) categories (<18, 18 to 23, 24 to 27, 28 to 30) and a seven-component lifestyle score (0 to 7) for their relationships with all-cause, cardiovascular, and cerebrovascular mortality.

RESULTS

Compared with individuals scoring 28 to 30 on the MMSE, lower scores were linked to elevated all-cause and cerebrovascular mortality but not cardiovascular mortality. Participants with lifestyle scores of 4 or 5 had a higher risk of all-cause mortality. Even optimal lifestyle practices did not fully mitigate the heightened mortality risk associated with declining cognitive performance.

DISCUSSION

A healthy lifestyle is beneficial but cannot fully offset the impact of cognitive impairment. Therefore, integrating routine cognitive assessments and targeted interventions with healthy lifestyle practices is crucial for effectively reducing mortality risk.

HIGHLIGHTS

A nationally representative, 10-year prospective cohort in China was employed to investigate the combined effects of lifestyle behaviors and cognitive function on all-cause, cardiovascular, and cerebrovascular mortality. Both healthy lifestyle and better cognitive function were associated with a reduced risk of all-cause mortality. Even among individuals practicing optimal lifestyle behaviors, cognitive impairment significantly elevated the risk of all-cause and cerebrovascular mortality. These findings underscore the necessity of incorporating routine cognitive assessments and targeted interventions with healthy lifestyle practices aimed at reducing mortality risk in aging populations.

Proteins Involved in Endothelial Function and Inflammation Are Implicated in Cerebral Small Vessel Disease

BACKGROUND

Endothelial dysfunction and inflammation have been implicated in the pathophysiology of cerebral small vessel disease (SVD). However, whether they are causal, and if so which components of the pathways represent potential treatment targets, remains uncertain.

METHODS

Two-sample Mendelian randomization (MR) was used to test the association between the circulating abundance of 996 proteins involved in endothelial dysfunction and inflammation and SVD. The genetic instruments predicting protein levels were obtained from the Iceland 36K (n=35 892) and the UK Biobank Proteomics (n=34 557) cohorts, both of which were longitudinal studies with follow-up from 2000 to 2023 and 2006 to 2023, respectively. SVD was represented by lacunar stroke (n=6030 cases) and 5 neuroimaging features (white matter hyperintensities [n=55 291], diffusion tensor imaging metrics: mean diffusivity [n=36 460] and fractional anisotropy [n=36 533], extensive white matter perivascular space burden [n=9324 cases], and cerebral microbleeds [n=3556 cases]). Among the proteins supported by causal evidence from the MR, cross-sectional analysis was performed to assess their associations with cognitive performance; survival analysis with Fine-Gray models was applied to examine their associations with incident all-cause dementia and stroke within the UK Biobank Proteomics cohort.

RESULTS

MR suggested COL2A1 (collagen type II α-1 chain) was associated with lacunar stroke (odds ratio, 0.89 [95% CI, 0.86-0.91]; P=5×10-5). Moreover, 12 proteins related to endothelial function and inflammation were associated with neuroimaging features of SVD. Cross-sectional analyses showed 5 of the 13 proteins (EPHA2 [ephrin type-A receptor 2], METAP1D [methionine aminopeptidase 1D, mitochondrial], FLT4 [vascular endothelial growth factor receptor 3], COL2A1, and TIMD4 [T-cell immunoglobulin and mucin domain-containing protein 4]) were associated with cognitive performance with effects concordant with their MR findings. Survival analyses with the Fine-Gray models indicated that 5 of the 13 proteins (EPHA2, METAP1D, FLT4, APOE [apolipoprotein E], and PDE5A [cGMP-specific 3',5'-cyclic phosphodiesterase]) were associated with the risk of all-cause dementia or stroke independent of age and sex, consistent with their MR evidence.

CONCLUSIONS

Our findings suggest that endothelial-platelet activation and complement-mediated regulation of inflammation play roles in SVD and identify potential therapeutic targets and pathways.

Modulatory Effects of Hypertension on Aging-Related White Matter Hyperintensities: A Comparative Study Among Stroke Patients and Stroke-Free Community-Based Cohort

The increased vulnerability of the aging human brain to hypertension-induced neurovascular impairments, including cerebral small vessel diseases (SVD), marked by MRI-visible white matter hyperintensities (WMH), is well recognized. We examined WMH burdens between stroke patients and stroke-free participants across three age groups and explored patterns of modifiable risk factors, specifically the modulating effects of hypertension on WMH burden, providing insights for potential therapeutic interventions. This study comprised one hospital-based cohort of 254 stroke patients and another community-based cohort of 254 stroke-free normative participants. Clinical variables were obtained consecutively, and MRI neuroimaging classified WMH as absent, mild, moderate, or severe. A step-by-step statistical analysis was performed to explore the said gaps. There were 508 participants (mean age 63.5 ± 8.9 years) with 285 males. A similar prevalence but different WMH burden was recorded between stroke and normative cohorts across different age groups. The modulating effect of hypertension on WMH severity varied across age groups and is greater in middle-aged adults; intriguingly, this effect diminished in elderly adults (b = -0.882, 95%CI [-1.591, -0.172], t = -2.442, p = 0.015). It was shown that, in a non-uniform fashion across different age groups, hypertension is a culprit risk factor for exacerbating WMH severity, and middle-aged adults are the most vulnerable. While the elevation of systolic blood pressure predisposes adults to brain white matter deterioration, the decline in diastolic blood pressure suggests a protective role. Recognizing hypertension as a modifiable risk factor and understanding the aging-related changes in blood pressure patterns open avenues for developing age-specific strategies for the mitigation and management of WMH progression.

Cerebellar pathology in forensic and clinical neuroscience

Recent research underscores the cerebellum's growing importance in forensic science and neurology, showing its functions extend beyond motor control, especially in identifying causes of death. Critical neuropathological markers including alpha-synuclein and tau protein aggregates, cellular degeneration, inflammation, and vascular changes are vital for identifying neurodegenerative diseases, injuries, and toxic exposures. Advanced forensic methods, such as Magnetic resonance imaging (MRI), immunohistochemistry, and molecular analysis, have greatly improved the accuracy of diagnoses. Promising new therapies, including neuroprotective agents like resveratrol and transcranial magnetic stimulation (TMS), offer potential in treating cerebellar disorders. The cerebellum's vulnerability to toxins, drugs, and traumatic brain injuries (TBIs) highlights its forensic relevance. Moreover, advancements in genetic diagnostics, such as next-generation sequencing and CRISPR-Cas9, are enhancing the understanding and treatment of genetic conditions like Joubert syndrome and Dandy-Walker malformation. These findings emphasize the need for further research into cerebellar function and its broader significance in both forensic science and neurology.

Edaravone dexborneol alleviates pericyte-mediated fibrosis depositing extracellular matrix through TGF-β1/IL-11 in cerebral small vessel disease

BACKGROUND

Chronic cerebral hypoperfusion (CCH) is a critical pathophysiological mechanism underlying cerebral small vessel disease (CSVD). Accumulating evidence have demonstrated that resident pericytes and deposit extracellular matrix (ECM) and play a key role in mediating fibrosis in hypoxic changes. Edaravone dexborneol (EDB) is known to target multiple pathways involved in fibrosis.

METHODS

We constructed the CCH mouse models that were subjected to either PBS or EDB at different concentrations. Measures of cognitive function, neuronal damage, white matter lesion (WML), the fibrous profiles of pericytes and ECM protein were investigated to assess the effect of EDB. RNA sequencing of OGD in pericytes was performed to identify a key signaling pathway.

