Clinical Commander

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neuro.vascular-dementia.v1

Vascular Cognitive Impairment / Vascular Dementia

neurologychronicsubacuteadultgeriatricoutpatientinpatientmixed
Start encounter →Print handoutPRODUCTION

Phase C shard-3 neuro wave-9 (2026-05-15): authored at INTEGRATED — manifest stub forward-declared; PRODUCTION requires full manifest + RxNav validation. 11 severity_triggers: post_stroke_cognitive_decline / subcortical_SVD / strategic_infarct / multi_infarct / CAA_overlap / CADASIL / mixed_VaD_AD / leukoaraiosis_severe / vascular_MCI_progressing / BP_control_secondary_prevention / SGLT2i_cognitive_benefit_signal. 5 setting playbooks: home (med adherence + BP log + RF) → outpatient (primary q3-6 mo + secondary prevention) → ed (stroke alert + delirium rule-out) → icu (malignant MCA + refractory ICH + status) → inpatient (post-stroke workup + DSD + HELP bundle). 7 PMID evidence anchor: AHA/ASA VCI Iadecola 2019 (21778438) + AHA/ASA 2021 (34024117) + SPRINT-MIND (30688979) + NINDS-AIREN (8094895) + Hachinski (1164215) + VASCOG (24632990) + CitAD (24549548). Schema-blocked: Hachinski Ischemic Score / NINDS-AIREN / VASCOG / MoCA / MMSE / CDR / FAST / Fazekas WMH grading / Modified Rankin Scale — not in clinical-tools-registry; surfaced in depth bundle. Critical safety: CAA + ≥4 microbleeds OR superficial siderosis → AVOID anticoag (LAA occlusion alternative for AF); DAPT × 21 d only for minor stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4) per CHANCE/POINT — long-term DAPT bleed-risk; citalopram max 20 mg in elderly (FDA QT); ChEI bradycardia / GI; memantine renal dose-adjust eGFR <30. Sibling differentiation routes to neuro.ischaemic-stroke.v1 (acute), neuro.tia.v1 (TIA + secondary prevention), neuro.ich.core.v1 (ICH + CAA), symptom.dementia.v1 (parent triage) — all PRODUCTION-registered.

Entry points (9)

  • symptom
    Cognitive decline within 3 mo of stroke (AHA/ASA VCI 2019 PMID 21778438)
    post_stroke_cognitive_decline
  • symptom
    Step-wise cognitive decline with cerebrovascular events (NINDS-AIREN PMID 8094895)
    stepwise_cognitive_decline
  • imaging
    Severe periventricular + deep white-matter hyperintensities (Fazekas 2-3) on MRI
    white_matter_hyperintensities_severe
  • imaging
    Multiple lacunar infarcts + chronic small-vessel disease
    multiple_lacunar_infarcts
  • imaging
    Strategic infarct (thalamus, caudate, angular gyrus) with cognitive impairment
    strategic_infarct_thalamus_caudate
  • history
    High vascular RF burden (HTN, DM, AF, dyslipidemia, smoking) + new cognitive complaint (AHA/ASA 2021 PMID 34024117)
    vascular_risk_factor_burden
  • history
    Young-onset stroke + migraine + family history → CADASIL (NOTCH3) workup
    cadasil_family_history
  • symptom
    Magnetic / shuffling gait + executive dysfunction (subcortical SVD pattern)
    gait_apraxia_lower_body_predominant
  • symptom
    Pseudobulbar affect + mood lability + apathy (subcortical SVD)
    mood_lability_pseudobulbar

Required inputs (18)

