Can we prevent poststroke cognitive impairment? An umbrella review of risk factors and treatments

Effect of a Cardiovascular Polypill on Poststroke Cognition Among Ghanaians: Secondary Analysis of a Randomized Clinical Trial

BACKGROUND

Poststroke cognitive impairment is prevalent worldwide, with no satisfactory preventative therapeutic strategies. We report on the effect of a cardiovascular polypill on cognitive performance among recent stroke survivors.

METHODS AND RESULTS

The SMAART (Stroke Minimization through Additive Anti-atherosclerotic Agents in Routine Treatment) trial was a phase II randomized trial primarily assessing the polypill versus usual care for secondary prevention after a recent ischemic stroke. Participants allocated to the experimental arm were provided 2 Polycaps taken orally once a day for 12 months. A capsule of Polycap contained aspirin 100 mg, simvastatin 20 mg, hydrochlorothiazide 12.5 mg, ramipril 5 mg, and atenolol 50 mg. Participants in the usual care arm received standard secondary prevention therapy. We compared slopes of the trajectory of raw scores in the executive, language, memory, and visuospatial cognitive domains and aggregated cognitive scores over 12 months via a linear mixed-effects model. We enrolled 148 eligible participants (n=74 in each arm) and 59 versus 64 participants in the polypill and usual care arms, respectively, at month 12. Compared with the usual care arm, the slopes of cognitive performance over 12 months in the polypill arm were steeper by 2.02 units (95% CI, 0.52-3.53), P=0.009 in executive domain, 1.88 units (95% CI, 0.42-3.34), P=0.012 in language domain, 2.60 (0.03-5.17), P=0.049 in memory domain, 0.55 (-0.80 to 1.91), P=0.42 in the visuospatial domain, and global cognitive performance 6.87 units (95% CI, 1.44-12.30), P=0.013.

CONCLUSIONS

The cardiovascular polypill is associated with a signal of better cognitive performance over 12 months among stroke survivors. Further definitive trials are warranted.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique Identifier: NCT03329599.

Moxibustion Promoted Axonal Regeneration and Improved Learning and Memory of Post-stroke Cognitive Impairment by Regulating PI3K/AKt and TACC3

BACKGROUND

This study aimed to investigate whether moxibustion could affect PI3K/Akt pathway to regulate Transforming acidic coiled-coil containing protein 3 (TACC3) and promote axonal regeneration to improve learning and memory function in middle cerebral artery occlusion (MCAO) rats.

METHODS

Sixty SD rats were randomly divided into 4 groups: sham-operated control group (SC), model control group (MC), model + moxibustion group (MM), and model + inhibitor + moxibustion group (MIM). The rats in MC, MM, and MIM groups were made into MCAO models, and PI3K inhibitor LY294002 was injected into the rats in MIM group before modeling; while the rats in SC group were only treated with artery separation without monofilament inserting. After that, the rats in MM and MIM groups were intervented with moxibustion. We used the Zea-Longa scale, micro-Magnetic Resonance Imaging (micro-MRI), Morris water maze (MWM), TUNEL, western blot (WB), immunofluorescence and immunohistochemistry to evaluate the neurological deficits, cerebral infarct volume, learning and memory, apoptotic cell percentage in the hippocampal, the expression level of axonal regeneration and PI3K/AKt related proteins, the expression level of TACC3. The detection of 2 h after surgery showed the result before moxibustion and 7 days after the intervention showed the results after moxibustion.

RESULTS

After 7 d of intervention, the scores of Zea-Longa and the cerebral infarct volume, the escape latency, the percentage of apoptosis cells of MM group were lower than that of MC and MIM groups; the frequency of rats crossed the previous platform location, PI3K, p-Akt/t-Akt and TACC3, the level of GAP-43 in MM group was more than MC and MIM groups (P < 0.05). While no statistical difference existed between MIM group and MC group (P > 0.05).

CONCLUSION

Moxibustion can promote axonal regeneration and improve learning and memory of Post-stroke cognitive impairment via activating the PI3K/AKT signaling pathway and TACC3.

Correlation between changes in serum YKL-40, LXRs, PPM1A, and TGF-β1 levels and airway remodeling and lung function in patients with bronchial asthma

OBJECTIVE

This study investigates the correlation between serum levels of YKL-40, LXRs, PPM1A, and TGF-β1 and airway remodeling and lung function in bronchial asthma patients.

METHODS

The study involved 80 bronchial asthma patients and 92 healthy individuals. Serum cytokines, airway remodeling, and lung function markers were compared across mild, moderate, and severe asthma cases using high-resolution CT, t-tests, ANOVA, and Pearson correlation analysis.

