Whether unusual sleep patterns increase the risk of SVD lesions is unclear although disordered night-time sleep is associated with brain atrophy and increased daytime sleep is associated with increased PVS on MRI. Itoh Y, Yamada S, Konoeda F, Koizumi K, Nagata H, Oya M, et al. [63] Interestingly, type 2 diabetes is associated with a greater increase in depressive symptoms, which SVD may contribute to.[23,64]. Eight studies, mostly in older community dwelling-subjects, detected urinary symptom associations with WMH (total n = 1944),[3441] while two did not (n = 648). Cognitive ability, education and socioeconomic status in childhood and risk of post-, 78. [13] While some LACS may masquerade as cortical stroke syndromes when the responsible brain lesion is close to the cortex,[27] or in specific locations such as the thalamus. [91] Trials assessing the effect of dietary sodium in SVD are lacking, as they are for other vascular disease, but reduction in dietary salt is good general health advice. Gyanwali B, Shaik MA, Tan BY, Venketasubramanian N, Chen C, Hilal S. 56. Most people in the United States get enough ALA from the foods they eat. Please enable scripts and reload this page. The STandards for ReportIng A comparison of location of acute symptomatic versus 'silent small vessel lesions. Future research should target whether emotional liability, delusions, and other neuropsychiatric symptoms relate to disease severity including progression. National Institutes of Health; National Heart, Lung and Blood Institute. Adopting a more integrated, holistic approach to identifying early and intermediate clinical brain damage markers is essential to permit prognostication, supportive management strategies, identification of patients for emerging treatment trials, and future refinement of targeted prevention and management strategies. Cerebral small vessel diseases (cSVDs) are a common cause of stroke and an Many clinical features described in this review are non-specific when considered in isolation. In the atherosclerosis risk in communities (ARIC) study, high triglycerides increased the risk of incident lacunes (OR 1.24, 95% CI 1.041.47), while elevated high-density lipoproteins (HDL) reduced the risk (OR 0.77, 95% CI 0.590.99). The previously mentioned LACI-1 trial randomized patients to ISMN, in addition to Cilostazol, in a factorial design. CNS small vessel disease: A clinical review. Vascular cognitive impairment (VCI) is a broad term, encompassing mild cognitive impairment and dementia. 14. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4832291/). Instead, treatment focuses on treating the symptoms and complications of cerebral atrophy. Lifestyle and behavioral interventions may have potential benefit in patients with SVD and are currently under investigation [Table 2]. [102], Unfortunately, there are no trial data pertaining to statins exclusively in lacunar stroke. A typical fish oil supplement provides about 1,000 milligrams Liu-Ambrose T, Best JR, Davis JC, Eng JJ, Lee PE, Jacova C, et al. Proposed pathophysiological mechanisms underlying SVD are outside the scope of this review but are described in detail elsewhere. [72], The lesions seen on MRI adopted as biomarkers of SVD include recent small subcortical (or lacunar) infarct (RSSI), WMH, lacune, CMB, visible PVS, and cerebral atrophy. 117. SVD often arises on a background of other complex comorbidities, and untangling SVD symptoms from those attributable to other conditions requires careful clinical judgment including neuroimaging review. 1 Despite its impact on the brain, there are currently no specific treatments for SVD, and therapeutic options for secondary prevention are particularly limited compared 2 Turmeric Westend61 / Getty Images Case vignette. WebFor people with heart disease, the AHA recommends consuming about 1 g per day EPA plus DHA, preferably from oily fish, but supplements are an option under the guidance of a health care provider. Microvascular ischemic disease is a brain condition that commonly affects older people. [89] Several ongoing trials intend to build upon this data. [53,54] The potential impact of dyslipidemia remains uncertain. [84] A trial of 80 patients with ischemic stroke (1/2 lacunar etiology) demonstrated reduced BP, augmentation index and carotid intima-media thickness progression following one year of receiving allopurinol. So, its important to go to the emergency room immediately if youre experiencing sudden: Microvascular ischemic disease can range from mild to severe. Tolerability, safety and intermediary pharmacological effects of cilostazol and isosorbide mononitrate, alone and combined, in patients with lacunar ischaemic, 109. We focus on the clinically sensitive DSM-V diagnostic criteria,[44] which require evidence of cognitive decline from a previous performance level in one or more domains including: (a) concern about decline from a patient, knowledgeable informant or clinician, and (b) objective impairment or decline on testing. 