  • agerequired
    demographic • used at CONTEXT
    Mean age ~75; younger onset → CADASIL / CAA / monogenic (Iadecola PMID 21778438)
  • stroke_or_tia_historyrequired
    history • used at CONTEXT
    Prior stroke / TIA establishes vascular substrate; temporal relationship (within 3 mo) supports VaD (NINDS-AIREN PMID 8094895)
  • htn_dm_af_dyslipidemia_smokingrequired
    history • used at CONTEXT
    Vascular RF bundle; secondary prevention targets per AHA/ASA 2021 PMID 34024117
  • iadl_adl_functionrequired
    history • used at CONTEXT
    Major vs mild VCI hinges on functional independence (VASCOG 2014 PMID 24632990)
  • symptom_onset_temporequired
    history • used at FRAME
    Step-wise (each stroke episode) OR insidious (chronic SVD) — both VaD patterns (NINDS-AIREN)
  • depression_screen_phq9_or_gdsrequired
    history • used at CONTEXT
    Post-stroke depression common + treatable; pseudodementia mimic (AHA/ASA VCI 2019)
  • cam_4at_for_deliriumrequired
    history • used at RED_FLAGS
    Acute confusion in stroke patient often delirium not VaD; CAM must be negative for chronic VaD label
  • current_meds_anticholinergicrequired
    medication • used at CONTEXT
    Anticholinergic burden reversibly worsens cognition (AGS Beers 2023)
  • current_antithromboticrequired
    medication • used at TREATMENT
    Aspirin / DAPT / DOAC / warfarin for secondary prevention; CAA limits anticoag
  • bp_averagerequired
    vital • used at TREATMENT
    BP control target <130/80 per AHA/ASA 2021 PMID 34024117; SPRINT-MIND PMID 30688979 supports intensive <120 in select older adults
  • hba1crequired
    lab • used at INITIAL_WORKUP
    DM control reduces SVD progression (AHA/ASA 2021)
  • lipid_panelrequired
    lab • used at INITIAL_WORKUP
    LDL <55 mg/dL per AHA/ASA 2021 secondary stroke prevention
  • tsh_b12required
    lab • used at INITIAL_WORKUP
    Hypothyroid + B12 deficiency reversible mimics (AAN 2018)
  • mri_brain_with_swirequired
    imaging • used at INITIAL_WORKUP
    MRI with SWI/T2*/FLAIR: lacunar infarcts + WMH (Fazekas) + microbleeds (CAA hint) + superficial siderosis; strategic infarcts (thalamus, caudate)
  • echocardiogram_af_screen
    lab • used at BRANCHING_WORKUP
    AF + LV thrombus + PFO + LV systolic dysfunction → cardioembolic source for VCI workup (AHA/ASA 2021)
  • notch3_genetics_if_cadasil_suspected
    lab • used at BRANCHING_WORKUP
    NOTCH3 sequencing for CADASIL (young-onset stroke + migraine + family history + anterior temporal WMH)
  • csf_amyloid_for_mixed_pathology
    lab • used at BRANCHING_WORKUP
    Mixed AD-vascular common; CSF Aβ42 + p-tau identifies AD biology overlap to guide mAb eligibility (NIA-AA 2018)
  • caregiver_burden_zarit
    history • used at FOLLOWUP
    Caregiver Zarit ≥21 → institutionalization risk (APA 2024)

12-phase flow (12)

