Vascular cognitive impairment and dementia: a narrative review

Vascular cognitive impairment (VCI) is the second most common cause of cognitive impairment after Alzheimer's disease. The VCI spectrum involves a decline in cognition attributable to vascular pathologies (e.g., large infarcts or hemorrhages, microinfarcts, microbleeds, lacunar infarcts, white matter hyperintensities, and perivascular space dilation). Pathophysiological mechanisms include direct tissue injury, small vessel disease, inflammaging (inflammation + aging), atrophy, and altered neurotransmission. VCI is diagnosed using distinct clinical and radiological criteria. It may lead to long-term disability and reduced quality of life. An essential factor for reducing cognitive impairment incidence is preventing stroke by managing traditional and non-traditional cerebrovascular risk factors. This article reviews the spectrum of VCI, epidemiology, risk factors, pathophysiology, diagnosis, available treatment, and preventive strategies.

A Systematic Review and Meta-Analysis on the Prevalence of Mild Cognitive Impairment and Dementia in Mexico

INTRODUCTION

Age remains one of the major risk factors for the onset of mild cognitive impairment (MCI) and dementia. Studies on the prevalence of these conditions in Mexico used different methods, tools, and populations with different health statuses. All these heterogeneous results may be a problem in identifying the true prevalence of MCI and dementia in Mexico. To our knowledge, there is not a systematic review available that presents essential figures on the prevalence of these conditions in Mexico. Therefore, we intend to access the maximum number of reports published on the topic and determine the prevalence of MCI and dementia in older Mexican adults.

METHODS

A systematic review using PubMed, Cochrane, Research Gate, Lilacs, and Scielo databases was performed. Meta-analysis of the prevalence of MCI and dementia was performed using a random-effects model and presented in a forest plot among cross-sectional, epidemiological, and pooled studies.

RESULTS

Sixteen articles were included. The overall prevalence of MCI of 18% (95% CI 0.10-0.27) was estimated from pooled information from 12 selected studies, in women 21% (95% CI 0.08-0.38) and in men 18% (95% CI 0.06-0.33). The overall prevalence of dementia of 10% (95% CI 0.06-0.14) was estimated from pooled information from 9 selected studies, in women 14% (95% CI 0.05-0.25) and in men 10% (95% CI 0.04-0.17).

CONCLUSION

Mexican older individuals have a similar prevalence of dementia and MCI as reported by international data; nevertheless, the prevalence is higher than in some Latin American countries. Mexico has particular issues that must be resolved, such as a lack of research in the southern regions of the country and the high incidence of comorbidities.

Brain health index as a predictor of possible vascular dementia in the Mexican health and aging study 2012-2015

To determine the burden of disease among subjects at risk of developing stroke or dementia, brain health indexes (BHI) tend to rely on anatomical features. Recent definitions emphasize the need of a broader perspective that encompasses cardiovascular risk factors (CVRFS) and lifestyle components which can be considered partial contributors to optimal brain health. In this study, we aimed to establish the association and risk detected by a Brain Health Index and the risk of possible vascular dementia (PVD) using data from the Mexican Health and Aging Study (MHAS) 2012-2015. The MHAS is a longitudinal study of adults aged ≥ 50 years. We analyzed the data obtained between 2012 and 2015. CVRFS included in the index were diabetes mellitus, hypertension, myocardial infarction, depression, obesity, physical inactivity, and smoking history. A PVD diagnosis was established when scores in the Cross-Cultural Cognitive Examination were below reference norms and limitations in ≥1 instrumental activities of daily living and a history of stroke were present. A multinomial regression model was developed to determine the association between BHI scores and PVD. In 2015, 75 PVD cases were identified. Mean age was 67.1 ±13.2 years, 35.8% were female, and the mean educational level was 5.8 ±5.5 years. In cases with a higher score in the BHI, the model revealed a hazards ratio of 1.63 (95% CI: 1.63-1.64, p< 0.001) for PVD. In this longitudinal study, with the use of a feasible multifactorial BHI in the Mexican population, a greater score was associated with a 1.63-fold risk of developing PVD during the 3-year follow-up, while the risk for stroke was 1.75. This index could potentially be used to predict the risk of PVD in adults with modifiable CVRFS.