48. [119] The small LACI-1 trial (n = 57) found that cilostazol was well tolerated over a 11 week period in patients with lacunar stroke and was associated with less progression of WMH as compared with patients randomised to no cilostazol. Advances in Understanding the Pathophysiology of Lacunar, 12. While some lesions are truly clinically silent, for instance if small or located in less eloquent regions,[13] careful questioning about historical stroke or transient ischemic attack (TIA) symptoms is recommended, as a positive history may render such individuals eligible for secondary stroke prevention. 123. Bos D, Wolters FJ, Darweesh SKL, Vernooij MW, de Wolf F, Ikram MA, et al. [25] Furthermore, other comorbidities may alter or obscure stroke presentations [Figure 4], for example, a patient with arthritis and peripheral neuropathy may not notice an ataxic hemiparesis. [29,30,50,79], The single strongest risk factor for SVD lesion progression identified so far is having a severe SVD lesion burden at presentation. Amarenco P, Goldstein LB, Messig M, ONeill BJ, Callahan A III, Sillesen H, et al. Diagnostic criteria for vascular cognitive disorders: a VASCOG statement. 63. The recommended daily intake of omega-3 fatty acids for all adults is between 1.1 and 1.6 grams. Incidence and prognosis of transient neurological attacks. In other words, your best bet for preventing or slowing down cerebral SVD may be to properly treat high blood pressure and other risk factors before you are 80, or otherwise have significant SVD. Furthermore, experts dont yet agree on how low to go, when it comes to optimal blood pressure for an older person with cerebral small vessel disease. Janghorbani M, Hu FB, Willett WC, Li TY, Manson JE, Logroscino G, et al. Effectiveness: Possibly Effective. [3] While specific syndromes including pure motor/hemisensory stroke and ataxic hemiparesis are more strongly associated with acute small subcortical infarcts,[24] LACS classification is imprecise[24,25] and one-third of minor strokes are not accompanied by a corresponding acute infarct radiologically, even on the most sensitive diffusion MRI (n = 264). 11. Effects of statins on the progression of cerebral white matter lesion: Post hoc analysis of the ROCAS (Regression of Cerebral Artery Stenosis) study. Serial imaging studies assessing neuropsychiatric symptoms are especially lacking. The AHA does not recommend omega-3 supplements for people who do not have a high risk of cardiovascular disease. [26] Non-lacunar pathology, for example, cortical infarcts, may manifest as LACS and conversely, small subcortical infarcts may present with other non-LACS syndromes[25,27] in around 15% to 20% (n = 137), or develop silently. Tadic SD, Griffiths D, Murrin A, Schaefer W, Aizenstein HJ, Resnick NM. Cerebral amyloid angiopathy: a systematic review. But they tend to worsen and become irreversible during the normal course of the disease. Chang KJ, Lee S, Lee Y, Lee KS, Back JH, Jung YK, et al. Fandler S, Gattringer T, Eppinger S, Doppelhofer K, Pinter D, Niederkorn K, et al. Genetic, environmental/lifestyle and cultural risk factors are likely related to SVD burden and to its associated outcomes such as cognitive impairment. We should use healthcare encounters to opportunistically seek features of SVD progression, for example, screening during vascular risk factor reviews. Similarly, adverse childhood socioeconomic status (SES) increases the risk of worse deep (r = 0.181) and periventricular (r = 0.146) WMH, and lower educational attainment is associated with more WMH in later life (OR 1.24; 95% CI, 1.051.47). Pharmacological agents under investigation. [8] Moreover, both TNAs and Transient Focal Neurological Episodes, a subset of TNAs typified by spreading, recurrent, stereotyped episodes and associated with cerebral amyloid angiopathy (CAA),[17] herald a higher risk of future ischemic and hemorrhagic stroke, while TNAs also associate with chronic SVD features and dementia. A cup