Cognitive Impairment in Transient Ischemic Attack Patients: A Systematic Review

Accelerometer-Measured Behavior Patterns in Incident Cerebrovascular Disease: Insights for Preventative Monitoring From the UK Biobank

BACKGROUND

The goal was to compare patterns of physical activity (PA) behaviors (sedentary behavior [SB], light PA, moderate-to-vigorous PA [MVPA], and sleep) measured via accelerometers for 7 days between patients with incident cerebrovascular disease (CeVD) (n=2141) and controls (n=73 938).

METHODS AND RESULTS

In multivariate models, cases spent 3.7% less time in MVPA (incidence rate ratio [IRR], 0.963 [95% CI, 0.929-0.998]) and 1.0% more time in SB (IRR, 1.010 [95% CI, 1.001-1.018]). Between 12 and 24 months before diagnosis, cases spent more time in SB (IRR, 1.028 [95% CI, 1.001-1.057]). Within the year before diagnosis, cases spent less time in MVPA (IRR, 0.861 [95% CI, 0.771-0.964]). Although SB time was not associated with CeVD risk, MVPA time, both total min/d (hazard ratio [HR], 0.998 [95% CI, 0.997-0.999]) and guideline threshold adherence (≥150 min/wk) (HR, 0.909 [95% CI, 0.827-0.998]), was associated with decreased CeVD risk. Comorbid burden had a significant partial mediation effect on the relationship between MVPA and CeVD. Cases slept more during 12:00 to 17:59 hours (IRR, 1.091 [95% CI, 1.002-1.191]) but less during 0:00 to 5:59 hours (IRR, 0.984 [95% CI, 0.977-0.992]). No between-group differences were significant at subgroup analysis.

CONCLUSIONS

Daily behavior patterns were significantly different in patients before CeVD. Although SB was not associated with CeVD risk, the association between MVPA and CeVD risk is partially mediated by comorbid burden. This study has implications for understanding observable behavior patterns in cerebrovascular dysfunction and may help in developing remote monitoring strategies to prevent or reduce cerebrovascular decline.

Cerebral hemodynamics and cognitive functions in the acute and subacute stage of mild ischemic stroke: a longitudinal pilot study

The association between cerebral hemodynamics and cognitive impairment has been reported in neurodegenerative and cerebrovascular disorders (CVD). However, it is still unclear whether changes occur in the acute phase of CVD. Here we investigated cognitive and hemodynamic parameters and their association in patients with CVD during the acute and subacute phases. Seventy-three patients with mild stroke, not undergoing endovascular treatment, were recruited. All subjects were devoid of intracranial or external carotid stenosis, significant chronic cerebrovascular pathology, dementia or non-compensated cardiovascular diseases. Patients were evaluated within 7 days from symptoms onset (T1) and after 3 months (T2). Clinical and demographic data were collected. NIHSS, MoCA, FAB, and Word-Color Stroop test (WCST) were used to evaluate disease severity and cognitive functions. Basal hemodynamic parameters in the middle cerebral artery were measured with transcranial Doppler. Differences between T2 and T1, correlations between cognitive and hemodynamic variables at T1 and T2, as well as correlations between the T2-T1 variation in cognitive and hemodynamic parameters were assessed. At T1, cognitive performance of MoCA, FAB, and WCST was lower compared with T2; and pulsatility index, a parameter reflecting distal vascular resistance, was higher. However, no correlations between the changes in cognitive and hemodynamic variables were found; therefore, the two seems to be independent phenomena. In the acute phase, the linear association between cerebral blood flow and cognitive performances was lost, probably due to a differential effect of microenvironment changes and vascular-specific phenomena on cognition and cerebral hemodynamics. This relationship was partially restored in the subacute phase.

Verbal and oral apraxia in patients with acute stroke: Frequency, relationship, and some risk factors

Verbal and oral apraxia are two possible consequences of stroke. It seems that there are not sufficient studies regarding the frequency of these disorders. This study aimed to evaluate the frequency of Verbal and oral apraxia. In addition, the relationship between apraxia and some variables such as age, gender, and education, as well as the relationship between types of apraxia with each other, and damaged areas of the brain in apraxia of the oral system in Persian-speaking patients with stroke were studied. In this descriptive-analytical study, 42 patients participated using the convenient sampling method. Verbal and oral apraxia were assessed using the oral and verbal apraxia tasks for adults test. Data were analyzed using independent t-test, Chi-square, and Fisher's exact test. The frequency of patients with oral apraxia was 35.7%, those with verbal apraxia was 2.3%, and the combination of both verbal and oral apraxia was 4.7%. People with apraxia were significantly older than those without apraxia. There was not any significant relationship between apraxia and gender, apraxia and education, and oral apraxia with verbal apraxia (p < 0.05). The present study's findings showed the high frequency of post-stroke apraxia and the high rate of its incidence with age.

Effects of a 1 year aerobic and strength training on cognitive functioning after transient ischemic attack or minor stroke: A randomized controlled trial

OBJECTIVES

Patients who have recently suffered a transient ischemic attack (TIA) or minor ischemic stroke are at increased risk of cognitive impairment. In the present study, we aimed to investigate the effect of a 1-year exercise intervention on cognitive functioning up to 2 years post intervention.

MATERIAL AND METHODS

We conducted a single-blind randomized controlled trial to investigate the effect of an exercise intervention on cognitive functioning, compared with usual care, for up to 2 years. Patients with a TIA or minor stroke were randomly allocated to an intervention group receiving the 1-year exercise intervention (n = 60) or to usual care (n = 59). Outcome measures were assessed at baseline and after 1 and 2 years. We measured cognition with neuropsychological tests on three domains: (1) executive functioning, (2) attention-psychomotor speed, and (3) memory. Linear mixed models were used for longitudinal data to determine the effect of the exercise intervention on cognitive functioning. Statistical analyses were performed using IBM SPSS software 24.0.

RESULTS

We found that over the two years study period -and corrected for age, sex, and educational level- the intervention group on average improved significantly more in executive functioning than the control group (β = 0.13; 95 % CI [0.02 to 0.25]; p = 0.03). No significant intervention effects were found on either memory or attention-psychomotor speed.

CONCLUSIONS

Our data show that a 1-year exercise intervention significantly improved executive functioning over time, compared to usual care. We recommend that health care professionals consider broadening standard secondary stroke prevention treatment in patients with TIA/minor stroke by adding exercise and physical activity.

Cognitive testing following transient ischaemic attack: A systematic review of clinical assessment tools

Cognitive deficits are prevalent after transient ischaemic attack (TIA) and result in loss of function, poorer quality of life and increased risks of dependency and mortality. This systematic review aimed to synthesise the available evidence on cognitive assessment in TIA patients to determine the prevalence of cognitive deficits, and the optimal tests for cognitive assessment. Medline, Embase, PsychINFO and CINAHL databases were searched for relevant articles. Articles were screened by title and abstract. Full-text analysis and quality assessment was performed using the National Institute of Health Tool. Data were extracted on study characteristics, prevalence of TIA deficits, and key study findings. Due to significant heterogeneity, meta-analysis was not possible. Twenty-five full-text articles met the review inclusion criteria. There was significant heterogeneity in terms of cognitive tests used, definitions of cognitive impairment and TIA, time points post-event, and analysis methods. The majority of studies used the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) (n = 23). Prevalence of cognitive impairment ranged from 2% to 100%, depending on the time-point and cognitive domain studied. The MoCA was more sensitive than the MMSE for identifying cognitive deficits. Deficits were common in executive function, attention, and language. No studies assessed diagnostic test accuracy against a reference standard diagnosis of cognitive impairment. Recommendations on cognitive testing after TIA are hampered by significant heterogeneity between studies, as well as a lack of diagnostic test accuracy studies. Future research should focus on harmonising tools, definitions, and time-points, and validating tools specifically for the TIA population.

Relation between sleep disorders and post-stroke cognitive impairment

Objective

To investigate the effects of sleep disorders on post-stroke cognitive impairment (PSCI) and other factors affecting post-stroke cognitive impairment.

Methods

A total of 1,542 first-ever stroke inpatients in department of neurology of Tianjin Huanhu Hospital from 2015.6.1 to 2016.12.31. We recorded the personal history of patients. The MMSE (mini-mental state examination), MoCA (Montreal Cognitive Assessment), HAMD (Hamilton Depression Scale), BI (Barthel index), mRS (Modified Rankin Scale), PSQI (Pittsburgh Sleep Quality Index), ESS (Epworth Sleepiness Scale), Berlin questionnaire, nocturnal TST (total sleep time) were assessed before discharge. All patients were followed up at 3 months, 6 months, and 4 years (2019-2020) after stroke. During follow-up, the above scales should be evaluated again to assess the sleep status and cognitive function of patients at that time.

Results

Nocturnal TST (>8 h) (OR 3.540, 95% CI 1.692-7.406, P = 0.001) was a risk factor for cognitive impairment 3 months after stroke. Nocturnal TST (<7 h) (OR 6.504, 95% CI 3.404-12.427, P < 0.001) was a risk factor for cognitive impairment 6 months after stroke. Low sleep quality (OR 2.079, 95% CI 1.177-3.672, P = 0.012), sleepiness (OR 3.988, 95% CI 1.804-8.818, P = 0.001), nocturnal TST (<7 h) (OR 11.334, 95% CI 6.365-20.183, P < 0.001), nocturnal TST (>8 h) (OR 4.096, 95% CI 1.682-9.975, P = 0.002) were risk factors for cognitive impairment 4 years after stroke. The prevalence of cognitive impairment with TIA were 79.3% at admission, 68.1% at 3-months follow-up, 62.1% at 6-months follow-up and 52.2% at 4-year follow-up.