RESULTS

We observed that both medium and high concentrations of EDB could ameliorate CCH-induced cognitive impairment and emotional disorders. Neuronal damage in cortical layer and hippocampus and WML in corpus callosum were improved by EDB, which was consistent with the tends of fibrous pericytes and ECM proteins in these regions. RNA sequencing suggested that TGF-β1/IL-11 plays an important role in mechanism of pericytes fibrosis. Subsequently, the results of sequencing were confirmed in both cellular and mouse model.

CONCLUSIONS

Our findings reveal the role of pericyte-mediated fibrosis in depositing ECM in the pathogenesis of CSVD. EDB could improve symptoms and the underlying pathogenesis of CCH mice and decrease the expression of the fibrous profiles of pericytes and ECM proteins, which may be regulated by TGF-β1/ IL-11. EDB treatment, targeting pericytes fibrosis, may be a novel therapeutic strategy for CSVD.

Association between cardiometabolic diseases and the risk and progression of motor neuron diseases in Sweden: a population-based case-control study

Background

The evidence on the link between cardiometabolic diseases (CMDs) and motor neuron diseases (MNDs) remains inconsistent. We aimed to determine whether there is an association of CMDs, namely, any cardiovascular disease, cardiac arrhythmia, heart failure, thromboembolic disease, hypertension, cerebrovascular disease, ischemic heart disease, diabetes mellitus type 2, and hypercholesterolemia with the risk and progression of MNDs.

Methods

We included 1463 MND patients (amyotrophic lateral sclerosis (ALS), primary lateral sclerosis (PLS), progressive spinal muscular atrophy (PSMA), and unspecified MND) diagnosed from January 1, 2015, to July 1, 2023, in Sweden according to the Swedish Motor Neuron Disease Quality Registry (i.e., cases), up to 5 MND-free population controls per case (N = 7311) who were individually matched to the cases on age and sex, and the full siblings (N = 2002) and spouses (N = 1220) of MND patients (i.e., relative controls). Conditional logistic regression models were used to estimate the risk of MND diagnosis in relation to previous CMDs, through comparing MND patients to population controls or relative controls. MND patients were followed from diagnosis to assess the role of pre-diagnostic CMDs on disease progression. A joint longitudinal-survival model was used to estimate risk of mortality (or use of invasive ventilation) in relation to CMDs after taking into account the longitudinal changes of ALS functional rating scale-revised (ALSFRS-R) in the time-to-event analysis. Hierarchical clustering with the Ward's linkage and a dissimilarity matrix created by Gower's method was used to identify clusters of MND patients with distinct phenotypes.

Findings

Among the CMDs studied, a history of diabetes mellitus type 2 (OR 0.75; 95% CI 0.62, 0.93) or hypercholesterolemia (OR 0.82; 95% CI 0.71, 0.94) more than one year before diagnosis was associated with a lower risk for MNDs. The associations persisted for more than five years before MND diagnosis. MND patients with a history of any cardiovascular disease (HR 1.43; 95% CI 1.13, 1.81), arrhythmia (HR 1.42; 95% CI 1.04, 1.93), heart failure (HR 1.79; 95% CI 1.02, 3.14), hypertension (HR 1.41; 95% CI 1.12, 1.77), or hypercholesterolemia (HR 1.28; 95% CI 1.01, 1.62) had an increased mortality risk, compared to others, after taking into consideration the longitudinal changes in ALSFRS-R. Cluster analysis identified two clusters of MND patients, where one cluster demonstrated higher age, worse functional status, and higher prevalence of CMDs at the time of diagnosis as well as a higher mortality and faster functional decline during follow-up, compared to the ones included in the other cluster.

Interpretation

Diabetes mellitus type 2 and hypercholesterolemia were associated with a lower future risk of MND. On the other hand, most of the CMDs were indicative of a poor disease progression after an MND diagnosis.

Funding

European Research Council, US Center for Disease Control and Prevention, Swedish Research Council.

Exploring the global impact of obesity and diet on dementia burden: the role of national policies and sex differences

Obesity is a significant modifiable risk factor for dementia. This study aims to quantify the global impact of obesity on dementia burden and examine how national strategies for managing overweight/obesity and dietary factors influence dementia prevalence and mortality, with a focus on sex-specific differences. We used data from the Global Burden of Disease (GBD) and World Health Organization (WHO) to evaluate the association between obesity age-standardized prevalence rate (ASPR) and dementia age-standardized mortality rate (ASMR) and ASPR across 161 countries. A two-step multivariate analysis adjusted for socioeconomic and lifestyle factors was performed. Temporal trends in dementia were analyzed based on the presence of national obesity management strategies and varying dietary scores. A 1% increase in national obesity prevalence was associated with a 0.36% increase in dementia mortality (OR: 1.0036; 95% CI: 1.0028-1.0045) in males and 0.12% in females (OR: 1.0012; 95% CI: 1.0007-1.0018). A 1% increase in national obesity ASPR was associated with an increase in ASPR of dementia by 0.26% for males (OR: 1.0026, 95% CI: 1.0024-1.0028) and 0.05% for females (OR: 1.0005, 95% CI: 1.0004-1.0006). Males exhibited a higher susceptibility to obesity-related dementia. Countries with national obesity management strategies showed a significantly greater reduction in dementia mortality, particularly among females (P = 0.025). Higher dietary scores were associated with a more significant decrease in dementia prevalence across both sexes. Rising obesity prevalence is linked to increased dementia burden globally, with males being more vulnerable to this relationship. National management of overweight/obesity and healthier dietary habits may help mitigate the dementia burden, emphasizing the need for integrated public health interventions.

Biological brain age and resilience in cognitively unimpaired 70-year-old individuals

INTRODUCTION

This study investigated the associations of brain age gap (BAG)-a biological marker of brain resilience-with life exposures, neuroimaging measures, biological processes, and cognitive function.

METHODS

We derived BAG by subtracting predicted brain age from chronological age in 739 septuagenarians without dementia or neurological disorders. Robust linear regression models assessed BAG associations with life exposures, plasma inflammatory and metabolic biomarkers, magnetic resonance imaging, and cerebrospinal fluid biomarkers of neurodegeneration and vascular brain injury, and cognitive performance.

RESULTS

Greater BAG (older-looking brains) was associated with physical inactivity, diabetes, and stroke, while prediabetes was related to lower BAG, that is, younger-looking brains. Physical activity mitigated the link between obesity and BAG. Greater BAG was associated with greater small vessel disease burden, white-matter alterations, inflammation, high glucose, poorer vascular-related cognitive domains. Sex-specific associations were identified.

DISCUSSION

Vascular-related lifestyles and health shape brain appearance. Inflammation and insulin-related processes may be keys to understanding vascular cognitive disorders.

HIGHLIGHTS

BAG, reflecting deviations from CA, can indicate resilience. Diabetes, stroke, and low physical activity link to "older" brains (greater BAG). Physical activity yielded to "younger" brains in septuagenarians with obesity. High cerebrovascular burden, inflammation, and glucose associate with "older" brains. Sex differences were detected in all BAG-associated factors.

Advances in the Study of Necroptosis in Vascular Dementia: Focus on Blood-Brain Barrier and Neuroinflammation

BACKGROUND

Vascular dementia (VaD) includes a group of brain disorders that are characterized by cerebrovascular pathology.Neuroinflammation, disruption of the blood-brain barrier (BBB) permeability, white matter lesions, and neuronal loss are all significant pathological manifestations of VaD and play a key role in disease progression. Necroptosis, also known asprogrammed necrosis, is a mode of programmed cell death distinct from apoptosis and is closely associated with ischemic injury and neurodegenerative diseases. Recent studies have shown that necroptosis in VaD exacerbates BBB destruction, activates neuroinflammation, promotes neuronal loss, and severely affects VaD prognosis.