RESULTS

Asthmatic patients exhibited higher levels of serum YKL-40, LXRα, LXRβ, TGF-β1, airway wall thickness (T)/outer diameter (D), and WA% of total cross-sectional area compared to controls. Conversely, their serum PPM1A, Peak Expiratory Flow (PEF), and Forced Expiratory Volume in 1 s (FEV1) were lower. Serum YKL-40 and TGF-β1 levels were positively correlated with T/D and WA%, and negatively correlated with PEF and FEV1. PPM1A levels were strongly associated with T/D, WA%, PEF, and FEV1.

CONCLUSION

The severity of bronchial asthma is associated with increased serum levels of YKL-40, LXRα, LXRβ, and TGF-β1 and decreased PPM1A. The levels of YKL-40, PPM1A, and TGF-β1 have a significant correlation with airway remodeling and lung function.

Effects of exercise dose based on the ACSM recommendations on patients with post-stroke cognitive impairment: a systematic review and meta-analyses

Purpose

This review aimed to assess the impact of different exercise dosages on cognitive function in individuals with post-stroke cognitive impairment (PSCI).

Methods

Four electronic databases-Embase, PubMed, Web of Science, and Cochrane Library-were systematically searched from inception to 01 January 2024, focusing on the impact of exercise therapy on cognitive function in individuals with PSCI. Only randomized controlled trials meeting the criteria were included. The exercise therapy dose and adherence were evaluated following the American College of Sports Medicine (ACSM) guidelines, categorized into a high compliance group with ACSM recommendations and a low or uncertain compliance group. A random-effects model compared the effect of ACSM compliance on cognitive function in individuals with PSCI, with the effect size represented by the standardized mean difference (SMD) and a 95% confidence interval (CI).

Results

In total, 18 studies meeting the criteria were included, with data from 1,742 participants. The findings suggested a beneficial effect of exercise on cognitive function in individuals with PSCI [SMD = 0.42, 95% CI (0.20, 0.65)]. Ten studies were categorized as the "high adherence group" and eight in the "low or uncertain adherence group" based on the ACSM recommendations. The subgroup analysis revealed that the SMD of the high compliance group was 0.46 (95% CI: 0.10, 0.82) (p = 0.01), while the SMD of the low or uncertain compliance group was 0.38 (95% CI: 0.07, 0.70) (p = 0.02).

Conclusion

Our study indicates the beneficial impact of exercise for patients with PSCI over no exercise. Furthermore, high adherence to the exercise dose recommended by ACSM guidelines demonstrated a more substantial improvement in cognitive function than low or uncertain adherence in patients with PSCI. Systematic Review Registration: https:// www.crd.york.ac.uk/prospero/#myprospero, identifier CRD42023487915.

Risk factors for cognitive impairment and dementia after stroke: a systematic review and meta-analysis

BACKGROUND

Cognitive impairment and dementia are highly prevalent among stroke survivors and represent a major burden for patients, carers, and health-care systems. We studied the risk factors for post-stroke cognitive impairment (PSCI) and dementia (PSD) beyond the well established risk factors of age and stroke severity.

METHODS

In this systematic review and meta-analysis we conducted a systematic literature search from database inception until Sept 15, 2023. We selected prospective and retrospective cohort studies, post-hoc analyses from randomised controlled trials, and nested case-control studies of patients with acute stroke (ischaemic, haemorrhagic, and transient ischaemic attack), exploring associations between risk factors at baseline and PSCI or PSD over a follow-up period of at least 3 months. Study quality was assessed using the Newcastle-Ottawa quality assessment scale. We calculated pooled relative risks (RRs) with random-effects meta-analyses and performed subgroup, meta-regression, and sensitivity analyses. This study was preregistered with PROSPERO, CRD42020164959.

FINDINGS

We identified 162 eligible articles for our systematic review, of which 113 articles (89 studies, 160 783 patients) were eligible for meta-analysis. Baseline cognitive impairment was the strongest risk factor for PSCI (RR 2·00, 95% CI 1·66-2·40) and PSD (3·10, 2·77-3·47). We identified diabetes (1·29, 1·14-1·45), presence or history of atrial fibrillation (1·29, 1·04-1·60), presence of moderate or severe white matter hyperintensities (WMH; 1·51, 1·20-1·91), and WMH severity (1·30, 1·10-1·55, per SD increase) as treatable risk factors for PSCI, independent of age and stroke severity. For PSD, we identified diabetes (1·38, 1·10-1·72), presence of moderate or severe WMH (1·55, 1·01-2·38), and WMH severity (1·61, 1·20-2·14, per SD increase) as treatable risk factors. Additional risk factors included lower educational attainment, previous stroke, left hemisphere stroke, presence of three or more lacunes, brain atrophy, and low baseline functional status. Associations of risk factors with PSD were weaker in studies conducted and published more recently. We found substantial interstudy heterogeneity and evidence of reporting bias.

