Impact of white matter lesions on cognition in stroke patients free from pre-stroke cognitive impairment: a one-year follow-up study

White Matter Hyperintensity Volume and Poststroke Cognition: An Individual Patient Data Pooled Analysis of 9 Ischemic Stroke Cohort Studies

BACKGROUND

White matter hyperintensities (WMH) are associated with cognitive dysfunction after ischemic stroke. Yet, uncertainty remains about affected domains, the role of other preexisting brain injury, and infarct types in the relation between WMH burden and poststroke cognition. We aimed to disentangle these factors in a large sample of patients with ischemic stroke from different cohorts.

METHODS

We pooled and harmonized individual patient data (n=1568) from 9 cohorts, through the Meta VCI Map consortium (www.metavcimap.org). Included cohorts comprised patients with available magnetic resonance imaging and multidomain cognitive assessment <15 months poststroke. In this individual patient data meta-analysis, linear mixed models were used to determine the association between WMH volume and domain-specific cognitive functioning (Z scores; attention and executive functioning, processing speed, language and verbal memory) for the total sample and stratified by infarct type. Preexisting brain injury was accounted for in the multivariable models and all analyses were corrected for the study site as a random effect.

RESULTS

In the total sample (67 years [SD, 11.5], 40% female), we found a dose-dependent inverse relationship between WMH volume and poststroke cognitive functioning across all 4 cognitive domains (coefficients ranging from -0.09 [SE, 0.04, P=0.01] for verbal memory to -0.19 [SE, 0.03, P<0.001] for attention and executive functioning). This relation was independent of acute infarct volume and the presence of lacunes and old infarcts. In stratified analyses, the relation between WMH volume and domain-specific functioning was also largely independent of infarct type.

CONCLUSIONS

In patients with ischemic stroke, increasing WMH volume is independently associated with worse cognitive functioning across all major domains, regardless of old ischemic lesions and infarct type.

Influence of Age, Gender and Education Level on Executive Functions and Functioning in People with Stroke

BACKGROUND

Alterations in mental functions are among the most frequent manifestations of stroke that have a direct impact on the patient's functionality. The objective of this study was to analyze the relationship of sociodemographic variables with the executive functions (EFs) of participants with right middle cerebral artery (MCA) stroke.

METHODS

A cross-sectional observational case-control study was conducted at the State Center for Brain Damage in Madrid, Spain. Fifty-eight subjects were recruited and divided into two groups. Each participant was administered the following: the FIM+FAM Functional Assessment Measure, the Lawton and Brody scale, The Trail-Making Test, the Zoo Map Test and the Hanoi Tower.

RESULTS

Statistically significant differences (p < 0.05) were identified between participants with ischemic stroke and control in functional and EF functions, as well as between participants with hemorrhagic stroke and control. No statistically significant differences were found in the experimental group between subjects who had sustained ischemic and hemorrhagic stroke. No significant associations were identified between the variables age, gender and education level in relation to functionality and executive functions (p > 0.05) in people with stroke.

CONCLUSION

People who have suffered a right cerebral artery stroke have deficiencies in the EFS, resulting in poorer performance of the activity of daily living, compared to healthy subjects of the same age, gender and education level. In the correlational analysis of the stroke participants, no significant associations were identified between the variables gender, age and education level in relation to functionality and EF.

Predictors for Late Post-Intracerebral Hemorrhage Dementia in Patients with Probable Cerebral Amyloid Angiopathy

BACKGROUND AND OBJECTIVE

Cerebral amyloid angiopathy (CAA) accounts for the majority of lobar intracerebral hemorrhage (ICH); however, the risk factors for dementia conversion after ICH occurrence in CAA patients are unknown, especially in the long-term period after ICH. Therefore, we aimed to unravel the predictors for late post-ICH dementia (6 months after ICH event) in probable CAA patients.

METHODS

From a large consecutive MRI prospective cohort of spontaneous ICH (2006-2017), we identified probable CAA patients (modified Boston criteria) without dementia 6 months post-ICH. Cognitive outcome during follow-up was determined based on the information from standardized clinical visit notes. We used Cox regression analysis to investigate the association between baseline demographic characteristics, past medical history, MRI biomarkers, and late post-ICH dementia conversion (dementia occurred after 6 months).