of wild blueberries is not only a tasty, low-calorie snack, but it also lowers blood pressure, improves blood vessel function and provides a small brain boost, a new study suggests. Effect of pravastatin on cerebral infarcts and white matter lesions. Sweeteners: None. Saini M, Ikram K, Hilal S, Qiu A, Venketasubramanian N, Chen C. Silent. The trends were similar for other SVD markers although sample sizes were not large enough to determine if similar associations are present for other SVD markers. Al-Shahi Salman R, Minks DP, Mitra D, Rodrigues MA, Bhatnagar P, du Plessis JC, et al. Cilostazol decreases cerebral arterial pulsatility in patients with mild white matter hyperintensities: subgroup analysis from the Effect of Cilostazol in Acute Lacunar Infarction Based on Pulsatility Index of Transcranial Doppler (ECLIPse) study. Miyamoto N, Pham LD, Hayakawa K, Matsuzaki T, Seo JH, Magnain C, et al. ISMN was well-tolerated and safe, but did not influence clinical or radiological outcomes in this small trial. Subcortical ischaemic vascular. Association of obstructive sleep apnea and cerebral, 76. Pharmacological treatment and prevention of cerebral small vessel disease: a review of potential interventions. This is easy to do since people may attribute symptoms to normal signs of aging. Hence, we report several outcomes depending on available data. 19. Aerobic exercise and vascular cognitive impairment: A randomized controlled trial. [108] The ongoing LACI-2 trial seeks to assess the effect of cilostazol on recurrent stroke, cognition, imaging markers of SVD and death and dependency in 400 participants with prior lacunar stroke. We support close liaison with patients, family members and general practitioners to monitor for clinical deterioration. Croall ID, Lohner V, Moynihan B, Khan U, Hassan A, OBrien JT, et al. Prevention of, 15. Cerebral small vessel disease (SVD) is a global brain disease affecting multiple clinical domains by disrupting normal function of the perforating cerebral arterioles, capillaries, venules, and brain parenchyma, manifesting on magnetic resonance imaging (MRI) as white matter hyperintensities (WMH), small subcortical infarcts, microinfarcts, lacunes, enlarged perivascular spaces (PVS), microbleeds, superficial siderosis, intracerebral hemorrhage (ICH), and atrophy. Diffusion-weighted MRI in vascular. Nonfocal transient neurological attacks are associated with cerebral. Karama S, Ducharme S, Corley J, Chouinard-Decorte F, Starr J, Wardlaw JM, et al. Dietary sodium and risk of. Vascular depression consensus report - a critical update. 73. Aribisala BS, Riha RL, Valdes Hernandez M, Munoz Maniega S, Cox S, Radakovic R, et al. Hilal S, Mok V, Youn YC, Wong A, Ikram MK, Chen CL. Diagnostic and Statistical manual of mental Disorders. Less WMH progression with intensive BP reduction. [4,18,19] Other neurological symptoms associated with SVD include dysphagia,[20] dysarthria,[21] pyramidal tract signs, and pseudobulbar palsy.[22]. Brain atrophy in cerebral small vessel diseases: extent, consequences, technical limitations and perspectives: The HARNESS initiative. A trial of two repurposed licenced drugs to prevent progression of cerebral, 110. Dao E, Barha CK, Best JR, Hsiung GY, Tam R, Liu-Ambrose T. The effect of aerobic exercise on white matter hyperintensity progression may vary by sex. Given the chronic nature and insidious progression of SVD, potential treatments will likely be required over the longer term as is done for the secondary prevention of vascular diseases. This approach should integrate clinical expertise in stroke neurology, cognitive, and physical dysfunctions. Get new journal Tables of Contents sent right to your email inbox, http://creativecommons.org/licenses/by-nc-nd/4.0, Clinical management of cerebral small vessel disease: a call for a holistic approach, Other articles in this journal by Una Clancy, China Association for Science and Technology, Chinese Medical Association (Sponsor of CMJ), Chinese Medical Association Publishing House, International Committee of Medical Journal Editors, Privacy Policy (Updated December 15, 2022), All below presentations + informant reports of altered behavior, deteriorating cognition and function, Functional decline requiring social support. The ENOS Trial Investigators. Diffusion-weighted imaging in transient neurological attacks. Roman GC, Erkinjuntti T, Wallin A, Pantoni L, Chui HC. Both are painless imaging tests. [57] Ambulatory blood pressure (BP) provides