Conclusion

Long or short nocturnal TST (<7 h or >8 h) was a risk factor for cognitive impairment after stroke (3 months, 6 months and 4 years). Poor sleep quality and sleepiness were shown to be risk factors for cognitive impairment at 4-year follow-up. Cognitive impairment was very common in patients with TIA.

Visualization of atrophy of medial temporal lobes and the septal nuclei in patients with transient ischaemic attack and controls

Introduction

Transient ischaemic attack (TIA) is associated with increased risk of cognitive decline and dementia as early as one-year post-event. Regional brain atrophy measurements may predict future cognitive decline. Aims: 1) To determine whether Medial Temporal Atrophy (MTA) scores and interseptal distance (ISD) measurements are greater in patients with TIA compared to controls; and 2) To determine whether MTA and ISD predicts cognitive change one year after TIA.

Methods

Baseline demographic, vascular risk factors, structural imaging and cognitive tests scores were compared between 103 Patients with TIA and 103 age-and-sex-matched controls from the Predementia Neuroimaging of Transient Ischaemic Attack (PREVENT) Study. MTA was assessed using the Schelten's Scale, and ISD was calculated as the distance between the septal nucleus of each hemisphere. Multiple linear regression models were used to evaluate how MTA and ISD related to cognitive change after adjusting for covariates.

Results

Patients with TIA had larger ISD measurements (1.4 mm [SD=1.2] vs. 0.9 mm [SD=1.0]); p < 0.001) and higher right/left MTA scores (both p < 0.05) compared to controls. At baseline, controls performed significantly better on the RAVLT (total recall), BVMT (total and delayed recall) and the Trail Making Task (A and B) compared to patients with TIA. However, at one-year follow-up there was no evidence of decline in the patients with TIA compared with controls. Higher MTA and ISD scores were not associated with cognitive decline.

Conclusions

Patients with TIA had higher MTA scores and ISD measurements than controls, but neither were predictors of cognitive decline at one year. Future studies with longer follow-up periods will be required to determine whether higher MTA scores and ISD predict risk of cognitive decline in patients with TIA.

Lasting impairments following transient ischemic attack and minor stroke: a systematic review protocol

Introduction

The focus on medical management and secondary prevention following Transient Ischemic Attack (TIA) and minor stroke is well-established. Evidence is emerging that people with TIA and minor stroke can experience lasting impairments as fatigue, depression, anxiety, cognitive impairment, and communication difficulties. These impairments are often underrecognized and inconsistently treated. Research in this area is developing rapidly and an updated systematic review is required to evaluate new evidence as it emerges. This living systematic review aims to describe the prevalence of lasting impairments and how they affect the lives of people with TIA and minor stroke. Furthermore, we will explore whether there are differences in impairments experienced by people with TIA compared to minor stroke.

Methods

Systematic searches of PubMed, EMBASE, CINAHL, PsycINFO, Cochrane Libraries will be undertaken. The protocol will follow the Cochrane living systematic review guideline with an update annually. A team of interdisciplinary reviewers will independently screen search results, identify relevant studies based on the defined criteria, conduct quality assessments, and extract data. This systematic review will include quantitative studies on people with TIA and/or minor stroke that report on outcomes in relation to fatigue, cognitive and communication impairments, depression, anxiety, quality of life, return to work/education, or social participation. Where possible, findings will be grouped for TIA and minor stroke and collated according to the time that follow-up occurred (short-term < 3 months, medium-term 3-12 months, and long-term > 12 months). Sub-group analysis on TIA and minor stroke will be performed based on results from the included studies. Data from individual studies will be pooled to perform meta-analysis where possible. Reporting will follow the Preferred Reporting Items for Systematic review and Meta-Analysis Protocol (PRISMA-P) guideline.

Perspectives

This living systematic review will collate the latest knowledge on lasting impairments and how these affect the lives of people with TIA and minor stroke. It will seek to guide and support future research on impairments emphasizing distinctions between TIA and minor stroke. Finally, this evidence will allow healthcare professionals to improve follow-up care for people with TIA and minor stroke by supporting them to identify and address lasting impairments.

Study protocol for a pilot randomised controlled trial evaluating the feasibility and effectiveness of non-pharmacological interventions to recover functionality after a transient ischaemic attack or a minor stroke: the 'Back to Normal' trial

INTRODUCTION

Transient ischaemic attack (TIA) and minor stroke are frequently assumed as temporary or non-disabling events. However, evidence suggests that these patients can experience relevant impairment and functional disability. Therefore, the present study aims to evaluate the feasibility and effectiveness of a 3-month multidomain intervention programme, composed of five non-pharmacological strategies, aimed at accelerating return to pre-event level of functionality in patients with TIA or minor stroke.

METHODS AND ANALYSIS

Patients diagnosed with a TIA or a minor stroke are being recruited at the emergency or neurology departments of the Hospital Pedro Hispano, located in Matosinhos, Portugal (n=70). Those who accept to participate will be randomly allocated to two groups (1:1): (a) Intervention-receives a 3 months combined approach, initiating early post-event, composed of cognitive training, physical exercise, nutrition, psychoeducation and assessment/correction of hearing loss; (b) Control-participants will not be subject to any intervention. Both groups will receive the usual standard of care provided to these diseases. Recruitment began in May 2022 and is expected to continue until March 2023. Socio-demographic characteristics, lifestyles, health status, cognitive function, symptoms of anxiety and depression and quality of life will be assessed; as well as anthropometry, blood pressure and physical condition. Time to complete or partial recovery of instrumental activities of daily living will be assessed using an adapted version of the Frenchay Activities Index. All participants will be evaluated before the intervention and after 3 months.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of the Local Health Unit of Matosinhos (Ref. 75/CES/JAS). Written informed consent will be required from all the participants; data protection and confidentiality will be also ensured. The findings of this project are expected to be submitted for publication in scientific articles, and the main results will be presented at relevant scientific meetings.

TRIAL REGISTRATION NUMBER

NCT05369637.

Working Memory Impairment in Transient Ischaemic Attack: N-back as a Sensitive Measure for Detection

BACKGROUND

Transient ischaemic attack (TIA) can lead to lasting changes in brain structure and function resulting in cognitive impairment. Cognitive screening tools may lack sensitivity for detecting cognitive impairments, particularly executive function, which tends to be the earliest affected domain in vascular cognitive impairment.

AIM

In this preliminary study, we examine a working memory (WMem) task as a sensitive measure of cognitive impairment in TIA.

METHOD

Patients referred to a TIA clinic for transient neurological symptoms completed a general cognitive screening tool (Montreal Cognitive Assessment; MoCA), and a WMem task (2-N-back) in a cross-sectional design.

RESULTS

TIA patients (n = 12) showed significantly reduced WMem performance on the N-back compared to patients diagnosed with mimic clinical conditions with overlapping symptoms (n = 16). No group differences were observed on the MoCA.

CONCLUSIONS

Assessing WMem may provide a sensitive measure of cognitive impairment after TIA, with implications for cognitive screening in TIA services to triage patients for further neuropsychological support, or for interventions to prevent vascular dementia.

Risk of dementia according to the smoking habit change after ischemic stroke: a nationwide population-based cohort study

There is a paucity of research regarding the association between the risk of incident dementia and changes in smoking habits in the acute ischemic stroke population. We aimed to investigate the effects of smoking habit change on the risk of incident dementia in an ischemic stroke population using data from the Korean National Health Insurance Services Database. This nationwide population-based cohort study included 197,853 patients with ischemic stroke. The patients were divided into never smokers, former smokers, smoking quitters, sustained smokers, and new smokers, based on the 2-year change in smoking status between the two consecutive health examinations before and after the index stroke. The patients were followed up from the index date to 2018 to assess the development of dementia. Dementia was further categorized into Alzheimer's, vascular, and other types of dementia according to the International Classification of Diseases, Tenth Revision diagnosis. Multivariable Cox proportional hazards models were used to assess the association between changes in smoking habits and the risk of dementia. After a median of 4.04 years of follow-up, 19,595 (9.9%) dementia cases were observed. Among them, 15,189 (7.7%) were diagnosed with Alzheimer's disease dementia and 2719 (1.4%) were diagnosed with vascular dementia. After adjusting for covariates, including age, sex, alcohol intake habits, cigarette pack-year, regular physical activity, income, history of hypertension, diabetes mellitus, dyslipidemia, and chronic kidney disease, new smokers, sustained smokers, and smoking quitters were significantly associated with a higher risk of all-cause dementia than never smokers (adjusted hazard ratio [aHR] 1.395, 95% confidence interval [CI] 1.254-1.552; aHR 1.324, 95% CI 1.236-1.418; and aHR 1.170, 95% CI 1.074-1.275, respectively). Similar trends were observed for both Alzheimer's dementia and vascular dementia, but the association between new smokers and vascular dementia was not significant. The impact of smoking habit change was more prominent in the 40-65-year-old group. New and sustained smokers had a substantially higher risk of incident dementia after ischemic stroke than never smokers. Smoking quitters also had an elevated risk of incident dementia, but the detrimental effects were lower than those in new and sustained smokers.

