Differentiation and Management of Intracranial Atherosclerosis–Related Cognitive Impairment From Vascular Dementia

Dementia affects more than 6 million individuals in the United States and represents a growing public health challenge. Intracranial atherosclerotic disease (ICAD) is highly prevalent in older adults and is increasingly recognized as an important contributor to cognitive impairment. However, vascular dementia (VaD) is also a major cause of cognitive impairment, and it is often very difficult to distinguish these common but separate conditions based on symptoms and even imaging alone. These conditions often coexist and have similar pathophysiologies. Differentiating ICAD-related cognitive impairment from VaD is essential as management strategies differ. Here, a narrative review of the literature was conducted focusing on epidemiology, diagnostic definitions, neuroimaging modalities, and treatment approaches for ICAD-associated cognitive impairment and VaD. Emphasis was placed on magnetic resonance imaging, positron emission tomography, and standardized neuroimaging criteria, as well as contemporary pharmacologic and interventional therapies. We found that advanced imaging techniques such as positron emission tomography metabolic patterns, magnetic resonance imaging markers of small vessel disease, and standardized grading systems such as the Fazekas scale can improve diagnostic accuracy. Management of both conditions centers on risk factor modification, but treatment strategies diverge slightly with respect to antiplatelet therapy and revascularization goals.