NINCDS-ADRDA Criteria for Diagnosis of AD

Summary of NINCDS-ADRDA Criteria for Diagnosis of AD

Probable AD

Deficits in two or more domains of cognition

Progressive decline of memory and other cognitive functions

Preserved consciousness

Onset between ages 40 and 90

Absence of systemic or other brain disease that could account for symptoms

Possible AD

Atypical onset, presentation, or clinical course of dementia

Presence of another illness capable of producing dementia

Definite AD

Clinical criteria for probable AD

Tissue diagnosis by autopsy or biopsy

NINCDS-ADRDA Criteria for the Diagnosis of Alzheimer's Disease *

I. Clinical Diagnosis of Probable Alzheimer's Disease

1. Dementia established by clinical examination and mental status testing and confirmed by neuropsychological testing
2. Deficits in at least two cognitive domains
3. Progressive cognitive decline, including memory
4. Normal level of consciousness
5. Onset between ages 40 and 90 (most common after 65) years
6. No other possible medical or neurological explanation

II. Probable Alzheimer's Disease Diagnosis Supported by

1. Progressive aphasia, apraxia, and agnosia
2. Impaired activities of daily living
3. Family history of similar disorder
4. Brain atrophy on CT/MRI, especially if progressive
5. Normal CSF, EEG (or nonspecifically abnormal)

III. Other Clinical Features Consistent with Probable Alzheimer's Disease

1. Plateau in course
2. Associated symptoms: depression; insomnia; incontinence; illusions; hallucinations; catastrophic verbal, emotional, or physical outbursts; sexual disorders; weight loss; during more advanced stages increased muscle tone, myoclonus, and abnormal gait
3. Seizures in advanced disease
4. CT normal for age

IV. Features That Make Alzheimer's Disease Uncertain or Unlikely

1. Acute onset
2. Focal sensorimotor signs
3. Seizures or gait disorder early in course

V. Clinical Diagnosis of Possible Alzheimer's Disease

1. Dementia with atypical onset or course in the absence of another medical/neuropsychiatric explanation
2. Dementia with another disease not felt otherwise to be the cause of dementia
3. For research purposes, a progressive focal cognitive deficit

VI. Definite Alzheimer's Disease

1. Meets clinical criteria for probable Alzheimer's disease
2. Tissue confirmation (autopsy or brain biopsy)

VII. Research Classification of Alzheimer's disease should specify

1. Familial?
2. Early onset (before age 65)?
3. Down's syndrome (trisomy 21)?
4. Coexistent other neurodegenerative disease (e.g., Parkinson's disease)?

McKhann G, Drachman D, Folstein M, et al: Clinical diagnosis of Alzheimer's disease: Report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer's Disease. Neurology 1984;34:939–944

DSM-IV criteria for the diagnosis of AD

1.       The development of multiple cognitive deficits manifested by both:

(a)     Memory impairment (impaired ability to learn new information or to recall previously learned information)

(b)     One or more of the following cognitive disturbances:

                                                   i.      Aphasia (language disturbance)

                                                  ii.      Apraxia (impaired ability to carry out motor activities despite intact motor function)

                                                iii.      Agnosia (failure to recognize or identify objects despite intact sensory function)

                                                iv.      Disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)

2.       The cognitive deficits in criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.

3.       The course is characterized by gradual onset and continuing cognitive decline.

4.       The cognitive deficits in Criteria A1 and A2 are not due to any of the following:

(a)     Other central nervous system conditions that cause progressive deficits in memory and cognition (e.g., cerebrovascular disease, Parkinson’s disease, Huntington’s disease, subdural hematoma, normal-pressure hydrocephalus, brain tumor)

(b)     Systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B12 or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis, HIV infection)

(c)     Substance-induced conditions

5.       The deficits do not occur exclusively during the course of a delirium.

6.       The disturbance is not better accounted for by another Axis I disorder (e.g., Major Depressive Disorder, Schizophrenia).