Incident Dementia After Spontaneous Intracerebral Hemorrhage

 Post-stroke cognitive impairment and dementia (PSCID) is a complication that affects long-term functional outcomes after stroke. Studies on dementia after long-term follow-up in stroke have focused predominantly on ischemic stroke, which may be different from the development of dementia after spontaneous intracerebral hemorrhage (ICH). In this review, we summarize the existing data and hypotheses on the development of dementia after spontaneous ICH, review the management of post-ICH dementia, and suggest areas for future research. Dementia after spontaneous ICH has a cumulative incidence of up to 32.0-37.4% at 5 years post-ICH. Although the pathophysiology of post-ICH dementia has not been fully understood, two main theoretical frameworks can be considered: 1) the triggering role of ICH (both primary and secondary brain injury) in precipitating cognitive decline and dementia; and 2) the contributory role of pre-existing brain pathology (including small vessel disease and neurodegenerative pathology), reduced cognitive reserve, and genetic factors predisposing to cognitive dysfunction. These pathophysiological pathways may have synergistic effects that converge on dysfunction of the neurovascular unit and disruptions in functional connectivity leading to dementia post-ICH. Management of post-ICH dementia may include screening and monitoring, cognitive therapy, and pharmacotherapy. Non-invasive brain stimulation is an emerging therapeutic modality under investigation for safety and efficacy. Our review highlights that there remains a paucity of data and standardized reporting on incident dementia after spontaneous ICH. Further research is imperative for determining the incidence, risk factors, and pathophysiology of post-ICH dementia, in order to identify new therapies for the treatment of this debilitating condition.

Tele neuropsychological exploratory assessment of indicators of mild cognitive impairment and autonomy level in Mexican population over 60 years old

Due to the cognitive decline associated with aging, it is necessary to determine the variables involved in this process to implement preventive actions to avoid or help slow the progression of cognitive decline to dementia in older adults. This is a priority in the current pandemic situation, due to the consequences of periods of confinement due to COVID-19. To address these challenges, this study was conducted through Information and Communication Technologies (ICTs), by adapting an in-person assessment protocol into an online Tele neuropsychological consultation. The correlation between autonomy and cognitive performance variables is analyzed in 47 Mexican subjects over 60 years of age. The results of the statistical analyses suggest a moderate correlation between the level of autonomy and cognitive performance (with MOCA and Clock Drawing Test), significant correlation values are outlined in some of the variables reviewed, and interesting data were found in the correlation of cognitive reserve with cognitive decline and the educational level from the participants. Finally, future analysis is proposed of the sensitivity of screening tests (CDT) to find indicators of Mild Cognitive Impairment (MCI) in this population that is not detected in classical tests (MOCA). Developing ICT-based screening protocols for the elderly may be a key tool in these coronavirus times or under any given circumstances.

[Risk factors for disability in patients with stroke in northeastern Mexico: A retrospective cross-sectional study]

OBJECTIVE

To determine the risk factors associated with disability in patients who had a stroke in northeastern Mexico.

DESIGN

This was an observational, retrospective, cross-sectional study. SITE: Conducted at the Family Medicine Unit No. 33 of the Mexican Institute of Social Security in Reynosa, Tamaulipas, Mexico.

PARTICIPANTS

One hundred and ninety-eight males and 146 females, above 18 years old, beneficiaries of the Mexican Institute of Social Security with a diagnosis of stroke between 2018 and 2021.

INTERVENTIONS

The Barthel index that assesses the degree of dependence to perform basic activities of daily living was applied to the participants and sociodemographic, biological and anthropometric variables were collected from the digital medical record.

MAIN MEASURES

A univariate, correlational and ordinal logistic regression statistical analysis was performed between independent and dependent variables to obtain measures of frequency, percentages, and associated risks.

RESULTS

The risk factors associated with disability were age (OR 1.03, CI 1.01-1.05), overweight (OR 1.81, CI 1.03-3.1), obesity grade I (OR 2.74, CI 1.46-5.1), obesity grade II (OR 4.38, CI 1.44-13), obesity grade III (OR 9.99, CI 2.12-47); type of stroke: ischemic (OR 4.60, CI 2.6-8) or thrombotic (OR 4.95, CI 1.57-15). The number of comorbidities was associated with disability when having one comorbidity (OR 2.80, CI 1.22-6.4), two comorbidities (OR 3.43, CI 1.37-8.5), three comorbidities (OR 2.71, CI 1.01-7.3), and with five comorbidities (OR 3.17, CI 1.01-9.9).

