Impact of different methods defining post-stroke neurocognitive disorder: The Nor-COAST study

Neopterin, kynurenine metabolites, and indexes related to vitamin B6 are associated with post-stroke cognitive impairment: The Nor-COAST study

BACKGROUND AND AIMS

We have previously shown that systemic inflammation was associated with post-stroke cognitive impairment (PSCI). Because neopterin, kynurenine pathway (KP) metabolites, and B6 vitamers are linked to inflammation, in our study we investigated whether those biomarkers were associated with PSCI.

MATERIAL AND METHODS

The Norwegian Cognitive Impairment After Stroke study is a prospective multicenter cohort study of patients with acute stroke recruited from May 2015 through March 2017. Plasma samples of 422 participants (59 % male) with ischemic stroke from the index hospital stay and 3 months post-stroke were available for analyses of neopterin, KP metabolites, and B6 vitamers using liquid chromatography-tandem mass spectrometry. Mixed linear regression analyses adjusted for age, sex, and creatinine, were used to assess whether there were associations between those biomarkers and cognitive outcomes, measured by the Montreal Cognitive Assessment scale (MoCA) at 3-, 18-, and 36-month follow-up.

RESULTS

Participants had a mean (SD) age of 72 (12) years, with a mean (SD) National Institutes of HealthStroke Scale score of 2.7 (3.6) at Day 1. Higher baseline values of quinolinic acid, PAr (i.e., an inflammatory marker based on vitamin B6 metabolites), and HKr (i.e., a marker of functional vitamin B6 status based on selected KP metabolites) were associated with lower MoCA score at 3, 18, and 36 months post-stroke (p < 0.01). Higher baseline concentrations of neopterin and 3-hydroxykynurenine were associated with lower MoCA scores at 18 and 36 months, and higher concentrations of xanthurenic acid were associated with higher MoCA score at 36 months (p < 0.01). At 3 months post-stroke, higher concentrations of neopterin and lower values of pyridoxal 5́-phosphate were associated with lower MoCA scores at 18- and 36-month follow-up, while lower concentrations of picolinic acid were associated with a lower MoCA score at 36 months (p < 0.01).

CONCLUSION

Biomarkers and metabolites of systemic inflammation, including biomarkers of cellular immune activation, indexes of vitamin B6 homeostasis, and several neuroactive metabolites of the KP pathway, were associated with PSCI.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02650531.

A Machine Learning Approach to Predict Post-stroke Fatigue. The Nor-COAST study

OBJECTIVE

This study aimed to predict fatigue 18 months post-stroke by utilizing comprehensive data from the acute and sub-acute phases after stroke in a machine-learning set-up.

DESIGN

A prospective multicenter cohort-study with 18-month follow-up.

SETTING

Outpatient clinics at 3 university hospitals and 2 local hospitals.

PARTICIPANTS

474 participants with the diagnosis of acute stroke (mean ± SD age; 70.5 (11.3), 59% male; N=474).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The primary outcome, fatigue at 18 months, was assessed using the Fatigue Severity Scale (FSS-7). FSS-7≥5 was defined as fatigue. In total, 45 prediction variables were collected, at initial hospital-stay and 3-month post-stroke.

RESULTS

The best performing model, random forest, predicted 69% of all subjects with fatigue correctly with a sensitivity of 0.69 (95% CI: 0.50, 0.86), a specificity of 0.74 (95% CI: 0.66, 0.83), and an Area under the Receiver Operator Characteristic curve of 0.79 (95% CI: 0.69, 0.87) in new unseen data. The proportion of subjects predicted to suffer from fatigue, who truly suffered from fatigue at 18-months was estimated to 0.41 (95% CI: 0.26, 0.57). The proportion of subjects predicted to be free from fatigue who truly did not have fatigue at 18-months was estimated to 0.90 (95% CI: 0.83, 0.96).

CONCLUSIONS

Our findings indicate that the model has satisfactory ability to predict fatigue in the chronic phase post-stroke and may be applicable in clinical settings.

Diagnostic accuracy of the Clock Drawing Test in screening for early post-stroke neurocognitive disorder: the Nor-COAST study

BACKGROUND

Post-stroke neurocognitive disorder, though common, is often overlooked by clinicians. Moreover, although the Montreal Cognitive Assessment (MoCA) has proven to be a valid screening test for neurocognitive disorder, even more time saving tests would be preferred. In our study, we aimed to determine the diagnostic accuracy of the Clock Drawing Test (CDT) for post-stroke neurocognitive disorder and the association between the CDT and MoCA.

METHODS

This study is part of the Norwegian Cognitive Impairment After Stroke study, a multicentre prospective cohort study following patients admitted with acute stroke. At the three-month follow-up, patients were classified with normal cognition, mild neurocognitive disorder, or major neurocognitive disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. Any neurocognitive disorder compromised both mild- and major neurocognitive disorder. The CDT at the three-month assessment was given scores ranging from 0 to 5. Patients able to complete the CDT and whose cognitive status could be classified were included in analyses. The CDT diagnostic accuracy for post-stroke neurocognitive disorder was identified using receiver operating characteristic curves, sensitivity, specificity, positive predictive value, and negative predictive value. The association between the MoCA and CDT was analysed with Spearman's rho.