more accurate data on BP status than office-based BP measurements and may help BP control in patients with extensive SVD. Cerebral small vessel disease, also known as cerebral microangiopathy , is an umbrella term for lesions in the brain attributed to pathology of small arteries, (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7817338/), (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6300773/), (https://www.nhlbi.nih.gov/health-topics/stroke). Conflicts of interest: The authors declare academic grants for research as listed above; JMW chairs the ESOC 2021 Planning Group, and participates in two ESO Guidelines; CA, JPA and UC have no conflicts to disclose. Inpatient admissions including unexplained falls, gait deterioration, delirium +/ obvious precipitant, Acute medical assessment unit and General internal medicine, Single antiplatelet therapy reduced recurrent. We screened 2169 papers for clinical diagnosis, 1094 for risk factors and progression, and 7695 for interventions in SVD, including the most relevant papers reporting SVD associations. You may be trying to access this site from a secured browser on the server. Paris, FR: Flix Alcan; 1901. 101. Clarkson BD, Griffiths D, Resnick NM. [50,53] Specifically, In community-based samples, WMH prevalence was low before 55 years of age but increased sharply with age thereafter, from 11% to 21% in the subjects 64 years of age on average to 94% in individuals 82 years of age on average. [1,2] The core clinical manifestations include lacunar ischemic stroke, intracerebral hemorrhage and cognitive decline, including vascular cognitive impairment and amplification of pathological and cognitive Alzheimer's disease manifestations. e. Effects of clopidogrel added to aspirin in patients with recent lacunar. Sage can also be consumed in tea form. Staekenborg SS, van der Flier WM, van Straaten EC, Lane R, Barkhof F, Scheltens P. Neurological signs in relation to type of cerebrovascular disease in vascular. 50. Wardlaw JM, Chappell FM, Valdes Hernandez MDC, Makin SDJ, Staals J, Shuler K, et al. [6971] Alcohol intake is associated with worse WMH in patients with minor stroke. Chokesuwattanaskul A, Cheungpasitporn W, Thongprayoon C, Vallabhajosyula S, Bathini T, Mao MA, et al. Please try after some time. Taking medications to lower high blood pressure and regulate cholesterol and glucose levels. Romero JR, Preis SR, Beiser A, DeCarli C, Viswanathan A, Martinez-Ramirez S, et al. 60. Banerjee G, Carare R, Cordonnier C, Greenberg SM, Schneider JA, Smith EE, et al. Sachdev P, Kalaria R, OBrien J, Skoog I, Alladi S, Black SE, et al. 8 Nattokinase Benefits + Dosage, Dangers, Side Effects. Cerebral Small Vessel Disease (CSVD): Symptoms and Treatment. Prevalence, 58.van Middelaar T, Argillander TE, Floris HBM, Deinum J, Richard E, Klijn CJM. to maintaining your privacy and will not share your personal information without [76], Brain and cognitive reserves in later life are influenced by lifetime experiences, including those early in life. Mok VC, Lam WW, Fan YH, Wong A, Ng PW, Tsoi TH, et al. 67. Single antiplatelet therapy reduced recurrent stroke as compared with no antiplatelet agent in a meta-analysis of 17 trials totaling 42,234 patients with previous lacunar ischemic stroke. inability to independently manage one's finances. The onset of sporadic SVD typically occurs during mid to late life and although the disease, its associated risk factors, and clinical features such as gait dysfunction and cognitive decline are more prevalent with advancing age, these are not just inevitable consequences of ageing. Bleeding in your brains small blood vessels (cerebral microbleeds). 6.de Laat KF, van Norden AG, Gons RA, van Oudheusden LJ, van Uden IW, Bloem BR, et al. Effect of a 24-month physical activity program on brain changes in older adults at risk of Alzheimer's disease: the AIBL active trial. 