RESULTS

Among 97 non-demented lobar ICH patients with probable CAA, 25 patients (25.8%) developed dementia during a median follow-up time of 2.5 years (IQR 1.5-3.8 years). Pre-existing mild cognitive impairment, increased white matter hyperintensities (WMH) burden, the presence of disseminated cortical superficial siderosis (cSS), and higher total small vessel disease score for CAA were all independent predictors for late dementia conversion.

CONCLUSION

In probable CAA patients presenting with lobar ICH, high WMH burden and presence of disseminated cSS are useful neuroimaging biomarkers for dementia risk stratification. These findings have implications for clinical practice and future trial design.

Assessing Performance on Digital Clock Drawing Test in Aged Patients With Cerebral Small Vessel Disease

The term small vessel disease (SVD) encompasses all the pathological processes that affect the small vessels of the brain, including small arteries and arterioles but also capillaries and small veins, which can result in multi-domain cognitive deficits. The digital clock drawing test (dCDT) has been proved to be a more useful assessment tool for cognitive disorders compared to traditional clock drawing test DT (tCDT) in many neuropsychological diseases. This study aimed to check whether this tool worked well in capturing some specific aspects of cognitive performance in aged patients with SVD. A total of 20 aged patients with high-burden SVD (severe-SVD), 10 aged patients with low burden SVD (low-SVD), and 10 age-matched (healthy) individuals were grouped according to Fazekas' score. The dCDT and a series of neuropsychological assessments were performed to evaluate the cognitive function of participants. severe-SVD patients showed higher air-time percentage and lower mean handwriting/drawing pressure on surface during drawing compared with low-SVD and healthy subjects. The linear regression analysis adjusted for age, gender and education showed that the air-time percentage during drawing correlated with the choice reaction test (CRT) and the digit symbol substitution test (DSST), and the mean handwriting/drawing pressure on surface showed a limited correlation with DSST. The data indicated that some early manifestations of cognitive deficits in aged patients with SVD could be detected using the dCDT with a brand-new perspective different from the tCDT.

Making More of IT: Enabling Intensive Motor Cognitive Rehabilitation Exercises in Geriatrics Using Information Technology Solutions

Although the health benefits of physical activity and exercise for older people are well established, a largely sedentary lifestyle still prevails in ageing western societies. Finding new ways to make exercise more accessible and acceptable for older adults must be developed to fully unleash its potential in preventing and weakening age-related physical and cognitive decline. Existing barriers to implement effective exercise-based treatment plans include motivational reservations on both the clinician's and patient's side, but also physical limitations caused by disease or deconditioning. Particularly in the more senior population, debilitating conditions do not allow adherence to currently recommended exercise regimes. A major rethinking of age- and user-adapted exercise is overdue. The high intensities required for physical and mental adaptations must be modifiable and personalized according to the functional status of each patient. Emerging information and communication technologies (ICT) have brought forward a plethora of attractive solutions for smart and adapted exercise, but there remains a vast gap between technological advancement and clinical relevance. Where in the beginning ICT for active ageing mainly focussed on aspects of usability and user experience, the current status of IT as applied in ageing populations noticeably shifted toward new services, applications, and devices that can be offered with the aim to prevent, compensate, care, and/or enhance daily life functioning of senior citizens. In this perspective paper, we aim to summarize the current state of the art in ICT-based interventions aimed at improved motor-cognitive control and make suggestions about how these could be combined with high-intensive interval exercise regimes to make rehabilitation for the impaired older adults more effective, and more fun.

Gait and balance one year after stroke; relationships with lesion side, subtypes of cognitive impairment and neuroimaging findings-a longitudinal, cohort study

OBJECTIVES

The aims of this study are to investigate impairments of balance and gait in various types of dementia and cognitive impairment, and neuroimaging correlates in patients one year after first-ever stroke or transient ischemic attack.

DESIGN

This is a longitudinal cohort study.