RESULTS

Of 554 participants, 238 (43.0%) were women. Mean (SD) age was 71.5 (11.8) years, while mean (SD) National Institutes of Health Stroke Scale score was 2.6 (3.7). The area under the receiver operating characteristic curve of the CDT for major neurocognitive disorder and any neurocognitive disorder was 0.73 (95% CI, 0.68-0.79) and 0.68 (95% CI, 0.63-0.72), respectively. A CDT cutoff of < 5 yielded 68% sensitivity and 60% specificity for any neurocognitive disorder and 78% sensitivity and 53% specificity for major neurocognitive disorder. Spearman's correlation coefficient between scores on the MoCA and CDT was 0.50 (95% CI, 0.44-0.57, p < .001).

CONCLUSIONS

The CDT is not accurate enough to diagnose post-stroke neurocognitive disorder but shows acceptable accuracy in identifying major neurocognitive disorder. Performance on the CDT was associated with performance on MoCA; however, the CDT is inferior to MoCA in identifying post-stroke neurocognitive disorder.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02650531). Retrospectively registered January 8, 2016.

Physical Activity Behavior and Its Association With Global Cognitive Function Three Months After Stroke: The Nor-COAST Study†

OBJECTIVE

The purposes of this study were to determine the association between physical activity (PA) behavior and global cognitive function 3 months after stroke and to explore the role of physical capacity as a mediating factor.

METHODS

Participants with stroke were successively recruited at 5 different hospitals in Norway. PA was measured using accelerometers, with a follow-up period of 7 consecutive days, and global cognitive function was assessed using the Montreal Cognitive Assessment (MoCA). The general pattern of PA and the percentage of participants adhering to World Health Organization PA recommendations (at least 150 minutes of moderate-intensity aerobic PA per week) were investigated using descriptive statistics. Multiple regression and mediator analyses were used to examine the relationship between PA behavior and MoCA scores; physical capacity, measured with the Short Physical Performance Battery, served as the mediating variable.

RESULTS

A total of 193 women (42.6%) and 260 men (57.4%) with a median age of 73.7 years (25th and 75th percentiles = 65.8 and 80.4, respectively) and a median MoCA score of 25 points (25th and 75th percentiles = 22 and 27, respectively) were included. Mean total time spent walking at moderate intensity was 251.7 (SD = 164.6) min/wk (mean bout length = 20.9 [SD = 7.3] seconds), which indicated 69.3% adherence to World Health Organization guidelines. With each point decrease in the MoCA score, there was an expected 8.6% increase in the odds of nonadherence to PA recommendations. Physical capacity was identified as an important mediating factor, explaining the strength of the association between cognition and PA behavior.

CONCLUSIONS

In contrast to previous research, in the present study, most participants adhered to the updated global PA guidelines. However, people who had survived stroke and had reduced cognitive function were at higher risk of inactivity, an association mediated by physical capacity.

IMPACT

A better understanding of the association between cognition and PA behavior after stroke might help for developing more targeted early-onset interventions.

A Hierarchical Multi-Dimensional Cognitive Training Program for Preventive Cognitive Decline in Acute Ischemic Stroke Patients: Study Protocol for a Randomized Controlled Trial

Background

One of the most popular ways to address cognitive decline is cognitive training. The fact that cognitive deterioration is permanent is one of the main issues. This issue might be resolved by preventive cognitive training when it is acute. As a result, this study aims to design and assess how well stroke patients respond to hierarchical, multi-dimensional preventative cognitive training.

Objective

To describe the study design of this center implementation trial.

Methods

Participants in the study will be recruited from a hospital in China and randomly assigned to the intervention group or the usual care group. Interventions will include four-week hierarchical multi-dimensional preventive cognitive training through a WeChat program. for Primary outcome measures will be the Montreal Cognitive Assessment, Mini-Mental State Examination, and Post-Stroke Cognitive Impairment (PSCI) Incidence. The secondary outcome measure will include the Hamilton Depression Scale, Hamilton Anxiety Scale, Modified Barthel Index, and National Institutes of Health Neurological Deficit Score. Outcomes will be measured at baseline, 12 weeks, and 24 weeks from the baseline.

Results

We expect that the hierarchical multi-dimensional preventive cognitive training program will be easy to implement, and the cognitive function, cognitive psychology, ability of daily living will vary in each setting.

Conclusions

The results will provide evidence highlighting differences in a new strategy of cognitive training through the WeChat program, which allows the home-based practice, puts forward an advanced idea of preventive cognitive training in the acute stage, and has the highest effectiveness of reducing cognitive impairment, and Alzheimer's disease.