CONCLUSIONS

The risk factors found for disability were age, overweight, obesity, and type of ischemic and thrombotic stroke. Being cared for by a relative and/or spouse reduces the probability of disability.

Education Level Modulates the Presence of Poststroke Depression and Anxiety, But It Depends on Age

ABSTRACT

Depression and anxiety are common complications after stroke and little is known about the modulatory roles of education and age. Our study aimed to evaluate the modulatory effects of education level on anxiety and depression after stroke and their effect on each age group. Adults with first stroke took part in this cross-sectional observational clinical study. We used the following instruments: Hospital Anxiety and Depression Scale (HADS), Montreal Cognitive Scale, Pittsburgh Sleep Quality Index, Barthel index, and Functional Independence Measure. There were 89 patients. The mean (SD) age was 58.01 (13) years, mean (SD) years of education was 9.91 (5.22), 55.1% presented depression symptoms and 47.2% anxiety symptoms, 56.2% were young adults and 43.8% were older adults. We identified a negative association between education and anxiety score (r = -0. 269, p = 0.011) and depression score (r = -0.252, p = 0.017). In the linear regression analysis, we found that education is negatively associated with HADS, but this influence was more consistent in young adults. In conclusion, a higher education level reduces the risk of depression and anxiety, but their effect is less consistent in older adults.

Homocysteine level at the acute stage of ischemic stroke as a biomarker of poststroke depression: A systematic review and meta-analysis

BACKGROUND

Studies on the association of homocysteine level with poststroke depression (PSD) have yielded conflicting results. This systematic review and meta-analysis aimed to evaluate the elevated homocysteine level at the acute stage of ischemic stroke in predicting PSD.

METHODS

Two authors systematically searched articles indexed in PubMed and Embase databases up to 31 January 2022. Studies evaluating the association of homocysteine level with the development of PSD in patients with acute ischemic stroke were selected.

RESULTS

A total of 10 studies involving 2,907 patients were identified. The pooled adjusted odds ratio (OR) of PSD was 3.72 [95% confidence intervals (CI) 2.03-6.81] for the top vs. bottom homocysteine level. The value of elevated homocysteine level in predicting PSD was stronger in ≥6-month follow-up (OR 4.81; 95% CI 3.12-7.43) than those in ≤ 3-month follow-up subgroup (OR 3.20; 95% CI 1.29-7.91). Moreover, a per unit increase in homocysteine level conferred a 7% higher risk of PSD.

CONCLUSION

Elevated homocysteine level in the acute stage of ischemic stroke may be an independent predictor of PSD.

Higher Serum Lactic Dehydrogenase is Associated with Post-Stroke Depression at Discharge

Purpose

Post-stroke depression (PSD) is one of the most common and severe psychological sequelae after stroke, negatively affecting the patient’s functional outcome and quality of life. Rapidly measurable biomarkers to predict PSD are pivotal for the optimized care and allocation of healthcare resources. Lactic dehydrogenase (LDH) levels are increased in patients with central nervous system (CNS) disorders such as cerebral infarction and hypoxic–ischemic encephalopathy, which may be related to the occurrence of PSD in acute ischemic stroke (AIS) patients. This study aimed to investigate whether LDH levels on admission are associated with PSD at discharge.

Patients and Methods

A multicenter prospective cohort study was conducted, including all consecutive AIS patients within 7 days after symptom onset from May 2018 to October 2019. According to the distribution of LDH and the number of patients, patients were divided into equal tertiles. PSD was evaluated by DSM-V criteria and the 17-item Hamilton Rating Scale for Depression (HRSD-17) at discharge.

Results

A total of 518 AIS patients were included. The optimal cut-off points of LDH were: lowest tertile (T1) 102–159/L, middle tertile (T2) 160–189 U/L, and upper tertile (T3) 190–520 U/L. A total of 249 patients (48.07%) were diagnosed with PSD at discharge. After adjusting for potential confounding factors, the odds ratio of T3 PSD was 1.698 (95% CI, 1.070–2.694, P=0.025), compared with T1.

Conclusion

In summary, LDH serum levels on admission are associated with PSD at discharge. Clinicians should pay more attention to the baseline LDH level in screening for PSD at discharge.

