Dementia after Three Months and One Year from Stroke: New Onset or Previous Cognitive Impairment?

Pre-stroke and early post-stroke apathy is associated with increased risk of dementia 3 months after stroke

OBJECTIVES

Apathy is a frequent neuropsychiatric syndrome after stroke. We determined whether pre-morbid and early post-stroke apathy predicts dementia 3 months after stroke.

METHODS

We included ischemic stroke patients without dementia who participated in the Prospective Observational Polish Study on post-stroke delirium. We used the Neuropsychiatric Inventory and clinician-reported version of Apathy Evaluation Scale to score apathy symptoms before stroke and on day 8 after stroke. Patients underwent neuropsychological examination 3 months after stroke.

RESULTS

Of 422 patients with ischemic stroke and without pre-stroke dementia, 194 patients (mean age: 67.5 ± 12.3; 45.9% female) underwent neuropsychological examination. Dementia was diagnosed in 21.6% of them. Patients with dementia had higher apathy scores before stroke (mean: 0.9 ± 1.7 vs. 0.2 ± 0.9, p < 0.01) and on day 8 (mean: 37.2 ± 9.3 vs. 29.0 ± 9.6, p < 0.01). Depressive symptoms did not differ between groups. In multivariate analysis adjusted for age, diabetes mellitus, stroke severity and in-hospital delirium, apathy symptoms before stroke and on day 8 after stroke predicted post-stroke dementia (adjusted OR: 1.59, 95%CI: 1.13-2.26, p = 0.01 and OR: 1.06, 95%CI: 1.01-1.11, p = 0.03, respectively).

CONCLUSIONS

Pre-stroke and early post-stroke apathy independently from age, stroke severity and delirium predicted dementia 3 months after stroke. Apathy might be useful in identifying at-risk patients.

The prevalence of apathy in stroke patients: A systematic review and meta-analysis

BACKGROUND

Apathy is a frequent neuropsychiatric disorder in stroke patients. However, its prevalence rates have conflicting results across studies. This meta-analysis aimed to estimate the overall prevalence of apathy in stroke patients from 1990 to 2022.

METHODS

PubMed, Web of Science, Embase and PsycINFO were systematically searched to identify relevant articles published from January 1, 1990 to October 29, 2022. Literature quality was assessed with the National Institutes of Health Study Quality Assessment Tool. The pooled prevalence, subgroup analyses and meta-regression were calculated by STATA 16.0.

RESULTS

A total of 39 observational studies involving 5168 stroke patients were eligible for this meta-analysis. The pooled prevalence of apathy in stroke patients was 33.0% (95% CI, 27.6-38.4). Subgroup analyses showed that the pooled prevalence of apathy among stroke patients was higher in Japan (36.6%), China (33.7%) and Turkey (63.5%) compared to that in other countries (30.2%). The pooled prevalence of apathy was higher in ischemic stroke samples (36.1%) than in hemorrhagic stroke samples (14.4%). The pooled prevalence of apathy measured with the Apathy Evaluation Scale (38.3%) was the highest in stroke patients. Meta-regression presented that higher literature quality was significantly associated with lower prevalence, while stroke severity, mean age and female percentage were not significantly associated with the prevalence of apathy in stroke patients.

CONCLUSION

Our findings revealed that the overall prevalence of apathy in stroke patients was 33.0% based on the current evidence. Furthermore, the prevalence was significantly correlated with countries, stroke subtypes, apathy criteria, and literature quality.

POSTOPERATIVE COGNITIVE DISORDERS IN PATIENTS UNDER CAROTID ENDARTERECTOMY

Evaluation of the impact of carotid endarterectomy on the cognitive status of patients remains debatable, since patients with atherosclerotic lesions of the carotid arteries suffer from chronic cerebrovascular insufficiency, and changes in the cognitive status of patients after carotid endarterectomy may be due to factors such as increased blood supply to the brain, microembolism after the start of blood flow, and cerebral ischemia during cross-clamping and also the effect of various anesthesia drugs on the cognitive status in these patients is ambiguous.Purpose. To assess age-related changes in cognitive status in patients with atherosclerotic lesions of the carotid arteries in the postoperative periodMaterial and methods. Neuropsychological testing was performed in 128 patients after eversion carotid endarterectomy, divided into age groups and depending on the methods of anesthesia: Propofol group and Sevoflurane group.Results. In patients under the age of 60 years, there is an improvement in cognitive status in the early and late postoperative period, while in patients of the older age group, there is a slowdown in the progression of cognitive dysfunction in both groups of anesthesia.Conclusion. An important criterion for evaluating the surgical prevention of cerebrovascular accidents is clinical effectiveness, in particular, the impact of operations and anesthesia methods on the cognitive sphere of patients of different ages with pathology of the main arteries of the head, which determines the quality of life not only for patients, but also for relatives.