PARTICIPANTS

180 participants were included and a total of 156 participated in the assessments at the one-year follow-up.

MAIN OUTCOME MEASURES

Measurements of balance and gait comprised the Berg Balance Scale (BBS) and the 10meter walk test (10MWT). Dementia was diagnosed with the International Classification of Diseases 10th revision. Magnet Resonance Imaging assessed vascular and degenerative changes in the brain. Multivariate linear regressions were conducted regarding associations between the motoric test performances, white matter lesions, lesion of the stroke and cognition.

RESULTS

Cognitive impairment was significant associated with BBS (β=-7.28, P=0.005) and MWS (β=1.89, P=0.046) in the linear regression analyses. An association between 10MWT to living arrangements (β=1.58, P=0.049) and lesion side of the stroke (β=-1.50, P=0.037) was also observed. Pairwise associations with Mann-Whitney U test showed that participants with mixed pathology differed significantly from degenerative pathology (P=0.04, z=-2.1) with more impaired balance measured by BBS.

CONCLUSIONS

Impaired balance and gait are associated with cognitive impairment, and a lesion in the right hemisphere is related to impaired gait in this cohort of stroke survivors.

Small Vessel Disease on Neuroimaging in a 75-Year-Old Cohort (PIVUS): Comparison With Cognitive and Executive Tests

Background and Purpose: Signs of small vessel disease (SVD) are commonly seen on magnetic resonance imaging (MRI) of the brain in cognitively healthy elderly individuals, and the clinical relevance of these are often unclear. We have previously described three different MRI manifestations of SVD as well as cerebral perfusion in a longitudinal study of non-demented 75-year-old subjects. The purpose of the present study was to evaluate the relationship of these findings to cognition and executive function at age 75 and changes after 5 years. Methods: In all, 406 subjects from the Prospective Investigation of the Vasculature in Uppsala Seniors (PIVUS) study were examined with MRI of the brain at age 75 years. Two-hundred and fifty of the subjects were re-examined 5 years later. White matter hyperintensities (WMHs) and lacunar infarcts (LIs) were assessed on both occasions, but microbleeds (MBs) and perfusion only at age 75. Cognitive function was screened by the Mini Mental State Examination (MMSE). Trail Making Test A and B (TMT-A and TMT-B) were performed at baseline and at follow-up at age 80. Results: At baseline, 93% performed >27 points in the MMSE. The TMT-B at age 75 was significantly related to WMH visual scoring after adjustment for sex, education and cerebrovascular disease risk factors (+80 s (95% CI 0.3-161 s), P < 0.05 for grade 2-3 vs. grade 0). Neither MMSE nor TMT-A was significantly related to WMH scoring. There was no relation between any test performance and WMH volume, white matter volume, number of MBs or brain perfusion at age 75. Subjects who had sustained a new LI (n = 26) showed a greater increase of the time to perform TMT-A at the 5-year follow-up (+25 s vs. +4 s in LI-free subjects, P = 0.003). Changes in MMSE or TMT-A and -B test performance between ages 75 and 80 were not related to changes in WMH scoring or volume during the 5 years follow-up, or to brain perfusion at age 75. Conclusion: In this cognitively healthy community-based population, moderate-severe WMHs and incident LIs on brain MRI in individuals aged 75-80 years were associated with a mild impairment of processing speed and executive function.

Only White Matter Hyperintensities Predicts Post-Stroke Cognitive Performances Among Cerebral Small Vessel Disease Markers: Results from the TABASCO Study

BACKGROUND

White matter hyperintensities (WMH) were shown to predict cognitive decline following stroke or transient ischemic attack (TIA). However, WMH are only one among other radiological markers of cerebral small vessel disease (SVD).

OBJECTIVE

The aim of this study was to determine whether adding other SVD markers to WMH improves prediction of post-stroke cognitive performances.

METHODS

Consecutive first-ever stroke or TIA patients (n = 266) from the Tel Aviv Acute Brain Stroke Cohort (TABASCO) study were enrolled. MRI scans were performed within seven days of stroke onset. We evaluated the relationship between cognitive performances one year following stroke, and previously suggested total SVD burden score including WMH, lacunes, cerebral microbleeds (CMB), and perivascular spaces (PVS).