Regional Brain Perfusion Is Associated with Endothelial Dysfunction Markers in Major Depressive Disorder

BACKGROUND

Major depressive disorder (MDD) is an important independent risk factor for cardiovascular disease. Cumulative data suggest that depressive patients exhibit derangement in regional cerebral blood flow (rCBF), although underlying mechanisms remain mostly unknown. Endothelial dysfunction (ED), defined as different forms of abnormal endothelial activity, plays a key role in the pathogenesis of vascular disease. ED is associated with several clinical conditions characterized by high cardiovascular risk. Diverse ED markers have been found in mood disorders.

PURPOSE

To evaluate the association between rCBF and peripheral ED markers in MDD patients, at baseline and after selective serotonin receptor inhibitors (SSRIs) therapy.

PATIENTS AND METHODS

Twenty-seven untreated unipolar MDD patients in their first episode were evaluated with the Hamilton Depression Rating Scale (HAM-D) and brain perfusion SPECT at baseline and after 2 months of SSRIs. Statistical Parametric Mapping (SPM) was employed to evaluate rCBF; circulating endothelial cells (CECs), plasma soluble intercellular adhesion molecule (sICAM), and high-sensitivity C-reactive protein (hsCRP) were used as independent covariates.

RESULTS

Baseline CECs and sICAM were increased in MDD patients compared with matching controls (p = 0.0001) and hsCRP (p = 0.03). HAM-D scores (21 items) and CECs diminished after SSRI therapy in MDD patients (p < 0.0001). There was a significant rCBF decrease, mainly in deep central structures. HAM-D change was associated with rCBF decrease at the left amygdala, right striatum levels, and Brodmann area 25. CEC change was associated with rCBF at deep brain level and sICAM with large rCBF areas at the left caudate and tectum; hsCRP was associated, to a lesser extent, with the left dorsal striatum and mesencephalic tectum.

CONCLUSION

ED markers in patients with MDD are associated with significant changes in rCBF which are features of depression. These findings suggest that systemic damage/activation of the endothelium may contribute to the abnormal rCBF observed in MDD patients.

A Nationwide Multi-Center Questionnaire Survey on the Real-World State and Clinical Management of Poststroke Dementia in Japan

Background:

Poststroke dementia (PSD) is a serious problem for stroke survivors. However, there is still limited data on the real-world state and clinical management of PSD worldwide, and several countries already have a super-aged society.

Objective:

We conducted a nationwide questionnaire survey to examine the real-world state and management of PSD in Japan.

Methods:

A survey was conducted in the top 500 Japanese hospitals regarding the number of stroke patients treated between July 2018 and August 2019. Thirteen questions regarding PSD were mailed to doctors responsible for stroke management.

Results:

Responses were obtained from 251 hospitals (50.2%). The chief doctors responsible for stroke management answered the questionnaires. The median numbers of patients admitted annually with stroke in the departments of neurology and neurosurgery in the hospitals were 281.0 (interquartile range [IQR], 231.8–385.3) and 253.5 (IQR, 210.0–335.3), respectively, and most hospitals were acute care hospitals. Executive dysfunction was the most common cognitive dysfunction (10.9%), followed by amnesia (9.5%) and apathy (4.1%). Surprisingly, many stroke survivors lived alone at home (23.7%). Montreal Cognitive Assessment was significantly uncommon compared to Mini-Mental State Examination (p < 0.01). Furthermore, objective evaluation tests for behavioral and psychological symptoms of dementia were not often performed. Cognitive rehabilitation treatments were performed more often and earlier than drug treatments. The first drug of choice for PSD was predominantly donepezil (79.1%), followed by galantamine (6.1%), cilostazol (4.9%), memantine (2.5%), and rivastigmine (1.8%).

Conclusion:

Our study provides real-world evidence for the state of clinical practice related to PSD in Japan.

Cognitive Impairment After Intracerebral Hemorrhage: A Systematic Review of Current Evidence and Knowledge Gaps