RESULTS AND CONCLUSIONS

In this review, we outline the significant roles of necroptosis and its molecular mechanisms in the pathological process of VaD, with a particular focus on the role of necroptosis in modulating neuroinflammation and exacerbating the disruption of BBB permeability in VaD, and elaborate on the molecular regulatory mechanisms and the centrally involved cells of necroptosis mediated by tumor necrosis factor-α in neuroinflammation in VaD. We also analyze the possibility and specific strategy that targeting necroptosis would help inhibit neuroinflammation and BBB destruction in VaD. With a focus on necroptosis, this study delved into its impact on the pathological changes and prognosis of VaD to provide new treatment ideas.

The vasoprotective role of IGF-1 signaling in the cerebral microcirculation: prevention of cerebral microhemorrhages in aging

Aging is closely associated with various cerebrovascular pathologies that significantly impact brain function, with cerebral small vessel disease (CSVD) being a major contributor to cognitive decline in the elderly. Consequences of CSVD include cerebral microhemorrhages (CMH), which are small intracerebral bleeds resulting from the rupture of microvessels. CMHs are prevalent in aging populations, affecting approximately 50% of individuals over 80, and are linked to increased risks of vascular cognitive impairment and dementia (VCID). Hypertension is a primary risk factor for CMHs. Vascular smooth muscle cells (VSMCs) adapt to hypertension by undergoing hypertrophy and producing extracellular matrix (ECM) components, which reinforce vessel walls. Myogenic autoregulation, which involves pressure-induced constriction, helps prevent excessive pressure from damaging the vulnerable microvasculature. However, aging impairs these adaptive mechanisms, weakening vessel walls and increasing susceptibility to damage. Insulin-like Growth Factor 1 (IGF-1) is crucial for vascular health, promoting VSMC hypertrophy, ECM production, and maintaining normal myogenic protection. IGF-1 also prevents microvascular senescence, reduces reactive oxygen species (ROS) production, and regulates matrix metalloproteinase (MMP) activity, which is vital for ECM remodeling and stabilization. IGF-1 deficiency, common in aging, compromises these protective mechanisms, increasing the risk of CMHs. This review explores the vasoprotective role of IGF-1 signaling in the cerebral microcirculation and its implications for preventing hypertension-induced CMHs in aging. Understanding and addressing the decline in IGF-1 signaling with age are crucial for maintaining cerebrovascular health and preventing hypertension-related vascular injuries in the aging population.

The brain and hypertension: how the brain regulates and suffers from blood pressure

The brain plays several roles in the relationship between blood pressure (BP) and the brain: it acts as the control center for BP regulation, a target organ in hypertension, and a crucial component for cognitive function. This mini-review introduces recent findings on "brain and hypertension" from Hypertension Research and other journals. Activation of the angiotensin II type 1 receptor (AT1R) signaling pathway in the brain causes sympathoexcitation and hypertension. AT1R-associated protein and β-arrestin promote AT1R internalization and suppress AT1R signaling, with brain-specific roles in BP regulation. The brain receives various inputs from the peripheral system, including the heart and kidneys, and controls central sympathetic outflow. The brain mechanism involved in the enhanced cardiac sympathetic afferent reflex and the beneficial effects of renal denervation have been demonstrated. The brain's vulnerability in hypertension includes stroke, with cerebral small vessel disease (SVD) contributing to stroke risk and brain changes. Sex differences and the age of hypertension onset influence these outcomes. High salt intake exacerbates hypertension and stroke risk, with central mechanisms like sympathoexcitation implicated. Hypertension significantly impacts cognitive function, linking to cerebral SVD and cognitive decline. Orthostatic BP regulation abnormalities also emerge as early risk markers for dementia. Improved BP control in hypertensive individuals can significantly reduce the risk of stroke and cognitive decline, as well as cardiovascular disease, enhancing overall brain health and quality of life. Further understanding the brain's role in BP regulation and the pathogenesis of hypertension will facilitate the development of novel hypertension treatments and prevention strategies.

Physical activity may protect myelin via modulation of high-density lipoprotein

INTRODUCTION

Physical activity is associated with greater myelin content in older individuals with cerebral small vessel disease (CSVD), a condition marked by demyelination. However, potential mechanisms underlying this relationship remain understudied.

METHODS

We assessed cross-sectionally whether serum high-density lipoprotein (HDL), low-density lipoprotein, and triglycerides moderated the association between physical activity and in vivo myelin in older individuals with CSVD and mild cognitive impairment.

RESULTS

We included 81 highly educated, community-dwelling older individuals (mean age 74.57 years), 64% of whom were female. Regression models revealed that HDL levels significantly moderated the relationship between physical activity and myelin in the sagittal stratum, wherein higher physical activity levels were linked to greater myelin levels for those with average or high HDL (standardized B [95% CI] = 0.289 [0.087 to 0.491], p = 0.006).

DISCUSSION

Physical activity may promote myelin health partly through HDL. Data from longitudinal studies are needed to confirm our findings.

HIGHLIGHTS

Myelin loss is common in individuals with cerebral small vessel disease (CSVD). Physical activity was positively associated with myelin in older adults with CSVD. High-density lipoproteins (HDL) levels were also positively related to myelin. Physical activity effects on myelin were moderated by HDL levels.

Imaging markers of cerebral small vessel disease are associated with Alzheimer's disease: a systematic review and meta-analysis

Objective

This study aims to assess the correlation between cerebral small vessel disease (CSVD) imaging markers and the risk of Alzheimer's disease (AD) through a systematic review and meta-analysis.

Methods

In July 2024, two researchers independently conducted a thorough literature search across databases such as PubMed, Embase, Web of Science, and the Cochrane Library. The selected studies investigated the correlations between white matter hyperintensities (WMHs), cerebral microbleeds (CMBs), lacunar infarction (LI), and enlarged perivascular spaces (EPVS) and the risk of AD. The Newcastle-Ottawa Scale (NOS) was employed to assess the risk of bias in the included cohort and case-control studies.

Results

A total of 6,487 articles were identified, with 15 articles meeting the inclusion criteria. Pooled analyses showed that WMHs (HR: 1.38, 95% CI: 1.10-1.74, N = 7,661), CMBs (HR: 1.60, 95% CI: 1.07-2.40, N = 6,567), and EPVS (HR: 1.84, 95% CI: 1.24-2.72, N = 3,045) were associated with an increased risk of AD, with EPVS showing the strongest correlation. LI did not show a statistically significant association with an increased risk of AD (HR: 1.41, 95% CI: 0.98-2.01, N = 4,014).

Conclusion

WMHs, CMBs, and EPVS are associated with an elevated risk of AD, whereas LI is considered a potential risk factor. However, additional studies are required to determine the role of CSVD markers in AD progression.

The immunology of stroke and dementia

Ischemic stroke and vascular cognitive impairment, caused by a sudden arterial occlusion or more subtle but protracted vascular insufficiency, respectively, are leading causes of morbidity and mortality worldwide with limited therapeutic options. Innate and adaptive immunity have long been implicated in neurovascular injury, but recent advances in methodology and new experimental approaches have shed new light on their contributions. A previously unappreciated dynamic interplay of brain-resident, meningeal, and systemic immune cells with the ischemic brain and its vasculature has emerged, and new insights into the frequent overlap between vascular and Alzheimer pathology have been provided. Here, we critically review these recent findings, place them in the context of current concepts on neurovascular pathologies and Alzheimer's disease, and highlight their impact on recent stroke and Alzheimer therapies.