Effect of an exercise intervention on global cognition after transient ischemic attack or minor stroke: the MoveIT randomized controlled trial

Background

Patients with a transient ischemic attack (TIA) or ischemic stroke are at increased risk of developing cognitive impairment in the subacute phase. At present, the effects of exercise on cognitive functioning following a TIA or stroke are not fully known. The purpose of this trial was to investigate the effect of exercise on global cognition.

Methods

The MoveIT trial is a single-centre, observer-blinded, randomized controlled trial involving a 1-year exercise intervention consisting of a 12-week group exercise program, combined with three counselling visits to the physiotherapists over a 9-month period. The control group received standard care. The primary outcome was global cognitive functioning, assessed at one year, using the Montreal Cognitive Assessment (MoCA). Secondary outcomes included cardiorespiratory fitness, the cardiovascular profile, and attainment of secondary prevention targets, anxiety, depression and fatigue at one and two years.

Results

The experimental group consisted of 60 patients, while the control group consisted of 59 patients. The mean age was 64.3 years and 41% were female. No between-group differences were found on global cognitive functioning (MD, 0.7 out of 30, 95% CI, − 0.2 to 1.6) or on secondary outcome measures at 12 months. The only significant between-group difference was found for fatigue, in favour of the experimental group at 12 months (MD, 0.6 out of 63, 95% CI, 0.1 to 1.1).

Conclusions

No benefit of this exercise intervention was found regarding global cognition. Future studies need to focus on optimizing rehabilitation strategies for this vulnerable group of patients.

Trial registration

http://www.trialregister.nl. Unique identifier: NL3721.

Date first registration: 06-03-2013.

Periventricular white matter hyperintensities are associated with gait and balance in patients with minor stroke

Objective

Cerebral small vessel disease (CSVD) is associated with gait and balance deficits in older adults. However, the effect of CSVD-related brain injury on post-stroke mobility is unknown. This study aimed to investigate the association of CSVD with gait and balance impairment after a minor stroke.

Methods

A total of 273 patients with a minor stroke (NIHSS ≤ 5 points) who were hospitalized at the Affiliated Hospital of Qingdao University were enrolled. The manifestations of white matter hyperintensities (WMH), lacunes, enlarged perivascular spaces (EPVS), and cerebral microbleeds (CMB) were statistically analyzed according to magnetic resonance imaging results, and the total burden score of CSVD was calculated. Gait function was assessed by a 6-m walking speed test, and balance function was assessed by the timed-up-and-go (TUG) test. Linear regression analysis was applied to determine the association after adjusting for key variables.

Results

The correlation results showed that in patients with minor stroke, age, sex, smoking history, and the infarct site were associated with gait speed, and age and the infarct site were associated with the TUG test. In the univariate linear regression model, periventricular white matter hyperintensities (PVWMH), deep white matter hyperintensities (DWMH), and the total burden of CSVD were correlated with gait speed, while only PVWMH correlated with the TUG test. After adjusting for confounders, only PVWMH were independent predictors of gait speed (β = −0.089, p &lt; 0.05) and the TUG test (β = 0.517, p &lt; 0.05).

Conclusions

Our study confirmed that CSVD is associated with gait and balance disorders after a minor stroke. PVWMH are independent predictors of gait and balance disorders in patients with minor stroke. These findings should be confirmed in larger prospective studies.

Structured follow-up pathway to support people after transient ischaemic attack and minor stroke (SUPPORT TIA): protocol for a feasibility study and process evaluation

INTRODUCTION

People who experience transient ischaemic attack (TIA) and minor stroke have limited follow-up despite rapid specialist review in hospital. This means they often have unmet needs and feel abandoned following discharge. Care needs after TIA/minor stroke include information provision (diagnosis and stroke risk), stroke prevention (medication and lifestyle change) and holistic care (residual problems and return to work or usual activities). This protocol describes a feasibility study and process evaluation of an intervention to support people after TIA/minor stroke. The study aims to assess the feasibility and acceptability of (1) the intervention and (2) the trial procedures for a future randomised controlled trial of this intervention.

METHODS AND ANALYSIS

This is a multicentre, randomised (1:1) feasibility study with a mixed-methods process evaluation. Sixty participants will be recruited from TIA clinics or stroke wards at three hospital sites (England). Intervention arm participants will be offered a nurse or allied health professional-led follow-up appointment 4 weeks after TIA/minor stroke. The multifaceted intervention includes: a needs checklist, action plan, resources to support management of needs, a general practitioner letter and training to deliver the intervention. Control arm participants will receive usual care. Follow-up will be self-completed questionnaires (12 weeks and 24 weeks) and a clinic appointment (24 weeks). Follow-up questionnaires will measure anxiety, depression, fatigue, health related quality of life, self-efficacy and medication adherence. The clinic appointment will collect body mass index, blood pressure, cholesterol and medication. Assessment of feasibility and acceptability will include quantitative process variables (such as recruitment and questionnaire response rates), structured observations of study processes, and interviews with a subsample of participants and clinical staff.

ETHICS AND DISSEMINATION

Favourable ethical opinion was gained from the Wales Research Ethics Committee (REC) 1 (23 February 2021, REC reference: 21/WA/0036). Study results will be published in peer-reviewed journals and presented at conferences. A lay summary and dissemination strategy will be codesigned with consumers. The lay summary and journal publication will be distributed on social media.

TRIAL REGISTRATION NUMBER

ISRCTN39864003.

Influence of Previous General Anesthesia on Cognitive Impairment: An Observational Study Among 151 Patients

Introduction

Preoperative neurocognitive disorder (preO-NCD) is a common condition affecting 14–51. 7% of the elderly population. General anesthesia has already been associated with the one-year post-operative neurocognitive disorder (PostO-NCD), specifically, a deficit in executive function, measured by the Trail Making Test B (TMT-B), but its long-term effects on cognitive function have not been investigated. We aimed to detect preO-NCD prevalence in patients scheduled for cardiac surgery and further investigate the possible role of previous general anesthesia (pGA) in general preoperative cognitive status [measured via the Montreal Cognitive Assessment (MoCA)] and/or in executive functioning (measured via TMT-B).

Methods

In this observational, prospective study, 151 adult patients scheduled for elective cardiac surgery underwent MoCA and TMT-B. Data on age, education, pGA, comorbidities, and laboratory results were collected.

Results

We discovered a general cognitive function impairment of 79.5% and an executive function impairment of 22%. Aging is associated with an increased likelihood (OR 2.99, p = 0.047) and education with a decreased likelihood (OR 0.35, p = 0.0045) of general cognitive impairment, but only education was significantly associated with a decreased likelihood (OR 0.22, p = 0.021) of executive function impairment. While pGA did not significantly affect preO-NCD, a noteworthy interaction between aging and pGA was found, resulting in a synergistic effect, increasing the likelihood of executive function impairment (OR 9.740, p = 0.0174).

Conclusion

We found a high prevalence of preO-NCD in patients scheduled for cardiac surgery. General cognitive function impairment is highly associated with advancing age (not pGA). However, older patients with at least one pGA appeared to be at an increased risk of preO-NCD, especially executive function impairment, suggesting that TMT-B should be associated with MoCA in the preoperative cognitive evaluation in this population.

The Cognitive Sequelae of Transient Ischemic Attacks—Recent Insights and Future Directions

There is now considerable evidence that Transient Ischemic Attack (TIA) carries important sequelae beyond the risk of recurrent stroke, particularly with respect to peri-event and post-event cognitive dysfunction and subsequent cognitive decline. The occurrence of a TIA could provide an important window in understanding the relationship of early mixed vascular-neurodegenerative cognitive decline, and by virtue of their clinical relevance as a “warning” event, TIAs could also furnish the opportunity to act preventatively not only for stroke prevention but also for dementia prevention. In this review, we discuss the current state of the literature regarding the cognitive sequelae associated with TIA, reviewing important challenges in the field. In particular, we discuss definitional and methodological challenges in the study of TIA-related cognitive impairment, confounding factors in the cognitive evaluation of these patients, and provide an overview of the evidence on both transient and long-term cognitive impairment after TIA. We compile recent insights from clinical studies regarding the predictors and mediators of cognitive decline in these patients and highlight important future directions for work in this area.

Factors influencing follow-up care post-TIA and minor stroke: a qualitative study using the theoretical domains framework

Background

Follow-up care after transient ischaemic attack (TIA) and minor stroke has been found to be sub-optimal, with individuals often feeling abandoned. We aimed to explore factors influencing holistic follow-up care after TIA and minor stroke.

Methods

Qualitative semi-structured interviews with 24 healthcare providers (HCPs): 5 stroke doctors, 4 nurses, 9 allied health professionals and 6 general practitioners. Participants were recruited from three TIA clinics, seven general practices and one community care trust in the West Midlands, England. Interview transcripts were deductively coded using the Theoretical Domains Framework and themes were generated from coded data.

Results

There was no clear pathway for supporting people with TIA or minor stroke after rapid specialist review in hospital; consequently, these patients had limited access to HCPs from all settings (‘Environmental context and resources’). There was lack of understanding of potential needs post-TIA/minor stroke, in particular residual problems such as anxiety/fatigue (‘Knowledge’). Identification and management of needs was largely influenced by HCPs’ perceived role, professional training (‘Social professional role and identity’) and time constraints (‘Environmental context and resources’). Follow-up was often passive – with onerous on patients to seek support – and predominantly focused on acute medical management (‘Intentions’/‘Goal’).

