Post-stroke cognitive impairment is common even after successful clinical recovery

Inter-relationships of depression and insomnia symptoms with life satisfaction in stroke and stroke-free older adults: Findings from the Health and Retirement Study based on network analysis and propensity score matching

BACKGROUND

Depression and insomnia are common co-occurring psychiatric problems among older adults who have had strokes. Nevertheless, symptom-level relationships between these disorders remain unclear.

OBJECTIVES

In this study, we compared inter-relationships of depression and insomnia symptoms with life satisfaction among older stroke patients and stroke-free peers in the United States.

METHODS

The study included 1026 older adults with a history of stroke and 3074 matched controls. Data were derived from the US Health and Retirement Study. Depression, insomnia and life satisfaction were assessed. Propensity score matching was employed to identify demographically-similar groups of stroke patients and controls. Central and bridge symptoms were assessed using Expected influence (EI) and bridge EI, respectively.

RESULTS

The prevalence of depression in the stroke group (25.0 %) was higher than that of controls (14.3 %, P < 0.001). In stroke group, "Feeling depressed" (CESD1; EI: 5.80), "Feeling sad" (CESD7; EI: 4.67) and "Not enjoying life" (CESD6; EI: 4.51) were the most central symptoms, while "Feeling tired in the morning" (JSS4; BEI: 1.60), "Everything was an effort" (CESD2; BEI: 1.21) and "Waking up during the night" (JSS2; BEI: 0.98) were key bridge symptoms. In controls, the most central symptoms were "Lack of happiness" (CESD4; EI: 6.45), "Feeling depressed" (CESD1; EI: 6.17), and "Feeling sad" (CESD7; EI: 6.12). Furthermore, "Feeling tired in the morning" (JSS4; BEI: 1.93), "Everything was an effort" (CESD2; BEI: 1.30), and "Waking up too early" (JSS3; BEI: 1.12) were key bridge symptoms. Life satisfaction had the most direct associations with "Not enjoying life" (CESD6) and "Feeling lonely" (CESD5) in the two groups, respectively.

CONCLUSION

Older adults with stroke exhibited more severe depression and insomnia symptoms. Interventions targeting central and bridge symptoms may help to mitigate the co-occurrence of these symptoms.

Involvement of P2X7R-mediated microglia polarization and neuroinflammation in the response to electroacupuncture on post-stroke memory impairment

PURPOSE

Post-stroke cognitive impairment (PSCI) is a common complication of ischemic stroke episodes. Memory impairment is an important component of the poststroke cognitive syndrome. Microglial activation plays a critical role in stroke-induced neuroinflammation. Previous studies have reported that electroacupuncture (EA) provides neuroprotective effects by reducing the expression levels of the Purinergic receptor P2X ligand-gated ion channel 7 (P2X7) and inhibiting neuroinflammation in rat model of ischemic stroke. Further understanding of the role and connections between P2X7R and microglial activation in EA-induced anti-inflammatory can reveal novel targets for post-stroke memory impairment treatment.

METHODS

A Middle cerebral artery occlusion and reperfusion (MCAO/R) model was established. We used 2'(3')-O-(4-benzoyl) benzoyl ATP (BzATP) as a P2X7R agonist. Following MCAO/R injury, the rats underwent EA therapy at the Baihui (DU20) and Shenting (DU24) acupoints for seven consecutive days. The Barnes maze test was used to evaluate memory function. Following intervention, a T2 weighted images (T2WI) scan was performed to identify changes in cerebral infarction volume in MCAO/R rats. The levels of Interleukin-1β (IL-1β), Interleukin-6 (IL-6) and Interleukin-4 (IL-4), Interleukin-10 (IL-10) in the peri-infarct hippocampal were examined by ELISA. Immunofluorescence was employed to evaluate Iba-1+ / P2X7R+, Iba-1+/ iNOS+ and Iba-1+/ Arg-1+ cell populations in the peri-infarct hippocampal DG area. The protein expression of P2X7R, Nuclear factor E2-related factor 2 (Nrf2), Recombinant nlr family, pyrin domain containing protein 3 (NLRP3), Inducible nitric oxide synthase (iNOS) and Arginase-1 (Arg-1) in the peri-infarct hippocampal were investigated using western blot assays. Besides, we also measured the levels of reactive oxygen species (ROS), superoxide dismutase (SOD) and malondialdehyde (MDA).

RESULTS

We found EA treatment reduced inflammation and oxidative stress, which is consistent with a decrease in P2X7R expression and improved learning and memory functions. In contrast, we found BzATP enhanced inflammation and oxidative stress. Moreover, our results showed EA treatment up-regulated Nrf2, down-regulated NLRP3, and promoted microglia M2 polarization. Finally, EA-mediated positive effects were reversed by intracerebroventricular injection of BzATP, which is consistent with an increase in P2X7R expression.

CONCLUSION

EA ameliorates memory impairment in a rat model of ischemic stroke by reducing inflammation and ROS through the inhibition of P2X7R expression. In turn, this mechanism regulates Nrf2 and NLRP3 expression, suggesting EA is beneficial for ischemic stroke treatment using P2X7R as target.

A literature review of outcome and treatment options after acquired brain injury: Suggestions for adult offenders using knowledge from the general population

BACKGROUND

Acquired brain injury (ABI) is a major health problem, often with negative effects on behaviour and mental health as well as cognition. Prevalence of ABI is exceptionally high among offenders and increases their re-offending risk. Information on risk factors for ABI and its outcomes among offenders that could guide effective treatment for them is, nevertheless, scarce and dispersed. However, there is a more substantial literature about the general population that could inform work with brain-injured offenders, especially when selecting for samples or subgroups with similar relevant characteristics, such as lower socio-economic status (SES), pre-injury lower tested intelligence score (<85) and pre-injury mental health problems.

AIMS

To explore brain injury data from non-offender samples of otherwise similar socio-economic and mental health and ability characteristics to offenders then, first, to describe their untreated outcomes and, secondly, outcomes after frequently used interventions in these circumstances, noting factors associated with their effectiveness.

METHOD

Three databases were systematically searched for the years 2010-2022; first, using terms for brain injury or damage and cognitive (dys)function, mental health or quality of life. Second, in a separate search, we used these terms and terms for interventions and rehabilitation. In the second review, studies were selected for clear, distinguishable data on age, sex, SES and lifestyle factors to facilitate inferences for offenders. A narrative analytical approach was adopted for both reviews.

RESULTS

Samples with characteristics that are typical in offender groups, including lower SES, lower pre-injury intelligence quotient (<85), prior cognitive impairments and prior mental health problems, had poorer cognitive and behavioural outcomes following ABI than those without such additional problems, together with lower treatment adherence. With respect to treatment, adequate motivation and self-awareness were associated with better cognitive and behavioural outcomes than when these were low or absent, regardless of the outcome measured.

CONCLUSIONS

More complex pre-injury mental health problems and social disadvantages typical of offenders are associated with poorer post-brain injury recovery. This paper adds to practical knowledge by bringing together work that follows specific outcome trajectories. Overall, succesful ABI-interventions in the general population that aim at pre-injury difficulties comparable to those seen among offenders, show that personalising injury-specific treatments and taking account of these difficulties, maximised positive outcomes.

Longitudinal neuropsychological performance of post-stroke adults with and without rehabilitation

This study compared the neuropsychological performance of two post-stroke groups, one undergoing rehabilitation and the other not receiving any intervention, on the acute and chronic stroke phases, and explored sociodemographic and neurological variables associated with changes in performance over time. Sixty-three adults underwent neuropsychological assessment with the Cognitive Screening Instrument (TRIACOG) less than thirty days after having a stroke and were reassessed three to six months after stroke. Thirty-eight participants did not undertake rehabilitation and twenty-five did physiotherapy and/or speech therapy between the two time points. The frequency of cognitive deficits (between groups) and the range of cognitive assessment scores over time (between and within groups) were analyzed. There was a significant decrease in the frequency of neuropsychological deficits and improvement on neuropsychological assessment scores over time only in the group undergoing rehabilitation. Severity of the neurological condition, years of education and being in rehabilitation explained the longitudinal changes in several cognitive domains measured by TRIACOG. Engaging in rehabilitation within three to six months post-stroke is crucial for enhancing the recovery of neuropsychological deficits. Cognitive screening instruments like TRIACOG can be used by health professionals to identify stroke-related neuropsychological changes and plan interventions.

Severity-Dependent Interhemispheric White Matter Connectivity Predicts Poststroke Neglect Recovery

Left-sided spatial neglect is a very common and challenging issue after right-hemispheric stroke, which strongly and negatively affects daily living behavior and recovery of stroke survivors. The mechanisms underlying recovery of spatial neglect remain controversial, particularly regarding the involvement of the intact, contralesional hemisphere, with potential contributions ranging from maladaptive to compensatory. In the present prospective, observational study, we assessed neglect severity in 54 right-hemispheric stroke patients (32 male; 22 female) at admission to and discharge from inpatient neurorehabilitation. We demonstrate that the interaction of initial neglect severity and spared white matter (dis)connectivity resulting from individual lesions (as assessed by diffusion tensor imaging, DTI) explains a significant portion of the variability of poststroke neglect recovery. In mildly impaired patients, spared structural connectivity within the lesioned hemisphere is sufficient to attain good recovery. Conversely, in patients with severe impairment, successful recovery critically depends on structural connectivity within the intact hemisphere and between hemispheres. These distinct patterns, mediated by their respective white matter connections, may help to reconcile the dichotomous perspectives regarding the role of the contralesional hemisphere as exclusively compensatory or not. Instead, they suggest a unified viewpoint wherein the contralesional hemisphere can - but must not necessarily - assume a compensatory role. This would depend on initial impairment severity and on the available, spared structural connectivity. In the future, our findings could serve as a prognostic biomarker for neglect recovery and guide patient-tailored therapeutic approaches.

Factors related to the quality and stability of partner relationships after stroke: A systematic literature review

OBJECTIVE

To provide an overview of the current state of knowledge on factors related to relationship quality and relationship stability following stroke.

DATA SOURCES

Cumulative Index to Nursing and Allied Health, Embase, MEDLINE, Psychology and Behavioral Sciences Collection, APA PsycINFO, and PubMed were searched on November 15, 2022, for literature on factors associated with (1) relationship quality and (2) relationship stability after stroke.