Brain imaging of vascular dementia

I. Topography

Radiologic lesions associated with dementia include ANY of the following or combinations thereof:

1. Large-vessel strokes in the following territories:

Bilateral anterior cerebral artery

Posterior cerebral artery, including paramedian thalamic infarctions, inferior medial temporal lobe lesions

Association areas: parietotemporal, temporo-occipital territories (including angular gyrus)

Watershed carotid territories: superior frontal, parietal regions

2. Small-vessel disease:

Basal ganglia and frontal white matter lacunes

Extensive periventricular white matter lesions

Bilateral thalamic lesions

II. Severity

In addition to the above, relevant radiologic lesions associated with dementia include:

Large-vessel lesions of the dominant hemisphere

Bilateral large-vessel hemispheric strokes

Leukoencephalopathy involving at least ?4 of the total white matter

Although volume of lesion is weakly related to dementia, an additive effect may be present. White matter changes observed only on T, MRI but not on T, MRI or CT may not be significant.

Absence of vascular lesions on brain CT/MRI rules out probable vascular dementia.

NINDS - AIREN criteria for the diagnosis of vascular dementia

I. The criteria for the clinical diagnosis of probable vascular dementia include all of the following:

1. Dementia:  

• Defined by cognitive decline from a previously higher level of functioning and
• Manifested by impairment of memory and of two or more cognitive domains (orientation, attention, language, visuospatial functions, executive functions, motor control, and praxis), preferable established by clinical examination and documented by neuropsychological testing;
• Deficits should be severe enough to interfere with activities of daily living not due to physical effects of stroke alone.
• Exclusion criteria: cases with disturbance of consciousness, delirium, psychosis, severe aphasia, or major sensorimotor impairment precluding neuropsychological testing. Also excluded are systemic disorders or other brain diseases (such as AD) that in and of themselves could account for deficits in memory and cognition.

2. Cerebrovascular disease:

·         Defined by the presence of focal signs on neurologic examination, such as hemiparesis, lower facial weakness, Babinski sign, sensory deficit, hemianopia, and dysarthria consistent with stroke (with or without history of stroke), and

·         Evidence of relevant CVD by brain imaging (CT or MRI) including multiple large vessel infarcts or a single strategically placed infarct (angular gyrus, thalamus, basal forebrain, or PCA or ACA territories), as well as multiple basal ganglia and white matter lacunes, or extensive periventricular white matter lesions, or combinations there of.

3. A relationship between the above two disorders: manifested or inferred by the presence of ≥ 1 of the following:
1. Onset of dementia within 3 months following a recognized stroke
2. Abrupt deterioration in cognitive functions; or fluctuating, stepwise progression of cognitive deficits.

II. Clinical features consistent with the diagnosis of probable vascular dementia include the following:

1.       Early presence of gait disturbance (small-step gait or marche a petits pas, or magnetic, apraxic-ataxic or parkinsonian gait);

2.       History of unsteadiness and frequent, unprovoked falls;

3.       Early urinary frequency, urgency, and other urinary symptoms not explained by urologic disease;

4.       Pseudobulbar palsy;

5.       Personality and mood changes, abulia, depression, emotional incontinence, or other subcortical deficits including psychomotor retardation and abnormal executive function.

III. Features that make the diagnosis of vascular dementia uncertain or unlikely include

1.       Early onset of  memory deficit and progressive worsening of memory deficit and progressive worsening of memory and other cognitive functions such as language (transcortical sensory aphasia), motor skills (apraxia), and perception (agnosia), in the absence of corresponding focal lesions on brain imaging;

2.       Absence of focal neurological signs, other than cognitive disturbance; and

3.       Absence of cerebrovascular lesions on brain CT or MRI

IV. Clinical diagnosis of possible vascular dementia may be made in the presence of dementia (section I-1) with focal neurologic signs in patients in whom brain imaging studies to confirm definite CVD are missing; or in the absence of clear temporal relationship between dementia and stroke; or in patients with subtle onset and variable course (plateau or improvement) of cognitive deficits and evidence of relevant CVD.

V. Criteria for diagnosis of definite vascular dementia are

1.       Clinical criteria for probable vascular dementia;

2.  Histopathologic evidence of CVD obtained from biopsy or autopsy;
Absence of neurofibrillary tangles and neuritic plaques exceeding those expected for age; and
Absence of other clinical or pathological disorder capable of producing dementia.