Functional brain connectivity in young adults with post-stroke epilepsy

Approximately 1 in 10 young stroke patients (18-50 years) will develop post-stroke epilepsy, which is associated with cognitive impairment. While previous studies have shown altered brain connectivity in patients with epilepsy, little is however known about the changes in functional brain connectivity in young stroke patients with post-stroke epilepsy and their relationship with cognitive impairment. Therefore, we aimed to investigate whether young ischaemic stroke patients have altered functional networks and whether this alteration is related to cognitive impairment. We included 164 participants with a first-ever cerebral infarction at young age (18-50 years), along with 77 age- and sex-matched controls, from the Follow-Up of Transient Ischemic Attack and Stroke patients and Unelucidated Risk Factor Evaluation study. All participants underwent neuropsychological testing and resting-state functional MRI to generate functional connectivity networks. At follow-up (10.5 years after the index event), 23 participants developed post-stroke epilepsy. Graph theoretical analysis revealed functional network reorganization in participants with post-stroke epilepsy, in whom a weaker (i.e. network strength), less-integrated (i.e. global efficiency) and less-segregated (i.e. clustering coefficient and local efficiency) functional network was observed compared with the participants without post-stroke epilepsy group and the controls (P < 0.05). Regional analysis showed a trend towards decreased clustering coefficient, local efficiency and nodal efficiency in contralesional brain regions, including the caudal anterior cingulate cortex, posterior cingulate cortex, precuneus, superior frontal gyrus and insula in participants with post-stroke epilepsy compared with those without post-stroke epilepsy. Furthermore, participants with post-stroke epilepsy more often had impairment in the processing speed domain than the group without post-stroke epilepsy, in whom the network properties of the precuneus were positively associated with processing speed performance. Our findings suggest that post-stroke epilepsy is associated with functional reorganization of the brain network after stroke that is characterized by a weaker, less-integrated and less-segregated brain network in young ischaemic stroke patients compared with patients without post-stroke epilepsy. The contralesional brain regions, which are mostly considered as hub regions, might be particularly involved in the altered functional network and may contribute to cognitive impairment in post-stroke epilepsy patients. Overall, our findings provide additional evidence for a potential role of disrupted functional network as underlying pathophysiological mechanism for cognitive impairment in patients with post-stroke epilepsy.

Therapeutic effects of repetitive transcranial magnetic stimulation on cognitive impairment in stroke patients: a systematic review and meta-analysis

Background

In recent years, repetitive transcranial magnetic stimulation (rTMS) has emerged as a noninvasive and painless treatment for post-stroke cognitive impairment (PSCI). However, few studies have analyzed the intervention parameters of cognitive function and the effectiveness and safety of rTMS for treating patients with PSCI. Thus, this meta-analysis aimed to analyze the interventional parameters of rTMS and evaluate the safety and effectiveness of rTMS for treating patients with PSCI.

Methods

According to the PRISMA guidelines, we searched the Web of Science, PubMed, EBSCO, Cochrane Library, PEDro, and Embase to retrieve randomized controlled trials (RCTs) of rTMS for the treatment of patients with PSCI. Studies were screened according to the inclusion and exclusion criteria, and two reviewers independently performed literature screening, data extraction, and quality assessment. RevMan 5.40 software was used for data analysis.

Results

12 RCTs involving 497 patients with PSCI met the inclusion criteria. In our analysis, rTMS had a positive therapeutic effect on cognitive rehabilitation in patients with PSCI (P < 0.05). Both high-frequency rTMS and low-frequency rTMS were effective in improving the cognitive function of patients with PSCI by stimulating the dorsolateral prefrontal cortex (DLPFC), but their efficacy was not statistically different (P > 0.05).

Conclusions

rTMS treatment on the DLPFC can improve cognitive function in patients with PSCI. There is no significant difference in the treatment effect of high-frequency rTMS and low-frequency rTMS in patients with PSCI between high-frequency and low-frequency rTMS.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=323720, identifier CRD 42022323720.

[The effect of rehabilitation with sensory glove and virtual reality on concentration of brain-derived neurotrophic factor and event related potential P300 in the early rehabilitation period after ischemic stroke]

OBJECTIVE

To study the effect of rehabilitation with sensory glove (SG) and virtual reality (VR) on changes in brain-derived neurotrophic factor (BDNF) concentration and amplitude and latency of event related potential (ERP) P300 in the early rehabilitation period after hemispheric ischemic stroke (IS).

MATERIAL AND METHODS

Ninety patients (mean age 58.0±9.7 years, time after stroke onset - 3.8±1.6 months) were randomized into intervention (IG) and control (CG) groups. Patients in both groups received 15 sessions of rehabilitation (30 min, 3 times a week). Patients in the IG (n=46) received rehabilitation with SG and VR. Patients in CG (n=44) received individualized physical therapy. The end points were a change in the MMSE, MoCA, 10-word Luria test, subtests of Wechsler Adult Intelligence Scale IV (WAIS IV) test, amplitude and latency of P300, and BDNF concentration on admission and at the end of rehabilitation.