  1. 1FRAME
    Cognitive decline temporally + spatially linked to cerebrovascular disease meeting AHA/ASA VCI 2019 + NINDS-AIREN + VASCOG criteria (Iadecola PMID 21778438; Roman PMID 8094895; Sachdev PMID 24632990)
    inputs: stroke_or_tia_history, symptom_onset_tempo
    advance: VaD criteria met (probable / possible / mixed)
  2. 2ENTRY
    Post-stroke cognitive screen at 3 mo + chronic SVD with new cognitive complaint + strategic infarct + vascular RF + cognitive change → VCI/VaD pathway
    inputs: age
    advance: VCI pathway activated
  3. 3CONTEXT
    IADL/ADL, vascular RFs, depression PHQ-9/GDS, anticholinergic burden, current antithrombotic, sleep / OSA, hearing / vision, MoCA preferred (sensitive to executive dysfunction of SVD) (AHA/ASA VCI 2019)
    inputs: htn_dm_af_dyslipidemia_smoking, iadl_adl_function, depression_screen_phq9_or_gds, current_meds_anticholinergic, current_antithrombotic
    advance: Full functional + vascular + medication context complete
  4. 4RED_FLAGS
    Acute stroke (route to neuro.ischaemic-stroke.v1); TIA (route to neuro.tia.v1); acute ICH (route to neuro.ich.core.v1); delirium superimposed (CAM/4AT); rapid decline → autoimmune / CJD workup (route to symptom.dementia.v1)
    inputs: cam_4at_for_delirium
    actions: workup.acute_stroke, workup.delirium
    advance: Acute cerebrovascular event triaged + delirium excluded
  5. 5INITIAL_WORKUP
    MoCA preferred (executive dysfunction sensitive); PHQ-9 or GDS; CBC, CMP, TSH, B12, HbA1c, lipid panel; MRI brain with SWI/T2*/FLAIR (lacunes + WMH + microbleeds + strategic infarcts) (AAN 2018; AHA/ASA VCI 2019)
    inputs: hba1c, lipid_panel, tsh_b12, mri_brain_with_swi, bp_average
    actions: panel.cbc, panel.renal, panel.thyroid, panel.lft, panel.lipid, panel.coag
    advance: Vascular substrate confirmed + reversible mimics screened
  6. 6BRANCHING_WORKUP
    Echo for cardioembolic source; carotid Doppler; NOTCH3 if CADASIL suspected; CSF amyloid + p-tau for mixed pathology + mAb eligibility; Hachinski Ischemic Score ≥7 supports VaD (AHA/ASA 2021 PMID 34024117; Hachinski PMID 1164215)
    inputs: echocardiogram_af_screen, notch3_genetics_if_cadasil_suspected, csf_amyloid_for_mixed_pathology
    advance: Etiology + mixed pathology + monogenic ruled in/out
  7. 7DIFFERENTIAL
    Probable VaD (NINDS-AIREN) vs possible VaD vs mixed VaD-AD vs pure AD (route to neuro.alzheimer.v1) vs FTD (route to neuro.frontotemporal-dementia.v1) vs DLB / PDD (route to neuro.parkinson.v1) vs NPH (Hakim triad) vs reversible mimics — CAA, CADASIL, post-stroke depression
    advance: VaD assigned with confidence
  8. 8RISK_STRATIFICATION
    Stroke recurrence risk (CHADS-VASc if AF; ABCD2 if TIA); cognitive trajectory (Hachinski Ischemic Score; Fazekas WMH grading); fall risk; depression; caregiver burden Zarit
    inputs: caregiver_burden_zarit
    advance: Recurrence + cognitive + functional + caregiver risk evaluated
  9. 9TREATMENT
    Secondary stroke prevention bundle: statin LDL <55, BP <130/80 (SPRINT-MIND signal PMID 30688979), antiplatelet (aspirin / clopidogrel) or anticoag for AF (DOAC preferred); donepezil trial 5-10 mg modest benefit per Cochrane; memantine for moderate-severe; treat depression SSRI; OSA workup; lifestyle (exercise 150 min/wk, MIND diet, smoking cessation) (AHA/ASA 2021 PMID 34024117)
    inputs: current_antithrombotic, bp_average
    advance: Prevention bundle + symptomatic Rx documented
  10. 10DISPOSITION
    Outpatient stroke + cognitive clinic q3-6 mo; admit for acute stroke / TIA / ICH (route to dedicated engines); admit for behavioural crisis or delirium superimposed; ICU rarely (refractory ICH, malignant MCA)
    advance: Disposition documented
  11. 11MONITORING
    Annual MoCA; quarterly BP + lipids (titrate); HbA1c q3 mo if DM; annual carotid Doppler if stenosis; echo as indicated; AGS Beers 2023 deprescribe q6 mo (APA 2024)
    advance: Monitoring plan documented
  12. 12FOLLOWUP
    Caregiver education + dementia care navigator; driving cessation per MoCA / on-road eval; advance directives / POLST; palliative referral at FAST 7 (NICE 2024 dementia)
    inputs: caregiver_burden_zarit
    advance: Caregiver + advance care plan established