VI. Classification of vascular dementia for research purposes may be made on the basis of clinical, radiologic, and neuropathologic features, for subcategories or defined conditions such as cortical vascular dementia, subcortical vascular dementia, BD, and thalamic dementia.

The term "AD with CVD" should be reserved to classify patients fulfilling the clinical criteria for possible AD and who also present clinical or brain imaging evidence of relevant CVD. Traditionally, these patients have been included with VaD in epidemiologic studies. The term "mixed dementia," used hitherto, should be avoided.

DSM-IV criteria for the diagnosis of vascular dementia

DSM-IV criteria for the diagnosis of vascular dementia

A. The development of multiple cognitive deficits manifested by both:

1. Memory impairment (impaired ability to learn new information or to recall previously learned information)
2. One or more of the following cognitive disturbances:

(a) Aphasia (language disturbance)

(b) Apraxia (impaired ability to carry out motor activities despite intact motor function)

(c) Agnosia (failure to recognize or identify objects despite intact sensory function)

(d) Disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)

B. The cognitive deficits in criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.

C. Focal neurological signs and symptoms (e.g., exggeration of deep tendon reflexes, extensor plantar response, psuedobulbar palsy, gait abnormalities, weakness of an extremity) or laboratory evidence indicative of cerebrovascular disease (e.g., multiple infarctions involving cortex and underlyig white matter) that are judged to be etiologically related to the disturbance.

D. The deficits do not occur exclusively during the course of a delirium

Vascular supply of brain

BRANCHES OF INTERNAL CAROTID

Meningohypophyseal trunk (that “Italian artery” Bernasconi-Casanari)

Ophthalmic

Superior hypophyseal

Posterior communicating (infundibulum, connects to PCA)

Anterior choroidal (AChoA – marker for temporal lobe herniation)

Anterior cerebral (ACA)

- Frontopolar

- Callosomarginal

- Pericallosal

Middle cerebral (MCA)

- Lenticulostriate (perforators to basal ganglia)

Internal Carotid (ICA)

- Cervical-Petrous-Cavernous-Supraclinoidsegments

POSTERIOR CIRCULATION BRANCHES

Vertebral

- Muscular (occipital) branches

- Meningeal branch

- PICA

Basilar

- AICA

- Superior cerebellar (SCA)

- Posterior cerebral (PCA)

- Posterior communicating

- Posterior choroidal (medial/ and lateral branches)

- Parietoccipital

- Posterior temporal

- Calcarine

EXTERNAL CAROTID BRANCHES

Superior thyroid

Lingual

Facial

Ascending pharyngeal

Occipital

Posterior auricular

Superficial temporal

Internal maxillary

- Middle meningeal (f. spinosum)

DEEP VENOUS DRAINAGE

Anterior septal

Thalamostriate

Internal cerebral veins (paired)

Basal vein(s) of Rosenthal (medial temporal lobe)

Great vein of Galen

Inferior sagittal sinus (free edge of Falx)

Straight sinus

Superior sagittal sinus (don’t forget the “Torcular Herophilus”)

Transverse sinus

Sigmoid sinus

Internal jugular

COMMENT: Superficial drainage is superficial middle cerebral vein, vein of Trolard and vein of Labbe to superior sagittal sinus

Thalamic Regions and Nuclei

Thalamic Regions and Nuclei
• Anterior

o Anterior nucleus

• Medial
o Medial (or dorsal) nucleus
o Midline nuclei
• Lateral
o Dorsal
 Lateral dorsal nucleus
o Ventral
 Ventral anterior nucleus
 Ventral lateral nucleus
 Ventral posterior lateral nucleus
 Ventral posterior medial nucleus
• Posterior
o Dorsal
 Lateral posterior nucleus
 Pulvinar
• Medial
• Lateral
• Inferior
o Ventral
 Posterior thalamic zone
 Medial geniculate body
 Lateral geniculate body
• Intralaminar
o Centromedian and parafascicular nuclei
o Smaller intralaminar nuclei
• Reticular nucleus