RESULTS

There was an improvement on MoCA test (p=0.049) and working memory index of the WAIS IV test (p=0.045) iIn the IG after completing rehabilitation the improvement on MoCA test (p=0.049) and working memory index of the WAIS IV test (p=0.045) was observed. There was aA trend tendency towards an significant increase on MMSE (p=0.093) and 10-word Luria test (p=0.052) was observed. In CG, an improvement with a trend towards significant differences (p≤0.12) on all above mentioned tests was also observednoted. In both groups there were no significant changes in the amplitude or latency of P300. Concentration of BDNF increased significantly in the IG (p=0.042), while in the CG a tendency (p=0.064) was observed (p=0.064). By the end of rehabilitation, the delta between groups in the increase of BDNF concentration was 17.9%, p=0.072. In both groups, there was a correlation between scores on cognitive tests and BDNF concentration. Absence/presence of cognitive disorders was not associated with initial or final BDNF concentrations or delta between groups.

RESULTS

In the IG after completing rehabilitation the improvement on MoCA test (p=0.049) and working memory index of the WAIS IV test (p=0.045) was observed. There was a tendency towards significant increase on MMSE (p=0.093) and 10 word Luria test (p=0.052). In CG an improvement with a trend towards significant differences (p≤0.12) on all above mentioned tests was also observed. In both groups there were no significant changes in the amplitude or latency of P300. Concentration of BDNF increased significantly in the IG (p=0.042), while in the CG a tendency was observed (p=0.064). By the end of rehabilitation, the delta between groups in the increase of BDNF concentration was 17.9%, p=0.072. In both groups there was a correlation between scores on cognitive tests and BDNF concentration. Absence/presence of cognitive disorders was not associated with initial or final BDNF concentration or delta between groups.

CONCLUSION

VR and SG in the early rehabilitation period after IS is are as equally effective as rehabilitation with individualized physical therapy (aerobic training) in increasing BDNF concentration and in improvement on cognitive tests.

Effectiveness of the Perceive, Recall, Plan and Perform intervention for persons with brain injury in community-based rehabilitation: protocol for a single-case experimental design with multiple baselines

INTRODUCTION

There is a need for standardised interventions in community-based rehabilitation to improve everyday performance for older adults with cognitive challenges due to acquired brain injury (ABI). The Perceive, Recall, Plan and Perform System (PRPP) of intervention has a growing research base. The intervention is suitable for any client with decreased performance in everyday tasks due to ineffective cognitive strategy application to enhance mastery in performance of needed or desired activities. There is no current evidence on the effectiveness of the PRPP intervention for this population.

PURPOSE

To describe a protocol for a clinical trial that investigates the effectiveness of the PRPP intervention in the context of community-based rehabilitation for persons (65+ years) with difficulties in task performance due to cognitive challenges after ABI.

METHODS AND ANALYSIS

A non-concurrent multiple baseline design across participants with systematic replications (n=6) will be used. Nine sessions of PRPP intervention will be applied by trained occupational therapists in two community-based rehabilitation units. The participants will complete five repeated measurements of everyday tasks as target behaviours. PRPP Assessment stages 1 and 2 serve as outcome measures at baseline, in the intervention period, in the postintervention period and in the follow-up phase. Mastery percentage of the tasks and the participants' application of cognitive strategies at baseline acts as a control and will be compared with the following phases within the participant. Delayed intervention phases act as a control between participants. Goal Attainment Scaling and the Barthel Index will serve as generalisation measures. Data will be analysed using systematic visual inspection of graphical data, descriptions of clinical significance and descriptive statistical analysis.

ETHICS AND DISSEMINATION

This trial, including the data management plan, is approved by The Norwegian Regional Ethics Committee (215391). Results will be published in congresses and scientific journals.

TRIAL REGISTRATION NUMBER

NCT05148247.

Further Validation of the Menu Task: Functional Cognition Screening for Older Adults

Occupational therapists need a brief tool to identify the potential for functional cognitive deficits leading to impaired occupational performance. The objective is to establish the sensitivity and specificity, concurrent and known-group validity of the Menu Task by comparison with performance on the Weekly Calendar Planning Activity (WCPA). Using a cross-sectional design, we administered the Menu Task and the WCPA to a community-dwelling convenience sample of 287 adults aged from 55 to 93 years. The receiver operating characteristic (ROC) analysis estimated sensitivity and specificity. Concurrent and known-group construct validity was examined by comparing scores on the Menu Task with the WCPA scores. As a result, a new cutoff score of 9 was established for the Menu Task (area under the curve [AUC] = 0.80, sensitivity = 0.89, 95% confidence interval [CI] = [0.73, 0.97]; specificity = 0.58, 95% CI = [0.52, 0.64]). Both concurrent and construct validity were supported. The Menu Task demonstrates sensitivity to functional cognitive impairments in a community sample.

Gait, physical function, and physical activity in three groups of home-dwelling older adults with different severity of cognitive impairment - a cross-sectional study

Background

The research on associations between gait, physical function, physical activity (PA), and cognitive function is growing. Still, clinical assessments of cognitive function and motor function is often kept separate. In this study, we aimed to look at a broad range of measures of gait, physical function, and PA in three groups of home-dwelling older adults with no or questionable dementia, mild dementia, and moderate/severe dementia.