Background: Cognitive impairment (CI) is commonly observed after intracerebral hemorrhage (ICH). While a growing number of studies have explored this association, several evidence gaps persist. This review seeks to investigate the relationship between CI and ICH. Methods: A two-stage systematic review of research articles, clinical trials, and case series was performed. Initial search used the keywords ["Intracerebral hemorrhage" OR "ICH"] AND ["Cognitive Impairment" OR "Dementia OR "Cognitive Decline"] within the PubMed (last accessed November 3rd, 2020) and ScienceDirect (last accessed October 27th, 2020) databases, without publication date limits. Articles that addressed CI and spontaneous ICH were accepted if CI was assessed after ICH. Articles were rejected if they did not independently address an adult human population or spontaneous ICH, didn't link CI to ICH, were an unrelated document type, or were not written in English. A secondary snowball literature search was performed using reviews identified by the initial search. The Agency for Healthcare research and Quality's assessment tool was used to evaluate bias within studies. Rates of CI and contributory factors were investigated. Results: Search yielded 32 articles that collectively included 22,631 patients. Present evidence indicates a high rate of post-ICH CI (65-84%) in the acute phase (<4 weeks) which is relatively lower at 3 (17.3-40.2%) and 6 months (19-63.3%). Longer term follow-up (≥1 year) demonstrates a gradual increase in CI. Advanced age, female sex, and prior stroke were associated with higher rates of CI. Associations between post-ICH CI and cerebral microbleeds, superficial siderosis, and ICH volume also exist. Pre-ICH cognitive assessment was missing in 28% of included studies. The Mini Mental State Evaluation (44%) and Montreal Cognitive Assessment (16%) were the most common cognitive assessments, albeit with variable thresholds and definitions. Studies rarely (<10%) addressed racial and ethnic disparities. Discussion: Current findings suggest a dynamic course of post-ICH cognitive impairment that may depend on genetic, sociodemographic and clinical factors. Methodological heterogeneity prevented meta-analysis, limiting results. There is a need for the methodologies and time points of post-ICH cognitive assessments to be harmonized across diverse clinical and demographic populations.

Development and Validation of 3-Month Major Post-Stroke Depression Prediction Nomogram After Acute Ischemic Stroke Onset

Purpose

The early detection of major post-stroke depression (PSD) is essential to optimize patient care. A major PSD prediction tool needs to be developed and validated for early screening of major PSD patients.

Patients and Methods

A total of 639 acute ischemic stroke (AIS) patients from three hospitals were consecutively recruited and completed a 3-month follow-up. Sociodemographic, clinical and laboratory test data were collected on admission. With major depression criteria being met in the DSM-V, 17-item Hamilton Rating Scale For Depression (HRSD) score ≥17 at 3 months after stroke onset was regarded as the primary endpoint. Multiple imputation was used to substitute the missing values and multivariable logistic regression model was fitted to determine associated factors with a bootstrap backward selection process. The nomogram was constructed based on the regression coefficients of the associated factors. Performance of the nomogram was assessed by discrimination (C-statistics) and calibration curve.

Results

A total of 7.04% (45/639) of patients were diagnosed with major PSD at 3 months. The final logistic regression model included age, baseline NIHSS and mRS scores, educational level, calcium-phosphorus product, history of hypertension and atrial fibrillation. The model had acceptable discrimination, based on a C-statistic of 0.81 (95% CI, 0.791-0.829), with 71.1% sensitivity and 78.6% specificity. We also transformed the model to a nomogram, an easy-to-use clinical tool which could be used to facilitate the early screening of major PSD patients at 3 months.

Conclusion

We identified several associated factors of major PSD at 3 months and constructed a convenient nomogram to guide follow-up and aid accurate prognostic assessment.

Prevalence and incidence of possible vascular dementia among Mexican older adults: Analysis of the Mexican Health and Aging Study

Introduction

Vascular dementia is the second most common cause of dementia. Physical disability and cognitive impairment due to stroke are conditions that considerably affect quality of life. We estimated the prevalence and incidence of possible vascular dementia (PVD) in older adults using data from the Mexican Health and Aging Study (MHAS 2012 and 2015 waves).

Methods

The MHAS is a representative longitudinal cohort study of Mexican adults aged ≥50 years. Data from 14, 893 participants from the 2012 cohort and 14,154 from the 2015 cohort were analyzed to estimate the prevalence and incidence of PVD. Self-respondents with history of stroke were classified as PVD if scores in two or more cognitive domains in the Cross-Cultural Cognitive Examination were ≥ 1.5 standard deviations below the mean on reference norms and if limitations in ≥ 1 instrumental activities of daily living were present. For proxy respondents with history of stroke, we used a score ≥3.4 on the Informant Questionnaire on Cognitive Decline in the Elderly. Crude and standardized rates of prevalent and incident PVD were estimated.