RESULTS

Significant negative associations were found between WMH and cognition (p < 0.05). Adding other SVD markers (lacunes, CMB, PVS) to WMH did not improve predication of post-stroke cognitive performances. Negative correlations between SVD burden score and cognitive scores were observed for global cognitive, memory, and visual spatial scores (all p < 0.05). However, following an adjustment for confounders, no associations remained significant.

CONCLUSION

WMH score was associated with poor post-stroke cognitive performance. Adding other SVD markers or SVD burden score, however, did not improve prediction.

Robotic exoskeleton assessment of transient ischemic attack

We used a robotic exoskeleton to quantify specific patterns of abnormal upper limb motor behaviour in people who have had transient ischemic attack (TIA). A cohort of people with TIA was recruited within two weeks of symptom onset. All individuals completed a robotic-based assessment of 8 behavioural tasks related to upper limb motor and proprioceptive function, as well as cognitive function. Robotic task performance was compared to a large cohort of controls without neurological impairments corrected for the influence of age. Impairment in people with TIA was defined as performance below the 5^th percentile of controls. Participants with TIA were also assessed with the National Institutes of Health Stroke Scale (NIHSS) score, Chedoke-McMaster Stroke Assessment (CMSA) of the arm, the Behavioural Inattention Test (BIT), the Purdue pegboard test (PPB), and the Montreal Cognitive Assessment (MoCA). Age-related white matter change (ARWMC), prior infarction and cella-media index (CMI) were assessed from baseline CT scan that was performed within 24 hours of TIA. Acute infarction was assessed from diffusion-weighted imaging in a subset of people with TIA. Twenty-two people with TIA were assessed. Robotic assessment showed impaired upper limb motor function in 7/22 people with TIA patients and upper limb sensory impairment in 4/22 individuals. Cognitive tasks involving robotic assessment of the upper limb were completed in 13 participants, of whom 8 (61.5%) showed significant impairment. Abnormal performance in the CMSA arm inventory was present in 12/22 (54.5%) participants. ARWMC was 11.8 ± 6.4 and CMI was 5.4 ± 1.5. DWI was positive in 0 participants. Quantitative robotic assessment showed that people who have had a TIA display a spectrum of upper limb motor and sensory performance deficits as well as cognitive function deficits despite resolution of symptoms and no evidence of tissue infarction.

Cerebral small vessel disease and post-stroke cognitive impairment

Cerebral small vessel disease (CSVD) refers to a group of pathological processes with multifarious etiologies that affect the small arteries, arterioles, venules, and capillaries of the brain. Features seen on neuroimaging include white matter hyperintensities, lacunar infarction, cerebral microbleeds, brain atrophy, microinfarcts and enlarged perivascular spaces (EPVS). CSVD gives rise to one in five strokes worldwide and is a leading cause of cognitive impairment and dementia, especially in the elderly. Post-stroke cognitive impairment (PSCI) is one of the most common subtypes of cognitive impairment. The underlying mechanisms of PSCI are not known in detail. A growing body of evidence has been suggesting that CSVD plays an important role in the pathogenesis of PSCI. This article reviews the advances in research on the relationship between CSVD and PSCI.

Middle Cerebral Artery Pulsatility Index is Associated with Cognitive Impairment in Lacunar Stroke

BACKGROUND AND PURPOSE

Pulsatility index (PI) of the middle cerebral artery is postulated to reflect the vascular resistance in the artery distal of the probe, and has been reported to increase in small vessel disease, diabetes mellitus, ageing, and dementia. Lacunar infarcts are considered to be related to cognitive impairment. We therefore conducted a study to assess the association between cognitive impairment and PI in patients with a lacunar infarct.

METHODS

Consecutive patients presenting with an acute lacunar syndrome who were admitted to the stroke unit were enrolled. The patients were examined with Doppler ultrasonography of the intracranial arteries, and the PI of the middle cerebral artery was recorded. Cognitive function was evaluated by mini-mental state examination (MMSE), clock drawing test, and trail making test (TMT) A and B.

