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Vascular dementia pathology — MRCPsych Paper A MCQ

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ModerateNeuropathologyVascular dementia pathologyMRCPsych Paper A

A 79-year-old man with longstanding hypertension and diabetes has experienced cognitive decline over 3 years. His function has worsened in abrupt increments, each following an episode of dysarthria or unilateral weakness. Examination shows emotional lability, slowed information processing, impaired set-shifting, brisk reflexes and a short-stepped gait. Recognition memory is relatively preserved. Which neuropathological finding most likely underlies this syndrome?

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Correct answer: E — Lacunar infarcts with arteriolosclerosis in deep nuclei and cerebral white matter

The correct answer is E. Abrupt stepwise deterioration after focal cerebrovascular episodes, together with executive slowing, emotional lability, pyramidal signs and a short-stepped gait, indicates subcortical vascular cognitive impairment. Hypertensive small-vessel disease causes arteriolosclerosis of penetrating arteries and multiple lacunes or microinfarcts in deep grey nuclei and white matter, disrupting frontal-subcortical circuits. Prion disease usually causes rapidly progressive dementia with features such as myoclonus or ataxia. Hippocampal sclerosis produces disproportionate episodic-memory impairment and may accompany temporal lobe epilepsy. Selective Purkinje-cell loss primarily causes a cerebellar syndrome. Pick bodies are associated with frontotemporal lobar degeneration, usually presenting with early behavioural, personality or language change rather than a stroke-related stepwise course.

Reference: Hainsworth AH, Markus HS, Schneider JA. Cerebral Small Vessel Disease, Hypertension, and Vascular Contributions to Cognitive Impairment and Dementia. Hypertension. 2024;81(1):75–86. https://pubmed.ncbi.nlm.nih.gov/38044814/