Results

Prevalence of PVD was 0.6% (95% CI, 0.5–0.8) (0.5 with age and sex- standardization). Rates increased with age reaching 2.0% among those aged 80 and older and decreased with educational attainment. After 3.0 years of follow-up, 87 new cases of PVD represented an overall incident rate of 2.2 (95% CI, 1.7–2.6) per 1,000 person-years (2.0 with age and sex- standardization). Incidence also increased with advancing age reaching an overall rate of 9.4 (95% CI, 6.3–13.6) per 1,000 person-years for participants aged >80 years. Hypertension and depressive symptoms were strong predictors of incident PVD.

Conclusion

These data provide new estimates of PVD prevalence and incidence in the Mexican population. We found that PVD incidence increased with age. Males aged 80 years or older showed a greater incidence rate when compared to females, which is comparable to previous estimates from other studies.

Psychological Complications at 3 Months Following Stroke: Prevalence and Correlates Among Stroke Survivors in Lebanon

Introduction: Stroke continues to be a common and debilitating medical condition which has a significant effect on public health as the second primary source of mortality and the third major root of disability worldwide. A wide range of complications affecting the survivor's life and interfering with the recovery process usually follows stroke; anxiety and depression are considered one of the major complications post-stroke. This study sought to investigate the short-term psychological consequences of stroke among Lebanese survivors and to identify their correlates.

Methods: This study is a prospective observational epidemiological study. 143 stroke patients admitted to hospitals in Mount Lebanon and Beirut between February and May 2018.were included in this study. Assessments of complications were carried out at 3 months post-stroke by completing a 30-min face-to-face interview questionnaire. The survey included the socio-demographic -characteristics of the patients, their lifestyle, health indicators, the severity of stroke, and the post-stroke consequences disturbing their quality of life.

Results: Complications were recorded for 117 stroke survivors (mean age, 72.46 years; 60.7% male). The analysis of results 3 months post stroke showed that 29 survivors suffered from neuropathic pain (24.8%), 110 (94%) suffered from fatigue, and 81 (69.2%) from cognitive impairment. High rates of anxiety (51.3%), and depression (76.1%) were recorded as well. Multivariate logistic regression confirmed that there is a significant association between depression and the following variables: anxiety (OR = 4.814, p-value = 0.017), pain (OR = 6.868, p-value = 0.002), and physical activity, which acts as a protective factor against depression (OR = 0.261; p-value = 0.029). However, the results of the multivariate logistic regression analysis for anxiety indicated that immobility-related complications increase the risk of anxiety by 8.457 in sedentary duration longer than 12 h (ORa = 8.457, p-value = 0.01). Furthermore, patients with neuropathic pain (24.8%) are 3.858 times more likely to have anxiety compared to patients without neuropathic pain (ORa = 3.858, p-value = 0.019).

Conclusion: Using a patient-centered structure more interventions should take place to evaluate stroke survivors' outcomes, and organize rehabilitation services that deal with stroke consequences, particularly high anxiety and depression levels, which are prevalent and persistent among the Lebanese stroke survivors.

Understanding Why Post-Stroke Depression May Be the Norm Rather Than the Exception: The Anatomical and Neuroinflammatory Correlates of Post-Stroke Depression

Ischemic Stroke precedes depression. Post-stroke depression (PSD) is a major driver for poor recovery, negative quality of life, poor rehabilitation outcomes and poor functional ability. In this systematic review, we analysed the inflammatory basis of post-stroke depression, which involves bioenergetic failure, deranged iron homeostasis (calcium influx, Na influx, potassium efflux etc), excitotoxicity, acidotoxicity, disruption of the blood brain barrier, cytokine-mediated cytotoxicity, reactive oxygen mediated toxicity, activation of cyclooxygenase pathway and generation of toxic products. This process subsequently results in cell death, maladapted, persistent neuro-inflammation and deranged neuronal networks in mood-related brain regions. Furthermore, an in-depth review likewise reveals that anatomic structures related to post-stroke depression may be localized to complex circuitries involving the cortical and subcortical regions.

Predictors of dementia after first ischemic stroke

Various mechanisms contribute to dementia after first ischemic stroke as lesions on strategic areas of cognition and stroke premorbidity.

Objectives

Assessing clinical and neuroimaging predictors of dementia after first ischemic stroke and its relation to stroke location, subtypes and severity.

Methods

Eighty first ischemic stroke patients were included. Forty patients with dementia after first stroke and forty patients without dementia according to DSM-IV diagnostic criteria of vascular dementia. All patients were subjected to general and neurological assessment, National Institute Health Stroke Scale (NIHSS) for stroke severity, Montreal Cognitive Assessment (MoCA) scale for cognition assessment, MRI brain and Trial of Org 10172 in acute stroke treatment (TOAST) classification for stroke subtypes.