Conclusions

Follow-up care post-TIA/minor stroke is currently sub-optimal. Through identifying factors which influence follow-up, we can inform guidelines and practical strategies to improve holistic healthcare.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07607-0.

Relationship between homocysteine levels and post-stroke cognitive impairment in female and male population: from a prospective multicenter study

Background and Objectives:

To investigate the relationship between homocysteine levels and post-stroke cognitive impairment (PSCI) in Chinese female and male populations with minor acute ischemic stroke or transient ischemic attack.

Materials and methods:

A total of 1070 participants with clinically confirmed acute minor ischemic stroke or transient ischemic attack and baseline homocysteine information from a nationwide multicenter prospective registry study in China were included in this study. Of these, 919 patients had cognitive assessments at 3-month follow-ups and 584 participants had cognitive assessments at 12-month follow-ups. The incidence of PSCI was defined as a Montreal Cognitive Assessment score ≤22. The differences in homocysteine levels and the incidence of PSCI were compared between female and male populations. Relationships between homocysteine levels and the incidence of PSCI in female and male populations were analyzed using multiple logistic regression, respectively.

Results:

Females had lower baseline homocysteine levels than males. Compared to males, females had lower education levels, lower rates of smoking and alcohol intake, and higher rates of diabetes and hypertension. No relationship was observed between elevated homocysteine level and 3-month PSCI incidence in either females or males. After adjusting the confounders, elevated baseline homocysteine significantly increased the 12-month PSCI risk (odds ratio 3.28, 95% confidence interval 1.47–7.34, P = 0.004) in females, but not in males (odds ratio 0.86, 95% confidence interval 0.49–1.49, P = 0.586).

Conclusion:

Elevated homocysteine levels increased the 12-month PSCI risk in females, but not in males with minor acute ischemic stroke or transient ischemic attack.

Increased 20-HETE Signaling Suppresses Capillary Neurovascular Coupling After Ischemic Stroke in Regions Beyond the Infarct

Neurovascular coupling, the process by which neuronal activity elicits increases in the local blood supply, is impaired in stroke patients in brain regions outside the infarct. Such impairment may contribute to neurological deterioration over time, but its mechanism is unknown. Using the middle cerebral artery occlusion (MCAO) model of stroke, we show that neuronal activity-evoked capillary dilation is reduced by ∼75% in the intact cortical tissue outside the infarct border. This decrease in capillary responsiveness was not explained by a decrease in local neuronal activity or a loss of vascular contractility. Inhibiting synthesis of the vasoconstrictive molecule 20-hydroxyeicosatetraenoic acid (20-HETE), either by inhibiting its synthetic enzyme CYP450 ω-hydroxylases or by increasing nitric oxide (NO), which is a natural inhibitor of ω-hydroxylases, rescued activity-evoked capillary dilation. The capillary dilation unmasked by inhibiting 20-HETE was dependent on PGE2 activation of endoperoxide 4 (EP4) receptors, a vasodilatory pathway previously identified in healthy animals. Cortical 20-HETE levels were increased following MCAO, in agreement with data from stroke patients. Inhibition of ω-hydroxylases normalized 20-HETE levels in vivo and increased cerebral blood flow in the peri-infarct cortex. These data identify 20-HETE-dependent vasoconstriction as a mechanism underlying capillary neurovascular coupling impairment after stroke. Our results suggest that the brain's energy supply may be significantly reduced after stroke in regions previously believed to be asymptomatic and that ω-hydroxylase inhibition may restore healthy neurovascular coupling post-stroke.

Carotid revascularization and cognitive impairment: the neglected role of cerebral small vessel disease

Carotid atherosclerosis is a pathological process that leads to narrowing of the vessel lumen and a consequent risk of stroke. Revascularization procedures such as carotid endarterectomy (CEA) and carotid stenting aim to reduce occurrence of stroke in selected patients. Due to the proven benefit and low intraoperative risk, CEA is currently the preferred choice in candidates for carotid revascularization. However, the risk of cognitive impairment subsequent to CEA has not been fully elucidated and is unclear whether certain conditions, such as frailty, may increase this risk. There is consistent evidence that shows that frail patients have higher risk of cognitive impairment after surgical procedure. Moreover, brain pre-existing conditions may play a role in cognitive impairment after CEA. Cerebral small vessel disease (SVD) is a pathology that involves microcirculation and is detectable with computed tomography or magnetic resonance. SVD shares common vascular risk factors with carotid atherosclerosis, is a major contributor to vascular cognitive impairment and vascular dementia, and has been proposed as a marker of brain frailty. In this review, we discuss the current evidence about the link between carotid revascularization and cognitive impairment and advance the hypothesis that SVD may play a relevant role in development of cognitive impairment after carotid revascularization.

Implementation of online psychosocial interventions for people with neurological conditions and their caregivers: A systematic review protocol

Background

As the burden of neurological conditions increases globally, online psychosocial interventions offer a potentially scalable solution to enabling healthcare access. However, their successful development and implementation require research into electronic healthcare implementation specifically.

Methods

Using a search strategy combining the concepts of implementation, electronic healthcare, psychosocial interventions and neurological conditions, we will conduct comprehensive electronic searches for primary implementation evidence in MEDLINE, EMBASE, PsycINFO, CINAHL, Scopus, SpeechBITE and NeuroBITE databases. Included studies will be analysed according to the Non-adoption, Abandonment, Scale-Up, Spread, and Sustainability framework, appraised using the Mixed-Methods Appraisal Tool and evaluated for theoretical underpinning in implementation science, with hybrid studies of effectiveness-implementation research classified according to the type of hybrid design.

Discussion

This review will be the first to use a theoretical underpinning in the Non-adoption, Abandonment, Scale-Up, Spread, and Sustainability framework to evaluate strengths and gaps in existing implementation research into online psychosocial interventions for people with neurological conditions and/or their caregivers. The results may be useful to provide direction and recommendations for future clinical implementation and research into online psychosocial interventions for people with neurological conditions and/or their caregivers.

Systematic review registration

PROSPERO 2020: CRD42020186387.

Quantifying changes over 1 year in motor and cognitive skill after transient ischemic attack (TIA) using robotics

Recent work has highlighted that people who have had TIA may have abnormal motor and cognitive function. We aimed to quantify deficits in a cohort of individuals who had TIA and measured changes in their abilities to perform behavioural tasks over 1 year of follow-up using the Kinarm Exoskeleton robot. We additionally considered performance and change over time in an active control cohort of migraineurs. Individuals who had TIA or migraine completed 8 behavioural tasks that assessed cognition as well as motor and sensory functionality in the arm. Participants in the TIA cohort were assessed at 2, 6, 12, and 52 weeks after symptom resolution. Migraineurs were assessed at 2 and 52 weeks after symptom resolution. We measured overall performance on each task using an aggregate metric called Task Score and quantified any significant change in performance including the potential influence of learning. We recruited 48 individuals to the TIA cohort and 28 individuals to the migraine cohort. Individuals in both groups displayed impairments on robotic tasks within 2 weeks of symptom cessation and also at approximately 1 year after symptom cessation, most commonly in tests of cognitive-motor integration. Up to 51.3% of people in the TIA cohort demonstrated an impairment on a given task within 2-weeks of symptom resolution, and up to 27.3% had an impairment after 1 year. In the migraine group, these numbers were 37.5% and 31.6%, respectively. We identified that up to 18% of participants in the TIA group, and up to 10% in the migraine group, displayed impairments that persisted for up to 1 year after symptom resolution. Finally, we determined that a subset of both cohorts (25-30%) experienced statistically significant deteriorations in performance after 1 year. People who have experienced transient neurological symptoms, such as those that arise from TIA or migraine, may continue to experience lasting neurological impairments. Most individuals had relatively stable task performance over time, with some impairments persisting for up to 1 year. However, some individuals demonstrated substantial changes in performance, which highlights the heterogeneity of these neurological disorders. These findings demonstrate the need to consider factors that contribute to lasting neurological impairment, approaches that could be developed to alleviate the lasting effects of TIA or migraine, and the need to consider individual neurological status, even following transient neurological symptoms.

Cerebral Hypoxia: Its Role in Age-Related Chronic and Acute Cognitive Dysfunction

Postoperative cognitive dysfunction (POCD) has been reported with widely varying frequency but appears to be strongly associated with aging. Outside of the surgical arena, chronic and acute cerebral hypoxia may exist as a result of respiratory, cardiovascular, or anemic conditions. Hypoxia has been extensively implicated in cognitive impairment. Furthermore, disease states associated with hypoxia both accompany and progress with aging. Perioperative cerebral hypoxia is likely underdiagnosed, and its contribution to POCD is underappreciated. Herein, we discuss the various disease processes and forms in which hypoxia may contribute to POCD. Furthermore, we outline hypoxia-related mechanisms, such as hypoxia-inducible factor activation, cerebral ischemia, cerebrovascular reserve, excitotoxicity, and neuroinflammation, which may contribute to cognitive impairment and how these mechanisms interact with aging. Finally, we discuss opportunities to prevent and manage POCD related to hypoxia.

