VasCog-2-WSO Vascular Dementia Criteria, With Perminder Sachdev, MD

The revised VasCog-2-WSO diagnostic criteria for vascular dementia, endorsed by the World Stroke Organization (WSO) and published in 2025, update the 2014 VasCog framework to reflect a decade of advances in small vessel disease imaging and Alzheimer disease biomarkers, according to Perminder Sachdev, MD, PhD, who discussed the revision at the 18th World Stroke Congress in Seoul, South Korea.¹

The original criteria, published in 2014 by the International Society for Vascular Behavioural and Cognitive Disorders, offered an operationalized framework for vascular cognitive disorders.² In an interview with HCPLive, Sachdev said the field now has a clearer understanding of the natural history of small vessel disease, along with greater standardization of its neuroimaging markers. He also pointed to imaging, cerebrospinal fluid, and blood biomarkers for Alzheimer disease now in clinical use, as well as markers available for dementia with Lewy bodies.

“Because these are co-pathologies and often competing pathologies in a differential diagnosis, having those biomarkers further aids the assessment of vascular dementia,” said Sachdev, co-director of the Centre for Healthy Brain Ageing at UNSW Sydney.

The revision also aimed to broaden representation. According to Sachdev, members of the VasCog Society largely developed the 2014 criteria, leaving some regions of the world underrepresented on the expert panel.

VasCog-2-WSO Consensus Process and Standardized Terminology

Investigators developed the revised criteria through an online Delphi survey requiring ≥ 75% agreement per item across a minimum of 3 rounds.¹ Of 70 international experts invited in 2023, between 49 and 54 participated in each of the 3 survey rounds.¹

The panel agreed on diagnostic criteria for preclinical, mild, and major dementia levels of vascular cognitive impairment, grouped under the overarching term vascular cognitive impairment and dementia (VCID).¹ The framework brings earlier labels, including vascular dementia, vascular neurocognitive disorder, and vascular cognitive disorder, under this single umbrella term.³

Sachdev said a central aim was to replace the many terms introduced in recent years with 1 standard terminology going forward. The WSO endorsed the final criteria, which gave the framework its VasCog-2-WSO name.¹

The panel also agreed on research guidelines for novel neuroimaging and fluid biomarkers.¹ According to Sachdev, the group reviewed recent work on fluid and retinal biomarkers to judge whether either was mature enough for clinical practice or research diagnoses.

MRI Markers of Small Vessel Disease in Vascular Dementia Diagnosis

Established MRI markers of small vessel disease include white matter hyperintensities, lacunes, and microbleeds, according to Sachdev. He noted the field now uses the term lacunes in place of lacunar infarcts, and evidence supporting dilated perivascular spaces as an additional marker has grown.

Diffusion-based measures form a second category. Sachdev cited peak width of skeletonized mean diffusivity (PSMD), a diffusion tensor imaging (DTI) metric currently used in research settings.

Functional techniques are also in development, including cerebrovascular reactivity testing with a carbogen challenge, blood-brain barrier integrity measures, and cerebral blood flow assessment with arterial spin labeling or gadolinium-based perfusion. Investigators are deriving network metrics from DTI. Recent studies have also examined brain age, particularly white matter age, as a marker of cerebrovascular disease.

“With this plethora of measures coming into the field, we wanted to see which ones were mature enough,” Sachdev said.

Editor’s note: Sachdev has no reported disclosures.

References

1. 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

2. Sachdev P, Kalaria R, O’Brien J, et al. Diagnostic criteria for vascular cognitive disorders: a VASCOG statement. Alzheimer Dis Assoc Disord. 2014;28(3):206-218. doi:10.1097/WAD.0000000000000034

3. Ellery S. New diagnostic criteria for vascular cognitive impairment and dementia. Medicine Today. Published November 2025. Accessed November 6, 2026. https://medicinetoday.com.au/mt/2025/november/in-brief/new-diagnostic-criteria-vascular-cognitive-impairment-and-dementia