STUDY SELECTION

English quantitative and qualitative studies investigating factors associated with relationship quality and/or stability after stroke were included. Three reviewers independently assessed eligibility. Consensus meetings were held in case of divergent opinions. A total of forty-four studies were included.

DATA EXTRACTION

Information regarding study objectives and characteristics, participant demographics, independent and dependent variables, and main findings was extracted. Study quality was rated using the JBI Checklist for Analytical Cross-Sectional Studies and/or the CASP Checklist for Qualitative Research. Both were performed by the lead reviewer and checked by the second reviewer. Identified factors are described and presented according to the domains of the International Classification of Functioning, Disability, and Health model.

DATA SYNTHESIS

Thirty-seven factors related to relationship quality after stroke were identified, covering the domains of body functions and structures (e.g., cognitive problems), activities (e.g., decrease of physical intimacy), participation (e.g., being socially active), environment (e.g., medication side effects), and personal factors (e.g., hyper-vigilance). Eight factors related to relationship stability were identified, covering the domains of participation (agreement on reciprocal roles) and personal factors (e.g., quality of pre-stroke relationship).

CONCLUSIONS

Relationship quality and stability after stroke are related to a multitude of factors. Future research should confirm the relevance of factors found in few studies of suboptimal quality, explore possible associations between relationship stability and factors falling in the domains of body functions & structure, activity, and environmental factors, and explicitly explore potential positive effects of stroke on relationships.

Prospero Homeobox 1 and Doublecortin Correlate with Neural Damage after Ischemic Stroke

OBJECTIVE

Markers of neuroinflammation during ischemic stroke are well characterized, but additional markers of neural damage are lacking. The study identified associations of behavioral disorders after stroke with histologic neural damage and molecular biological change.

METHODS

Eight-week-old, 25 g male mice of the C57BL/6J strain were subjected to middle cerebral artery occlusion (MCAO) to induce ischemic stroke. The control group was a healthy wild type (WT), and the experimental group were designed as a low severity MCAO1 and a high severity MCAO2 based on post-stroke neurological scoring. All groups underwent behavioral tests, realtime polymerase chain reaction, triphenyltetrazolium chloride (TTC) staining and Hematoxylin and Eosin staining. One-way analysis of variance was used to analyze statistical significance between groups.

RESULTS

In TTC staining, MCAO1 showed 29.02% and MCAO2 showed 38.94% infarct volume (p<0.0001). The pro-inflammatory cytokine interleukin (IL)-1β was most highly expressed in MCAO2 (WT 0.44 vs. MCAO1 2.69 vs. MCAO2 5.02, p<0.0001). From the distance to target in the Barnes maze test, WT had a distance of 178 cm, MCAO1 had a distance of 276 cm, and MCAO2 had a distance of 1051 (p=0.0015). The latency to target was 13.3 seconds for WT, 27.9 seconds for MCAO1, and 87.9 seconds for MCAO2 (p=0.0007). Prospero homeobox 1 (Prox1) was most highly expressed in MCAO2 (p=0.0004). Doublecortin (Dcx) was most highly expressed in MCAO2 (p<0.0001).

CONCLUSION

The study demonstrated that histological damage to neural cells and changes in brain mRNA expression were associated with behavioral impairment after ischemic stroke. Prox1 and Dcx may be biomarkers of neural damage associated with long-term cognitive decline, and increased expression at the mRNA level was consistent with neural damage and long-term cognitive dysfunction.

Associations of cognitive impairment and longitudinal change in cognitive function with the risk of fatal stroke in middle-aged to older Chinese

It is unclear whether cognitive impairment and the longitudinal change in cognition are associated with the risk of fatal stroke in aging populations. Based on the Guangzhou Biobank Cohort Study data a sum of 26,064 participants at baseline and all deaths caused by stroke in a mean follow-up of 14.3 years (standard deviation = 3.2) were included, and the Cox proportional hazard regression was used in this prospective cohort study. Cognitive impairment was respectively associated with an increased risk of fatal strokes (the adjusted hazard ratio (aHR) = 1.38, 95% CI1.16-1.64, P < 0.001) and fatal ischaemic stroke (aHR = 1.39, 95% CI1.10-1.77, P = 0.007), compared to median cognition; the Delayed Word Recall Test (DWRT) score was associated with a decreasing trend for the risk of fatal strokes in a restricted cubic spline analysis; the longitudinal DWRT score decline was associated with the increased risks of fatal strokes (aHR = 1.42, 95% CI 1.11-1.82, P = 0.006) and fatal haemorrhagic stroke (aHR = 1.75, 95% CI 1.10-2.78, P = 0.02), compared to the longitudinal DWRT score rise. In summary, cognitive impairment and the longitudinal decline in DWRT scores were associated with the increased risk of fatal strokes; early screening of cognitive function should be conducive to predictive intervention in fatal stroke among relatively healthy middle-aged to older populations.

Relationship between electronically monitored adherence to direct oral anticoagulants and ischemic or hemorrhagic events after an initial ischemic stroke-A case control study

BACKGROUND

Patients with atrial fibrillation (AF) have a high risk for recurrent clinical events after an ischemic stroke. Direct oral anticoagulants (DOAC) are prescribed for secondary prevention. Adherence to DOAC is crucial mainly because of their short elimination half-life. Non-adherence to DOAC can negatively impact patients' outcomes. The relationship between (non-)adherence and recurrent clinical events is unknown in AF patients after initial stroke. We investigated adherence to DOAC in stroke survivors with AF who were included in the MAAESTRO study at the University Hospital Basel, Switzerland, between 2008 and 2022.

METHODS

This study is a secondary analysis of data from MAAESTRO with a matched nested case-control design and 1:2 ratio. DOAC intake was measured with a small electronic device (Time4MedTM). We defined two arbitrary intervals of 17 days and 95 days as the longest time spans with electronic monitoring data per patient to maximize the number of participants with adequate amount of observation time available for analysis. Taking and timing adherence were calculated retrospectively i.e., prior to the recurrent event for cases. Trendline analysis of adherence over 95 days was calculated. Linear regression analysis was performed after adjusting for the co-variables age and daily pill burden. Sensitivity analysis was performed with controls for intervals in the reverse direction (prospectively).

RESULTS

We analyzed 11 cases and 22 matched controls (mean age: 75.9 ± 9.2 years vs. 73.1 ± 8.4 years; n.s.) with similar stroke characteristics (NIHSS, mRS, MoCA) and 36.4% women in each group. Mean adherence values were high and similar between cases and controls (95 days taking: 87.0 ± 18.9% (cases) vs. 90.8 ± 9.8% (controls), n.s.; similar values for timing adherence). Six hemorrhagic and five ischemic events had occurred. Compared to controls, a significantly higher 95 days taking adherence was observed for hemorrhagic events (96.0 ± 5.0% (cases) vs. 88.1 ± 11.5% (controls); p<0.01) and a significantly lower 95 days taking adherence was observed for ischemic events (75.7 ± 24.8% (cases) vs. 94.2 ± 6.2% (controls), p = 0.024). Values for timing adherence were similar. A non-significant downward linear trend of adherence was observed over 95 days independently of the clinical events. The sensitivity analysis showed that the direction of the interval had negligible impact on the 95 days adherence.

CONCLUSION

Because recurrent ischemic events after an AF-related stroke were associated with low adherence to DOAC <76%, adherence enhancing interventions seem crucial in anticoagulated AF-patients. However, AF-patients with high adherence might benefit from a regular re-assessment of the bleeding risk as hemorrhagic complications were associated with adherence to DOAC >96%.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03344146.

Domain-specific cognitive impairments, mood and quality of life 6 months after stroke

PURPOSE

To identify which acute and 6-month domain-specific cognitive impairments impact mood, participation, and stroke-related quality of life 6 months post-stroke.

MATERIALS AND METHODS

A prospective cohort of 430 stroke survivors completed the Oxford Cognitive Screen (OCS) acutely and 6 months post-stroke. Participants completed the Stroke Impact Scale (SIS) and Hospital Depression and Anxiety Scale (HADS) at 6 months. Multivariable regression analyses assessed whether severity of, and domain-specific, cognitive impairment acutely and at 6 months was associated with composite 6-month SIS scores, each SIS subscale, and HADS scores.

RESULTS

Increased severity of acute and 6-month cognitive impairment was associated with lower 6-month SIS composite scores independent of age, sex, education years, and stroke severity (both p < 0.001). Domain-specific impairments in memory (p < 0.001) and attention (p = 0.002) acutely, and language (p < 0.001), memory (p = 0.001) and number processing (p = 0.006) at 6 months showed the strongest associations with worse SIS composite scores. Severity of acute and 6-month cognitive impairment was associated with poorer functioning in each SIS subscale, and greater levels of depression (acute p = 0.021, 6-months p < 0.001), but not anxiety (p = 0.174, p = 0.129).

CONCLUSIONS

Both acute and 6-month domain-specific cognitive impairments, particularly in memory, were found to negatively impact overall functional and mood outcomes 6 months post-stroke.

Ion transporter cascade, reactive astrogliosis and cerebrovascular diseases

Cerebrovascular diseases and their sequalae, such as ischemic stroke, chronic cerebral hypoperfusion, and vascular dementia are significant contributors to adult disability and cognitive impairment in the modern world. Astrocytes are an integral part of the neurovascular unit in the CNS and play a pivotal role in CNS homeostasis, including ionic and pH balance, neurotransmission, cerebral blood flow, and metabolism. Astrocytes respond to cerebral insults, inflammation, and diseases through unique molecular, morphological, and functional changes, collectively known as reactive astrogliosis. The function of reactive astrocytes has been a subject of debate. Initially, astrocytes were thought to primarily play a supportive role in maintaining the structure and function of the nervous system. However, recent studies suggest that reactive astrocytes may have both beneficial and detrimental effects. For example, in chronic cerebral hypoperfusion, reactive astrocytes can cause oligodendrocyte death and demyelination. In this review, we will summarize the (1) roles of ion transporter cascade in reactive astrogliosis, (2) role of reactive astrocytes in vascular dementia and related dementias, and (3) potential therapeutic approaches for dementing disorders targeting reactive astrocytes. Understanding the relationship between ion transporter cascade, reactive astrogliosis, and cerebrovascular diseases may reveal mechanisms and targets for the development of therapies for brain diseases associated with reactive astrogliosis.