Domain-Specific Cognitive Trajectories Among Patients with Minor Stroke or Transient Ischemic Attack in a 6-Year Prospective Asian Cohort: Serial Patterns and Indicators

BACKGROUND

Long-term post-stroke cognitive impairment (PSCI) has often been overlooked, especially among patients with minor stroke or transient ischemic attack (TIA).

OBJECTIVE

To assess 6-year domain-specific cognitive trajectories among survivors of minor stroke or TIA and to identify possible indicators associated with cognitive trajectories, as well as long-term and incident PSCI.

METHODS

Eligible participants completed cognitive and clinical assessments at baseline (2 weeks after stroke) and up to 5 follow-up visits in 6 years. Mixed linear models and generalized estimating equations were adopted to analyze longitudinal data and survival analysis to explore incident PSCI, controlling for demographic, clinical, and vascular indicators.

RESULTS

The prevalence of PSCI and mortality rate ranged from 34.6% to 53.7%, and 0 to 7.7% respectively, among 244 patients. Incidence of PSCI was 21.9%. While visual memory demonstrated a significant improvement (p <  0.05), other cognitive domains showed a fluctuating yet stable pattern across visits (all ps >  0.05). Besides age, baseline IQCODE (attention: -0.218 SD/y, executive function: -0.238 SD/y, visual memory: -0.266 SD/y), and MoCA improvement within 1 year (visuoconstruction: 0.007 SD/y, verbal memory: 0.012 SD/y) were associated with longitudinal cognitive changes. Baseline MoCA (OR = 0.66, 95% CI = [0.59-0.74]), MoCA improvement within 3-6 months (OR = 0.79, 95% CI = [0.71-0.89], and within 1 year (OR = 0.86, 95% CI = [0.76-0.96]) were associated with long-term PSCI, while baseline MoCA (OR = 0.76, 95% CI = [0.61-0.96]) was also associated with incident PSCI.

CONCLUSION

While most domains remained stable across-time, visual memory demonstrated an overall improvement. Short-term cognitive improvement could be an early indicator of long-term cognitive trajectory to identify individuals who may be resilient to PSCI.

Changes in Health-Related Quality of Life After Transient Ischemic Attack

IMPORTANCE

Numerous studies have found that patients diagnosed with TIA have decreased health-related quality of life, which has been interpreted as suggesting that patients with TIA have residual symptoms after the event. Studies assessing health status in the same patients before and after an event are lacking but may allow a direct determination of the association of TIA with postevent health status.

OBJECTIVE

To examine patient-reported health before transient ischemic attack (TIA) among individuals diagnosed with this event and evaluate change in patient-reported health after the event overall and by TIA characterization subgroups.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted among 236 patients with a clinical diagnosis of TIA from October 2015 to December 2017 in a large US health system that collects a patient-reported outcome measure in ambulatory setting as part of routine care. Included patients had patient-reported global health scale assessments completed as part of routine care before and after a TIA event. Data were analyzed from March through July 2020.

MAIN OUTCOMES AND MEASURES

The main outcome was Patient-Reported Outcome Measurement Information System Global Health (PROMIS GH) scale score before and after TIA. A change of 5 or more points in this score is considered clinically relevant. The secondary outcomes included change in patient-reported global health by clinical impression of the probability of a TIA event, pattern of neurological deficits, and short-term risk of stroke, as assessed by the ABCD2 score.

RESULTS

Among 263 patients who experienced TIA, mean (SD) age was 67.9 (13.4) years and 138 (52.5%) were women. The median (interquartile range) time between patient-reported global health scores was 152 (94-284) days. Mean (SD) baseline patient-reported global physical health and mental health scale summary scores were 43.4 (8.2) and 47.7 (9.7), respectively, and were statistically significantly decreased compared with the general population mean (SD) scores of 50 (10; P < .001) for physical and mental health. The difference between physical health summary score among study participants and the general population was clinically relevant. Mean (SD) summary scores were not statistically significantly different after the event compared with before the event overall (physical health: 44.1 [8.2], for a mean [SE] improvement of 0.65 [0.38] points; P = .09; mental health: 47.4 [9.1], for a mean [SE] worsening of 0.25 [0.38] points; P = .51) or within subgroups.

CONCLUSIONS AND RELEVANCE

These findings suggest that impaired health status among patients diagnosed with TIA reflect, at least in part, an impaired premorbid state of health. This study did not find that TIA events were associated with worsening of health status overall or within subgroups.

Altered Functional Connectivity and Cognition Persists 4 Years After a Transient Ischemic Attack or Minor Stroke

Background and Purpose: Altered executive functions and resting-state functional connectivity (rsFC) are common following a minor stroke or transient ischemic attack (TIA). However, the long-term persistence of these abnormalities is not well-studied. We investigated whether there were cognitive and rsFC differences between (a) controls and minor cerebrovascular event (CVE) patients and (b) between CVE patients with and without an imaging confirmed infarct (i.e., minor stroke and TIA, respectively) at an average of 3.8 years following their event.

Methods: Structural and resting-state imaging and cognitive assessments including the Montreal Cognitive Assessment, the Trail Making Task and the National Institute of Health (NIH) Cognition Toolbox were conducted on 42 patients (minor stroke = 17, TIA = 25) and 20 healthy controls (total N = 62).

Results: Controls performed better than patients on two measures of executive functioning (both p < 0.046) and had reduced rsFC between the frontoparietal and default mode networks (FPN and DMN, respectively; p = 0.035). No cognitive differences were found between minor stroke and TIA patients, however, rsFC differences were found within the FPN and the DMN (both p < 0.013). Specifically, increased connectivity within the FPN was associated with faster performance in the minor stroke group but not the TIA group (p = 0.047).

Conclusions: These findings suggest that transient or relatively minor cerebrovascular events are associated with persistent disruption of functional connectivity of neural networks and cognitive performance. These findings suggest a need for novel interventions beyond secondary prevention to reduce the risk of persistent cognitive deficits.

Acupuncture May Decrease the Incidence of Post-stroke Dementia: A Taiwan Nationwide Retrospective Cohort Study

Background: Post-stroke dementia may affect up to one-third of stroke survivors. Acupuncture as a complementary treatment for stroke has been shown to be beneficial for subsequent post-stroke rehabilitation. The purpose of this retrospective cohort study was to investigate the potential effect of acupuncture to protect stroke patients from dementia.

Methods: We included 9,547 patients receiving ambulatory or hospital care for stroke and 9.547 non-stroke patients; patients were matched for sex, age, and Charlson Comorbidity Index. Each individual was traced for the subsequent development of dementia. Two thousand four hundred and forty-nine stroke patients received acupuncture treatment and 7,098 residue stroke patients without acupuncture treatment served as control groups. This is a 3-year follow-up cohorts study: the incidence and adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of post- stroke dementia in the Cox proportional hazard regression.

Results: During the 3-year follow-up, 1,403 patients with stroke (14.70%) and 427 patients without stroke (4.47%) developed dementia. The adjusted HRs of development of dementia among stroke patients were 3.64-times (range, 3.27–4.06), and the incidence of dementia was higher in male. Stroke patients receiving acupuncture treatment had a lower probability of dementia than those without acupuncture during the follow-up period, the adjusted HRs was 0.49 (95% CI, 0.42–0.58; p < 0.001).

Conclusions: The association between stroke and dementia existed in both sexes, more prominent in male. Patients with stroke receiving acupuncture treatments showed decreased risk of dementia. Care must be taken evaluating these results because this study was limited to lack of information regarding lifestyles, stroke severities, and acupuncture methods that were used in treatments.

Rates, risks and routes to reduce vascular dementia (R4vad), a UK-wide multicentre prospective observational cohort study of cognition after stroke: Protocol

BACKGROUND

Stroke commonly affects cognition and, by definition, much vascular dementia follows stroke. However, there are fundamental limitations in our understanding of vascular cognitive impairment, restricting understanding of prevalence, trajectories, mechanisms, prevention, treatment and patient-service needs.

AIMS

Rates, Risks and Routes to Reduce Vascular Dementia (R4VaD) is an observational cohort study of post-stroke cognition. We aim to recruit a wide range of patients with stroke, presenting to geographically diverse UK hospitals, into a longitudinal study to determine rates of, and risk factors for, cognitive and related impairments after stroke, to assess potential mechanisms and improve prediction models.

METHODS

We will recruit at least 2000 patients within six weeks of stroke with or without capacity to consent and collect baseline demographic, clinical, socioeconomic, lifestyle, cognitive, neuropsychiatric and informant data using streamlined patient-centred methods appropriate to the stage after stroke. We will obtain more detailed assessments at four to eight weeks after the baseline assessment and follow-up by phone and post yearly to at least two years. We will assess diagnostic neuroimaging in all and high-sensitivity inflammatory markers, genetics, blood pressure and diffusion tensor imaging in mechanistic sub-studies.Planned outputs: R4VaD will provide reliable data on long-term cognitive function after stroke, stratified by prior cognition, stroke- and patient-related variables and improved risk prediction. It will create a platform enabling sharing of data, imaging and samples. Participants will be consented for re-contact, facilitating future clinical trials and providing a resource for the stroke and dementia research communities.