Genetics of intracerebral hemorrhage

Spontaneous intracerebral hemorrhage(ICH) represents a life-threatening form of stroke, marked by its impact on survival and quality of life. ICH can be categorized from monogenic disorders linked to causal germline variants in ICH-related genes to complex sporadic cases, highlighting the interaction among lifestyle factors, environmental influences, and genetic components in determining risk. Among sporadic ICH, the influence of these factors varies across ICH subtypes, evidenced by heritability rates of up to 73% for lobar ICH versus 34% for non-lobar ICH. This review presents an outline of the genetic landscape of ICH, covering both monogenic and sporadic forms. It highlights associations between ICH risk and genetic variants, including rare and common variants in genes such as COL4A1, COL4A2, APOE, ACE, MTHFR, and PMF1. However, replication has been constrained, and most findings originate from single-candidate gene studies, largely due to ancestry heterogeneity, small sample sizes, and scarce subtype-specific data. To bridge this gap, collaborative efforts like the International Stroke Genetic Consortium have been established. Additionally, the review discusses the emerging role of polygenic risk scores, Mendelian randomization, and the potential of genetic and omics research to elucidate causal pathobiology. Such insights could lead to preventive measures and personalized ICH treatment strategies.

The relationship between postoperative cognitive dysfunction and cerebral small vessel disease: A comprehensive review

Postoperative cognitive dysfunction (POCD) is a common complication in elderly patients, and cerebral small vessel disease (CSVD) has been suggested as a potential risk factor. This review examines the relationship between POCD and CSVD from epidemiological, pathophysiological, and clinical perspectives, while also considering the role of Alzheimer's disease (AD) pathology. We conducted a comprehensive literature search of major databases, supplemented by reference list checking, to ensure a thorough review of studies published between 2000 and 2023 on the relationship between POCD and CSVD. Epidemiological studies have shown that POCD and CSVD are associated in terms of common risk factors, including advanced age, vascular comorbidities, impaired baseline cognitive function, and certain population characteristics. Animal studies have revealed that CSVD and POCD share similar neuropathological changes, including abnormal cerebral hypoperfusion, inflammatory responses, and blood-brain barrier disruption. Furthermore, recent research suggests a complex interplay between CSVD, AD pathology, and POCD, with potential synergistic effects on cognitive decline. Neuroimaging studies have further demonstrated that preoperative CSVD burden and postoperative CSVD progression are associated with the development of POCD, and the presence of both CSVD and AD markers may increase the risk of cognitive decline. The association between CSVD and POCD has important implications for the perioperative management of elderly patients, including preoperative assessment, choice of anesthesia and surgical methods, intraoperative management, postoperative care, and long-term follow-up. A better understanding of the relationship between CSVD and POCD will guide evidence-based strategies to prevent and manage this debilitating complication in the aging population.

The glymphatic system

The glymphatic system, a brain-wide network-supporting cerebrospinal fluid (CSF) and interstitial fluid (ISF) exchange, is essential for removing metabolic waste from the brain. This system's proper functioning is crucial for maintaining neural health and preventing the accumulation of harmful substances that can lead to neurodegenerative diseases. This chapter explores the glymphatic system's mechanisms, its dysfunction in various neurologic disorders, and potential therapeutic strategies. Recent discoveries reveal the glymphatic system's involvement in aging, sleep, cerebral edema, and conditions, such as Alzheimer, Parkinson, Huntington diseases, amyotrophic lateral sclerosis, small vessel disease, hydrocephalus, migraine, stroke, traumatic brain injury, and psychiatric disorders, where impaired waste clearance contributes to disease pathogenesis. Moreover, therapeutic interventions targeting glymphatic dysfunction present promising avenues for mitigating the effects of neurodegenerative diseases. The chapter underscores the potential of integrating glymphatic research into broader clinical practices, offering new strategies for disease management and prevention.

[Animal experimental models in the study of age-dependent cerebral microangiopathy]

The modeling of age-dependent cerebral microangiopathy (CMA) is highly relevant due to its high prevalence and the heavy burden of clinical manifestations - strokes and cognitive disorders in the elderly, as well as the lack of effective pathogenetic treatment. Experimental modeling of CMA is a promising area of preclinical scientific research that contributes to the study of the disease pathogenesis at the genetic, molecular, and cellular levels and the search for optimal methods of its treatment and prevention. This review aimed to analyze, systematize, and compare data on current experimental models of CMA. The review analyzed the results of various studies on experimental models published in journals indexed in the PubMed, Scopus, and eLibrary databases. Available CMA models reflect different CMA attributes and mechanisms. The choice of research model should be based on the experiment's objectives. Understanding available models, combining them, and developing new models should be aimed at choosing the most relevant ones, reproducing the features of modern CMA, characterized by the control of classical risk factors, to assess pathological mechanisms and develop pathogenetic treatment.

Narrowings of the Deep Cerebral Perforating Arteries Ostia: Geometry, Structure, and Clinical Implications

BACKGROUND AND PURPOSE

The pathogenesis of neurovascular diseases and various types of dementia is tightly connected to cerebral circulation. An area that requires further exploration is the system of deep cerebral perforating arteries-arteries branching directly from high-pressure intracranial arteries, supplying vital neural structures such as the internal capsule, and characterized by a diameter of well below 1 mm, which makes them difficult to visualize with standard radiological examinations. This study aimed to analyze the morphology of the perforator origins, which constitute connection points between high-pressure intracranial arteries and microcirculation.

METHODS

Twenty-three human basal ganglia specimens with the middle cerebral artery (MCA, including 172 perforating arteries) and ten brainstem specimens with the basilar artery (BA, including 162 perforating arteries) were prepared and scanned using microcomputed tomography. The geometry and structure of the perforating arteries were analyzed using radiological images and additional histological studies.

RESULTS

The ostia of the perforating arteries were ellipsoidal in shape with median stenosis severity of 23% and 20% for MCA and BA perforators, respectively. The local narrowing structure was typical of neointimal hyperplasia. Statistical analysis revealed that the severity of stenosis may be related to age and cardiovascular health.

CONCLUSION

Origins of the deep cerebral perforators are locally narrowed by neointimal hyperplasia, which may be a protective mechanism to adjust high blood pressure to the microcirculation. The narrowings may lead to chronic hypoperfusion and play a role in the pathophysiology of cerebral small vessel disease.

Cerebrovascular regulation in patients with active tumors and an acute ischemic stroke: a retrospective analysis

Introduction

Ischemic stroke in patients with a systemic tumor disease or cancer not in remission (active tumors) is less well understood. Some aspects of such paraneoplastic strokes remind on a generalized cerebrovascular disorder. We hypothesized that cerebrovascular regulation in active tumor patients with a stroke is different from other patients with stroke who have no active tumor disease.

Methods

Within the first 72 h after the acute ischemic stroke, cerebral blood flow regulation was analyzed by means of transfer function analysis between middle cerebral artery blood flow velocity and blood pressure with estimation of coherence, gain and phase in the very low (0.02-0.07 Hz), low (0.07-0.20 Hz) and high frequencies (0.20-0.5 Hz) in four stroke groups: active tumors, inactive tumors (untreated and in remission), hypertensive lacunar stroke (LS), and non-hypertensive embolic stroke (NHES).

Results

The 4 groups did not differ regarding age, sex distribution, and brain infarct size on magnet resonance imaging Between the four stroke groups, phase was not different in any frequency range in both hemispheres. Gain was highest (either significant or by trend) in the active tumor group in the HF range in comparison to all other stroke subgroups, it was also higher in the LF range in the stroke affected hemisphere when compared to the LS group. The HF gain findings were independent of end-tidal CO2 levels but exhibited some dependency of coherence.

Discussion

The high gain can be interpreted as a generalized high vascular resistance. The cerebrovascular regulation in active tumor patients seems to exhibit some analogy to hypertensive patients with lacunar stroke.

Clinical Trial Registration

clinicaltrials.gov, identifier NCT04611672.