Prolonged myelin deficits contribute to neuron loss and functional impairments after ischaemic stroke

Ischaemic stroke causes neuron loss and long-term functional deficits. Unfortunately, effective approaches to preserving neurons and promoting functional recovery remain unavailable. Oligodendrocytes, the myelinating cells in the CNS, are susceptible to oxygen and nutrition deprivation and undergo degeneration after ischaemic stroke. Technically, new oligodendrocytes and myelin can be generated by the differentiation of oligodendrocyte precursor cells (OPCs). However, myelin dynamics and their functional significance after ischaemic stroke remain poorly understood. Here, we report numerous denuded axons accompanied by decreased neuron density in sections from ischaemic stroke lesions in human brain, suggesting that neuron loss correlates with myelin deficits in these lesions. To investigate the longitudinal changes in myelin dynamics after stroke, we labelled and traced pre-existing and newly-formed myelin, respectively, using cell-specific genetic approaches. Our results indicated massive oligodendrocyte death and myelin loss 2 weeks after stroke in the transient middle cerebral artery occlusion (tMCAO) mouse model. In contrast, myelin regeneration remained insufficient 4 and 8 weeks post-stroke. Notably, neuronal loss and functional impairments worsened in aged brains, and new myelin generation was diminished. To analyse the causal relationship between remyelination and neuron survival, we manipulated myelinogenesis by conditional deletion of Olig2 (a positive regulator) or muscarinic receptor 1 (M1R, a negative regulator) in OPCs. Deleting Olig2 inhibited remyelination, reducing neuron survival and functional recovery after tMCAO. Conversely, enhancing remyelination by M1R conditional knockout or treatment with the pro-myelination drug clemastine after tMCAO preserved white matter integrity and neuronal survival, accelerating functional recovery. Together, our findings demonstrate that enhancing myelinogenesis is a promising strategy to preserve neurons and promote functional recovery after ischaemic stroke.

Pre-stroke physical activity matters for functional limitations: A longitudinal case-control study of 12,860 participants

Objective

In the chronic phase after a stroke, limitations in activities of daily living (ADLs) and instrumental ADL (IADLs) initially plateau before steadily increasing. The benefits of pre-stroke physical activity on these limitations remain unclear. To clarify this relationship, we examined the effect of physical activity on the long-term evolution of functional limitations in a cohort of stroke survivors and compared it to a cohort of matched stroke-free adults.

Methods

Longitudinal data from 2,143 stroke survivors and 10,717 stroke-free adults aged 50 years and older were drawn from a prospective cohort study based on the Survey of Health, Ageing and Retirement in Europe (2004-2022; 8 data collection waves). Physical activity was assessed in the pre-stroke wave. Functional limitations were assessed in the post-stroke waves. Each stroke survivor was matched with 5 stroke-free adults who had similar propensity scores computed on the basis of key covariates, including baseline age, sex, body mass index, limitations in ADL and IADL, chronic conditions and country of residence, before any of the participants from either cohort had experienced a stroke.

Results

Results showed an interaction between stroke status and physical activity on ADL limitations (b = -0.076; 95% CI = -0.142 to -0.011), with the effect of physical activity being stronger in stroke survivors (b = -0.345, 95% CI = -0.438 to -0.252) than in stroke-free adults (b = -0.269, 95% CI = -0.269 to -0.241).

Conclusion

The beneficial effect of pre-stroke physical activity on ADL limitations after stroke is stronger than its effect in matched stroke-free adults followed for a similar number of years.

Impact

Physical activity, an intervention within the physical therapist's scope of practice, is effective in reducing the risk of functional dependence after stroke. Moreover, pre-stroke levels of physical activity can inform the prognosis of functional dependence in stroke survivors.

Structural brain networks correlating with poststroke cognition

Cognitive deficits are a common and debilitating consequence of stroke, yet our understanding of the structural neurobiological biomarkers predicting recovery of cognition after stroke remains limited. In this longitudinal observational study, we set out to investigate the effect of both focal lesions and structural connectivity on poststroke cognition. Sixty-two patients with stroke underwent advanced brain imaging and cognitive assessment, utilizing the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE), at 3-month and 12-month poststroke. We first evaluated the relationship between lesions and cognition at 3 months using voxel-based lesion-symptom mapping. Next, a novel correlational tractography approach, using multi-shell diffusion-weighted magnetic resonance imaging (MRI) data collected at both time points, was used to evaluate the relationship between the white matter connectome and cognition cross-sectionally at 3 months, and longitudinally (12 minus 3 months). Lesion-symptom mapping did not yield significant findings. In turn, correlational tractography analyses revealed positive associations between both MoCA and MMSE scores and bilateral cingulum and the corpus callosum, both cross-sectionally at the 3-month stage, and longitudinally. These results demonstrate that rather than focal neural structures, a consistent structural connectome underpins the performance of two frequently used cognitive screening tools, the MoCA and the MMSE, in people after stroke. This finding should encourage clinicians and researchers to not only suspect cognitive decline when lesions affect these tracts, but also to refine their investigation of novel approaches to differentially diagnosing pathology associated with cognitive decline, regardless of the aetiology.

Clinical application of repetitive transcranial magnetic stimulation in improving functional impairments post-stroke: review of the current evidence and potential challenges

In recent years, the stroke incidence has been increasing year by year, and the related sequelae after stroke, such as cognitive impairment, motor dysfunction, and post-stroke depression, seriously affect the patient's rehabilitation and daily activities. Repetitive transcranial magnetic stimulation (rTMS), as a safe, non-invasive, and effective new rehabilitation method, has been widely recognized in clinical practice. This article reviews the application and research progress of rTMS in treating different functional impairments (cognitive impairment, motor dysfunction, unilateral spatial neglect, depression) after stroke in recent years, and preliminary summarized the possible mechanisms. It has been found that the key parameters that determine the effectiveness of rTMS in improving post-stroke functional impairments include pulse number, stimulated brain areas, stimulation intensity and frequency, as well as duration. Generally, high-frequency stimulation is used to excite the ipsilateral cerebral cortex, while low-frequency stimulation is used to inhibit the contralateral cerebral cortex, thus achieving a balance of excitability between the two hemispheres. However, the specific mechanisms and the optimal stimulation mode for different functional impairments have not yet reached a consistent conclusion, and more research is needed to explore and clarify the best way to use rTMS. Furthermore, we will identify the issues and challenges in the current research, explore possible mechanisms to deepen understanding of rTMS, propose future research directions, and offer insightful insights for better clinical applications.

Screening for post-stroke neurocognitive disorders in diverse populations: A systematic review

Objective: Although neurocognitive disorders (NCD) are common post-stroke, many populations do not have adapted cognitive screens and cut-offs. We therefore reviewed the appropriateness of the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA) and Oxford Cognitive Screen (OCS) for diagnosing NCD in culturally diverse stroke populations. Method: Using an extensive search string, diagnostic accuracy studies for MMSE, MoCA and OCS in the stroke population were retrieved from four databases. We compared translations and adaptations, adjustments in scores and cut-offs, and their diagnostic accuracy. Results: The search resulted in 28 MMSE, 39 MoCA and 5 OCS-studies in 13 western, educated, industrialized, rich and democratic (WEIRD) and 4 other countries. There was a lack of studies on South-American, African, and non-Chinese-Asian populations. All three tests needed adaptation for less WEIRD populations and populations with languages with non-Latin features. Optimal MMSE and OCS subtest cut-offs were similar across WEIRD and less WEIRD populations, whereas optimal MoCA cut-offs appeared lower for less WEIRD populations. The use of adjusted scores resulted in different optimal cut-offs or similar cut-offs with better accuracy. Conclusions: MoCA, MMSE and OCS are promising tools for diagnosing post-stroke-NCD. For culturally diverse populations, translation, adaptation and adjusted scores or cut-offs are necessary for diagnostic accuracy. Available studies report scarcely about their sample's cultural background and there is a lack of diagnostic accuracy studies in less WEIRD or culturally diverse populations. Future studies should report more cultural characteristics of their sample to provide better insight into the tests' accuracy in culturally diverse populations.

Post-stroke cognitive impairment remains highly prevalent and disabling despite state-of-the-art stroke treatment

BACKGROUND

State-of-the-art stroke treatment significantly reduces lesion size and stroke severity, but it remains unclear whether these therapeutic advances have diminished the burden of post-stroke cognitive impairment (PSCI).

AIMS

In a cohort of patients receiving modern state-of-the-art stroke care including endovascular therapy, we assessed the frequency of PSCI and the pattern of domain-specific cognitive deficits, identified risk factors for PSCI, and determined the impact of acute PSCI on stroke outcome.

METHODS

In this prospective monocentric cohort study, we examined patients with first-ever anterior circulation ischemic stroke without pre-stroke cognitive decline, using a comprehensive neuropsychological assessment ⩽10 days after symptom onset. Normative data were stratified by demographic variables. We defined PSCI as at least moderate (<1.5 standard deviation) deficits in ⩾2 cognitive domains. Multivariable regression analysis was applied to define risk factors for PSCI.

RESULTS

We analyzed 329 non-aphasic patients admitted from December 2020 to July 2023 (67.2 ± 14.4 years old, 41.3% female, 13.1 ± 2.7 years of education). Although most patients had mild stroke (median National Institutes of Health Stroke Scale (NIHSS) 24 h = 1.00 (0.00; 3.00); 87.5% with NIHSS ⩽ 5), 69.3% of them presented with PSCI 2.7 ± 2.0 days post-stroke. The most severely and often affected cognitive domains were verbal learning, episodic memory, executive functions, selective attention, and constructive abilities (39.1%-51.2% of patients), whereas spatial neglect was less frequent (18.5%). The risk of PSCI was reduced with more years of education (odds ratio (OR) = 0.47, 95% confidence interval (CI) = 0.23-0.99) and right hemisphere lesions (OR = 0.47, 95% CI = 0.26-0.84), and increased with stroke severity (NIHSS 24 h, OR = 4.19, 95% CI = 2.72-6.45), presence of hyperlipidemia (OR = 1.93, 95% CI = 1.01-3.68), but was not influenced by age. After adjusting for stroke severity and depressive symptoms, acute PSCI was associated with poor functional outcome (modified Rankin Scale > 2, F = 13.695, p < 0.001) and worse global cognition (Montreal Cognitive Assessment (MoCA) score, F = 20.069, p < 0.001) at 3 months post-stroke.