70. B vitamins and. Read Reviews (32) Treatment name FISH OIL. Obesity, insulin resistance, and incident. Kwok CS, Shoamanesh A, Copley HC, Myint PK, Loke YK, Benavente OR. 16. Infant health and development To uncover whether non-stroke symptoms may be associated with acute infarcts on brain imaging, some studies have focused on transient neurological attacks (TNAs). [42,43] These findings need to be reproduced in large prospective blinded studies, adjusting for mobility, frailty and co-morbidities. [54] Data are currently unclear on male-female differences, and apparent differences may reflect age or recruitment bias, rather than a true difference in SVD burden, However, some hospital-based studies suggest that males have a higher burden of both sporadic[70] and monogenic SVDs,[71] but further research is needed to differentiate any true male-female difference in incidence or severity and the reasons behind any difference observed. Further, detailed, observational research on modifiable and non-modifiable factors is required, integrating these into clinical trial design, determining whether using different treatment strategies for individuals with non-modifiable risk factors produces any additional benefit. Heye AK, Thrippleton MJ, Chappell FM, Valdes Hernandez MC, Armitage PA, Makin SD, et al. Understanding the role of the perivascular space in cerebral. Thus, WMH progression is worse in those with increased baseline WMH volume,[81,82] and worsening WMH burden associates with brain atrophy including cortical thinning. How lesion volume, location, background SVD burden and rate of lesion change interact with symptoms, cognition, function, and physical and cognitive reserves needs to be determined. Dickie DA, Ritchie SJ, Cox SR, Sakka E, Royle NA, Aribisala BS, et al. [106], Cilostazol, a phosphodiesterase 3 inhibitor, is commonly used for stroke prevention in the Asia-Pacific region. Staals J, Makin SDJ, Doubal F, Dennis M, Wardlaw JM. Sibolt G, Curtze S, Melkas S, Pohjasvaara T, Kaste M, Karhunen PJ, et al. Best for: Heart health and healthy aging. Severity of white matter hyperintensities and length of hospital stay in patients with cognitive impairment: a CREDOS (Clinical Research Center for, 52. Wehrberger C, Jungwirth S, Fischer P, Tragl KH, Krampla W, Marlies W, et al. 97. Highlight selected keywords in the article text. Policy. 106. Example agents include nitric oxide (NO) donors, prostacyclin (PGI 2 ), phosphodiesterase (PDE)-inhibitors, and statins (as discussed below and in Supplement By addressing your specific risk factors, you can manage or minimize these complications and live a healthier life. WebMicrovascular ischemic disease is a brain condition that commonly affects older people. 86. Ay H, Arsava EM, Rosand J, Furie KL, Singhal AB, Schaefer PW, et al. The natural history of VCI including subcortical subtypes needs to be better defined, for example, prevalence of stepwise vs. progressive cognitive decline. Vascular, 68. In 1901, Marie[10] described ltat lacunaire or the lacunar state, involving one or more lacunes on neuropathology, characterized by progressive neurological decline, episodes of mild hemiparesis, and later, dysarthria, marche petit pas (gait with little steps), imbalance, incontinence, pseudobulbar signs, and dementia. [66] In contrast, lower HDL may predict WMH volume increase in people aged between 73 and 76 years[67] so the relationship between HDL and SVD needs further research. 120. Sudden urge to urinate (urinary urgency). Other cases where LACS and partial anterior circulation stroke (PACS) are confused may simply reflect disappearance of, or failure to recognize, cortical symptoms, mistaking dysarthria for dysphasia, or overlooking visual field defects. We should devise electronic record-based alerts based on notification of relevant healthcare referrals [Table 1], combined with existing imaging data. This work is supported by the UK Dementia Research Institute (JMW, CA) which receives its funding from DRI Ltd, funded by the UK MRC, Alzheimer's Society and Alzheimer's Research UK; the Fondation Leducq Network for the Study of Perivascular Spaces in Small Vessel Disease (JMW; 16 CVD 05); The European Union Horizon 2020, [emailprotected] (JMW, FD, PHC-03-15, project No 666881); The Row Fogo Charitable Trust Centre for Research into Aging and the Brain (JMW); The British Heart Foundation (LACI-2 and Centre for Research Excellence; CS/15/5/31475, RE/18/5/34216); The Chief Scientist Office of Scotland (CZB/4/281, ETM/326, and Clinical Academic Fellowship UC; CAF/18/08); Chest Heart Stroke Scotland (Res14/A157); NHS Research Scotland (FND); Stroke Association (Garfield Weston Foundation Senior Clinical Lectureship FND, TSALECT 2015/04; Small Vessel Disease-Spotlight on Symptoms, FD, JMW, UC, SVD-SOS; SAPG 19\100068; R4VaD, JMW, FD, PMB, 16 VAD 07; Princess Margaret Research Development Fellowship, UC, 2018; and Stroke Association Professor of Stroke Medicine PMB); PMB is a NIHR Senior Investigator. Relative and cumulative effects of lipid and blood pressure control in the. Glucose regulation, cognition, and