Single-nucleus RNA sequencing of human periventricular white matter in vascular dementia

Vascular dementia (VaD) refers to a variety of dementias driven by cerebrovascular disease and is the second leading cause of dementia globally. VaD may be caused by ischemic strokes, intracerebral hemorrhage, and/or cerebral small vessel disease, commonly identified as white matter hyperintensities on MRI. The mechanisms underlying these white matter lesions in the periventricular brain are poorly understood. In this study we perform an extensive transcriptomic analysis on human postmortem periventricular white matter lesions in patients with VaD with the goal of identifying molecular pathways in the disease. We find increased cellular stress responses in astrocytes, oligodendrocytes, and oligodendrocyte precursor cells as well as transcriptional and translational repression in microglia in our dataset. We show that several genes identified by GWAS as being associated with white matter disease are differentially expressed in cells in VaD. Finally, we compare our dataset to an independent snRNAseq dataset of PVWM in VaD and a scRNAseq dataset on human iPSC-derived microglia exposed to oxygen glucose deprivation (OGD). We identify the increase of the heat shock protein response as a conserved feature of VaD across celltypes and show that this increase is not linked to OGD exposure. Overall, our study is the first to show that increased heat shock protein responses are a common feature of lesioned PVWM in VaD and may represent a potential therapeutic target.

The Level of Fibrinogen-to-Albumin Ratio Was Associated with the Severity of Cerebral Small Vessel Disease in Patients with Transient Ischemic Attack

Purpose

Inflammation plays a role in cerebral small vessel disease (CSVD) pathophysiology. This study aimed to explore the association of the fibrinogen-to-albumin ratio (FAR), a novel inflammatory marker, with CSVD burden in patients with transient ischemic attack (TIA).

Patients and Methods

From October 1, 2022, to November 30, 2023, continuous patients with TIA were recruited in the study. The total CSVD burden score and modified total CSVD burden score were used to assess the severity of CSVD. Multivariable regression analysis was used to explore the correlation between the FAR and CSVD in TIA patients.

Results

A total of 455 participants were recruited, of whom 225 (48.35%), according to the total CSVD burden score, and 181 (40.67%), according to the modified CSVD burden score were finally identified as moderate-severe CSVD. Spearman correlation analysis showed that levels of FAR correlated with the total CSVD (r=0.392, P<0.001) and the modified total CSVD burden scores (r=0.379, P<0.001). Multivariable logistic regression analysis showed that FAR was independently associated with moderate-severe CSVD, both as a continuous variable and as a tertile variable (P<0.001).

Conclusion

The level of FAR on admission was independently associated with the severity of CSVD in patients with TIA.

Medial intracranial carotid artery calcifications and hematoma expansion in deep intracerebral hemorrhage

BACKGROUND

Medial intracranial carotid artery calcifications (ICAC) are associated with impaired vascular physiology, increased arterial stiffness and pulse pressure. Their presence might therefore be associated with increased risk of intracerebral hemorrhage (ICH) expansion, according to the avalanche model. We explored the association between ICAC presence and pattern and hematoma expansion (HE).

METHODS

Retrospective analysis of a monocentric, prospectively collected cohort of ICH patients admitted between June 2017 and October 2023. ICAC pattern was determined by Kockelkoren's rating scale on admission CT; medial ICAC were defined with a >6 points cutoff. A follow-up CT scan was performed within 72 h. HE was analyzed as a dichotomous (≥6 mL and/or ≥33%) and as a categorical (none/mild/moderate/severe) variable, and its predictors were explored with logistic and ordinal regression respectively, accounting for baseline volume, onset-to-CT time, and anticoagulation. All the analyses were stratified by ICH location (supratentorial deep vs lobar ICH).

RESULTS

A total of 201 patients were included (median age 78, 42% females, 59% deep ICH). Medial ICAC were significantly more common in deep ICH with HE compared with non-expanders (72% vs 49%, p = 0.03), whereas there was no association between ICAC and HE in lobar ICH (53% vs 52%, p = 0.85). This association between medial ICAC and HE in deep ICH remained significant in logistic (aOR 3.11, 95% CI [1.19-9.06], p = 0.03) and ordinal regression (acOR 2.42, 95% CI [1.19-4.99], p = 0.01).

INTERPRETATION

Ipsilateral medial ICAC are associated with higher odds of HE in deep ICH. Our findings are best interpreted as hypothesis generating, requiring prospective validation and further research to characterize the underlying biological mechanisms.

Medin, a link between vascular pathology and dementia?

Medin is a protein fragment derived from milk fat globule epidermal growth factor VIII (MFG-E8). Medin aggregates are present in the vessel wall of most subjects over 50 years of age. In this narrative review, we focus on the consequences of medin aggregation in relation to the development of dementia. Recent literature revealed medin as biomarker for dementia in CSF, specifically of a vascular subtype. Preclinical work showed that medin is associated with aging-related cerebral vascular dysfunction, vascular stiffening, hypertension, and. vascular amyloid β deposition. These findings position medin as a potential mechanistic link between aging, vascular pathology and dementia.

Brain endothelial cell activation and dysfunction associate with and contribute to the development of enlarged perivascular spaces and cerebral small vessel disease

Multiple injurious stimuli to the brain's endothelium results in brain endothelial cell activation and dysfunction (BECact/dys) with upregulation of inflammatory signaling cascades and a decrease in bioavailable nitric oxide respectively. These injurious stimuli initiate a brain injury and a response to injury wound healing genetically programed cascade of events, which result in cellular remodeling of the neurovascular unit and blood-brain barrier with increased inflammation and permeability. These remodeling changes also include the perivascular spaces that become dilated to form enlarged perivascular spaces (EPVS) that may be identified noninvasively by magnetic resonance imaging. These EPVS are associated with and considered to be a biomarker for cerebral small vessel disease (SVD) and a dysfunctional glymphatic system with impaired removal of neurotoxic waste, which ultimately results in neurodegeneration with impaired cognition and dementia. The penultimate section discusses the understudied role of venous cerebral circulation in relation to EPVS, SVD, and the vascular contribution to cognitive impairment (VCID). The focus of this review will be primarily on BECact/dys that associates with and contributes to the development of EPVS, SVD, and impaired glymphatic system efflux. Importantly, BECact/dys may be a key piece of the puzzle to unlock this complicated story of EPVS and SVD. Multiple transmission electron micrographs and illustrations will be utilized to depict anatomical ultrastructure and allow for the discussion of multiple functional molecular cascades.

Linking peripheral atherosclerosis to blood-brain barrier disruption: elucidating its role as a manifestation of cerebral small vessel disease in vascular cognitive impairment

Aging plays a pivotal role in the pathogenesis of cerebral small vessel disease (CSVD), contributing to the onset and progression of vascular cognitive impairment and dementia (VCID). In older adults, CSVD often leads to significant pathological outcomes, including blood-brain barrier (BBB) disruption, which in turn triggers neuroinflammation and white matter damage. This damage is frequently observed as white matter hyperintensities (WMHs) in neuroimaging studies. There is mounting evidence that older adults with atherosclerotic vascular diseases, such as peripheral artery disease, ischemic heart disease, and carotid artery stenosis, face a heightened risk of developing CSVD and VCID. This review explores the complex relationship between peripheral atherosclerosis, the pathogenesis of CSVD, and BBB disruption. It explores the continuum of vascular aging, emphasizing the shared pathomechanisms that underlie atherosclerosis in large arteries and BBB disruption in the cerebral microcirculation, exacerbating both CSVD and VCID. By reviewing current evidence, this paper discusses the impact of endothelial dysfunction, cellular senescence, inflammation, and oxidative stress on vascular and neurovascular health. This review aims to enhance understanding of these complex interactions and advocate for integrated approaches to manage vascular health, thereby mitigating the risk and progression of CSVD and VCID.