[Surgical prevention of progressive cerebral ischemia after ischemic stroke]

OBJECTIVE

To evaluate the effectiveness of carotid endarterectomy after ischemic stroke and to analyze postoperative neurological status.

MATERIAL AND METHODS

There were 120 patients with carotid artery stenosis complicated by chronic cerebrovascular insufficiency (CVI). Patients with CVI grade I-III were included in the first group (n=70), 50 patients had previous ischemic stroke (the second group). Age of patients was 61-89 years. All patients underwent unilateral carotid endarterectomy.

RESULTS

Over 36-month follow-up period, postoperative stroke occurred in 5 (7.2%) and 9 (18.3%) patients in both groups, respectively. The combined end-point (stroke + mortality) was significantly less common in group I compared to group II (10 (14.5%) and 15 (30%) cases, p>0.05). Positive changes in neurological status were found in the 2^nd group (relief of focal neurological deficit, symptoms of cerebrovascular insufficiency, no progression of vascular dementia). Barthel score increased from 74.3 to 92.8 after carotid endarterectomy in the 2^nd group. Baseline FAB score <11 was observed in 9% of patients in the 1^st group and 22% in the 2^nd group. No progression of dementia was observed in long-term period.

CONCLUSION

Carotid endarterectomy is effective in prevention of primary and recurrent stroke. Moreover, this procedure slows down progression of chronic cerebral ischemia and cognitive impairment.

Review of the Protective Effects of Statins on Cognition

Elevated cholesterol is a major risk factor in the development of cardiovascular disease. Statins have proven to be effective in lowering low-density lipoprotein cholesterol as well as the incidence of cardiovascular events. As a result, statins are widely prescribed in the United States, with an estimated 35 million patients on statins. Many of these patients are older than age 65 and suffer from various comorbidities, including mild to severe cognitive impairment. Early studies looking at the effects of statins on cognition have shown that statin use may lead to mild reversible cognitive decline, although long-term studies have shown inconclusive findings. In recent years, studies have shown that the use of statins in certain groups of patients may lead to a reduction in the rate of cognitive decline. One hypothesis for this finding is that statin use can reduce the risk of cerebrovascular disease which may, in turn, reduce the risk of mild cognitive decline and dementia. With numerous patients currently prescribed statins and the likelihood that more patients will be prescribed the medication in the coming years, it is important to review the current literature to determine the association between statin use and cognitive decline, as well as determine how statins may be beneficial in preventing cognitive decline.

Delirium Post-Stroke-Influence on Post-Stroke Dementia (Research Study-Part of the PROPOLIS Study)

BACKGROUND

Previous research confirmed association between delirium and subsequent dementia in different clinical settings, but the impact of post-stroke delirium on cognitive functioning is still under-investigated. Therefore, we aimed to assess the risk of dementia among patients with stroke and in-hospital delirium.

METHODS

A total of 750 consecutive patients admitted to the stroke unit with acute stroke or transient ischemic attacks were screened for delirium, during the first seven days after admission. At the three- and twelve-month follow-up, patients underwent cognitive evaluation. The DSM-5 definition for dementia was used. Cases with pre-stroke dementia were excluded from the analysis.

RESULTS

Out of 691 included cases, 423 (61.22%) and 451 (65.27%) underwent cognitive evaluation, three and twelve months after stroke; 121 (28.61%) and 151 (33.48%) patients were diagnosed with dementia, respectively. Six (4.96%) patients with dementia, three months post-stroke did not meet the diagnostic criteria for dementia nine months later. After twelve months, 37 (24.50%) patients were diagnosed with dementia, first time after stroke. Delirium in hospital was an independent risk factor for dementia after three months (OR = 7.267, 95%CI 2.182-24.207, p = 0.001) but not twelve months after the stroke.