Methods

This cross-sectional study included 100 home-dwelling older adults, recruited from an outpatient geriatric memory clinic. Severity of dementia was categorised using the clinical dementia rating scale (CDR), with no or questionable dementia (CDR score 0 and 0.5), mild dementia (CDR score 1) and moderate/severe dementia (CDR score 2 and 3). We used thigh worn accelerometers to measure daily PA, the Short Physical Performance Battery (SPPB) to measure physical function, and an electronic gait mat to evaluate gait characteristics. Associations between severity of dementia and measures of PA, physical function, and gait characteristics were assessed by linear regression.

Results

Participants’ (mean age 78.9 (SD 6.7) years, 57% women) average gait speed was 0.93 m/sec, and average upright time was 301 min/day. Statistically significant associations were found for the severity of dementia and gait speed (p=0.002), step time (p=0.001), physical function (SPPB, p=0.007), and PA (upright time, p=0.031), after adjusting for age. Overall, having no or questionable dementia was associated with faster gait speed (mean difference 0.163 (95% CI: 0.053 to 0.273)), shorter step time (-0.043 (-0.082 to -0.005)), better SPPB score (1.7 (0.5 to 2.8)), and longer upright time (78.9 (18.9 to 139.0)), compared to those with mild dementia. Furthermore, having no or questionable dementia was also associated with faster gait speed and better SPPB scores, as compared to those with moderate to severe dementia. No evidence of any differences was found between the participants with the mild dementia versus the moderate to severe dementia.

Conclusions

After adjusting for age, we found that the no or questionable dementia group to be associated with better gait and physical function, and more PA, as compared with the two groups with mild or moderate/severe dementia. Evaluation of gait, physical function, and PA can add clinically important information of everyday functioning in memory clinics meeting geriatric patients, but investigations on how to use these results to guide interventions are still needed.

Predicting the Emergence of Major Neurocognitive Disorder Within Three Months After a Stroke

Background: Neurocognitive disorder (NCD) is common after stroke, with major NCD appearing in about 10% of survivors of a first-ever stroke. We aimed to classify clinical- and imaging factors related to rapid development of major NCD 3 months after a stroke, so as to examine the optimal composition of factors for predicting rapid development of the disorder. We hypothesized that the prediction would mainly be driven by neurodegenerative as opposed to vascular brain changes. Methods: Stroke survivors from five Norwegian hospitals were included from the "Norwegian COgnitive Impairment After STroke" (Nor-COAST) study. A support vector machine (SVM) classifier was trained to distinguish between patients who developed major NCD 3 months after the stroke and those who did not. Potential predictor factors were based on previous literature and included both vascular and neurodegenerative factors from clinical and structural magnetic resonance imaging findings. Cortical thickness was obtained via FreeSurfer segmentations, and volumes of white matter hyperintensities (WMH) and stroke lesions were semi-automatically gathered using FSL BIANCA and ITK-SNAP, respectively. The predictive value of the classifier was measured, compared between classifier models and cross-validated. Results: Findings from 227 stroke survivors [age = 71.7 (11.3), males = (56.4%), stroke severity NIHSS = 3.8 (4.8)] were included. The best predictive accuracy (AUC = 0.876) was achieved by an SVM classifier with 19 features. The model with the fewest number of features that achieved statistically comparable accuracy (AUC = 0.850) was the 8-feature model. These features ranked by their weighting were; stroke lesion volume, WMH volume, left occipital and temporal cortical thickness, right cingulate cortical thickness, stroke severity (NIHSS), antiplatelet medication intake, and education. Conclusion: The rapid (<3 months) development of major NCD after stroke is possible to predict with an 87.6% accuracy and seems dependent on both neurodegenerative and vascular factors, as well as aspects of the stroke itself. In contrast to previous literature, we also found that vascular changes are more important than neurodegenerative ones. Although possible to predict with relatively high accuracy, our findings indicate that the development of rapid onset post-stroke NCD may be more complex than earlier suggested.

The Impact of Vascular Risk Factors on Post-stroke Cognitive Impairment: The Nor-COAST Study

Introduction: Post-stroke cognitive impairment (PSCI) is common, but evidence on the impact of vascular risk factors is lacking. We explored the association between pre-stroke vascular risk factors and PSCI and studied the course of PSCI.

Materials and Methods: Vascular risk factors were collected at baseline in stroke survivors (n = 635). Cognitive assessments of attention, executive function, memory, language, and the Montreal Cognitive Assessment (MoCA) were performed at 3 and/or 18 months post-stroke. Stroke severity was assessed with the National Institutes of Health Stroke Scale (NIHSS). PSCI was measured with global z; MoCA z-score; and z-score of the four assessed cognitive domains. Mixed-effect linear regression was applied with global z, MoCA z-score, and z-scores of the cognitive domains as dependent variables. Independent variables were the vascular risk factors (hypertension, hypercholesterolemia, smoking, diabetes mellitus, atrial fibrillation, coronary heart disease, previous stroke), time, and the interaction between these. The analyses were adjusted for age, education, and sex. There were between 5 and 25% missing data for the variables for PSCI.