brain MRI in type 2 diabetes: a systematic review. Whether initially silent infarcts due to SVD are clinically unmasked later by increasing SVD burden and/or increasing physical frailty, revealing delayed typical or atypical symptoms, is a target for future research. Sakakibara R, Hattori T, Uchiyama T, Yamanishi T. Urinary function in elderly people with and without leukoaraiosis: relation to cognitive and gait function. Georgakis MK, Duering M, Wardlaw JM, Dichgans M. WMH and long-term outcomes in ischemic. The authors acknowledge academic research funding sources as listed below. A cup of wild blueberries is not only a tasty, low-calorie snack, but it also lowers blood pressure, improves blood vessel function and provides a small brain boost, Engage in different types of exercise that improve your balance, strength and heart health. We supplemented the electronic search with the authors personal files and searched reference lists of identified papers. High dietary sodium was associated with increased stroke, particularly lacunar events, WMH and SVD burden in patients with stroke[69] and with risk of stroke in population studies. The neurological examination provides clues to subtyping VCI: subtle abnormalities including dysarthria, dysphagia, and parkinsonian, rather than hemiplegic gait, are all more prevalent in subcortical vascular dementia (n = 706). Chin Med J 2021;134:127142. Clinical management of cerebral small vessel disease: a call for a holistic approach. WebB-vitamin supplementation with folate and vitamins B12 and B6 reduces homocysteine concentrations. She has a past medical history of hypertension, hypercholesterolaemia and recent lacunar, AIBL: Australian Imaging Biomarkers and Lifestyle study; BP: blood pressure; CADASIL: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy; CBF: cerebral blood flow; CMB: cerebral microbleeds; DTI: diffuse tensor imaging; ENOS: Efficacy of Nitric Oxide in, 3. White matter hyperintensity reduction and outcomes after minor, 82.van Leijsen EMC, van Uden IWM, Ghafoorian M, Bergkamp MI, Lohner V, Kooijmans ECM, et al. [35] There is increasing recognition that its multidomain involvement extends beyond stroke and dementia [Figure 1] to include gait and balance dysfunction, behavioral and neuropsychiatric symptoms, and subtle, non-focal neurological features [Figure 2],[68] resulting in presentations to diverse general and specialist services [Table 1]. 37. You may search for similar articles that contain these same keywords or you may Gait and balance dysfunction, shortened stride length (n = 431),[6] unexplained dizziness (n = 122),[31] falls (n = 187),[32] and features of vascular parkinsonism such as bradykinesia, rigidity, and gait disturbances (n = 503 community-dwelling)[33] are all associated with SVD. Cerebral atherosclerosis, small vessel disease, cerebral amyloid angiopathy, and blood-brain barrier dysfunction have all been reported in AD . WebOmega-3 dietary supplements include fish oil, krill oil, cod liveroil, and algal oil (a vegetariansource that comes from algae). Olive oil lowers amounts of LDL cholesterol and increases the level of protective HDL cholesterol. It has also been proven to reduce elevated blood triglycerides (another risk factor for heart disease), though it is not as effective as fish oils. Which Nutritional Supplements Should I Take for Cerebral Vascular Insufficiency? In the PRESERVE trial, 111 hypertensive patients with lacunar ischemic stroke and established SVD were randomized to intensive BP lowering (<125 mmHg) vs. standard care and demonstrated no difference in white matter damage on diffusion tensor imaging,[101] while in a further subgroup cerebral blood flow was not compromised by intensive BP lowering. Due to the worldwide prevalence of SVD and association with increasing age, potential therapeutic agents will need to be affordable, easy to administer, safe, simple and have limited drug-drug interactions. 104. The epidemiology of silent brain infarction: a systematic review of population-based cohorts. Lower urinary tract. 88. Regarding ethnic or geographical differences, it is difficult to disentangle effects of socioeconomic, dietary and medical histories, and use of different protocols, from true ethnic or geographical differences in the prevalence of SVD. Burden of overactive bladder symptom on quality of life in. Vascular dysfunction-The disregarded partner of Alzheimer's disease.

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