CONCLUSION

Despite modern stroke therapy and many strokes having mild severity, PSCI in the acute stroke phase remains frequent and associated with worse outcome. The most prevalent were learning and memory deficits. Cognitive reserve operationalized as years of education independently protects post-stroke cognition.

Post-stroke Cognition is Associated with Stroke Survivor Quality of Life and Caregiver Outcomes: A Systematic Review and Meta-analysis

Disability arising from post-stroke cognitive impairment is a likely contributor to the poor quality of life (QoL) stroke survivors and their carers frequently experience, but this has not been summarily quantified. A systematic literature review and meta-analysis was completed examining the association between general and domain-specific post-stroke cognitive functioning and adult stroke survivor QoL, caregiver QoL, and caregiver burden. Five databases were systematically searched, and eligibility for inclusion, data extraction, and study quality were evaluated by two reviewers using a standardised protocol. Effects sizes (r) were estimated using a random effects model. Thirty-eight studies were identified, generating a sample of 7365 stroke survivors (median age 63.02 years, range 25-93) followed for 3 to 132 months post-stroke. Overall cognition (all domains combined) demonstrated a significant small to medium association with QoL, r = 0.23 (95% CI 0.18-0.28), p < 0.001. The cognitive domains of speed, attention, visuospatial, memory, and executive skills, but not language, also demonstrated a significant relationship with QoL. Regarding caregiver outcomes, 15 studies were identified resulting in a sample of 2421 caregivers (median age 58.12 years, range 18-82) followed for 3 to 84 months post-stroke. Stroke survivor overall cognitive ability again demonstrated a significant small to medium association with caregiver outcomes (QoL and burden combined), r = 0.17 (95% CI 0.10-0.24), p < 0.001. In conclusion, lower post-stroke cognitive performance is associated with significant reductions in stroke survivor QoL and poorer caregiver outcomes. Cognitive assessment is recommended early to identify those at risk and implement timely interventions to support both stroke survivors and their caregivers.

Effectiveness of early cognitive exercise intervention on improvement cognitive function of stroke patients in the acute phase

The purpose of this study was to assess the efficacy of early cognitive training in enhancement of cognitive function in stroke patients. This research used a quasi-experimental design, 45 patients were divided into two groups, and sequential sampling was employed. The experimental group (n = 22) received two weeks of early cognitive training six times per week, whereas the control group (n = 23) received regular hospital care. The Indonesian version of the Montreal Cognitive Assessment was used to evaluate cognitive function (MoCA-Ina). On the second day of therapy, pre-test data were taken, and post-test data were gathered after the intervention. Statistical test outcomes The MoCA-Ina score changed considerably between the intervention and control groups (p = 0.000 and p = 0.003, respectively). Several tests determined that the score was p = 0.017; the score after the intervention was substantially different between the two groups. It means cognitive function improves after exercise in the acute phase.

Domain-specific cognitive impairment 6 months after stroke: The value of early cognitive screening

BACKGROUND

Cognitive screening following stroke is widely recommended, yet few studies have considered the prognostic value of acute domain-specific function for longer-term cognitive outcome. Identifying which post-stroke cognitive impairments more commonly occur, recover, and persist, and which impairments hold prognostic value, could inform care planning, and resource allocation.

AIMS

This study aimed to determine the prevalence of domain-specific impairment acutely and at 6 months, assess the proportion of change in cognitive performance, and examine the prognostic value of acute domain-specific cognitive screening.

METHODS

A prospective stroke cohort completed the Oxford Cognitive Screen acutely (⩽2 weeks) and 6 months post-stroke. We determined the prevalence of acute and 6-month domain-specific impairment and proportion of change in performance from acute to 6 months. Hierarchical multivariable regression was used to predict global and domain-specific cognitive impairment at 6 months adjusted for demographic/vascular factors, stroke severity, and lesion volume.

RESULTS

A total of 430 stroke survivors (mean/SD age 73.9/12.5 years, 46.5% female, median/interquartile range (IQR) National Institute of Health Stroke Scale (NIHSS) 5/2-10) completed 6-month follow-up. Acutely, domain-specific impairments were highly prevalent ranging from 26.7% (n = 112) in praxis to 46.8% (n = 183) in attention. At 6 months, the proportion of domain-specific recovery was highest in praxis (n = 73, 71%) and lowest in language (n = 89, 46%) and memory (n = 82, 48%). Severity of 6-month cognitive impairment was best predicted by the addition of acute cognitive impairment (adj R2 = 0.298, p < 0.0001) over demographic and clinical factors alone (adj R2 = 0.105, p < 0.0001). Acute cognitive function was the strongest predictor of 6-month cognitive performance (p < 0.0001). Acute domain-specific impairments in memory (p < 0.0001), language (p < 0.0001), and praxis (p < 0.0001) significantly predicted overall severity of cognitive impairment at 6 months.

CONCLUSION

Post-stroke cognitive impairment is highly prevalent across all domains acutely, while impairments in language, memory, and attention predominate at 6 months. Early domain-specific screening can provide valuable prognostic information for longer-term cognitive outcomes.

A qualitative study investigating the views of stroke survivors and their family members on discussing post-stroke cognitive trajectories

Cognitive impairment is common early after stroke but trajectories over the long term are variable. Some stroke survivors make a full recovery, while others retain a stable impairment or decline. This study explored the perceived advantages and disadvantages of discussing potential cognitive trajectories with stroke survivors and their family members. Stroke survivors at least six-months post-stroke were purposively sampled from an existing pool of research volunteers recruited originally for the OCS-Recovery study. They were invited, alongside a family member, to participate in a semi-structured interview. Interviews were audio recorded, transcribed, and analyzed using reflexive thematic analysis. Twenty-six stroke survivors and eleven family members participated. We identified one overarching theme and three related subthemes. The overarching theme was: One size does not fit all. The subthemes were: (1) Hearing about potential cognitive trajectories helps to develop realistic expectations; (2) Discussions about cognitive trajectories may be motivating; (3) Cognitive decline and post-stroke dementia discussions may be anxiety-provoking and depressing. Healthcare professionals should adopt a person-centred approach to sharing information about post-stroke cognitive trajectories. Discussions should be tailored to individual needs and preferences, with dementia-related topics in particular addressed with the utmost selectivity and sensitivity.

Stroke Severity, Caregiver Feedback, and Cognition in the REGARDS-CARES Study

Objective

Cognitive impairment after stroke is common, present up to 60% of survivors. Stroke severity, indicated by both volume and location, is the most consequential predictor of cognitive impairment, with severe strokes predicting higher chances of cognitive impairment. The current investigation examines the associations of two stroke severity ratings and a caregiver-report of post-stroke functioning with longitudinal cognitive outcomes.

Methods

The analysis was conducted on 157 caregivers and stroke survivor dyads who participated in the Caring for Adults Recovering from the Effects of Stroke (CARES) project, an ancillary study of the REasons for Geographic and Racial Differences in Stroke (REGARDS) national cohort study. Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) collected at hospitalization discharge were included as two primary predictors of cognitive impairment. The number of caregiver-reported problems and impairments at nine months following stroke were included as a third predictor. Cognition was assessed using a biennial telephone battery, incorporating multiple cognitive assessments to assess learning, memory, and executive functioning. Longitudinal cognitive scores were analyzed up to five years post-stroke, controlling for baseline (pre-stroke) cognitive scores and demographic variables of each stroke survivor collected at CARES baseline.

Results

Separate mixed models showed significant main effects of GOS (b=0.3280, p=0.0009), mRS (b=-0.2119, p=0.0002), and caregiver-reported impairments (b=-0.0671, p<0.0001) on longitudinal cognitive scores. In a combined model including all three predictors, only caregiver-reported problems significantly predicted cognitive outcomes (b=-0.0480, p<0.0001).

Impact

These findings underscore the importance of incorporating caregivers feedback in understanding cognitive consequences of stroke.

Comparative efficacy of non-invasive brain stimulation for post-stroke cognitive impairment: a network meta-analysis

BACKGROUND

Non-invasive brain stimulation (NIBS) is a burgeoning approach with the potential to significantly enhance cognition and functional abilities in individuals who have undergone a stroke. However, the current evidence lacks robust comparisons and rankings of various NIBS methods concerning the specific stimulation sites and parameters used. To address this knowledge gap, this systematic review and meta-analysis seek to offer conclusive evidence on the efficacy and safety of NIBS in treating post-stroke cognitive impairment.

METHODS

A systematic review of randomized control trials (RCT) was performed using Bayesian network meta-analysis. We searched RCT in the following databases until June 2022: Cochrane Central Register of Controlled Trials (CENTRAL), PUBMED, and EMBASE. We compared any active NIBS to control in terms of improving cognition function and activities of daily living (ADL) capacity following stroke.

RESULTS

After reviewing 1577 retrieved citations, a total of 26 RCTs were included. High-frequency (HF)-repetitive transcranial magnetic stimulation (rTMS) (mean difference 2.25 [95% credible interval 0.77, 3.66]) was identified as a recommended approach for alleviating the global severity of cognition. Dual-rTMS (27.61 [25.66, 29.57]) emerged as a favorable technique for enhancing ADL function. In terms of stimulation targets, the dorsolateral prefrontal cortex exhibited a higher ranking in relation to the global severity of cognition.

CONCLUSIONS

Among various NIBS techniques, HF-rTMS stands out as the most promising intervention for enhancing cognitive function. Meanwhile, Dual-rTMS is highly recommended for improving ADL capacity.

Intraindividual variability in post-stroke cognition and its relationship with activities of daily living and social functioning: an ecological momentary assessment approach

INTRODUCTION

Ecological momentary assessment (EMA) is a methodological approach to studying intraindividual variation over time. This study aimed to use EMA to determine the variability of cognition in individuals with chronic stroke, identify the latent classes of cognitive variability, and examine any differences in daily activities, social functioning, and neuropsychological performance between these latent classes.

METHODS

Participants (N = 202) with mild-to-moderate stroke and over 3-month post-stroke completed a study protocol, including smartphone-based EMA and two lab visits. Participants responded to five EMA surveys daily for 14 days to assess cognition. They completed patient-reported measures and neuropsychological assessments during lab visits. Using latent class analysis, we derived four indicators to quantify cognitive variability and identified latent classes among participants. We used ANOVA and Chi-square to test differences between these latent classes in daily activities, social functioning, and neuropsychological performance.