Results: Mean age was 71.6 years (SD 11.7); 42% were females; and the mean NIHSS score at admittance was 3.8 (SD 4.8). Regardless of vascular risk factors, global z, MoCA, and all the assessed cognitive domains were impaired at 3 and 18 months, with MoCA being the most severely impaired. Atrial fibrillation (AF) was associated with poorer language at 18 months and coronary heart disease (CHD) with poorer MoCA at 18 months (LR = 12.80, p = 0.002, and LR = 8.32, p = 0.004, respectively). Previous stroke was associated with poorer global z and attention at 3 and 18 months (LR = 15.46, p < 0.001, and LR = 16.20, p < 0.001). In patients without AF, attention improved from 3 to 18 months, and in patients without CHD, executive function improved from 3 to 18 months (LR = 10.42, p < 0.001, and LR = 9.33, p = 0.009, respectively).

Discussion: Our findings indicate that a focal stroke lesion might be related to pathophysiological processes leading to global cognitive impairment. The poorer prognosis of PSCI in patients with vascular risk factors emphasizes the need for further research on complex vascular risk factor interventions to prevent PSCI.

Pre-stroke cognitive impairment is associated with vascular imaging pathology: a prospective observational study

BACKGROUND

Chronic brain pathology and pre-stroke cognitive impairment (PCI) is predictive of post-stroke dementia. The aim of the current study was to measure pre-stroke neurodegenerative and vascular disease burden found on brain MRI and to assess the association between pre-stroke imaging pathology and PCI, whilst also looking for potential sex differences.

METHODS

This prospective brain MRI cohort is part of the multicentre Norwegian cognitive impairment after stroke (Nor-COAST) study. Patients hospitalized with acute ischemic or hemorrhagic stroke were included from five participating stroke units. Visual rating scales were used to categorize baseline MRIs (N = 410) as vascular, neurodegenerative, mixed, or normal, based on the presence of pathological imaging findings. Pre-stroke cognition was assessed by interviews of patients or caregivers using the Global Deterioration Scale (GDS). Stroke severity was assessed with the National Institute of Health Stroke Scale (NIHSS). Univariate and multiple logistic regression analyses were performed to investigate the association between imaging markers, PCI, and sex.

RESULTS

Patients' (N = 410) mean (SD) age was 73.6 (±11) years; 182 (44%) participants were female, the mean (SD) NIHSS at admittance was 4.1 (±5). In 68% of the participants, at least one pathological imaging marker was found. Medial temporal lobe atrophy (MTA) was present in 30% of patients, white matter hyperintensities (WMH) in 38% of patients and lacunes in 35% of patients. PCI was found in 30% of the patients. PCI was associated with cerebrovascular pathology (OR 2.5; CI = 1.4 to 4.5, p = 0.001) and mixed pathology (OR 3.4; CI = 1.9 to 6.1, p = 0.001) but was not associated with neurodegeneration (OR 1.0; CI = 0.5 to 2.2; p = 0.973). Pathological MRI markers, including MTA and lacunes, were more prevalent among men, as was a history of clinical stroke prior to the index stroke. The OR of PCI for women was not significantly increased (OR 1.2; CI = 0.8 to 1.9; p = 0.3).

CONCLUSIONS

Pre-stroke chronic brain pathology is common in stroke patients, with a higher prevalence in men. Vascular pathology and mixed pathology are associated with PCI. There were no significant sex differences for the risk of PCI.

TRIAL REGISTRATION

NCT02650531 , date of registration: 08.01.2016.

Vascular risk factor control and adherence to secondary preventive medication after ischaemic stroke

BACKGROUND

Studies regarding adequacy of secondary stroke prevention are limited. We report medication adherence, risk factor control and factors influencing vascular risk profile following ischaemic stroke.

METHODS

A total of 664 home-dwelling participants in the Norwegian Cognitive Impairment After Stroke study, a multicenter observational study, were evaluated 3 and 18 months poststroke. We assessed medication adherence by self-reporting (4-item Morisky Medication Adherence Scale) and medication persistence (defined as continuation of medication(s) prescribed at discharge), achievement of guideline-defined targets of blood pressure (BP) (<140/90 mmHg), low-density lipoprotein cholesterol (LDL-C) (<2.0 mmol L^-1 ) and haemoglobin A1c (HbA1c) (≤53 mmol mol^-1 ) and determinants of risk factor control.

RESULTS

At discharge, 97% were prescribed antithrombotics, 88% lipid-lowering drugs, 68% antihypertensives and 12% antidiabetic drugs. Persistence of users declined to 99%, 88%, 93% and 95%, respectively, at 18 months. After 3 and 18 months, 80% and 73% reported high adherence. After 3 and 18 months, 40.7% and 47.0% gained BP control, 48.4% and 44.6% achieved LDL-C control, and 69.2% and 69.5% of diabetic patients achieved HbA1c control. Advanced age was associated with increased LDL-C control (OR 1.03, 95% CI 1.01 to 1.06) and reduced BP control (OR 0.98, 0.96 to 0.99). Women had poorer LDL-C control (OR 0.60, 0.37 to 0.98). Polypharmacy was associated with increased LDL-C control (OR 1.29, 1.18 to 1.41) and reduced HbA1c control (OR 0.76, 0.60 to 0.98).