Results

Left hemispheric ischemic stroke, strategic infarctions, diabetes mellitus and stroke of anterior circulation were found to be independent risk factors for dementia after first ischemic stroke (OR=3.09, 95%CI 1.67-10.3, OR=2.33, 95%CI 1.87-8.77, OR=1.88, 95%CI 1.44-4.55, OR=1.86, 95%CI 1.45-6.54, respectively). Hypertension, dyslipidemia, smoking, ischemic heart disease, high NIHSS score and large vessel infarction were significantly higher among post stroke dementia patients. However, on binary logistic regression, they did not reach to be independent risk factors.

Conclusion

Stroke location (left stroke, strategic infarction, anterior circulation stroke) and diabetes mellitus could be predictors of dementia after first ischemic stroke, but stroke severity, stroke subtypes, hypertension, dyslipidemia, smoking and ischemic heart could not.

Targeting the renin angiotensin system for the treatment of anxiety and depression

Emotional disorders like anxiety and depression are responsible for considerable morbidity and mortality all over the world. Several antidepressant and anxiolytic medications are available for the treatment of anxiety and depression. However, a significant number of patients either do not respond to these medications or respond inadequately. Hence, there is a need to identify novel targets for the treatment of anxiety and depression. In this review we focus on the renin angiotensin system (RAS) as a potential target for the treatment of these disorders. We review work that has evaluated the effects of various compounds targeting the RAS on anxiety- and depression-like behaviors. Further, we suggest future work that must be carried out to fully exploit the RAS for the treatment of anxiety and depression. The RAS provides an attractive target for both the identification of novel anxiolytic and antidepressant medications and/or for enhancing the efficacy of currently available medications used for the treatment of anxiety and depression.

Serum Kynurenines Correlate With Depressive Symptoms and Disability in Poststroke Patients: A Cross-sectional Study

Background

Poststroke depression (PSD) is related to adverse functional and cognitive prognosis in stroke patients. The participation of kynurenine pathway metabolites in depression has been previously proposed; however, there are few studies on its role in PSD and disability in stroke.

Objective

To investigate if there is a correlation between serum kynurenines levels with poststroke anxiety and depression symptoms and disability scales.

Methods

A cross-sectional case-control study was conducted in patients with first stroke, of >1 month and <1 year of evolution, with no history of previous psychiatric or neurological disorders; the Hospital Anxiety and Depression Scale (HADS), Montreal Cognitive Assessment (MoCA), functional evaluations (Barthel index, Functional Independence Measure [FIM]) were applied and serum kynurenines (Kyns) were determined.

Results

Sixty patients were included; significant depressive symptoms were found in 63% of the cases; a significant and positive correlation was obtained between levels of 3-hydroxykynurenine (3-HK) with HADS-T ( r = 0.30, P = .025) and HADS-D ( r = 0.28, P = .039). Depressed patients showed significantly higher levels of 3HK ( P = .048) and KYNA ( P = .0271) than nondepressed patients; the 3HK levels were inversely correlated with functional scales: Barthel index ( r = −0.31, P = .02), FIM ( r = −0.40, P = .01); in addition, serum 3HK levels were significantly higher in patients with poor sleep quality ( P = .0190).

Conclusions

Serum Kyns show correlation with the presence and severity of depressive symptoms and with the disability and sleep quality. Kyns may be a potential marker of depression risk and disability in stroke in future.

Association between Higher Blood Pressure and Risk of Diabetes Mellitus in Middle-Aged and Elderly Chinese Adults

BACKGROUND

To examine the prospective association between higher blood pressure (BP) and risk of type 2 diabetes mellitus (T2DM) in middle-aged and elderly Chinese adults.

METHODS

A total of 9,642 middle-aged and elderly Chinese adults (≥45 years old; 47.30% men) without diabetes from the China Health and Retirement Longitudinal Study were included for analyses. Participants were categorized into three groups: normal BP, prehypertension, and hypertension, according to the 2010 Chinese Guidelines for the Management of Hypertension. The incidence of T2DM was determined by self-reported physician diagnosis during two follow-up surveys conducted in 2013 to 2014 and 2015 to 2016.