RESULTS

The latent class analysis converged on a three-class model. The moderate and high variability classes demonstrated significantly greater problems in daily activities and social functioning than the low class. They had significantly higher proportions of participants with problems in daily activities and social functioning than the low class. Neuropsychological performance was not statistically different between the three classes, although a trend approaching statistically significant difference was observed in working memory and executive function domains.

DISCUSSION

EMA could capture intraindividual cognitive variability in stroke survivors. It offers a new approach to understanding the impact and mechanism of post-stroke cognitive problems in daily life and identifying individuals benefiting from self-regulation interventions.

Processing Speed and Attentional Shift/Mental Flexibility in Patients with Stroke: A Comprehensive Review on the Trail Making Test in Stroke Studies

The Trail Making Test (TMT) is one of the most commonly administered tests in clinical and research neuropsychological settings. The two parts of the test (part A (TMT-A) and part B (TMT-B)) enable the evaluation of visuoperceptual tracking and processing speed (TMT-A), as well as divided attention, set-shifting and cognitive flexibility (TMT-B). The main cognitive processes that are assessed using TMT, i.e., processing speed, divided attention, and cognitive flexibility, are often affected in patients with stroke. Considering the wide use of TMT in research and clinical settings since its introduction in neuropsychological practice, the purpose of our review was to provide a comprehensive overview of the use of TMT in stroke patients. We present the most representative studies assessing processing speed and attentional shift/mental flexibility in stroke settings using TMT and applying scoring methods relying on conventional TMT scores (e.g., time-to-complete part A and part B), as well as derived measures (e.g., TMT-(B-A) difference score, TMT-(B/A) ratio score, errors in part A and part B). We summarize the cognitive processes commonly associated with TMT performance in stroke patients (e.g., executive functions), lesion characteristics and neuroanatomical underpinning of TMT performance post-stroke, the association between TMT performance and patients' instrumental activities of daily living, motor difficulties, speech difficulties, and mood statue, as well as their driving ability. We also highlight how TMT can serve as an objective marker of post-stroke cognitive recovery following the implementation of interventions. Our comprehensive review underscores that the TMT stands as an invaluable asset in the stroke assessment toolkit, contributing nuanced insights into diverse cognitive, functional, and emotional dimensions. As research progresses, continued exploration of the TMT potential across these domains is encouraged, fostering a deeper comprehension of post-stroke dynamics and enhancing patient-centered care across hospitals, rehabilitation centers, research institutions, and community health settings. Its integration into both research and clinical practice reaffirms TMT status as an indispensable instrument in stroke-related evaluations, enabling holistic insights that extend beyond traditional neurological assessments.

An exploratory study of longitudinal trajectory of language, swallowing and cognition post endovascular clot retrieval

BACKGROUND

Endovascular clot retrieval (ECR) is known to reduce global disability at 3 months post stroke however limited research exists regarding the trajectory of specific clinical impairments including language, swallowing and cognitive deficits between onset and 3 months.

AIMS

To assess language, swallowing, and cognitive performance following ECR and explore whether impairment severity is correlated with modified Thrombolysis in Cerebral Infarction score (mTICI), stroke severity or quality of life (QoL).

METHODS

Assessment was completed within 7 days (T1), 1 month (T2) and 3 months (T3) post-stroke. Performance was measured with the Functional Oral Intake Scale (FOIS), Repeatable Battery for Assessment of Neuropsychological Status (RBANS), Trail Making Test (TMT A and B) and Brixton Spatial Awareness Test. The Western Aphasia Battery (WAB) was used for left hemisphere stroke. QoL was measured with the Stroke and Aphasia Quality of Life Scale.

RESULTS

Twenty-five participants (median 72 years; 64% male) were prospectively recruited following ECR. High reperfusion success (68% mTICI 3) and low stroke severity post ECR (median 24 h NIHSS = 3, IQR 7-18) were noted. At T1, 10 participants presented with aphasia, eight required a modified diet and 20 had impaired cognition. At T3 all had recovered to a normal oral diet, 39% had persistent cognitive impairment and 45% of patients with left hemisphere stroke remained aphasic. Performance on the WAB, FOIS, RBANS and TMT changed significantly over time (all p < 0.05). The severity score at T1 for all measures, excluding TMT B and Brixton, was significantly correlated with 24 h NIHSS. WAB scores at T3 were correlated with QoL (r = 0.618; p = 0.043).

CONCLUSION

This exploratory study found the longitudinal performance of language, swallowing and cognition significantly improved over time and severity in the first-week post-ECR was correlated with 24 h NIHSS rather than the degree of reperfusion.

WHAT THIS PAPER ADDS

What is already known on the subject Randomised control trials have demonstrated the benefit of ECR in patients with ischemic stroke using global measures of disability and function. Limited research exists regarding the trajectory of specific clinical impairments including language, swallowing and cognitive deficits. There is also a reliance on screening assessments and a lack of consideration of the influence of co-occurring impairments. What this paper adds to existing knowledge This prospective study is amongst the first to explore the longitudinal trajectory of language, swallowing and cognitive impairment using a standardised assessment battery. Twenty-four-hour NIHSS was significantly correlated with language, swallowing, global cognition and some measures of executive function. Language performance post ECR was correlated with domain-specific cognitive assessment of attention, immediate memory and delayed memory, which differed from swallowing performance post ECR that correlated with measures of executive function. What are the potential or actual clinical implications of this work? It is important for speech-language pathologists and the wider medical team to monitor language, swallowing and cognitive performance post ECR regardless of treatment success. Stroke severity at 24 h post-ECR influences the severity of language, swallowing and cognitive impairments.

Insomnia complaints correlated with higher risk of cognitive impairment in older adults following stroke: a National Representative Comparison Study

Although associations among insomnia, cognitive impairment, and stroke have been demonstrated, whether insomnia increases the risk of cognitive impairment after stroke remains unclear. The aim of this study was to examine whether insomnia complaints moderated the association between stroke and cognitive impairment in older adults. This study was a secondary data analysis that used data from the National Health Interview Survey 2009. A total of 447 older adults with a mean age of 74.63 years (50.1% men) were included. Self-reported insomnia and stroke occurrence were determined using a questionnaire. Cognitive impairment was assessed using the Mini-Mental State Examination. We used multivariate logistic regression to analyze the association between insomnia complaints and cognitive impairment. Participants were categorized into four groups: those with stroke and insomnia (58), those with stroke without insomnia (91), those without stroke with insomnia (116), and those without stroke or insomnia (182). The prevalence of insomnia complaints was 38.9%, and the frequency of poststroke cognitive impairment was 50.3%. After controlling for potential confounders, participants with stroke (with or without insomnia) had a significantly higher risk of cognitive impairment than those without stroke or insomnia (adjusted odds ratios: 4.16 and 2.91, 95% confidence intervals: 1.91-9.07 and 1.56-5.43, respectively). Stroke with or without insomnia complaints was associated with a higher risk of cognitive impairment relative to older adults without stroke or insomnia. The risk of cognitive impairment was the highest among participants with both stroke and insomnia.

Addressing ADL ability in people with poststroke cognitive impairments: A Danish survey of clinical practice

BACKGROUND

In Denmark, stroke represents a leading disability cause. While people with difficulties in performing activities of daily living (ADL) due to poststroke cognitive impairments are often referred to occupational therapy, limited knowledge is available on the nature of these services.

AIM/OBJECTIVE

To explore how Danish occupational therapists describe their practice when addressing decreased ADL ability in people with poststroke cognitive impairments in hospital and municipality settings.

MATERIAL AND METHODS

National, cross-sectorial, web-based public survey.

RESULTS

244 occupational therapists accessed the survey; 172 were included in the analysis. Most respondents could indicate the theory guiding their reasoning; half used standardised assessments. Regarding intervention, restorative and acquisitional models were preferred; specific strategies were identified. Intensity: 30-45 min 3-4 times/week in hospitals; 30-60 min 1-2 times/week in municipalities.

CONCLUSIONS

Therapists report to be guided by theory in their reasoning. Standardised assessments are used to a higher extend than previously reported. Still, the results invite critical reflections on correct use of assessment instruments, content and intensity of interventions, and how therapists keep themselves updated.

SIGNIFICANCE

The results document the need for practice improvements and may inform the definition of standard care in future trials.

Stroke and Vascular Cognitive Impairment: The Role of Intestinal Microbiota Metabolite TMAO

The gut microbiome interacts with the brain bidirectionally through the microbiome-gutbrain axis, which plays a key role in regulating various nervous system pathophysiological processes. Trimethylamine N-oxide (TMAO) is produced by choline metabolism through intestinal microorganisms, which can cross the blood-brain barrier to act on the central nervous system. Previous studies have shown that elevated plasma TMAO concentrations increase the risk of major adverse cardiovascular events, but there are few studies on TMAO in cerebrovascular disease and vascular cognitive impairment. This review summarized a decade of research on the impact of TMAO on stroke and related cognitive impairment, with particular attention to the effects on vascular cognitive disorders. We demonstrated that TMAO has a marked impact on the occurrence, development, and prognosis of stroke by regulating cholesterol metabolism, foam cell formation, platelet hyperresponsiveness and thrombosis, and promoting inflammation and oxidative stress. TMAO can also influence the cognitive impairment caused by Alzheimer's disease and Parkinson's disease via inducing abnormal aggregation of key proteins, affecting inflammation and thrombosis. However, although clinical studies have confirmed the association between the microbiome-gut-brain axis and vascular cognitive impairment (cerebral small vessel disease and post-stroke cognitive impairment), the molecular mechanism of TMAO has not been clarified, and TMAO precursors seem to play the opposite role in the process of poststroke cognitive impairment. In addition, several studies have also reported the possible neuroprotective effects of TMAO. Existing therapies for these diseases targeted to regulate intestinal flora and its metabolites have shown good efficacy. TMAO is probably a new target for early prediction and treatment of stroke and vascular cognitive impairment.

Description of an interdisciplinary, holistic cognitive rehabilitation program for adults with mild to moderate cognitive impairment after acquired brain injury

PURPOSE

Cognitive rehabilitation research has progressed slowly, in part due to incomplete reporting of intervention content and delivery and the difficulties this produces for discerning program effectiveness. This knowledge gap can be reduced by providing detailed intervention descriptions. We document the content/ingredients and therapeutic targets of a cognitive rehabilitation program for adults with mild-to-moderate cognitive impairment.