CONCLUSION

Risk factor control is suboptimal despite high medication persistence and adherence. Improved understanding of this complex clinical setting is needed for optimization of secondary preventive strategies.

Clinically accessible neuroimaging predictors of post-stroke neurocognitive disorder: a prospective observational study

Background

Neurocognitive disorder (NCD) is common in stroke survivors. We aimed to identify clinically accessible imaging markers of stroke and chronic pathology that are associated with early post-stroke NCD.

Methods

We included 231 stroke survivors from the “Norwegian Cognitive Impairment after Stroke (Nor-COAST)” study who underwent a standardized cognitive assessment 3 months after the stroke. Any NCD (mild cognitive impairment and dementia) and major NCD (dementia) were diagnosed according to “Diagnostic and Statistical Manual of Mental Disorders (DSM-5)” criteria. Clinically accessible imaging findings were analyzed on study-specific brain MRIs in the early phase after stroke. Stroke lesion volumes were semi automatically quantified and strategic stroke locations were determined by an atlas based coregistration. White matter hyperintensities (WMH) and medial temporal lobe atrophy (MTA) were visually scored. Logistic regression was used to identify neuroimaging findings associated with major NCD and any NCD.

Results

Mean age was 71.8 years (SD 11.1), 101 (43.7%) were females, mean time from stroke to imaging was 8 (SD 16) days. At 3 months 63 (27.3%) had mild NCD and 65 (28.1%) had major NCD. Any NCD was significantly associated with WMH pathology (odds ratio (OR) = 2.73 [1.56 to 4.77], p = 0.001), MTA pathology (OR = 1.95 [1.12 to 3.41], p = 0.019), and left hemispheric stroke (OR = 1.8 [1.05 to 3.09], p = 0.032). Major NCD was significantly associated with WMH pathology (OR = 2.54 [1.33 to 4.84], p = 0.005) and stroke lesion volume (OR (per ml) =1.04 [1.01 to 1.06], p = 0.001).

Conclusion

WMH pathology, MTA pathology and left hemispheric stroke were associated with the development of any NCD. Stroke lesion volume and WMH pathology were associated with the development of major NCD 3 months after stroke. These imaging findings may be used in the routine clinical setting to identify patients at risk for early post-stroke NCD.

Trial registration

ClinicalTrials.gov, NCT02650531, Registered 8 January 2016 – Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02117-8.

Are Sarcopenia and Cognitive Dysfunction Comorbid after Stroke in the Context of Brain-Muscle Crosstalk?

Stroke is a leading cause of death and disability and is responsible for a significant economic burden. Sarcopenia and cognitive dysfunction are common consequences of stroke, but there is less awareness of the concurrency of these conditions. In addition, few reviews are available to guide clinicians and researchers on how to approach sarcopenia and cognitive dysfunction as comorbidities after stroke, including how to assess and manage them and implement interventions to improve health outcomes. This review synthesises current knowledge about the relationship between post-stroke sarcopenia and cognitive dysfunction, including the physiological pathways, assessment tools, and interventions involved.

Associations between post-stroke motor and cognitive function: a cross-sectional study

BACKGROUND

Motor and cognitive impairments are frequently observed following stroke, but are often managed as distinct entities, and there is little evidence regarding how they are related. The aim of this study was to describe the prevalence of concurrent motor and cognitive impairments 3 months after stroke and to examine how motor performance was associated with memory, executive function and global cognition.

METHODS

The Norwegian Cognitive Impairment After Stroke (Nor-COAST) study is a prospective multicentre cohort study including patients hospitalized with acute stroke between May 2015 and March 2017. The National Institutes of Health Stroke Scale (NIHSS) was used to measure stroke severity at admission. Level of disability was assessed by the Modified Rankin Scale (mRS). Motor and cognitive functions were assessed 3 months post-stroke using the Montreal Cognitive Assessment (MoCA), Trail Making Test Part B (TMT-B), 10-Word List Recall (10WLR), Short Physical Performance Battery (SPPB), dual-task cost (DTC) and grip strength (Jamar®). Cut-offs were set according to current recommendations. Associations were examined using linear regression with cognitive tests as dependent variables and motor domains as covariates, adjusted for age, sex, education and stroke severity.

RESULTS

Of 567 participants included, 242 (43%) were women, mean (SD) age was 72.2 (11.7) years, 416 (75%) had an NIHSS score ≤ 4 and 475 (84%) had an mRS score of ≤2. Prevalence of concurrent motor and cognitive impairment ranged from 9.5% for DTC and 10WLR to 22.9% for grip strength and TMT-B. SPPB was associated with MoCA (regression coefficient B = 0.465, 95%CI [0.352, 0.578]), TMT-B (B = -9.494, 95%CI [- 11.726, - 7.925]) and 10WLR (B = 0.132, 95%CI [0.054, 0.211]). Grip strength was associated with MoCA (B = 0.075, 95%CI [0.039, 0.112]), TMT-B (B = -1.972, 95%CI [- 2.672, - 1.272]) and 10WLR (B = 0.041, 95%CI [0.016, 0.066]). Higher DTC was associated with more time needed to complete TMT-B (B = 0.475, 95%CI [0.075, 0.875]) but not with MoCA or 10WLR.