RESULTS

Among the 113 patients included, 85 patients had an acute lacunar infarct and 28 had one or more nonlacunar infarcts. The mean PI was 1.46 (SD = .33). PI was significantly (P < .05) associated with MMSE, TMT A and TMT B in patients with lacunar infarct, even after adjustment for multiple patient characteristics (age, sex, prestroke hypertension, smoking, previous stroke, and diabetes).

CONCLUSIONS

PI was associated with the cognitive performance in patients with lacunar infarcts and a lacunar syndrome. An elevated PI may be related to impairment in several cognitive domains. These findings suggest that transcranial Doppler ultrasonography could be an adjunct tool for early diagnosis of cognitive impairment after stroke.

Medial temporal lobe atrophy, white matter hyperintensities and cognitive impairment among Nigerian African stroke survivors

BACKGROUND

Neuroimaging features associated with vascular cognitive impairment have not been examined in sub-Saharan Africans. We determined magnetic resonance imaging (MRI) features associated with cognitive impairment in a sample of Nigerian stroke survivors.

METHODS

Stroke survivors underwent brain MRI with standardized assessment of brain volumes and visual rating of medial temporal lobe atrophy (MTA), and white matter hyperintensities (WMH) at 3 months post-stroke. Demographic, clinical and psychometric assessments of global cognitive function, executive function, mental speed and memory were related to changes in structural MRI.

RESULTS

In our pilot sample of 58 stroke survivors (60.1 ± 10.7 years old) MTA correlated significantly with age (r = 0.525), WMH (r = 0.461), memory (r = -0.702), executive function (r = -0.369) and general cognitive performance (r = -0.378). On univariate analysis, age >60 years (p = 0.016), low educational attainment (p < 0.001 to p < 0.003), total brain volume (p < 0.024 and p < 0.025) and MTA (p < 0.003 to p < 0.007) but not total WMH (p < 0.073, p = 0.610) were associated with cognitive outcome. In a two-step multivariate regression analysis, MTA (p < 0.035 and p < 0.016) and low educational attainment (p < 0.012 and p < 0.019) were sustained as independent statistical predictors of cognitive outcome.

CONCLUSIONS

Medial temporal lobe atrophy was a significant neuroimaging predictor of early post-stroke cognitive dysfunction in the Nigerian African stroke survivors. These observations have implications for a vascular basis of MTA in older stroke survivors among sub-Saharan Africans.

Cognitive state following stroke: the predominant role of preexisting white matter lesions

Background and purpose

Stroke is a major cause of cognitive impairment and dementia in adults, however the role of the ischemic lesions themselves, on top of other risk factors known in the elderly, remains controversial. This study used structural equation modeling to determine the respective impact of the new ischemic lesions' volume, preexisting white matter lesions and white matter integrity on post stroke cognitive state.

Methods

Consecutive first ever mild to moderate stroke or transient ischemic attack patients recruited into the ongoing prospective TABASCO study underwent magnetic resonance imaging scans within seven days of stroke onset and were cognitively assessed one year after the event using a computerized neuropsychological battery. The volumes of both ischemic lesions and preexisting white matter lesions and the integrity of the normal appearing white matter tissue were measured and their contribution to cognitive state was assessed using structural equation modeling path analysis taking into account demographic parameters. Two models were hypothesized, differing by the role of ischemic lesions' volume.

Results

Structural equation modeling analysis of 142 patients confirmed the predominant role of white matter lesion volume (standardized path coefficient β = −0.231) and normal appearing white matter integrity (β = −0.176) on the global cognitive score, while ischemic lesions' volume showed no such effect (β = 0.038). The model excluding the ischemic lesion presented better fit to the data (comparative fit index 0.9 versus 0.092).

Conclusions

Mild to moderate stroke patients with preexisting white matter lesions are more vulnerable to cognitive impairment regardless of their new ischemic lesions. Thus, these patients can serve as a target group for studies on cognitive rehabilitation and neuro-protective therapies which may, in turn, slow their cognitive deterioration.