METHODS

The documentation process used a method of participatory/collaborative research. Discussions with the clinical team identified session content/ingredients and therapeutic targets, which were then described using Body Functions, and Activities & Participation domains from the International Classification of Function, Disability and Health (ICF). Domains most frequently targeted by each clinician were identified as Primary Targets.

RESULTS

Each clinician produced a detailed description of session content, implementation, and ICF-coded therapeutic targets. This revealed that the whole program targets 29 ICF domains, seven of which were identified as Primary Targets: Higher-level Cognitive; Attention; Memory; Emotional; Global Psychosocial, Temperament and Personality, and Conversation.

CONCLUSIONS

Documentation of treatment targets enabled identification of appropriate outcome measures which are now being used to investigate program efficacy. This step-by-step explanation of the documentation process could serve as a guide for other teams wanting to document their rehabilitation interventions and/or establish similar programs.IMPLICATIONS FOR REHABILITATIONIncomplete reporting of intervention content and delivery contributes to difficulties in discerning the effectiveness of complex rehabilitation programs.Current recommendations for rehabilitation intervention reporting suggest that these difficulties can be partially overcome by providing detailed descriptions of intervention content/ingredients and treatment targets.Human and physical resources differ widely from one clinical setting to another and the existence of clear program descriptions can guide clinicians who wish to create similar programs.Detailed descriptions of rehabilitation interventions are necessary to accurately measure patient outcomes and generate testable hypotheses about proposed mechanisms of action.Program descriptions are needed for the development of treatment theories and the advancement of evidence-based practice in rehabilitation.

Mapping the trajectory of acute mild-stroke cognitive recovery using serial computerised cognitive assessment

INTRODUCTION

Cognitive impairment is common post-stroke. There is a need to understand patterns of early cognitive recovery post-stroke to guide both clinical and research practice. The aim of the study was to map the trajectory of cognitive recovery during the first week to 90-days post-stroke using serial computerised assessment.

METHOD

An observational cohort study recruited consecutive stroke patients admitted to a stroke unit within 48 hours of onset. Cognitive function was assessed using the computerised Cambridge Neuropsychological Test Automated Battery (CANTAB) daily for seven days, then 14, 30 and 90 days post-stroke. The CANTAB measured visual episodic memory and learning, information processing speed, visuo-spatial working memory, complex sustained attention and mental flexibility. Repeated measures MANOVA/ANOVA with Least Squares Difference post-hoc analyses were performed to ascertain significant change over time.

RESULT

Forty-eight participants, mean age 73, primarily mild, ischaemic stroke, completed all assessment timepoints. There was a trajectory of early, global cognitive improvement, indicative of a post-stroke delirium, that largely stabilised between 6 and 14-days post-stroke. Change over time was examined within each cognitive test, with one measure stabilising by day 6 (Reaction Time) and others detecting improving performances up to 14 days post-stroke.

CONCLUSIONS

Serial, computerised cognitive assessment can effectively map post-stroke cognitive recovery and revealed an early phase of global improvement over 14 days that is evidence for an acute post-stroke delirium. Resolution of post-stroke delirium in the second week following mild stroke indicates more extensive neuropsychological testing may be undertaken earlier than previously thought.

Measurement properties of performance-based instruments for assessing mental function during activity and participation in persons with stroke: A systematic review

BACKGROUND

Various performance-based instruments exist to assess mental function after stroke and users have to select one for research or clinical practice.

OBJECTIVES

To evaluate the measurement properties of performance-based instruments to assess (any aspect of) mental function during activity and participation in persons after stroke.

MATERIAL AND METHODS

We searched in five electronic databases. COSMIN methodology was used to conduct the review. The strength of evidence was assessed using a modified GRADE approach.

RESULTS

Fifty articles were included reporting on 20 instruments assessing (1) multiple mental functions including ≥ four subdomains (2) attention, memory and executive functions, or single subdomains (3) executive functions, (4) perception, and (5) mental function of language. Highest quality evidence for sufficient results was found for some measurement properties in seven instruments. These instruments included: FIM + FAM, MPAI-4 and EFPT, MET, CBS/KF-NAP, BIT and the Scenario Test.

CONCLUSIONS

Further studies of high methodological quality are needed that evaluate the measurement properties of instruments to allow clinicians and researchers to select the most suitable performance-based measures for purpose.

SIGNIFICANCE

Results may be used to select the most suitable performance-based instrument to measure mental function during activity and participation in persons with stroke.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42018086744.

Modified Suanzaoren decoction in treating post-stroke cognitive impairment with comorbid insomnia symptoms: A clinical trial

BACKGROUND

Cognitive impairment and insomnia are common complications for stroke patients, and often coexist without effective therapy. Modified Suanzaoren decoction (M-SZRD), derived from a famous classic prescription, has been used as an alternative treatment for these patients. The objective of this study is to investigate the effectiveness of M-SZRD in treating post-stroke cognitive impairment with comorbid insomnia symptoms.

METHODS

A total of 80 participants were randomly assigned into 2 groups to 40 cases in the treatment group (treated with modified Suanzaoren decoction) and 40 cases in the control group (treated with zolpidem). The intervention period was 4 weeks. Cognitive function, sleep quality, depression, and anxiety disorders were evaluated in both groups before and after treatment. Clinical assessment of patients with stroke included National Institutes of Health Stroke Scale and Barthel Index evaluations. Hormone levels of the hypothalamic-pituitary-adrenal and hypothalamus-pituitary-thyroid axis were also measured.

RESULTS

Out of the total 80 participants, 5 withdrew during the experiment and did not complete the study, leaving 75 patients for analysis to 38 in the treatment group and 37 in the control group. The findings showed that M-SZRD was more effective than the control group in improving cognitive function (P = .006). However, both groups were found to have a similar effect in improving insomnia (P = .323). There was no significant difference between the 2 groups in terms of activities of daily living and National Institutes of Health Stroke Scale improvement. M-SZRD was superior to the control group in improving depression state (P = .034), but when including dropouts in the intention-to-treat analysis, the difference was not statistically significant (P = .150). Furthermore, the M-SZRD group was better than the control group in reducing cortisol levels (P = .036), and the improvement in serum-free triiodothyronine (FT3) levels was also more significant in the M-SZRD group than in the control group (P = .0007).

CONCLUSION

M-SZRD is a more effective treatment for improving cognitive function in patients with post-stroke cognitive impairment and comorbid insomnia symptoms, possibly by regulating the cortisol levels of the hypothalamic-pituitary-adrenal axis and FT3 levels of the hypothalamus-pituitary-thyroid axis.

Which cutoff value of the Montreal Cognitive Assessment should be used for post-stroke cognitive impairment? A systematic review and meta-analysis on diagnostic test accuracy

BACKGROUND

Post-stroke cognitive impairment (PSCI) is one of the serious complications of stroke. The Montreal Cognitive Assessment (MoCA), as a brief cognitive impairment screening tool, is widely used in stroke survivors. However, some studies have suggested that the use of the universal cutoff value of 26 may be inappropriate for detecting cognitive impairments in stroke settings.

AIM

We conducted this study to identify the optimal cutoff value of the MoCA in screening for PSCI.

METHODS

PubMed, CINAHL, Embase, the Cochrane Library, and Web of Science were searched for eligible studies until March 23, 2023. All studies were screened by two independent researchers. The quality of each article was evaluated by the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A bivariate mixed-effects model was used to pool sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and the summary receiver operating characteristic curve.

RESULTS

Twenty-four studies with a total of 4231 patients were included in this review. Despite the lack of evidence of publication bias, a high degree of heterogeneity was observed. A meta-analysis revealed that a cutoff value of 21/22 yielded the best diagnostic accuracy. The optimal cutoff varied in different regions, stroke types, and stroke phases as well.

CONCLUSION

The optimal cutoff of MoCA was 21/22 for stroke populations rather than the initially recommended cutoff of 26. A revised (lower) cutoff should be considered for stroke survivors.

Web-based psychoeducational interventions for managing cognitive impairment-a systematic review

Objective

Web-based rehabilitation, a branch of telerehabilitation, is carried out over the internet, unrestricted by time or place. Even though web-based interventions have been reported as feasible and effective in cases of mood disorders, for example, such evidence on the effectiveness of web-based cognitive rehabilitation remains unclear. This systematic review summarizes current knowledge on web-based psychoeducational programs aiming to manage cognitive deficits in patients with diseases that affect cognition.

Methods

Using the Ovid database and the Web of Science, we systematically searched the Cochrane Database of Systematic Reviews, Medline, and PsycINFO to identify eligible studies. The review protocol (CRD42021257315) was pre-registered with the PROSPERO International Prospective Register of Systematic Reviews. The search was performed 10/13/2022. Two reviewers independently screened titles, abstracts, and full-texts, and extracted data for the selected studies. Two independent reviewers assessed the methodological quality.

Results

The search retrieved 6,487 articles. Four studies with different patient groups (stroke, traumatic brain injury, brain tumor, and cancer) met the inclusion criteria of this systematic review. The studies examined systematic cognition-focused psychoeducational rehabilitation programs in which the patient worked independently. Three studies found positive effects on subjective cognitive functions, executive functions, and self-reported memory. No effects were found on objective cognitive functions. However, the studies had methodological weaknesses (non-randomized designs, small sample sizes, vaguely described interventions). Overall, adherence and patient satisfaction were good/excellent.

Conclusion

Web-based cognitive intervention programs are a new approach to rehabilitation and patient education. The evidence, although scarce, shows that web-based interventions are feasible and support subjective cognitive functioning. However, the literature to date is extremely limited and the quality of the studies is weak. More research with high-quality study designs is needed.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=257315, identifier: CRD42021257315.

Mobile applications for cognitive training: Content analysis and quality review

Background

As the number of individuals suffering from cognitive diseases continues to rise, dealing with the diminished cognitive function that comes with age has become a serious public health concern. While the use of mobile applications (apps) as digital treatments for cognitive training shows promise, the analysis of their content and quality remains unclear.

Objective

The aim of this study was to systematically search and assess cognitive training apps using the multidimensional mobile app rating scale (MARS) to rate objective quality and identify critical points.

Methods

A search was conducted on the Google Play Store and Apple App Store in February 2022 using the terms "cognitive training" and "cognitive rehabilitation." The cognitive domains provided by each app were analyzed, and the frequency and percentage according to the apps were obtained. The MARS, a mHealth app quality rating tool including multidimensional measures, was used to analyze the quality of the apps. The relationship between the MARS score, the number of reviews, and 5-star ratings were examined.