Post-Stroke Working Memory Dysfunction: A Meta-Analysis and Systematic Review

This review investigates the severity and nature of post-stroke working memory deficits with reference to the multi-component model of working memory. We conducted a systematic search in PubMed up to March 2019 with search terms for stroke and memory. Studies on adult stroke patients, that included a control group, and assessed working memory function, were selected. Effect sizes (Hedges' g) were extracted from 50 studies (in total 3,084 stroke patients) based on the sample size, mean and standard deviation of patients and controls. Performance of stroke patients was compared to healthy controls on low-load (i.e. capacity) and high-load (executively demanding) working memory tasks, grouped by modality (verbal, non-verbal). A separate analysis compared patients in the sub-acute and the chronic stage. Longitudinal studies and effects of lesion location were systematically reviewed. Stroke patients demonstrated significant deficits in working memory with a moderate effect size for both low-load (Hedges' g = -.58 [-.82 to -.43]) and high-load (Hedges' g = -.59 [-.73 to -.45]) tasks. The effect sizes were comparable for verbal and non-verbal material. Systematically reviewing the literature showed that working memory deficits remain prominent in the chronic stage of stroke. Lesions in a widespread fronto-parietal network are associated with working memory deficits. Stroke patients show decrements of moderate magnitude in all subsystems of working memory. This review clearly demonstrates the global nature of the impairment in working memory post-stroke.

Bridging therapy is associated with improved cognitive function after large vessel occlusion stroke - an analysis of the German Stroke Registry

BACKGROUND

The targeted use of endovascular therapy (EVT), with or without intravenous thrombolysis (IVT) in acute large cerebral vessel occlusion stroke (LVOS) has been proven to be superior compared to IVT alone. Despite favorable functional outcome, many patients complain about cognitive decline after EVT. If IVT in addition to EVT has positive effects on cognitive function is unclear.

METHODS

We analyzed data from the German Stroke Registry (GSR, an open, multicenter and prospective observational study) and compared cognitive function 90 days after index ischemic stroke using MoCA in patients with independent (mRS ≤ 2 pts) and excellent (mRS = 0 pts) functional outcome receiving combined EVT and IVT (EVT + IVT) vs. EVT alone (EVT-IVT).

RESULTS

Of the 2636 GSR patients, we included 166 patients with mRS ≤ 2 at 90 days in our analysis. Of these, 103 patients (62%) received EVT + IVT, 63 patients (38%) were treated with EVT alone. There was no difference in reperfusion status between groups (mTICI ≥ 2b in both groups at 95%, p = 0.65). Median MoCA score in the EVT + IVT group was 20 pts. (18-25 IQR) vs. 18 pts. (16-21 IQR) in the EVT-IVT group (p = 0.014). There were more patients with cognitive impairment (defined as MoCA < 26 pts) in the EVT-IVT group (54 patients (86%)) compared to the EVT + IVT group (78 patients (76%)). EVT + IVT was associated with a higher MoCA score at 90 days (mRS ≤ 2: p = 0.033, B = 2.39; mRS = 0: p = 0.021, B = 4.38).

CONCLUSIONS

In Patients with good functional outcome after LVOS, rates of cognitive impairment are lower with combined EVT and IVT compared to EVT alone.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03356392.

Cognition in the First Year After a Minor Stroke, Transient Ischemic Attack, or Mimic Event and the Role of Vascular Risk Factors

Background: Cognitive impairment following a minor stroke or transient ischemic attack (TIA) is common; however, due to diagnostic difficulties, the prevalence and underlying cause of impairment remain poorly defined. We compared cognition in patients after a minor stroke, TIA, or mimic event at three time points in the first year following the event. We examine whether cognitive impairment occurs following these events and whether this impairment differs based on the event type. Further, we measure whether these findings persist after controlling for age, education, and the presence of vascular risk factors and whether the presence of vascular risk factors, independent of event etiology, is associated with cognitive impairment. Lastly, we investigate whether increased stroke risk, as assessed by the ABCD2, is associated with reduced cognition.

Methods: Medical information, a cognitive screening test, and a measure of executive functioning were collected from 613 patients (123 minor stroke, 175 TIA, and 315 mimics) using phone interviews at three time points in the first year following the event. Linear mixed models were used to determine the effect of event type, vascular risk factors, and predicted stroke risk on cognitive performance while controlling for confounders.

Results: There was no relationship between event type and performance on either cognitive measure. When all confounders are controlled for, performance on the cognitive screening test was uniquely accounted for by the presence of heart failure, myocardial infarction, angina, and hypertension (all p < 0.047), whereas the measure of executive functioning was uniquely accounted for by the presence of hypertension and angina (all p < 0.032). Increased stroke risk also predicted performance on the cognitive screening test and the measure of executive functioning (all p < 0.002).

Conclusions: Our findings indicate that cognitive impairment following a minor stroke or TIA may be attributed to the high prevalence of chronic vascular risk factors in these patients. This highlights the importance of long-term management of vascular risk factors beyond event recovery to reduce the risk of cognitive impairment. Increased stroke risk (i.e., ABCD2 score) was also associated with reduced cognition, suggesting that it may be helpful in signaling the need for further cognitive evaluation and intervention post-event.

Updated Approach to Stroke Rehabilitation

This article summarizes stroke rehabilitation, with a particular focus on rehabilitation from acute diagnosis to chronic impairments of stroke. The emphasis is on both pharmacologic and nonpharmacologic intervention and interdisciplinary collaboration.

TIA and minor stroke: a qualitative study of long-term impact and experiences of follow-up care

Background

Transient ischaemic attack (TIA) and minor stroke are often considered transient events; however, many patients experience residual problems and reduced quality of life. Current follow-up healthcare focuses on stroke prevention and care for other long-term problems is not routinely provided.

We aimed to explore patient and healthcare provider (HCP) experiences of residual problems post-TIA/minor stroke, the impact of TIA/minor stroke on patients’ lives, and current follow-up care and sources of support.

Methods

This qualitative study recruited participants from three TIA clinics, seven general practices and one community care trust in the West Midlands, England. Semi-structured interviews were conducted with 12 TIA/minor stroke patients and 24 HCPs from primary, secondary and community care. Data was analysed using framework analysis.

Results

A diverse range of residual problems were reported post-TIA/minor stroke, including psychological, cognitive and physical impairments. Consultants and general practitioners generally lacked awareness of these long-term problems; however, there was better recognition among nurses and allied HCPs. Residual problems significantly affected patients’ lives, including return to work, social activities, and relationships with family and friends. Follow-up care was variable and medically focused. While HCPs prioritised medical investigations and stroke prevention medication, patients emphasised the importance of understanding their diagnosis, individualised support regarding stroke risk, and addressing residual problems.

Conclusion

HCPs could better communicate information about TIA/minor stroke diagnosis and secondary stroke prevention using lay language, and improve their identification of and response to important residual impairments affecting patients.

[Mild cognitive impairment: what's next?]

The concept of mild cognitive impairment is one of the promising directions for studying the predementia stages of different diseases. The feasibility of studying this phenomenon is due not only to a high risk of dementia, but also the potential reversibility of cognitive decline in old age. Long-term follow-up of patients shows different trajectories of cognitive decline in aging. The study of risk factors for the progression of moderate cognitive impairment provided an opportunity to highlight new horizons of prevention of dementia of various etiologies. Despite the insufficient effectiveness of drug therapy in patients with moderate cognitive impairment, exploring the opportunities for possible treatment of their subtypes seems promising from the point of view of improving clinical symptoms and a possible reduction in the rate of disease progression.

Long-term neuropsychological sequelae, emotional wellbeing and quality of life in patients with acquired thrombotic thrombocytopenic purpura

Neurological symptoms related to microthrombosis are the hallmark of acute manifestations of acquired thrombotic thrombocytopenic purpura (TTP). Despite the achievement of hematological remission, patients may report persisting neurological impairment that affects their quality of life. To assess the long-term neuropsychological consequences of acute TTP, we recruited 35 acquired TTP patients (77% females, median age at onset 41 years, interquartile range: 35–48) regularly followed at our out-patient clinic of thrombotic microangiopathies in Milan (Italy) from December 2015 to October 2016. Patients underwent a psychological evaluation of memory and attentional functions, emotional wellbeing and health-related quality of life at least three months after their last acute TTP event (median 36 months, interquartile range: 17–54). During the psychological consultation, 17 patients (49%) referred persisting subjective neurological impairment in the frame of a remission phase, with at least one symptom as disorientation, loss of concentration, dizziness, lack of balance, headache and diplopia. Neuropsychological assessment revealed lower scores than the Italian general population pertaining to direct, indirect and deferred memory. A higher degree of impairment of memory domains was found in patients with neurological involvement at the time of presentation of the first acute TTP episode. Anxiety and depression were detected in seven (20%) and 15 (43%) patients, respectively. Health-related quality of life was lower than the Italian general population, with mental domains more impacted than physical domains (mean difference 58.43, 95% confidence interval: 71.49–45.37). Our study demonstrates compromised memory and attention functions, persisting anxiety/depression symptoms and a generally reduced quality of life in patients recovering from acute acquired TTP. New clinical strategies should be considered to improve these symptoms.

Incidence and prevalence of dementia associated with transient ischaemic attack and stroke: analysis of the population-based Oxford Vascular Study

BACKGROUND

Risk of dementia after stroke is a major concern for patients and carers. Reliable data for risk of dementia, particularly after transient ischaemic attack or minor stroke, are scarce. We studied the risks of, and risk factors for, dementia before and after transient ischaemic attack and stroke.