INTERPRETATION

Our results highlight the importance of cognitive impairment in the acute phase after stroke for long-term prediction of PSCI and PSD. Treatable risk factors include diabetes, atrial fibrillation, and markers of cerebral small vessel disease (ie, white matter hyperintensities and lacunes). Future trials should explore these risk factors as potential targets for prevention of PSCI and PSD.

FUNDING

German Research Foundation.

The Rehabilitation of Cognitive Impairment Following Stroke: A Commentary on a Systematic Review

Stroke is regarded as one of the leading causes of death and disability worldwide. Cognitive impairment occurs in nearly 60% of stroke survivors. Despite the high prevalence and significant impact on post-stroke functioning, there remains a lack of clarity regarding effective interventions to support rehabilitation of cognitive impairment. This article critically appraises a systematic review which assessed the effectiveness of interventions to improve clinical outcomes associated with cognition for adults, post-onset of stroke.

Commentary on O'Donoghue M, Leahy S, Boland P, Galvin R, McManus J, Hayes S. Rehabilitation of cognitive deficits poststroke: systematic review and meta-analysis of randomized controlled trials. Stroke. 2022;53(5):1700–1710. 10.1161/strokeaha.121.034218

Comparative efficacy and safety of multiple acupuncture therapies for post stroke cognitive impairment: a network meta-analysis of randomized controlled trials

Background

Acupuncture therapy has been widely used to treat post-stroke cognitive impairment (PSCI). However, acupuncture therapy includes multiple forms. Which acupuncture therapy provides the best treatment outcome for patients with PSCI remains controversial.

Objective

We aimed to compare and evaluate the efficacy and safety of different acupuncture-related therapies for PSCI in an attempt to identify the best acupuncture therapies that can improve cognitive function and self-care in daily life for patients with PSCI, and bring new insights to clinical practice.

Method

We searched eight databases including PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, China Biomedical Literature Database (CBM), China Science and Technology Journal (VIP) database, China National Knowledge Infrastructure (CNKI) database, and Wan fang database to find randomized controlled trials (RCTs) of acupuncture-related therapies for PSCI from the inception of the database to January 2023. Two researchers independently assessed the risk of bias in the included studies and extracted the study data. Pairwise meta-analyzes for direct comparisons were performed using Rev. Man 5.4 software. Bayesian network meta-analysis (NMA) was performed using STATA 17.0 and R4.2.4 software. The quality of evidence from the included studies was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Adverse effects (AEs) associated with acupuncture therapy were collected by reading the full text of the included studies to assess the safety of acupuncture therapy.

Results

A total of 62 RCTs (3 three-arm trials and 59 two-arm trials) involving 5,073 participants were included in this study. In the paired meta-analysis, most acupuncture-related therapies had a positive effect on cognitive function and self-care of daily living in patients with PSCI compared with cognitive training. Bayesian NMA results suggested that ophthalmic acupuncture plus cognitive training (79.7%) was the best acupuncture therapy for improving MMSE scores, with scalp acupuncture plus cognitive training ranking as the second (73.7%). The MoCA results suggested that warm acupuncture plus cognitive training (86.5%) was the best acupuncture therapy. In terms of improvement in daily living self-care, scalp acupuncture plus body acupuncture (87.5%) was the best acupuncture therapy for improving MBI scores. The most common minor AEs included subcutaneous hematoma, dizziness, sleepiness, and pallor.

Conclusion

According to our Bayesian NMA results, ophthalmic acupuncture plus cognitive training and warm acupuncture plus cognitive training were the most effective acupuncture treatments for improving cognitive function, while scalp acupuncture plus body acupuncture was the best acupuncture treatment for improving the performance of self-care in daily life in patients with PSCI. No serious adverse effects were found in the included studies, and acupuncture treatment appears to be safe and reliable. However, due to the low methodological quality of the included studies, our findings need to be treated with caution. High-quality studies are urgently needed to validate our findings.

Systematic review registration

https://www.crd.york.ac.uk/prospero/#recordDetails, identifier: CRD42022378353.

[The effect of the start date of cognitive rehabilitation after ischemic stroke on the level of recovery]

OBJECTIVE

The dependence of result of cognitive training in patients who have suffered an ischemic stroke (IS) on the timing of their onset continues to be discussed. The aim was to study the results of cognitive rehabilitation of patients after IS during various periods after it.

