Neuropsychological screening in the acute phase of cerebrovascular diseases

The Luigi Sacco Hospital VAS-COG stroke care pathway: A five-year experience

Background

Psycho-cognitive consequences are a frequent cause of disability in stroke survivors but are often underdiagnosed also because of lack of services dedicated to these aspects. We started assessing systematically cognitive and behavioral functions in acute stroke patients and to follow them up. Here, we report a retrospective analysis of the organization of the Sacco VAS-COG stroke care pathway and the refinements implemented during 5 years of activity.

Methods

The protocol includes baseline collection of clinical history, general and neurologic examinations, functional, neuropsychological, and neuroimaging assessment. At follow-up, a diagnosis of cognitive decline was made based on best clinical judgment in the first period (January 2018 to May 2019, namely VAS-COG protocol 1.0) and then based on an extensive neuropsychological battery (May 2019 to January 2023, namely VASCOG protocol 2.0); psychiatric and behavioral disturbances are investigated through suitable scales.

Results

From January 2018 to December 2022, 834 patients (mean age 76±13.6 years; 46.6 % females) with acute cerebrovascular events were admitted to the stroke unit, mostly (80 %) for ischemic strokes. Pre-event cognitive impairment was not assessable in 78 patients (9.3 %) because no reliable informant was present and was reported in 327/756 (43 %) patients. During follow-up, post-stroke cognitive impairment was detected in 124/217 (57.1 %) patients in VAS-COG protocol 1.0 and in 137/201(68.2 %) patients in VAS-COG protocol 2.0, while 95/218 (43.2 %) patients were found to be depressed and patients presented on average 2.5 neuropsychiatric symptoms on Neuropsychiatric Inventory-questionnaire.

Conclusions

The VAS-COG stroke care pathway represents a model for patients and for their families.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Outcome of patients older than 85 years hospitalized in a neurology unit

BACKGROUND

Advanced age is a major determinant of mortality and poor outcome at any level. In hospitalized patients, advanced age is a major issue in terms of prognosis, resource use, and therapeutic choices.

AIMS

We aimed at assessing the 1 year outcome of elderly patients admitted to a neurology unit for various acute conditions.

METHODS

Consecutive patients admitted to a neurology unit were enrolled and followed-up at 3, 6, and 12 months with structured phone interviews gathering information about mortality, disability, hospital readmissions, and place of residency. Inclusion criteria were age ≥ 85 years, availability of written consent and phone contact; no exclusion criteria were applied.

RESULTS

Over a period of 16 months, 131 patients (88.8 ± 3.3, 92 females, 39 males) were admitted. The pre-hospitalization modified Rankin Scale (mRS) median (IQR) score, obtainable in 125 patients, was 2 (0, 3) and > 3 in 28/125 (22.4%) patients. Fifty-eight (46.8%) patients had pre-existing dementia (this information was missing for one patient). Eleven patients died during hospitalization. Of the 120 discharged patients, 60 (50%) were alive at 12 months, 41 died during follow-up (34.2%), and 19 (15.8%) were lost. At 12 months, out of the 60 alive patients, 29 (48.3%) had a mRS > 3. We did not detect predictors of 12-month survival. Predictors of 12-month worsening of functional status were pre-hospitalization mRS, pre-existing cognitive impairment, and male sex.

CONCLUSIONS

One-year mortality of elderly patients admitted to a neurology unit is extremely high. After one year, less than one fourth of elderly patients hospitalised for an acute neurological disease are left with only no-to-moderate disability.

Associations between cognitive impairment and computed tomography perfusion in different lobes in acute stroke of the anterior circulation

BACKGROUND

 Cognitive impairment (CI) during the acute phase of stroke should not be ignored. The present study analyzed the relationship between computed tomography perfusion (CTP) in different lobes and CI during the acute phase of stroke in patients with cerebral infarction.

METHODS

 The present study included 125 subjects: 96 in the acute phase of stroke and 29 elderly healthy subjects as a control group. The Montreal Cognitive Assessment (MoCA) was used to evaluate the cognitive status of the two groups. The CTP scans include four parameters: cerebral blood flow (CBF), cerebral blood volume (CBV), time to peak (TTP), and mean transit time (MTT).

RESULTS

 The MoCA scores for naming, language and delayed recall significantly decreased only in patients with left cerebral infarctions. The MTT of the left vessels in the occipital lobe and the CBF of the right vessels in the frontal lobe were negatively related to the MoCA scores of patients with left infarction. The CBV of the left vessels in the frontal lobe and the CBF of left vessels in the parietal lobe were positively linked to the MoCA scores of patients with left infarction. The CBF of the right vessels in the temporal lobe was positively related to the MoCA scores of patients with right infarction. Finally, the CBF of the left vessels in the temporal lobe was inversely correlated with the MoCA scores of patients with right infarctions.

CONCLUSION

 During the acute phase of stroke, CTP was closely associated with CI. Changed CTP could be a potential neuroimaging biomarker to predict CI during the acute phase of stroke.