METHODS

The Oxford Vascular Study is a prospective incidence study of all vascular events in a population of 92 728 people residing in Oxfordshire, UK. Patients with transient ischaemic attack or stroke occurring between April 1, 2002, and March 31, 2012, were ascertained with multiple methods, including assessment in a dedicated daily emergency clinic and daily review of all hospital admissions. Pre-event and post-event (incident) dementia were diagnosed at initial assessment and during 5-years' follow-up on the basis of cognitive testing supplemented by data obtained from hand searches of all hospital and primary care records. We assessed the association between post-event dementia and stroke severity (as measured with the US National Institutes of Health Stroke Scale [NIHSS] score), location (ie, dysphasia), previous events, markers of susceptibility or reserve (age, low education, pre-morbid dependency, leucoaraiosis), baseline cognition, and vascular risk factors with Cox regression models adjusted for age, sex, and education. We compared incidence and prevalence of dementia in our population with published UK population age-matched and sex-matched rates.

FINDINGS

Among 2305 patients (mean age 74·4 years [SD 13·0]), 688 (30%) had transient ischaemic attacks and 1617 (70%) had strokes. Pre-event dementia was diagnosed in 225 patients; prevalence was highest in severe stroke (ie, NIHSS >10) and lowest in transient ischaemic attack. Of 2080 patients without pre-event dementia, 1982 (95%) were followed up to the end of study or death. Post-event dementia occurred in 432 of 2080 patients during 5 years of follow-up. The incidence of post-event dementia at 1 year was 34·4% (95% CI 29·7-41·5) in patients with severe stroke (NIHSS score >10), 8·2% (6·2-10·2) in those with minor stroke (NIHSS score <3), and 5·2% (3·4-7·0) in those with transient ischaemic attack. Compared with the UK age-matched and sex-matched population, the 1-year standardised morbidity ratio for the incidence of dementia was 47·3 (95% CI 35·9-61·2), 5·8 (4·4-7·5), and 3·5 (2·5-4·8), respectively. Consequently, prevalence of dementia in 1-year survivors was brought forward by approximately 25 years in those who had severe strokes, 4 years in those who had minor strokes, and 2 years in those who had transient ischaemic attacks. 5-year risk of dementia was associated with age, event severity, previous stroke, dysphasia, baseline cognition, low education, pre-morbid dependency, leucoaraiosis, and diabetes (p<0·0001 for all comparisons, except for previous stroke [p=0·006]).

INTERPRETATION

The incidence of dementia in patients who have had a transient ischaemic attack or stroke varies substantially depending on clinical characteristics including lesion burden and susceptibility factors. Incidence of dementia is nearly 50 times higher in the year after a major stroke compared with that in the general population, but excess risk is substantially lower after transient ischaemic attack and minor stroke.

FUNDING

Wellcome Trust, Wolfson Foundation, British Heart Foundation, National Institute for Health Research, and the National Institute for Health Research Oxford Biomedical Research Centre.

Screening for cognitive impairment with the Montreal Cognitive Assessment in Spanish patients with minor stroke or transient ischaemic attack

OBJECTIVE

The symptoms of minor stroke and transient ischemic attack (TIA) are temporary and mild. Despite the transient nature of the focal symptoms and the absence of visible brain lesions in some patients, many experience persistent cognitive problems subsequently. We aimed to establish the discriminant capacity of the Montreal Cognitive Assessment (MoCA) in screening for cognitive impairment (CI) within 90 days of TIA.

METHOD

A total of 50 patients with minor stroke or TIA were recruited. Patients were administered the MoCA test and a formal neuropsychological test battery. CI was defined clinically according to neuropsychological test findings.

RESULTS

The average age of recruited patients was 57.7±8.0 years; 70.0% were men; all patients had completed at least primary education. Thirty-seven patients (74.0%) presented CI. Receiver operating characteristic curve analysis obtained an optimal MoCA cut-off point of 25 for discriminating between patients with CI and those without, with an area under the curve of 0.835 (95% confidence interval [95% CI] 0.720-0.949), sensitivity of 78.4% (95% CI 62.8-88.6%), specificity of 76.9% (95% CI 49.7-91.8%), positive predictive value of 90.6% (95% CI 81.0-95.6%), and negative predictive value of 55.6% (95% CI 39.5-70.4%).

CONCLUSIONS

More than half of the patients presented CI as determined by the formal battery of neuropsychological tests. A MoCA cut-off point of 25 is sufficiently sensitive and specific for detecting CI after minor stroke or TIA, and may be implemented as a screening technique in routine clinical practice.

Vascular Mild Cognitive Impairment: Identifying Disease in Community-Dwelling Older Adults, Reducing Risk Factors, and Providing Support. The Osaki-Tajiri and Kurihara Projects

Vascular mild cognitive impairment (MCI) is a critical disease. Its prognosis includes not only onset of vascular dementia, but also death by cardiovascular disease. The vascular risk factors for vascular MCI are treatable, and appropriate treatment can prevent or delay the progression to dementia. Therefore, this group is an excellent candidate for secondary prevention. However, community-dwelling older adults with vascular MCI are often undetected and are not clinically identified until they develop frank dementia. Furthermore, older adults with undetected vascular MCI often have decreased ability to follow their medication regimens and this poor medication adherence worsens their vascular comorbidities. This vicious cycle needs to be prevented through community-based interventions. There is evidence that treatment of hypertension or diabetes mellitus could lead to a reduced incidence of vascular MCI and dementia. In this review article, we first explain the background and etiology of vascular MCI. We then summarize phenotype of subcortical vascular dementia which is often unrecognized or "hidden" in the community. Then we introduce the Osaki-Tajiri and Kurihara Projects which have been conducted in Northern Japan, as an example of prevention projects aimed to identify early-stage vascular MCI in the community, reduce the risk factors and facilitate their treatment. Early identification of vascular MCI in the community could lead to a large reduction in the dementia burden worldwide. The outreach efforts presented here could be useful in developing secondary prevention strategies targeted to vascular MCI.

Evaluating the Impact of Personalized Stroke Management Tool Kits on Patient Experience and Stroke Recovery

Hallmarks of the difficult period of transition from hospital to home following stroke include stroke survivor and caregiver uncertainty about actionable steps toward recovery and prevention and unfamiliarity with related resources. Current research shows that interdisciplinary interventions focusing on patient experience and patient education enable health-care providers to activate and empower patients, potentially leading to better clinical outcomes. Tool kit approaches have been successfully used to aid patients through ongoing education after hospital discharge and to improve patient experience. In this article, we describe our efforts to iteratively develop and test personalized stroke management tool kits aimed at connecting stroke survivors and their caregivers to empowering resources, while soliciting feedback from patients and family members.

Patient-reported outcomes across cerebrovascular event types: More similar than different

OBJECTIVES

To compare the degrees to which 8 domains of health are affected across types of cerebrovascular events and to identify factors associated with domain scores in different event types.

METHODS

This was an observational cohort study of 2,181 patients with ischemic stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or TIA in a cerebrovascular clinic from February 17, 2015, to June 2, 2017 who completed Quality of Life in Neurologic Disorders executive function and the following Patient-Reported Outcomes Measurement Information System scales as part of routine care: physical function, satisfaction with social roles, fatigue, anxiety, depression, pain interference, and sleep disturbance.

RESULTS

All health domains were affected to similar degrees in patients with ICH, SAH, and ischemic stroke after adjustment for disability and other clinical factors, whereas patients with TIA had worse adjusted scores for 5 of the 8 domains of health. Female sex, younger age, lower income, and event <90 days were associated with worse scores in multiple domains. Factors associated with health domain scores were similar for all cerebrovascular events. Most affected domains for all were physical function, satisfaction with social roles, and executive function.

CONCLUSIONS

The subtype of stroke (ischemic stroke, ICH, and SAH) had similar effects in multiple health domains, while patients with TIA had worse adjusted outcomes, suggesting that the mechanisms for outcomes after TIA may differ from those of other cerebrovascular events. The most affected domains across all event types were physical function, satisfaction with social roles, and executive function, highlighting the need to develop effective interventions to improve these health domains in survivors of these cerebrovascular events.

Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus

BACKGROUND

Diabetes mellitus is associated with an increased risk of cardiovascular events. Aspirin use reduces the risk of occlusive vascular events but increases the risk of bleeding; the balance of benefits and hazards for the prevention of first cardiovascular events in patients with diabetes is unclear.

METHODS

We randomly assigned adults who had diabetes but no evident cardiovascular disease to receive aspirin at a dose of 100 mg daily or matching placebo. The primary efficacy outcome was the first serious vascular event (i.e., myocardial infarction, stroke or transient ischemic attack, or death from any vascular cause, excluding any confirmed intracranial hemorrhage). The primary safety outcome was the first major bleeding event (i.e., intracranial hemorrhage, sight-threatening bleeding event in the eye, gastrointestinal bleeding, or other serious bleeding). Secondary outcomes included gastrointestinal tract cancer.

RESULTS

A total of 15,480 participants underwent randomization. During a mean follow-up of 7.4 years, serious vascular events occurred in a significantly lower percentage of participants in the aspirin group than in the placebo group (658 participants [8.5%] vs. 743 [9.6%]; rate ratio, 0.88; 95% confidence interval [CI], 0.79 to 0.97; P=0.01). In contrast, major bleeding events occurred in 314 participants (4.1%) in the aspirin group, as compared with 245 (3.2%) in the placebo group (rate ratio, 1.29; 95% CI, 1.09 to 1.52; P=0.003), with most of the excess being gastrointestinal bleeding and other extracranial bleeding. There was no significant difference between the aspirin group and the placebo group in the incidence of gastrointestinal tract cancer (157 participants [2.0%] and 158 [2.0%], respectively) or all cancers (897 [11.6%] and 887 [11.5%]); long-term follow-up for these outcomes is planned.