Effect on anxiety and depression of a multifactorial risk factor intervention program after stroke and TIA: a randomized controlled trial

OBJECTIVES

Depression and anxiety related to stroke are caused by vascular lesions and psychological reactions. Treatment of vascular and modifiable behavioral risk factors reduces the risk of stroke and may also reduce the risk of emotional changes after stroke. We aimed to investigate whether a multifactorial risk factor intervention program in patients with first-ever stroke or transient ischemic attack (TIA) can influence post-stroke anxiety and depressive symptoms in patients one year post-stroke.

METHOD

The study population consisted of first-ever stroke and TIA patients allocated in a randomized, evaluator-blinded, controlled trial to care as usual or a structured and multidisciplinary follow-up including intensive treatment of vascular risk. The primary endpoint (cognition) has previously been reported. The secondary endpoint, reported here, was changes in the Hospital Anxiety and Depression Scale (HADS) from baseline to 12-month follow-up.

RESULTS

One hundred and ninety-five patients were randomized. The estimated difference between treatment groups, in changes in HADS, from baseline to 12 months was -1.32 (95% confidence interval: -2.61, -0.04; P = 0.044) in favor of the intervention group. One year post-stroke, 4/85 (4.7%) patients in the intervention group and 12/89 (13.5%) in the control group suffered from depression (P = 0.045), while 7/85 (8.2%) patients in the intervention group and 13/89 (14.6%) patients in the control group suffered from anxiety (P = 0.19).

CONCLUSION

A structured, multidisciplinary, multifactorial risk factor program including vascular risk factor management may be associated with reduced HADS scores and a lower prevalence of depressive symptoms one year after stroke.

Performance of an adult Brazilian sample on the Trail Making Test and Stroop Test

Objective

The Trail Making Test (TMT) and Stroop Test (ST) are attention tests widely used in clinical practice and research. The aim of this study was to provide normative data for the adult Brazilian population and to study the influence of gender, age and education on the TMT parts A and B, and ST cards A, B and C.

Methods

We recruited 1447 healthy subjects aged ≥18 years with an educational level of 0-25 years who were native speakers of Portuguese (Brazilian). The subjects were evaluated by the Matrix Reasoning and Vocabulary subtests of the Wechsler Adult Intelligence Scale-III, along with the TMTA, TMTB and ST A, B and C.

Results

Among the participants, mean intellectual efficiency was 103.20 (SD: 12.0), age 41.0 (SD: 16.4) years and education 11.9 (SD: 5.6) years. There were significant differences between genders on the TMTA (p=0.002), TMTB (p=0.017) and STC (p=0.024). Age showed a positive correlation with all attention tests, whereas education showed a negative correlation. Gender was not found to be significant on the multiple linear regression model, but age and education maintained their interference.

Conclusion

Gender did not have the major impact on attentional tasks observed for age and education, both of which should be considered in the stratification of normative samples.

[Executive function deficits following stroke]

BACKGROUND

Executive function deficit is a cognitive dysfunction resulting in a reduced ability to initiate, control and monitor targeted behaviour. Our clinical experience indicates that this often remains undiagnosed following stroke.

METHOD

The article is based on literature searches using the search terms «Stroke» and «Executive function» via the search engine McMaster Plus, in the databases Cochrane Library and PubMed, coupled with the authors' own experience.

RESULTS

Executive function deficit is a common form of stroke-related cognitive dysfunction which often accompanies emotional instability and depression. The condition is an important risk factor for loss of self-sufficiency and for reduced survival. Diagnosis is based on the patient's history and observation, supplemented by cognitive testing. Executive function deficits also occur in patients with no clinical signs of stroke, but who have image diagnostic signs of cerebral ischaemia, and with other cerebral diseases such as Parkinson's disease and dementia. Executive function is mainly located in the prefrontal cortex and the subcortical circuits, but executive function deficits are also seen in cases of lesions in other areas of the brain. The treatment of executive function deficits focuses on compensatory strategies and on recovery of lost function.

INTERPRETATION

Executive function deficits are common with stroke-related cognitive impairment, and may affect the prognosis. There is a need for systematic testing and strategies for treatment and prevention.