Results

Of the 53 apps, 52 (98 %) included memory function, 48 (91 %) included attention function, 24 (45 %) included executive function, and 19 (36 %) included visuospatial function. The mean (SD) scores of MARS, 5-star ratings, and reviews of 53 apps were 3.09 (0.61), 4.33 (0.30), and 62,415.43 (121,578.77). From the between-section comparison, engagement (mean 2.97, SD 0.68) obtained lower scores than functionality (mean 3.18, SD 0.62), aesthetics (mean 3.13, SD 0.72), and information (mean 3.11, SD 0.54). The mean quality score and reviews showed a statistically significant association (r = 0.447 and P = .001*). As the number of domains increased, the mean quality score showed a statistically significant increasing trend (P = .002*).

Conclusions

Most apps provided training for the memory and attention domains, but few apps included executive function or visuospatial domains. The quality of the apps improved significantly when more domains were provided, and was positively associated with the number of reviews received. These results could be useful for the future development of mobile apps for cognitive training.

Three-month Practice Effect of the National Institutes of Health Toolbox Cognition Battery in Young Healthy Adults

The National Institutes of Health Toolbox-Cognition Battery (NIHTB-CB) is a tablet-based cognitive assessment intended for individuals with neurological diseases of all ages. NIHTB-CB practice effects (PEs), however, need clarification if this measure is used to track longitudinal change. We explored the test-retest PEs on NIHTB-CB performance at 3 months in young healthy adults (n = 22). We examined corrected T-scores normalized for demographic factors and calculated PEs using Cohen's d. There were significant PEs for all NIHTB-CB composite scores and on 4/7 subtests. This work suggests the need to further assess NIHTB-CB PEs as this may affect the interpretation of study results incorporating this battery.

Using MemTrax memory test to screen for post-stroke cognitive impairment after ischemic stroke: a cross-sectional study

Background

Whereas the Montreal Cognitive Assessment (MoCA) and Addenbrooke's cognitive examination-revised (ACE-R) are commonly used tests for the detection of post-stroke cognitive impairment (PSCI), these instruments take 10-30 min to administer and do not assess processing speed, which is a critical impairment in PSCI. MemTrax (MTx) is a continuous recognition test, which evaluates complex information processing, accuracy, speed, and attention, in 2 min.

Aim

To evaluate whether MTx is an effective and practical tool for PSCI assessment.

Methods

This study enrolled acute ischemic stroke (AIS) patients who have assessed the cognitive status including MTx, clinical dementia rating (CDR), MoCA, Neuropsychiatric Inventory (NPI), Hamilton depression scale (HAMD), Hamilton anxiety scale (HAMA), the National Institute of Health Stroke Scale (NIHSS), modified Rankin scale (mRS), and Barthel Index of activity of daily living (BI) combined with the physical examinations of the neurologic system at the 90-day (D90) after the AIS. The primary endpoint of this study was establishing MTx cut-offs for distinguishing PSCI from AIS.

Results

Of the 104 participants, 60 were classified to the PSCI group. The optimized cut-off value of MTx-%C (percent correct) was 78%, with a sensitivity and specificity for detecting PSCI from Non-PSCI of 90.0 and 84.1%, respectively, and an AUC of 0.919. Regarding the MTx-Cp (Composite score = MTx-%C/MTx-RT), using 46.3 as a cut-off value, the sensitivity and specificity for detecting PSCI from Non-PSCI were 80.0 and 93.2%, with an AUC of 0.925. Multivariate linear regression showed that PSCI reduced the MTx-%C (Coef. -14.18, 95% CI -18.41∼-9.95, p < 0.001) and prolonged the MTx-RT (response time) (Coef. 0.29, 95% CI 0.16∼0.43, p < 0.001) and reduced the MTx-CP (Coef. -19.11, 95% CI -24.29∼-13.93, p < 0.001).

Conclusion

MemTrax (MTx) is valid and effective for screening for PSCI among target patients and is a potentially valuable and practical tool in the clinical follow-up, monitoring, and case management of PSCI.

Language-Specific Dual-Task Effects After Stroke: A Systematic Review

PURPOSE

The dual-task paradigm has been frequently used to examine stroke-related deficits because it samples behavioral performance under conditions of distraction similar to functioning in real-life environments. This original systematic review synthesizes studies that examined dual-task effects involving spoken language production in adults affected by stroke, including transient ischemic attack (TIA) and poststroke aphasia.

METHOD

Five databases were searched (inception to March 2022) for eligible peer-reviewed articles. The 21 included studies reported a total of 561 stroke participants. Thirteen studies focused on single word production, for example, word fluency, and eight on discourse production, for example, storytelling. Most studies included participants who had suffered a major stroke. Six studies focused on aphasia, whereas no study focused on TIA. A meta-analysis was not appropriate because of the heterogeneity of outcome measures.

RESULTS

Some single word production studies found dual-task language effects whereas others did not. This finding was compounded by the lack of appropriate control participants. Most single word and discourse studies utilized motoric tasks in the dual-task condition. Our certainty (or confidence) assessment was based on a methodological appraisal of each study and information about reliability/fidelity. As 10 of the 21 studies included appropriate control groups and limited reliability/fidelity information, the certainty of the findings may be described as weak.

CONCLUSIONS

Language-specific dual-task costs were identified in single word studies, especially those that focused on aphasia as well as half of the nonaphasia studies. Unlike single word studies, nearly all studies of discourse showed dual-task decrements on at least some variables.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23605311.

Scientific Evidence of Acupuncture for Post-Stroke Cognitive Impairment: An Overview of Systematic Reviews and Meta-Analyses

Background

Acupuncture may be effective to treat post-stroke cognitive impairment (PSCI). We aimed to evaluate the reliability of the systematic reviews/meta-analyses (SRs/MAs) evidence regarding acupuncture treatment of PSCI.

Methods

The methodological quality was appraised with Methodological Quality of Systematic Reviews 2 (AMSTAR-2). We evaluated reporting quality with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and evidence quality with Grade of Recommendation, Assessment, Development and Evaluation (GRADE) system.

Results

The inclusion criteria were met by fifteen reviews. All studies assessed by AMSTAR-2 had critically poor methodological quality due to the limitations on the lack of the provision of the list of excluded trails, screening of duplicate study, and protocol registration. For reporting quality, response rate of "yes" was less than 50% in Q5 (protocol and registration topic), Q8 (Search) and Q23 (Additional analysis). Evidence quality of outcome measures was low or worse with GRADE because when the data was qualitatively synthesized, low quality and small sample size trials provided the data.

Conclusion

Acupuncture may be beneficial for PSCI. Because of limitations and inconsistent conclusions, further research is needed to provide higher evidence for acupuncture on PSCI.

Cognitive assessment after stroke: A qualitative study of patients' experiences

OBJECTIVES

Clinical guidelines recommend early cognitive assessment after stroke to inform rehabilitation and discharge decisions. However, little is known about stroke survivors' experiences of the cognitive assessment process. This qualitative study aimed to explore patients' experiences of poststroke cognitive assessments.

DESIGN

Stroke survivors were purposively sampled in an iterative process through a pool of research volunteers who had previously taken part in the Oxford Cognitive Screen Recovery study. Stroke survivors and their family caregivers were invited to participate in a semistructured interview steered by a topic guide. Interviews were audio recorded, transcribed and analysed using reflexive thematic analysis. Demographic, clinical and cognitive data were acquired from patients' previous research data.

SETTING

Stroke survivors were originally recruited from the acute inpatient unit at Oxford University Hospital (John Radcliffe), UK. Participants were interviewed after discharge either at their homes or via telephone or videocall.

PARTICIPANTS

Twenty-six stroke survivors and eleven caregivers participated in semi-structured interviews.

RESULTS

We identified three key phases of the cognitive assessment process and themes pertaining to each phase. The phases (numbered) and themes (lettered) were as follows: (1) before the cognitive assessment: (A) lack of explanation, (B) considering the assessment useless; (2) during the cognitive assessment: varied emotional responses, moderated by (D) perception of the purpose behind cognitive assessment, (E) perception of cognitive impairment, (F) confidence in cognitive abilities, (G) assessment administration style and (3) after the cognitive assessment: (H) feedback can impact self-confidence and self-efficacy, (I) vague feedback and clinical jargon are unhelpful.

CONCLUSIONS

Stroke survivors require clear explanations about the purpose and outcomes of poststroke cognitive assessments, including constructive feedback, to promote engagement with the process and protect their psychological wellbeing.

What follow-up interventions, programmes and pathways exist for minor stroke survivors after discharge from the acute setting? A scoping review

OBJECTIVE

To identify the breadth and range of follow-up interventions currently provided to people after minor stroke with a focus on the definitions used for minor stroke, intervention components, intervention theory and outcomes used. These findings will inform the development and feasibility testing of a pathway of care.

DESIGN

Scoping review.

SEARCH STRATEGY

The final search was run in January 2022. Five databases were searched-EMBASE, MEDLINE, CINAHL, British Nursing Index and PsycINFO. Grey literature was also searched. Title and abstract screening and full-text reviews were conducted by two researchers and a third was involved when differences of opinion existed. A bespoke data extraction template was created, refined and then completed. The Template for Intervention Description and Replication (TIDieR) checklist was used to describe interventions.

RESULTS

Twenty-five studies, using a range of research methodologies were included in the review. A range of definitions were used for minor stroke. Interventions focused largely on secondary prevention and management of increased risk of further stroke. Fewer focused on the management of hidden impairments experienced after minor stroke. Limited family involvement was reported and collaboration between secondary and primary care was seldom described. The intervention components, content, duration and delivery were varied as were the outcome measures used.

CONCLUSION

There is an increasing volume of research exploring how best to provide follow-up care to people after minor stroke. Personalised, holistic and theory-informed interdisciplinary follow-up is needed that balances education and support needs with adjustment to life after stroke.