CONCLUSIONS

Aspirin use prevented serious vascular events in persons who had diabetes and no evident cardiovascular disease at trial entry, but it also caused major bleeding events. The absolute benefits were largely counterbalanced by the bleeding hazard. (Funded by the British Heart Foundation and others; ASCEND Current Controlled Trials number, ISRCTN60635500 ; ClinicalTrials.gov number, NCT00135226 .).

A Longitudinal Functional Magnetic Resonance Imaging Study of Working Memory in Patients Following a Transient Ischemic Attack: A Preliminary Study

In this study, we used functional magnetic resonance imaging (fMRI) to investigate longitudinal changes in brain activation during a verbal working memory (VWM) task performed by patients who had experienced a transient ischemic attack (TIA). Twenty-five first-ever TIA patients without visible lesions in conventional MRI and 25 healthy volunteers were enrolled. VWM task-related fMRI was conducted 1 week and 3 months post-TIA. The brain activity evoked by the task and changes over time were assessed. We found that, compared with controls, patients exhibited an increased activation in the bilateral inferior frontal gyrus (IFG), right dorsolateral prefrontal cortex (DLPFC), insula, inferior parietal lobe (IPL), and cerebellum during the task performed 1 week post-TIA. But only the right IFG still exhibited an increased activation at 3 months post-TIA. A direct comparison of fMRI data between 1 week and 3 months post-TIA showed greater activation in the bilateral middle temporal gyrus, right DLPFC, IPL, cerebellum, and left IFG in patients at 1 week post-TIA. We conclude that brain activity patterns induced by a VWM task remain dynamic for a period of time after a TIA, despite the cessation of clinical symptoms. Normalization of the VWM activation pattern may be progressively achieved after transient episodes of ischemia in TIA patients.

Establishing research priorities relating to the long-term impact of TIA and minor stroke through stakeholder-centred consensus

PLAIN ENGLISH SUMMARY

What is the problem and why is this important? Mini-strokes are similar to full strokes, but symptoms last less than 24 h. Many people (up to 70%) have long-term problems after a mini-stroke, such as anxiety; depression; problems with brain functioning (like memory loss); and fatigue (feeling tired). However, the current healthcare pathway only focuses on preventing another stroke and care for other long-term problems is not routinely given. Without proper treatment, people with long-term problems after a mini-stroke could have worse quality of life and may find it difficult to return to work and their social activities. What is the aim of the research? We wanted to understand the research priorities of patients, health care professionals and key stakeholders relating to the long-term impact of mini-stroke. How did we address the problem? We invited patients, clinicians, researchers and other stakeholders to attend a meeting. At the meeting people discussed the issues relating to the long-term impact of mini-stroke and came to an agreement on their research priorities. There were three stages: (1) people wrote down their individual research suggestions; (2) in smaller groups people came to an agreement on what their top research questions were; and (3) the whole group agreed final research priorities. What did we find? Eleven people attended who were representatives for patients, GPs, stroke consultants, stroke nurses, psychologists, the Stroke Association (charity) and stroke researchers, The group agreed on eleven research questions which they felt were the most important to improve health and well-being for people who have had a mini-stroke.The eleven research questions encompass a range of categories, including: understanding the existing care patients receive (according to diagnosis and geographical location); exploring what optimal care post-TIA/minor stroke should comprise (identifying and treating impairments, information giving and support groups) and how that care should be delivered (clinical setting and follow-up pathway); impact on family members; and education/training for health care professionals.

ABSTRACT

Background Clinical management after transient ischaemic attack (TIA) and minor stroke focuses on stroke prevention. However, evidence demonstrates that many patients experience ongoing residual impairments. Residual impairments post-TIA and minor stroke may affect patients' quality of life and return to work or social activities. Research priorities of patients, health care professionals and key stakeholders relating to the long-term impact of TIA and minor stroke are unknown.Methods Our objective was to establish the top shared research priorities relating to the long-term impact of TIA and minor stroke through stakeholder-centred consensus. A one-day priority setting consensus meeting took place with representatives from different stakeholder groups in October 2016 (Birmingham, UK). Nominal group technique was used to establish research priorities. This involved three stages: (i) gathering research priorities from individual stakeholders; (ii) interim prioritisation in three subgroups; and (iii) final priority setting.Results The priority setting consensus meeting was attended by 11 stakeholders. The individual stakeholders identified 34 different research priorities. During the interim prioritisation exercise, the three subgroups generated 24 unique research priorities which were discussed as a whole group. Following the final consensus discussion, 11 shared research priorities were unanimously agreed.The 11 research questions encompass a range of categories, including: understanding the existing care patients receive (according to diagnosis and geographical location); exploring what optimal care post-TIA/minor stroke should comprise (identifying and treating impairments, information giving and support groups) and how that care should be delivered (clinical setting and follow-up pathway); impact on family members; and education/training for health care professionals.Conclusions Eleven different research priorities were established through stakeholder-centred consensus. These research questions could usefully inform the research agenda and policy decisions for TIA and minor stroke. Inclusion of stakeholders in setting research priorities is important to increase the relevance of research and reduce research waste.

Influence of Severe Carotid Stenosis on Cognition, Depressive Symptoms and Quality of Life

BACKGROUND

Carotid artery disease is not just a causal risk factor of ischemic stroke, but may predispose patients to depressive symptoms and low health related quality of life (HRQoL).

OBJECTIVES

The objectives of the present study were to assess the association between severe carotid artery stenosis (CAS) and cognitive impairment, frequency of depressive symptoms and status of HRQoL.

METHODS

Cross - sectional study involved 55 patients with severe CAS and 54 patients with lower extremity peripheral artery disease (PAD). Cognitive impairment was assessed using Montreal Cognitive Assessment Scale (MoCA), depressive symptoms - PHQ-9 scale. HRQoL was measured using Medical Outcome Survey Short Form version 2 (SF-36v2).

RESULTS

Median MoCA score 24 [23;26] was significantly lower in patients with severe CAS than in patients with PAD - 26 [25-28],(p=0.005; effect size r=0.3). There was no statistically significant difference of median PHQ-9 scores the in CAS group (median PHQ-9 score 4.0 [5]) and in the PAD group (median PHQ-9 score 5.5 [7]), (p=0.08, effect size r=0.18). Mean SF-36v2 scores were similar in CAS and PAD groups except for bodily pain (p=0.001, Cohen's d value = 0.77) and vitality (p=0.02, Cohen's d value = 0.49).

CONCLUSION

In summary, our findings indicate that severe CAS could play a role in cognitive decline. Further studies should be conducted using larger patient cohorts without ischemic brain lesions and with balanced vascular risk profiles to investigate impact of CAS on cognition. There was no association between severe CAS and depressive symptoms in the present study. As patients with severe CAS did not exhibit physical symptoms, HRQoL was better for those patients than for patients with lower extremity PAD.

Post-stroke dementia - a comprehensive review

Post-stroke dementia (PSD) or post-stroke cognitive impairment (PSCI) may affect up to one third of stroke survivors. Various definitions of PSCI and PSD have been described. We propose PSD as a label for any dementia following stroke in temporal relation. Various tools are available to screen and assess cognition, with few PSD-specific instruments. Choice will depend on purpose of assessment, with differing instruments needed for brief screening (e.g., Montreal Cognitive Assessment) or diagnostic formulation (e.g., NINDS VCI battery). A comprehensive evaluation should include assessment of pre-stroke cognition (e.g., using Informant Questionnaire for Cognitive Decline in the Elderly), mood (e.g., using Hospital Anxiety and Depression Scale), and functional consequences of cognitive impairments (e.g., using modified Rankin Scale). A large number of biomarkers for PSD, including indicators for genetic polymorphisms, biomarkers in the cerebrospinal fluid and in the serum, inflammatory mediators, and peripheral microRNA profiles have been proposed. Currently, no specific biomarkers have been proven to robustly discriminate vulnerable patients ('at risk brains') from those with better prognosis or to discriminate Alzheimer's disease dementia from PSD. Further, neuroimaging is an important diagnostic tool in PSD. The role of computerized tomography is limited to demonstrating type and location of the underlying primary lesion and indicating atrophy and severe white matter changes. Magnetic resonance imaging is the key neuroimaging modality and has high sensitivity and specificity for detecting pathological changes, including small vessel disease. Advanced multi-modal imaging includes diffusion tensor imaging for fiber tracking, by which changes in networks can be detected. Quantitative imaging of cerebral blood flow and metabolism by positron emission tomography can differentiate between vascular dementia and degenerative dementia and show the interaction between vascular and metabolic changes. Additionally, inflammatory changes after ischemia in the brain can be detected, which may play a role together with amyloid deposition in the development of PSD. Prevention of PSD can be achieved by prevention of stroke. As treatment strategies to inhibit the development and mitigate the course of PSD, lowering of blood pressure, statins, neuroprotective drugs, and anti-inflammatory agents have all been studied without convincing evidence of efficacy. Lifestyle interventions, physical activity, and cognitive training have been recently tested, but large controlled trials are still missing.