Introduction and Context
Vascular cognitive impairment and dementia (VCID) is a major global health challenge, representing the second most common cause of cognitive decline after Alzheimer’s disease. Despite its prevalence, diagnosing VCID has historically been difficult due to the heterogeneity of the disease and overlapping symptoms with other neurodegenerative conditions. For decades, clinicians relied on various sets of criteria, which often led to inconsistent diagnoses across different regions and research studies.
In 2014, the International Society for Vascular Behavioural and Cognitive Disorders (VasCog) published a set of comprehensive criteria intended to standardize diagnosis. However, the last decade has seen an explosion in medical technology, specifically in the realms of neuroimaging (MRI/CT) and fluid biomarkers (blood and cerebrospinal fluid). To reflect these advances, a global consortium of experts collaborated to produce the VasCog-2-WSO criteria. Endorsed by the World Stroke Organization (WSO), these new guidelines provide a modernized roadmap for identifying, staging, and treating vascular-related cognitive decline.
New Guideline Highlights
The VasCog-2-WSO criteria mark a significant evolution from previous diagnostic frameworks. The primary goal was to move beyond the binary classification of ‘dementia’ and instead view vascular cognitive impairment as a spectrum. The major highlights include:
- Overarching Terminology: The term VCID is used to encompass the entire range of cognitive disorders associated with vascular brain injury.
- Staging Model: The criteria now recognize three distinct stages: Preclinical VCI, Mild VCI, and Major VCI (Dementia).
- Biomarker Integration: For the first time, specific guidance is provided on the use of plasma (blood-based) and neuroimaging biomarkers to support a diagnosis.
- Global Consensus: Developed through a rigorous Delphi process involving 70 international experts, ensuring the criteria are applicable in diverse healthcare settings worldwide.
Updated Recommendations and Key Changes
The transition from the 2014 VasCog criteria to the 2025 VasCog-2-WSO criteria involves several critical updates. The following table summarizes the key shifts in diagnostic strategy:
| Feature | 2014 VasCog Criteria | 2025 VasCog-2-WSO Criteria |
|---|---|---|
| Staging | Mild and Major VCI | Added Preclinical VCI (silent brain injury with subtle decline) |
| Biomarkers | Primarily neuroimaging (MRI) | Integration of Fluid Biomarkers (NfL, p-tau) and advanced MRI sequences |
| Vascular Evidence | Qualitative assessment | Operationalized Thresholds for white matter lesions and lacunes |
| Mixed Pathology | Acknowledged but not prioritized | Detailed guidance on identifying Mixed VCID-Alzheimer’s profiles |
Topic-by-Topic Recommendations
1. Diagnostic Categories and Staging
The VasCog-2-WSO criteria utilize a three-tier staging system to capture the disease earlier in its progression:
- Preclinical VCI: Evidence of vascular brain injury on imaging or via biomarkers, accompanied by subjective cognitive complaints or subtle decline that does not yet meet the threshold for ‘mild’ impairment.
- Mild VCI: Cognitive impairment in at least one domain (commonly executive function or processing speed) that does not significantly interfere with independent daily living.
- Major VCI (Dementia): Cognitive impairment in multiple domains that is severe enough to interfere with independence and daily functioning.
2. Cognitive Domains
While Alzheimer’s disease often begins with memory loss, VCID typically presents differently. The guidelines emphasize testing in:
- Executive Function: Planning, organizing, and multitasking.
- Processing Speed: The speed at which a patient can complete mental tasks.
- Complex Attention: Sustained focus and mental flexibility.
3. Neuroimaging and Biomarker Requirements
A definitive diagnosis of VCID requires evidence of cerebrovascular disease. The guidelines recommend:
- MRI (Preferred): Identification of lacunar infarcts, white matter hyperintensities (WMH), microbleeds, and cortical infarcts. The criteria provide specific thresholds (e.g., Fazekas scale scores) to help clinicians grade the severity of white matter disease.
- Fluid Biomarkers: While still primarily for research, the consensus supports the use of Neurofilament Light Chain (NfL) in blood or CSF as a marker of axonal injury, and markers like p-tau to rule in or rule out co-existing Alzheimer’s pathology.
A Patient Vignette: Applying the Criteria
Consider Arthur, a 68-year-old retired accountant with long-standing hypertension. Arthur visits his doctor complaining that he is ‘slower’ at managing his taxes and finds it difficult to focus on long conversations. His memory scores on the Mini-Mental State Exam (MMSE) are normal, but a detailed neuropsychological evaluation reveals significant deficits in processing speed and executive function.
Under previous guidelines, Arthur might have been told his symptoms were ‘normal aging’ because his memory was intact. However, applying the VasCog-2-WSO criteria, an MRI reveals moderate white matter hyperintensities and two small lacunar strokes. Because these symptoms impact his complex tasks but he remains independent, Arthur is diagnosed with Mild VCI. This early diagnosis allows his physician to aggressively manage his blood pressure and start a targeted exercise program to prevent progression to Major VCI.
Expert Commentary and Insights
The VasCog-2-WSO working group highlighted that the inclusion of ‘Preclinical VCI’ is perhaps the most forward-looking aspect of the update. Expert members noted that by the time a patient reaches the stage of dementia, much of the vascular damage is irreversible. Identifying patients in the preclinical or mild stages offers a critical window for intervention.
One area of debate during the Delphi rounds was the accessibility of advanced biomarkers. To address this, the committee structured the criteria to be ‘resource-stratified.’ In high-resource settings, fluid biomarkers and high-resolution MRI are encouraged. In lower-resource settings, the criteria still allow for a diagnosis based on clinical history and CT scans, ensuring the guidelines are a truly international standard.
Experts also emphasized the importance of ‘Mixed Dementia.’ Most elderly patients do not have a ‘pure’ disease; they often have both vascular changes and amyloid plaques. The new criteria provide better tools for clinicians to weigh the relative contribution of vascular disease to a patient’s cognitive profile.
Practical Implications
For clinicians, the VasCog-2-WSO criteria provide a more objective framework for diagnosis. By using operationalized thresholds for imaging, the ‘guesswork’ is reduced, leading to more reliable diagnoses. For researchers, these criteria will serve as the backbone for future clinical trials. Having a standardized way to define ‘Mild VCI’ means that drug trials can compare ‘apples to apples’ across different countries.
Ultimately, these guidelines shift the focus toward prevention. By recognizing that vascular health is cognitive health, the VasCog-2-WSO criteria empower patients and doctors to manage cardiovascular risk factors—like hypertension, diabetes, and smoking—as direct strategies for preserving brain function into old age.
References
- VasCog-2-WSO Criteria Consortium; Sachdev PS, Bentvelzen AC, Kochan NA, et al. Revised Diagnostic Criteria for Vascular Cognitive Impairment and Dementia-The VasCog-2-WSO Criteria. JAMA Neurol. 2025;82(11):1103-1112. doi:10.1001/jamaneurol.2025.3242.
- Sachdev P, Kalaria R, O’Brien J, et al. Diagnostic criteria for vascular cognitive impairment: a VASCOG statement. Alzheimer Dis Assoc Disord. 2014;28(3):206-218. doi:10.1097/WAD.0000000000000034.
- Gorelick PB, Scuteri A, Black SE, et al. Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(9):2672-2713.