Predictivity of the clock drawing test in the acute phase of cerebrovascular diseases on cognitive decline at a 6-month neuropsychological evaluation

INTRODUCTION

We showed that the Clock Drawing Test (CDT) performed during the acute phase of cerebrovascular diseases predicted worsening of cognitive function defined based on a clinical judgement at a 3-month follow-up. The aim of this study was to verify the predictivity of the CDT on the worsening of cognitive status assessed with an extensive neuropsychological evaluation 6 months after the acute event.

METHODS

Patients with a stroke or transient ischemic attack underwent a baseline clinical, neuroimaging, and neuropsychological assessment, including the CDT. Premorbid cognitive status was evaluated by means of the Clinical Dementia Rating scale. Between 6 and 7 months after the acute event, all patients underwent a neuropsychological evaluation that included tests for executive function, attention, language, memory, and visuospatial abilities.

RESULTS

Fifty patients (29 males; mean age 72.2 years) were enrolled: 28 (56%) had no premorbid cognitive impairment, 15 (30%) had premorbid mild cognitive impairment (MCI), and 4 (8%) had premorbid dementia; for 3 patients, evaluation of premorbid status was not available. At follow-up, 11 (22%) had no cognitive impairment, 28 (56%) were diagnosed with MCI, and 11 (22%) dementia. In patients who were non-demented before the event, on regression analysis, the score obtained at CDT was predictive of decline of cognitive status at the 6-month follow-up (OR 1.65; 95% CI 1.08-2.52).

DISCUSSION

Our study confirms that administering the CDT during the acute phase of cerebrovascular diseases is informative with regard to the worsening of cognitive function after 6 months.

The montreal cognitive assessment and mini-mental state examination visuoexecutive subtests in acute ischemic stroke patients and their correlations with demographic and clinical factors

Visuoexecutive impairment is common among acute ischemic stroke patients. This study aimed to examine the ability of the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) visuoexecutive subtests to detect visuoexecutive abnormality in acute ischemic stroke patients and to identify the predictors for their impairments. 336 patients who completed the MMSE and MoCA were enrolled in this study. We compared the proportion of participants with incorrect MoCA visuoexecutive tasks and MMSE pentagon copying. Multivariate logistic regression analysis was used to evaluate the associations between the visuoexecutive dysfunction and demographic and clinical characteristics in the samples. Among all the participants, the MoCA detected more visuoexecutive dysfunction than the MMSE (88.69% vs. 45.83%, respectively; p < 0.001). The predictors identified by the univariate analysis included the factors of gender, age, educational level, smoking, alcohol consumption, Oxfordshire Community Stroke Project (OCSP), previous strokes, initial NIHSS score and number of old lacunar infarctions, while from the multivariate logistic regression analysis, the factors of age, educational level, NIHSS score, previous strokes and number of old lacunar infarctions served as predictive factors for the visuoexecutive impairment in acute stroke patients. In conclusion, visuoexecutive impairment is associated with the factors of the educational level, stroke severity, stroke history and number of old lacunar infarctions. Our findings may guide the clinicians to intervene the risks for the patients at an early stage after stroke and form the basis for good rehabilitation plans.

Comparison of Oxford Cognitive Screen and Montreal Cognitive Assessment feasibility in the stroke unit setting. A pilot study

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MoCA and OCS are brief tools to assess cognition in stroke patients.

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We found good agreement between MoCA and OCS measures.

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MoCA and OCS were feasible in the stroke unit setting.

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Qualitative information related to the patients and setting were registered.

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We found high level of acceptability by patients for both tests.

Background

: Cognitive status evaluation is not routine in the acute stroke setting and there is no consensus on which neuropsychological tool is more feasible and informative. The aim of this pilot study was to compare the feasibility and acceptability of two brief cognitive tests, the Montreal Cognitive Assessment (MoCA) and the Oxford Cognitive Screen (OCS), in acute stroke, with a focus on patients' experience, administration time, and the cognitive data obtained.

Methods

: Patients with a diagnosis of ischemic or hemorrhagic stroke or of transient ischemic attack admitted to two stroke units were included. The sample consisted of 34 participants (mean age ±SD 71.1 ± 16.1 years, 25 males). Within five days of onset, patients were evaluated by means of the MoCA and OCS by a trained neuropsychologist.

Results

Both tests were feasible in the stroke unit setting and had a high level of acceptability by patients. MoCA test was fully completed by 25 patients, OCS by 21 patients. The OCS administration time was longer than that of the MoCA. However, OCS was perceived less demanding than MoCA by patients. Twenty patients completed both the MoCA and the OCS entirely, and only 2 of them did not show any impairment in both tests. Seventeen patients showed at least an impaired domain on the OCS and 15 patients presented with a MoCA global score below cut-off for cognitive impairment.

Conclusions

Our preliminary study did not show a superiority of the OCS over the widely used MoCA, and suggests the need for further validation in larger samples of stroke patients, exploring tests accuracy in detecting cognitive post-stroke impairment.