Association between hypertension, diabetes, depression, and serum calcium with the risk of all-cause and vascular dementia: findings from the UK biobank

PURPOSE

The associations between serum calcium levels and the risk of all-cause dementia and vascular dementia (VaD) are not well understood. Additionally, the potential roles of hypertension, diabetes, and depression in this association need to be explored. This study aimed to investigate the links between serum calcium and all-cause dementia and VaD and to assess the role of hypertension, diabetes, and depression in that association.

METHODS

For this cohort study, data were extracted from the UK Biobank, a population-based longitudinal survey with baseline assessments from 2006 to 2010 in England, Wales, and Scotland. A total of 363 182 participants without dementia at baseline were included. Cases of all-cause dementia and VaD were identified through database linkage until December 31, 2022. The hazards of all-cause dementia and VaD were estimated using Cox proportional hazards regression models. Mediation analyses were performed to evaluate the mediation effect of hypertension, diabetes, and depression.

RESULTS

During a median follow-up of 13.8 years, 5 836 cases of all-cause dementia and 1 301 cases of VaD were identified. Participants with higher levels of serum calcium (in the third and fourth quartile, > 2.37 to ≤ 2.43 mmol/L and > 2.43 mmol/L) had a lower risk of all-cause dementia compared to those in the first quartile (≤ 2.32 mmol/L) (Hazard Ratio [HR] [95% Confidence Interval (CI)] in Q3: 0.87 (0.81-0.93), HR [95% CI] in Q4: 0.90 [0.84-0.97]). For VaD, HRs (95% CIs) in the second, third, and fourth quartiles were 0.80 (0.69-0.93), 0.76 (0.65-0.89), and 0.80 (0.69-0.93), respectively. Hypertension, diabetes, and depression significantly explained 18.67%, 2.57%, and 18.91% of the mediation effects on serum calcium-related dementia, respectively. Diabetes and depression contributed 1.85% and 15.34% of mediation effects on the association between serum calcium and the risk of VaD.

CONCLUSION

This study found that individuals with higher serum calcium levels (> 2.37 mmol/L) had a reduced risk of developing dementia. Hypertension, diabetes, and depression significantly mediated the association. These findings highlight the significance of considering serum calcium levels as a potential indicator for the development of dementia. Further, optimizing the treatment of associated diseases and managing risk factors, particularly for individuals with lower serum calcium levels, is important.

MRI in older patients-A focused review

MRI has considerably increased our pathophysiological knowledge of age-related brain abnormalities. Brain abnormalities regularly seen on MRI of older adults are atrophy, and changes related to small vessel disease (SVD). SVD-related changes include white matter hyperintensities (WMH), lacunes, microbleeds, microinfarcts and perivascular spaces. While atrophy, WMH and lacunes are recognized as important contributors to cognitive decline and dementia, relationships are less clear for microbleeds, microinfarcts and perivascular spaces. Vascular risk factors are considered critical in the development of these changes and being potentially modifiable have become increasingly interesting to researchers and clinicians alike. Managing vascular risk early, particularly hypertension, is a key factor in slowing down the evolution of age-related brain abnormalities and decelerate their detrimental cognitive consequences. Cognition and visible brain abnormalities have a complex relationship, which reaches far beyond what we can understand using standard MRI. Remote effects of lesions and associated- as well as independent network changes likely explain much of the different cognitive trajectories observed with aging. Because of the versatility of MRI in the diagnostic of various diseases, including epilepsy, incident signs of brain aging will be encountered ever more frequently on standard MRI of older adults. To facilitate understanding and ultimately reporting these changes to patients, this review will give a brief overview of MRI findings encountered on MRI of older people. We will discuss their pathology, risk factors, and relationships with cognition. Special emphasis will be given to more recent developments, including remote effects of lesions, and effects on the structural brain network. Relationships between MRI findings in older people and epilepsy will be discussed as well.

Assessing stroke recurrence in sICAS: a study on mCSVD score and culprit plaque magnetic resonance characteristics

Background

Recurrent ischemic stroke in patients with symptomatic intracranial atherosclerotic stenosis (sICAS) can be attributed to two main causes: intracranial atherosclerotic stenosis (ICAS) and cerebral small vessel disease (CSVD). This study investigates the potential associations between stroke recurrence and the modified cerebral small vessel disease (mCSVD) burden score, as well as the characteristics of culprit plaques related to intracranial artery high-resolution vessel wall imaging (HR-VWI).

Methods

A total of 145 patients presenting sICAS underwent intracranial artery HR-VWI and routine cranial MRI at two large Chinese hospitals from December 2019-2022 were participants of this retrospective analysis. Standard MRI scans were used to calculate the mCSVD score. Following a 12-month observation period, the patients were categorized into two distinct groups depending on whether or not they experienced a subsequent stroke.

Results

Within 12 months, 32 patients experienced stroke recurrence. The recurrence group's mCSVD score was higher compared to the non-recurrence group (p < 0.001). Their luminal stenosis and culprit plaque thickness and burden were also higher (p < 0.05). Additionally, higher rates of diabetes, T1WI hyperintensity of culprit plaques, and significant plaque enhancement were observed in the recurrence group (p < 0.05). The adjusted Cox regression model indicated that the mCSVD score (HR = 1.730, 95% CI 1.021-2.933, p = 0.042) and T1WI hyperintensity of the culprit plaque (HR = 6.568, 95% CI 1.104-39.059, p = 0.039) remained significantly independent risk variables. The combination of the mCSVD score and T1WI hyperintensity of the culprit plaque demonstrated the highest efficacy in predicting stroke recurrence (z = 2.678, p < 0.05).

Conclusion

The mCSVD score, associated with T1WI hyperintensity of culprit plaque, effectively predicts stroke recurrence and can be easily obtained, offering high clinical value.

Associations between carotid plaques and white matter hyperintensities in cerebral small vessel disease

BACKGROUND

Cerebral small vessel disease (CSVD) can lead to stroke and cognitive impairment. Small vessels cannot be visualized by neuroimaging directly, and CSVD can only be evaluated by cerebral parenchymal changes in MRI. Therefore, a convenient screening method for identifying high-risk and susceptible patients is needed. Recently, some studies found that CSVD was related to large atherosclerosis, and atherosclerosis was an essential pathological feature of CSVD. Therefore, we aimed to investigate the association between carotid plaque size characteristics and white matter hyperintensities (WMHs) in patients with CSVD.

METHODS

We continuously enrolled patients with CSVD. Carotid plaque features were evaluated using carotid ultrasound, and WMHs were evaluated using brain magnetic resonance imaging. Plaque characteristics were compared between patients with no/mild WMHs and those with severe WMHs. Associations between the plaque characteristics and WMH severity were analyzed using logistic regression.

RESULTS

In total, 180 patients were recruited, of whom 92 had severe WMHs. The severe WMHs group had a higher sum of the bilateral maximum intima-media thickness (4.15 mm vs. 3.30 mm), longer maximum plaque length (17.20 mm vs. 13.90 mm), thicker plaques (2.70 mm vs. 2.30 mm), and more plaques (3 vs. 2) than the no/mild WMHs group. Adjusted logistic regression analyses revealed that maximum plaque length and thickness were associated with WMHs.

CONCLUSIONS

Carotid atherosclerotic plaque features, such as plaque length and thickness, were associated with the severity of WMHs, which suggested that carotid atherosclerotic plaque characteristics measured using ultrasound might be helpful indicators for identifying high-risk patients with CSVD.