CONCLUSION

Three months after suffering mainly minor strokes, 30-40% of participants had motor or cognitive impairments, while 20% had concurrent impairments. Motor performance was associated with memory, executive function and global cognition. The identification of concurrent impairments could be relevant for preventing functional decline.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02650531 .

The Risk of Selection Bias in a Clinical Multi-Center Cohort Study. Results from the Norwegian Cognitive Impairment After Stroke (Nor-COAST) Study

Purpose

The Norwegian Cognitive Impairment After Stroke (Nor-COAST) study aimed to estimate the prevalence and incidence of neurocognitive disorder in an unselected stroke cohort. The aim of the present study was to investigate whether selection bias occurred by comparing baseline characteristics from participants with non-participants in Nor-COAST.

Patients and Methods

Nor-COAST is a prospective cohort multi-center study, recruiting participants from five Norwegian hospitals. Patients with the diagnosis of acute stroke were screened for inclusion. Baseline data from the participants recruited between May 2015 and March 2017 were compared to corresponding data from those not participating in Nor-COAST but registered in the Norwegian Stroke Registry. Regression analysis was used to assess whether age, stroke severity, sex and stroke subtype were independently associated with inclusion in the study.

Results

Out of 2505 available patients, 815 (32.5%) were included in Nor-COAST. There were no differences between participants and non-participants with respect to age (mean (SD) age 73.5 (11.7) versus 74.2 (14.5) years) or sex (44.8% versus 46.9% women). A significantly larger proportion of the participants were independent prior to stroke (87% versus 78%), had mild strokes (69% versus 55%) and suffered from cerebral infarction (90% versus 84%). The regression analysis showed decreased odds ratio (OR) of being included for those with higher degree of pre-stroke dependency (OR 0.895, 95% CI 0.825 to 0.971, p=0.007) and a more severe stroke (OR 0.952, 95% CI 0.939 to 0.966, p<0.001).

Conclusion

The participants in Nor-COAST had a better pre-stroke health condition and milder strokes compared to non-participants. However, the participants should be regarded as representative of the majority of the stroke population which suffers from mild strokes. Nevertheless, baseline information for non-participants should be available also in future clinical studies to make it easier to identify which part of the stroke population the results can be generalized to.

Post-stroke Cognitive Impairment-Impact of Follow-Up Time and Stroke Subtype on Severity and Cognitive Profile: The Nor-COAST Study

Background: Post-stroke cognitive impairment (PSCI) is common, but evidence of cognitive symptom profiles, course over time, and pathogenesis is scarce. We investigated the significance of time and etiologic stroke subtype for the probability of PSCI, severity, and cognitive profile.

Methods: Stroke survivors (n = 617) underwent cognitive assessments of attention, executive function, memory, language, perceptual-motor function, and the Montreal Cognitive Assessment (MoCA) after 3 and/or 18 months. PSCI was classified according to DSM-5 criteria. Stroke severity was assessed with the National Institutes of Health Stroke Scale (NIHSS). Stroke subtype was categorized as intracerebral hemorrhage (ICH), large artery disease (LAD), cardioembolic stroke (CE), small vessel disease (SVD), or un-/other determined strokes (UD). Mixed-effects logistic or linear regression was applied with PSCI, MoCA, and z-scores of the cognitive domains as dependent variables. Independent variables were time as well as stroke subtype, time, and interaction between these. The analyses were adjusted for age, education, and sex. The effects of time and stroke subtype were analyzed by likelihood ratio tests (LR).

Results: Mean age was 72 years (SD 12), 42% were females, and mean NIHSS score at admittance was 3.8 (SD 4.8). Probability (95% CI) for PSCI after 3 and 18 months was 0.59 (0.51–0.66) and 0.51 (0.52–0.60), respectively and remained constant over time. Global measures and most cognitive domains were assessed as impaired for the entire stroke population and for most stroke subtypes. Executive function and language improved for the entire stroke population (LR) = 9.05, p = 0.003, and LR = 10.38, p = 0.001, respectively). After dividing the sample according to stroke subtypes, language improved for ICH patients (LR = 18.02, p = 0.003). No significant differences were found in the severity of impairment between stroke subtypes except for attention, which was impaired for LAD and CE in contrast to no impairment for SVD (LR = 56.58, p < 0.001).

Conclusions: In this study including mainly minor strokes, PSCI is common for all subtypes, both early and long-term after stroke, while executive function and language improve over time. The findings might contribute to personalizing follow-up and offer new insights into underlying mechanisms. Further research is needed on underlying mechanisms, PSCI prevention and treatment, and relevance for rehabilitation.