CONCLUSIONS

Patients with stroke complicated by in-hospital delirium are at a higher risk for dementia at three but not twelve months post-stroke.

Association of blood lipids, atherosclerosis and statin use with dementia and cognitive impairment after stroke: A systematic review and meta-analysis

BACKGROUND

Trial and observational evidence is conflicting in terms of the association of blood lipids, atherosclerosis and statin use with dementia and cognitive impairment in the general population. It is uncertain whether the associations occur in stroke patients, who are at known higher risk of cognitive decline. This systematic review was to synthesize the evidence for these associations among stroke patients.

METHODS

MEDLINE, EMBASE, the Cochrane Library and trial registries were searched. We included randomized controlled trials (RCTs) or observational cohort studies conducted among patients with stroke and reported on the association of blood lipids, atherosclerosis or statin use with dementia or cognitive impairment. Meta-analysis was conducted separately for crude and maximally adjusted odds ratios (ORs) and hazard ratios (HRs).

RESULTS

Of 18,026 records retrieved, 56 studies (one RCT and 55 cohort studies) comprising 38,423 stroke patients were included. For coronary heart disease, the pooled OR of dementia and cognitive impairment was 1.32 (95%CI 1.10-1.58, n = 15 studies, I² = 0%) and 1.23 (95%CI 0.99-1.54, n = 14, I² = 26.9%), respectively. Peripheral artery disease was associated with dementia (OR 3.59, 95%CI 1.47-8.76, n = 2, I² = 0%) and cognitive impairment (OR 2.70, 95%CI 1.09-6.69, n = 1). For carotid stenosis, the pooled OR of dementia and cognitive impairment was 2.67 (95%CI 0.83-8.62, n = 3, I² = 77.9%) and 3.34 (95%CI 0.79-14.1, n = 4, I² = 96.6%), respectively. For post-stroke statin use, the pooled OR of dementia and cognitive impairment was 0.89 (95%CI 0.65-1.21, n = 1) and 0.56 (95%CI 0.46-0.69, n = 3, I² = 0%), respectively. No association was observed for hypercholesterolemia. These results were mostly consistent with adjusted ORs or HRs, which were reported from limited evidence.

CONCLUSION

Atherosclerosis was associated with an increased risk of post-stroke dementia. Post-stroke statin use was associated with decreased risk of cognitive impairment. To confirm whether or not statins confer advantages in the post-stroke population in terms of preventing cognitive decline over and above their known effectiveness in reducing risk of further vascular events, further stroke trials including cognitive assessment and observational analyses adjusted for key confounders, focusing on key subgroups or statin use patterns are required.

Cilostazol May Decrease Plasma Inflammatory Biomarkers in Patients with Recent Small Subcortical Infarcts: A Pilot Study

BACKGROUND

The mechanism of progressive neurological deficit in patients with recent small subcortical infarcts has not yet been clarified. Inflammatory biomarkers and the use of cilostazol may be associated with this phenomenon.

METHODS

Between May 2013 and April 2014, we evaluated consecutive first-ever patients with stroke due to recent small subcortical infarcts within 48 hours of onset. We divided patients into 2 groups according to the use of antiplatelet agents (cilostazol with or without aspirin versus aspirin alone). Plasma biomarkers such as matrix metalloproteinase-9, interleukin-6, high sensitive C-reactive protein, and amyloid β precursor protein (APP770, indicating endothelial dysfunction) were measured twice: (1) within 24 hours; and (2) 1 week after their admission. Multivariable logistic regression analyses were performed to identify the variables independently associated with progressive neurological deficit and poor functional outcome.

RESULTS

We analyzed 41 patients (male: 63.4%, mean age: 70.8 years). Most of the patients (90%) who were treated with cilostazol were concomitantly treated with aspirin. Matrix metalloproteinase-9 and high sensitive C-reactive protein were higher in patients with progressive neurological deficit compared with those without. APP770 were more likely to be decreased in cilostazol group compared with aspirin group. Multivariable analyses show that traditional risk factors such as age and National Institutes of Health Stroke Scale scores were independently associated with both progressive neurological deficit and poor functional outcome.

CONCLUSIONS

Inflammatory biomarkers may be associated with progressive neurological deficit. Early initiation of cilostazol may decrease the levels of plasma biomarkers.