Unveiling the theranostic potential of SPIONs in Alzheimer's disease management

Alzheimer's disease (AD) is a devastating kind of dementia that is becoming more common worldwide. Toxic amyloid-beta (Aβ) aggregates are the primary cause of AD onset and development. Superparamagnetic iron oxide nanoparticles (SPIONs) have received a lot of interest in AD therapy over the last decade because of their ability to redirect the Aβ fibrillation process and improve associated brain dysfunction. The potential diagnostic application of SPIONs in AD has dramatically increased this interest. Furthermore, surface-modified engineered SPIONs function as drug carriers to improve the efficacy of current therapies. Various preclinical and clinical studies on the role of SPIONs in AD pathology have produced encouraging results. However, due to their physicochemical properties (e.g., size, surface charge, and particle concentration) in the biological milieu, SPIONs may play the role of a preventive or accelerative agent in AD. Even though SPIONs are potential therapeutic and diagnostic options in AD, significant efforts are still needed to overcome the inconsistencies and safety concerns. This review evaluated the current understanding of how various SPIONs interact with AD models and explored the discrepancies in their efficacy and safety.

Intracranial Aneurysms and Cerebral Small Vessel Disease: Is There an Association between Large- and Small-Artery Diseases?

Background/Objectives: Intracranial aneurysms (IAs) may be connected to interactions between large and small intracranial vessels. We aimed to investigate the association between IAs and cerebral small-vessel disease (CSVD) and assess CSVD impact on IA patient management. Methods: This retrospective study analyzed clinical data and MRI features of CSVD in 192 subarachnoid hemorrhage (SAH) patients: 136 with incidental IA, 147 with severe CSVD without SAH/IA, and 50 controls without SAH, IA, or severe CSVD. MRI assessments followed the Standards for Reporting Vascular Changes on Neuroimaging (STRIVE), with a total burden of small-vessel disease (TBSVD) score calculated. Statistical analyses included forward selection and binary logistic regression. Results: TBSVD differed significantly across groups (p < 0.001), except between SAH and IA groups (p = 0.8). Controls had the lowest TBSVD (1.00; 1.22 ± 0.996), followed by SAH (2.00; 2.08 ± 1.013) and IA groups (2.00; 2.04 ± 1.141), with the highest in the CSVD group (1.00; 1.22 ± 0.996). White-matter hyperintensity (WMH) patterns varied with IA rupture status (p = 0.044); type A was prevalent in SAH patients and type D in the IA group. Incorporating MRI CSVD features and TBSVD into risk assessments did not enhance IA prediction or outcome models. Conclusions: IA patients exhibit a higher CSVD burden than controls, suggesting a link between small and large intracranial vessels. WMH patterns distinguish between ruptured and unruptured IA patients, offering potential markers for IA rupture risk assessment and signaling a paradigm shift in understanding IAs and CSVD.

Atherosclerotic burden and cerebral small vessel disease: exploring the link through microvascular aging and cerebral microhemorrhages

Cerebral microhemorrhages (CMHs, also known as cerebral microbleeds) are a critical but frequently underestimated aspect of cerebral small vessel disease (CSVD), bearing substantial clinical consequences. Detectable through sensitive neuroimaging techniques, CMHs reveal an extensive pathological landscape. They are prevalent in the aging population, with multiple CMHs often being observed in a given individual. CMHs are closely associated with accelerated cognitive decline and are increasingly recognized as key contributors to the pathogenesis of vascular cognitive impairment and dementia (VCID) and Alzheimer's disease (AD). This review paper delves into the hypothesis that atherosclerosis, a prevalent age-related large vessel disease, extends its pathological influence into the cerebral microcirculation, thereby contributing to the development and progression of CSVD, with a specific focus on CMHs. We explore the concept of vascular aging as a continuum, bridging macrovascular pathologies like atherosclerosis with microvascular abnormalities characteristic of CSVD. We posit that the same risk factors precipitating accelerated aging in large vessels (i.e., atherogenesis), primarily through oxidative stress and inflammatory pathways, similarly instigate accelerated microvascular aging. Accelerated microvascular aging leads to increased microvascular fragility, which in turn predisposes to the formation of CMHs. The presence of hypertension and amyloid pathology further intensifies this process. We comprehensively overview the current body of evidence supporting this interconnected vascular hypothesis. Our review includes an examination of epidemiological data, which provides insights into the prevalence and impact of CMHs in the context of atherosclerosis and CSVD. Furthermore, we explore the shared mechanisms between large vessel aging, atherogenesis, microvascular aging, and CSVD, particularly focusing on how these intertwined processes contribute to the genesis of CMHs. By highlighting the role of vascular aging in the pathophysiology of CMHs, this review seeks to enhance the understanding of CSVD and its links to systemic vascular disorders. Our aim is to provide insights that could inform future therapeutic approaches and research directions in the realm of neurovascular health.

Utility of cerebrovascular imaging biomarkers to detect cerebral amyloidosis

INTRODUCTION

The relationship between cerebrovascular disease (CVD) and amyloid beta (Aβ) in Alzheimer's disease (AD) is understudied. We hypothesized that magnetic resonance imaging (MRI)-based CVD biomarkers-including cerebral microbleeds (CMBs), lacunar infarction, and white matter hyperintensities (WMHs)-would correlate with Aβ positivity on positron emission tomography (Aβ-PET).

METHODS

We cross-sectionally analyzed data from the Alzheimer's Disease Neuroimaging Initiative (ADNI, N = 1352). Logistic regression was used to calculate odds ratios (ORs), with Aβ-PET positivity as the standard-of-truth.

RESULTS

Following adjustment, WMHs (OR = 1.25) and superficial CMBs (OR = 1.45) remained positively associated with Aβ-PET positivity (p < 0.001). Deep CMBs and lacunes exhibited a varied relationship with Aβ-PET in cognitive subgroups. The combined diagnostic model, which included CVD biomarkers and other accessible measures, significantly predicted Aβ-PET (pseudo-R2 = 0.41).

DISCUSSION

The study highlights the translational value of CVD biomarkers in diagnosing AD, and underscores the need for more research on their inclusion in diagnostic criteria.

CLINICALTRIALS

gov: ADNI-2 (NCT01231971), ADNI-3 (NCT02854033).

HIGHLIGHTS

Cerebrovascular biomarkers linked to amyloid beta (Aβ) in Alzheimer's disease (AD). White matter hyperintensities and cerebral microbleeds reliably predict Aβ-PET positivity. Relationships with Aβ-PET vary by cognitive stage. Novel accessible model predicts Aβ-PET status. Study supports multimodal diagnostic approaches.

Vascular Impairment, Muscle Atrophy, and Cognitive Decline: Critical Age-Related Conditions

The triad of vascular impairment, muscle atrophy, and cognitive decline represents critical age-related conditions that significantly impact health. Vascular impairment disrupts blood flow, precipitating the muscle mass reduction seen in sarcopenia and the decline in neuronal function characteristic of neurodegeneration. Our limited understanding of the intricate relationships within this triad hinders accurate diagnosis and effective treatment strategies. This review analyzes the interrelated mechanisms that contribute to these conditions, with a specific focus on oxidative stress, chronic inflammation, and impaired nutrient delivery. The aim is to understand the common pathways involved and to suggest comprehensive therapeutic approaches. Vascular dysfunctions hinder the circulation of blood and the transportation of nutrients, resulting in sarcopenia characterized by muscle atrophy and weakness. Vascular dysfunction and sarcopenia have a negative impact on physical function and quality of life. Neurodegenerative diseases exhibit comparable pathophysiological mechanisms that affect cognitive and motor functions. Preventive and therapeutic approaches encompass lifestyle adjustments, addressing oxidative stress, inflammation, and integrated therapies that focus on improving vascular and muscular well-being. Better understanding of these links can refine therapeutic strategies and yield better patient outcomes. This study emphasizes the complex interplay between vascular dysfunction, muscle degeneration, and cognitive decline, highlighting the necessity for multidisciplinary treatment approaches. Advances in this domain promise improved diagnostic accuracy, more effective therapeutic options, and enhanced preventive measures, all contributing to a higher quality of life for the elderly population.