MATERIAL AND METHODS

140 patients were examined during complex rehabilitation in terms up to 1, 2-3, 4-6 and 7-12 months after IS, 78 of them received drug support (DS) of rehabilitation with intravenous injections of ampasse. The Montreal Cognitive Assessment (MoCA) and Hospital Anxiety and Depression Scale (HADS) were used to monitor the effectiveness of rehabilitation.

RESULTS

In all subgroups, there was a statistically significant increase in the MoCA score after the course, but number of people with an increase in the score by 1 or more points was highest among those who started the course 3 or more months after the development of IS (p=0.015). Among those who received DS, an increase in the MoCA was noted in 87.2%, in those who did not receive it - 38.7% (p<0.001). There was no statistically significant increase in the severity of anxiety and depression after the course of treatment in any of the subgroups.

CONCLUSION

The used approach of a combination of cognitive, physical rehabilitation and DS proved to be justified for achieving results during a two-week course of inpatient rehabilitation of patients both in the early and late recovery period after IS.

Exploring the perspectives of key stakeholders on the design and delivery of a cognitive rehabilitation intervention for people post-stroke

Purpose

Stroke is a leading cause of death and disability worldwide. Despite the prevalence and associated burden of post-stroke cognitive impairment, there is uncertainty regarding optimum interventions to improve cognitive function in people post-stroke. The aim of this study is to explore the perspectives of key stakeholders on the design and development of a multidisciplinary intervention to rehabilitate cognitive deficits in people post-stroke.

Materials and methods

Audio-recorded, semi-structured interviews were employed with people post-stroke, caregivers, healthcare professionals and academics. All transcribed interviews were exported to NVivo software and analysed using reflexive thematic analysis.

Results

Thirty interviews were conducted across stakeholder groups including people post-stroke (n = 10), caregivers (n = 5), healthcare professionals (n = 14) and academics (n = 1). Four themes relevant to the design and development of the intervention were identified (i) engagement in the intervention must be meaningful, (ii) the point of readiness to engage, (iii) a familiar but flexible setting is key (iv) pragmatics of intervention delivery.

Conclusions

These findings present new perspectives across stakeholder groups on the design and delivery of an intervention to rehabilitate cognitive deficits in people post-stroke. Taken together with existing quantitative evidence, these findings will inform the development of a feasibility trial, examining patient and process outcomes, to rehabilitate cognitive deficits post-stroke.

Methodological approaches for assessing certainty of the evidence in umbrella reviews: A scoping review

INTRODUCTION

The number of umbrella reviews (URs) that compiled systematic reviews and meta-analysis (SR-MAs) has increased dramatically over recent years. No formal guidance for assessing the certainty of evidence in URs of meta-analyses exists nowadays. URs of non-interventional studies help establish evidence linking exposure to certain health outcomes in a population. This study aims to identify and describe the methodological approaches for assessing the certainty of the evidence in published URs of non-interventions.

METHODS

We searched from 3 databases including PubMed, Embase, and The Cochrane Library from May 2010 to September 2021. We included URs that included SR-MAs of studies with non-interventions. Two independent reviewers screened and extracted data. We compared URs characteristics stratified by publication year, journal ranking, journal impact factor using Chi-square test.

RESULTS

Ninety-nine URs have been included. Most were SR-MAs of observational studies evaluating association of non-modifiable risk factors with some outcomes. Only half (56.6%) of the included URs assessed the certainty of the evidence. The most frequently used criteria is credibility assessment (80.4%), followed by GRADE approach (14.3%). URs published in journals with higher journal impact factor assessed certainty of evidence than URs published in lower impact group (77.1 versus 37.2% respectively, p < 0.05). However, criteria for credibility assessment used in four of the seven URs that were published in top ranking journals were slightly varied.

CONCLUSIONS

Half of URs of MAs of non-interventional studies have assessed the certainty of the evidence, in which criteria for credibility assessment was the commonly used method. Guidance and standards are required to ensure the methodological rigor and consistency of certainty of evidence assessment for URs.

Post-Stroke Cognitive Impairment: Epidemiology, Risk Factors, and Management

Stroke, characterized as a neurological deficit of cerebrovascular cause, is very common in older adults. Increasing evidence suggests stroke contributes to the risk and severity of cognitive impairment. People with cognitive impairment following stroke often face with quality-of-life issues and require ongoing support, which have a profound effect on caregivers and society. The high morbidity of post-stroke cognitive impairment (PSCI) demands effective management strategies, in which preventive strategies are more appealing, especially those targeting towards modifiable risk factors. In this review article, we attempt to summarize existing evidence and knowledge gaps on PSCI: elaborating on the heterogeneity in current definitions, reporting the inconsistent findings in PSCI prevalence in the literature, exploring established or less established predictors, outlining prevention and treatment strategies potentially effective or currently being tested, and proposing promising directions for future research.