Assessing stroke rehabilitation degree based on quantitative EEG index and nonlinear parameters

The assessment of motor function is critical to the rehabilitation of stroke patients. However, commonly used evaluation methods are based on behavior scoring, which lacks neurological indicators that directly reflect the motor function of the brain. The objective of this study was to investigate whether resting-state EEG indicators could improve stroke rehabilitation evaluation. We recruited 68 participants and recorded their resting-state EEG data. According to Brunnstrom stage, the participants were divided into three groups: severe, moderate, and mild. Ten quantitative electroencephalographic (QEEG) and five non-linear parameters of resting-state EEG were calculated for further analysis. Statistical tests were performed, and the genetic algorithm-support vector machine was used to select the best feature combination for classification. We found the QEEG parameters show significant differences in Delta, Alpha1, Alpha2, DAR, and DTABR (P < 0.05) among the three groups. Regarding nonlinear parameters, ApEn, SampEn, Lz, and C0 showed significant differences (P < 0.05). The optimal feature classification combination accuracy rate reached 85.3%. Our research shows that resting-state EEG indicators could be used for stroke rehabilitation evaluation.

Can we trust computers to assess the cognition of stroke patients? A systematic review

Purpose

To summarize the classification of computerized cognitive assessment (CCA) tools for assessing stroke patients, to clarify their benefits and limitations, and to reveal strategies for future studies on CCA tools.

Methods

A literature review was performed using PubMed, Embase, Scopus, JAMA Network, Cochrane Library and PsycINFO databases from January 1st, 2010, to August 1st, 2022. Two authors independently screened the literature following the same criteria, evaluated the study quality, and collected data from the articles.

Results

A total of 8,697 papers were acquired from the six databases. A total of 74 potentially eligible articles were selected for review. Of these, 29 articles were not relevant to this research, 3 were reviews, 2 were not written in English, and 1 was on an ongoing trial. By screening the references of the reviews, 3 additional articles were included in this study. Thus, a total of 42 articles met the criteria for the review. In terms of the CCA tools analyzed in these studies, they included five types: virtual reality (VR)-based, robot-based, telephone-based, smartphone-based, and computer-based cognitive assessments. Patients' stages of the disease ranged from the subacute phase and rehabilitation phase to the community phase. A total of 27 studies supported the effectiveness of CCA tools, while 22 out of 42 articles mentioned their benefits and 32 revealed areas for future improvement of CCA tools.

Conclusions

Although the use of CCA tools for assessing the cognition of post-stroke patients is becoming popular, there are still some limitations and challenges of using such tools in stroke survivors. More evidence is thus needed to verify the value and specific role of these tools in assessing the cognitive impairment of stroke patients.

Characteristics of cognition impairment in patients after stroke based on the Wechsler Adult Intelligence Scale-Revised in China

We aimed to explore the cognitive characteristics of patients with post-stroke cognition impairment (PSCI) on the basis of the Wechsler Adult Intelligence Scale-Revised in China (WAIS-RC) and the individual contribution of the subtests to WAIS score. We included 227 patients with PSCI who were assessed using the WAIS-RC. We described the characteristics and score distribution of the scale and subtests individually and compared them with those of the normal group to measure the damage degree of these patients. We performed item response theory analysis to explore the best criterion score for all dimensions that allowed ideal discrimination and difficulty for reflecting cognitive level. Finally, we analyzed the contribution of each dimension to the overall cognitive function. Patients with PSCI showed worse cognition levels than healthy individuals in terms of overall intelligence quotient (73.26-100, -1.78 SD), with a difference of 4.54-7.96 points in each dimension (-0.68 to -1.82 SD), and a range of 5-7 points is the appropriate range for reflecting cognitive ability in patients with PSCI. The average cognitive level of patients with PSCI was significantly inferior to normal people (-1.78 SD, 96.25%). Vocabulary contributes most to WAIS score.

Association between exercise habit changes and incident dementia after ischemic stroke

We aimed to investigate the effects of exercise habit changes on the risk of incident dementia after ischemic stroke using the Korean National Health Insurance Services Database. This study included 223,426 patients with a new diagnosis of ischemic stroke between 2010 and 2016 who underwent two serial ambulatory health checkups. The participants were divided into four categories according to their habit change or regular exercise: persistent non-exercisers, new exercisers, exercise dropouts, and exercise maintainers. The primary outcome was new diagnosis of dementia. Multivariate Cox proportional models were used to assess the effects of changes in exercise habits on the risk of incident dementia. After a median of 4.02 years of follow-up, 22,554 (10.09%) dementia cases were observed. After adjusting for covariates, exercise dropouts, new exercisers, and exercise maintainers were significantly associated with a lower risk of incident dementia than persistent non-exercisers (adjusted hazard ratio [aHR] 0.937; 95% confidence interval [CI] 0.905-0.970, aHR 0.876; 95% CI 0.843-0.909, aHR 0.705; 95% CI 0.677-0.734, respectively). The impact of changes in exercise habit was more prominent in the 40-65 years age group. An energy expenditure ≥ 1000 metabolic equivalents of task-min/wk post-stroke, regardless of pre-stroke physical activity status, was mostly associated with a lower risk of each outcome. In this retrospective cohort study, initiating or continuing moderate-to-vigorous exercise after ischemic stroke was associated with a lower risk of dementia development. Further, pre-stroke regular physical activity also reduced the risk of incident dementia. The promotion of exercise in ambulatory stroke patients may reduce their future risk of incident dementia.

Association Between the Serum Iron and Acute Cognitive Impairment After Stroke: A Cross-Sectional Study

BACKGROUND

Complications such as cognitive impairment are common in stroke victims. The goal of this study was to see if there was a link between blood iron levels and post-stroke cognitive impairment (PSCI) within 2 weeks after stroke.

METHODS

A total of 313 patients with ischemic stroke were recruited and separated into two groups: PSCI (n = 202) and non-PSCI (n = 111). The Mini-mental state examination scale was used to evaluate the cognitive status within 2 weeks after stroke (acute phase). The serum iron levels were divided into 4 layers: Q1 ≤ 11.7 μmol/L, Q2 11.8-15.1 μmol/, Q3 15.2-19.3 μmol/L, Q4 ≥ 19.4 μmol/L, respectively. The connection between serum iron and PSCI was then investigated further using binary logistic regression, which was adjusted for confounders.

RESULTS

The difference in serum iron levels between the PSCI and non-PSCI group was initially conducted by the Mann-Whitney test, and a significant difference was found (14.5 (11.0-17.8) vs. 16.9 (13.7-21.8), p < .001), with no confounders being adjusted. After adjusting for confounding factors, the binary regression analysis showed that the Q4 layer showed the lowest risk of PSCI, with the Q1 layer being the reference. (odds ratio (OR) = 0.297, 95% confidence interval (CI) = 0.136-0.649, p = 0.002).

CONCLUSION

A decreased risk of early-onset PSCI was linked to high serum iron levels. Low serum iron levels were found to be a risk factor for acute cognitive impairment following stroke, which could help physicians identify and take intervention measures early to reduce the risk of cognitive impairment after stroke.

The cognitive status of chronic subdural hematoma patients after treatment: an exploratory study

OBJECTIVE

Chronic subdural hematoma (CSDH) is a common neurological condition, often affecting the elderly. Cognitive impairment is frequently observed at presentation. However, the course and longer term aspects of the cognitive status of CSDH patients are unknown. In this study, we aim to explore the cognitive status of CSDH patients after treatment.

METHODS

An exploratory study in which CSDH patients were assessed 3 months after treatment and compared to healthy controls. A total of 56 CSDH patients (age 72.1 SD ± 10.8 years with 43 [77%] males) and 60 healthy controls were included (age 67.5 ± SD 4.8 with 34 [57%] males). Cognitive testing was performed using the Telephonic Interview of Cognitive Status-modified (TICS-m), a 12-item questionnaire in which a total of 50 points can be obtained on several cognitive domains.

RESULTS

Median time between treatment and cognitive testing was 93 days (range 76-139). TICS-m scores of CSDH patients were significantly lower than healthy controls, after adjusting for age and sex: mean score 34.6 (95% CI: 33.6-35.9) vs. 39.6 (95% CI: 38.5-40.7), p value < 0.001. More than half (54%) of CSDH patients have cognitive scores at follow-up that correspond with cognitive impairment.

CONCLUSION

A large number of CSDH patients show significantly worse cognitive status 3 months after treatment compared to healthy controls. This finding underlines the importance of increased awareness for impaired cognition after CSDH. Further research on this topic is warranted.

Hippocampal Vascular Supply and Its Role in Vascular Cognitive Impairment

The incidence of age-related dementia is increasing as the world population ages and due to lack of effective treatments for dementia. Vascular contributions to cognitive impairment and dementia are increasing as the prevalence of pathologies associated with cerebrovascular disease rise, including chronic hypertension, diabetes, and ischemic stroke. The hippocampus is a bilateral deep brain structure that is central to learning, memory, and cognitive function and highly susceptible to hypoxic/ischemic injury. Compared with cortical brain regions such as the somatosensory cortex, less is known about the function of the hippocampal vasculature that is critical in maintaining neurocognitive health. This review focuses on the hippocampal vascular supply, presenting what is known about hippocampal hemodynamics and blood-brain barrier function during health and disease, and discusses evidence that supports its contribution to vascular cognitive impairment and dementia. Understanding vascular-mediated hippocampal injury that contributes to memory dysfunction during healthy aging and cerebrovascular disease is essential to develop effective treatments to slow cognitive decline. The hippocampus and its vasculature may represent one such therapeutic target to mitigate the dementia epidemic.

The nonverbal BriefScreen: A cognitive screening method for patients with limited language and motor abilities

Dementia and significant cognitive decline are frequent sequelae of stroke, but are difficult to evaluate when aphasia and/or motor impairment are present. The linguistic and motor requirements of commonly employed screening tests render them problematic for use post-stroke. The present study examines the validity of the Nonverbal BriefScreen, a brief screening method with limited verbal and motor requirements, in groups of patients with known cognitive impairment using the MMSE as a gold standard. Participants were 137 healthy middle aged and older community dwellers, 21 patients with MCI/early dementia and 35 patients with different types of dementia. The sensitivity and specificity of the Nonverbal BriefScreen were calculated for various cutoff scores, with the MMSE as comparison. The Nonverbal BriefScreen was effective in discriminating between healthy controls and patients with dementia, as well as between healthy controls and all patients, with areas under the ROC curve similar to that of the MMSE. ROC analyses with a smaller sample of 35 age-matched healthy controls showed adequate discriminant ability to detect cognitive impairment. The Nonverbal BriefScreen was shown to be a valid method for screening for cognitive impairment that could be employed as a screening method for patients with limited language.