Asymptomatic carotid artery stenosis is associated with increased Alzheimer's disease and non-Alzheimer's disease dementia risk

BACKGROUND

In the absence of a cerebrovascular accident, whether asymptomatic extracranial carotid atherosclerotic disease (aECAD) affects Alzheimer's disease (AD) and non-AD dementia risk is not clear. Understanding whether aECAD is associated with an increased risk for AD is important as it is present in roughly 10% of the population over 60 and could represent a modifiable risk factor for AD and non-AD dementia.

METHODS

This retrospective cohort study analysed Mariner insurance claims. Enrolment criteria included patients aged 55 years or older with at least 5 years of data and no initial dementia diagnosis. Subjects with and without aECAD were evaluated for subsequent AD and non-AD dementia diagnoses. Propensity score matching was performed using confounding factors identified by logistic regression. χ2 tests and Kaplan-Meier survival curves were used to evaluate the impact of aECAD diagnosis on AD and non-AD dementia risk over time.

RESULTS

767 354 patients met enrolment criteria. After propensity score matching, 62 963 subjects with aECAD and 62 963 subjects without ECAD were followed through data records. The aECAD cohort exhibited an increased relative risk of 1.22 (95% CI 1.15 to 1.29, p<0.001) for AD and 1.48 (95% CI 1.38 to 1.59, p<0.001) for non-AD dementias compared with the propensity score-matched cohort without aECAD. The increased AD risk associated with aECAD was evident in patients younger than 75 years old and was less apparent in patients over 75 years of age.

CONCLUSIONS

aECAD is associated with an increased risk of developing AD and non-AD dementias. These findings underscore the need for further prospective evaluation of interactions between aECAD and dementia, with potential implications for change of clinical care in both of these large patient populations.

Association between the incident hypertension duration and cognitive performance in older adults: data from the NHANES 2011-2014

BACKGROUND

Established evidences have demonstrated that hypertension was associated with the cognitive impairment. But the associations between the duration of hypertension exposure and cognitive performance are still inconclusive.

OBJECTIVES

The objective of this study was to assess the association between the duration of hypertension diagnosis and cognitive performance in older adults by the National Health and Nutrition Examination Survey (2011-2014).

METHODS

To evaluate the relationship between the hypertension duration and cognitive performance, we conducted the logistic regression analysis. Furthermore, we also performed the Restricted cubic spline (RCS) analysis to assess the nonlinear relationship between the duration of exposure to hypertension and cognitive performance.

RESULTS

Initially, total 19,931 participants were included in this study, and 2928 individuals were enrolled. With the increase of hypertension duration, more risk of cognitive impairment was observed in the Digit Symbol Substitution test (DSST) (OR = 1.012, 1.006-1.019), and a similar trend was observed in Animal Fluency test (AFT) (OR = 1.009,1.003-1.016). The RCS results showed that the hypertension duration pattern was linear associated with the risk of cognitive impairment in DDST (P for non-linearity = 0.758). Meanwhile, subgroups analysis of midlife hypertension, we revealed that linear association with the risk of cognitive impairment in DSST (P for non-linearity = 0.391) and CERAD (P for non-linearity = 0.849) among hypertension diagnose < 55 years populations.

CONCLUSION

Collectively, our finding indicates that longer duration of exposure to hypertension worsens the cognition performance, especially for middle-aged hypertension.

Interplay of mitochondrial calcium signalling and reactive oxygen species production in the brain

Intracellular communication and regulation in brain cells is controlled by the ubiquitous Ca2+ and by redox signalling. Both of these independent signalling systems regulate most of the processes in cells including the cell surviving mechanism or cell death. In physiology Ca2+ can regulate and trigger reactive oxygen species (ROS) production by various enzymes and in mitochondria but ROS could also transmit redox signal to calcium levels via modification of calcium channels or phospholipase activity. Changes in calcium or redox signalling could lead to severe pathology resulting in excitotoxicity or oxidative stress. Interaction of the calcium and ROS is essential to trigger opening of mitochondrial permeability transition pore - the initial step of apoptosis, Ca2+ and ROS-induced oxidative stress involved in necrosis and ferroptosis. Here we review the role of redox signalling and Ca2+ in cytosol and mitochondria in the physiology of brain cells - neurons and astrocytes and how this integration can lead to pathology, including ischaemia injury and neurodegeneration.

The promise of molecular science in brain health. What breakthroughs are anticipated in the next 20 years?

Brain health means optimal physiological brain function across the normal life-course. It encompasses not only healthy brain aging but also brain diseases, their diagnosis and treatment. In all these areas, molecular science has advanced our understanding. This multi-disciplinary review combines viewpoints from laboratory science, clinical medicine and the bioscience industry. First, we review the advances that molecular science has brought to brain health in the past twenty years. These include therapeutic antibodies for CNS diseases (multiple sclerosis, Alzheimer disease) and the dramatic introduction of RNA-targeted therapeutics. Second, we highlight areas where greater molecular understanding is needed. Salient examples are the relation of brain structure to cognitive symptoms, and molecular biomarkers for diagnosis, target discovery and testing of interventions. Finally, we speculate on aspects of molecular science that are likely to advance brain health in the next twenty years. These include: cell senescence and chronobiology; gene editing (notably, CRISPR) and RNA targeting (RNA interference, miRNA manipulation); brain-immune interactions; novel drug targets (AQP4, HIF1, Toll-like receptors); and novel chemistry to make new drugs (molecular machines, quantum molecular modelling and "click" chemistry). Early testing of the relationships between molecular pathways and clinical manifestations will drive much-needed breakthroughs in neurology and psychiatry.

A Review: Visuospatial Dysfunction in Patients with the Cerebral Small Vessel Disease

Cerebral small vessel disease (CSVD) impairs visuospatial function, and this is one of the most obvious areas of cognitive impairment in CSVD. So, recognizing, monitoring, and treating visuospatial dysfunction are all important to the prognosis of CSVD. This review discussed the anatomical and pathological mechanisms, clinical recognition (scales, imaging, and biomarkers), and treatment of cognitive impairment especially visuospatial dysfunction in CSVD.

Saponin components in Polygala tenuifolia as potential candidate drugs for treating dementia

Objective

This study aims to elucidate the intervention effects of saponin components from Polygala tenuifolia Willd (Polygalaceae) on dementia, providing experimental evidence and new insights for the research and application of saponins in the field of dementia.

Materials and Methods

This review is based on a search of the PubMed, NCBI, and Google Scholar databases from their inception to 13 May 2024, using terms such as "P. tenuifolia," "P. tenuifolia and saponins," "toxicity," "dementia," "Alzheimer's disease," "Parkinson's disease dementia," and "vascular dementia." The article summarizes the saponin components of P. tenuifolia, including tenuigenin, tenuifolin, polygalasaponins XXXII, and onjisaponin B, as well as the pathophysiological mechanisms of dementia. Importantly, it highlights the potential mechanisms by which the active components of P. tenuifolia prevent and treat diseases and relevant clinical studies.

Results

The saponin components of P. tenuifolia can reduce β-amyloid accumulation, exhibit antioxidant effects, regulate neurotransmitters, improve synaptic function, possess anti-inflammatory properties, inhibit neuronal apoptosis, and modulate autophagy. Therefore, P. tenuifolia may play a role in the prevention and treatment of dementia.

Conclusion

The saponin components of P. tenuifolia have shown certain therapeutic effects on dementia. They can prevent and treat dementia through various mechanisms.