RESULTS

During the 4-year follow-up, 429 participants (4.45%) developed T2DM, including 3.51% of the men and 5.29% of the women. The incidence rates of T2DM were 2.57%, 3.75%, and 6.71% in the normal BP, prehypertension, and hypertension groups, respectively. After adjustment for age, sex, education level, residence, smoking status, alcohol consumption, body mass index, waist circumference, and dyslipidemia, both prehypertension (odds ratio [OR], 1.32; 95% confidence interval [CI], 0.98 to 1.77) and hypertension (OR, 2.02; 95% CI, 1.54 to 2.64) were associated with increased risk of T2DM, compared to those with a normal BP. The ORs associated with T2DM were 1.08 (95% CI, 1.03 to 1.13) for an increase of 10 mm Hg in systolic BP and 1.06 (95% CI, 1.01 to 1.10) for an increase of 5 mm Hg in diastolic BP.

CONCLUSION

Higher BP is a risk factor for T2DM in middle-aged and elderly Chines. It may be a potential target for diabetes prevention.

Vascular Depression and Cognition in Mexican Americans

BACKGROUND

Mexican Americans are at increased risk of developing mild cognitive impairment (MCI) and Alzheimer's disease compared to non-Hispanic whites. This study sought to examine the relationship between vascular risk, depression, and cognition in Mexican American elders.

METHODS

Data from 470 (390 normal controls, 80 MCI patients) Mexican Americans enrolled in the Health and Aging Brain among Latino Elders (HABLE) study were used. The cardiovascular risk was assessed by the Framingham Risk Score. Cognition was assessed with a neuropsychological battery, and depression was assessed based on scores from the Geriatric Depression Scale (GDS). ANOVAs were utilized to determine the differences in neuropsychological scores of normal controls with and without depression and CVD risk (low vs. high). Follow-up logistic regression was conducted to determine MCI risk.

RESULTS

The results of this study indicated that comorbid depression and a high CVD risk were associated with poorer cognitive performance in Mexican Americans. Depressed women with high CVD risk were more likely to have executive dysfunction, language deficits, and poorer global cognition than nondepressed women with a high CVD risk. In Mexican American men, those with a high vascular risk and depression were more likely to have executive dysfunction and poorer immediate memory than the nondepressed high-risk group. Higher GDS scores (OR = 1.10; 95% CI 1.02-1.10, p = 0.001) and higher vascular risk scores (OR = 1.05; 95% CI 1.02-1.10, p = 0.001) significantly predicted MCI status in Mexican Americans.

CONCLUSION

The results of this study indicated that comorbid depression and a high CVD risk were associated with poorer cognitive performance and increased risk of MCI in Mexican Americans.

Systematic Review and Meta-Analysis of Prevalence in Post-Stroke Neurocognitive Disorders in Hospital-Based Studies

BACKGROUND/AIMS

Post-stroke neurocognitive disorders (post-stroke NCD) have been reported with a very variable prevalence.

METHODS

Based on a systematic literature search, hospital-based studies published between January 1990 and September 2015 were selected when they reported the prevalence of total, mild, and major post-stroke NCD diagnosed by using specified criteria. Factors affecting prevalence were assessed using meta-regression analysis.

RESULTS

Among the 7,440 references evaluated, 16 hospital-based studies were selected, corresponding to a total of 3,087 patients. The overall prevalence of total post-stroke NCD was 53.4% (95% CI: 46.9-59.8): 36.4% for mild post-stroke NCD (95% CI: 29-43.8) and 16.5% (95% CI: 12.1-20.8) for major post-stroke NCD. The overall prevalence was mainly influenced by the threshold score used for categorization (p = 0.0001) and, in the subgroup of studies using a conservative threshold (i.e., ≤7th percentile), by the recurrent stroke rate (p = 0.0005). The prevalence of major post-stroke NCD was mainly influenced by age (p = 0.003).

CONCLUSION

More than half of stroke survivors experience post-stroke NCD, corresponding to mild post-stroke NCD in two-thirds of cases and major post-stroke NCD in one-third of cases. Harmonization of stroke assessment and cognitive score thresholds is urgently needed to allow more accurate estimation of post-stroke NCD prevalence, especially mild post-stroke NCD.

Systematic review and meta-analysis of the prevalence of cognitive impairment no dementia in the first year post-stroke

Introduction

Increasing attention is being paid to interventions for cognitive impairment (CI) post-stroke, including for CI that does not meet dementia criteria. The aim of this paper was to conduct a systematic review and meta-analysis of the prevalence of cognitive impairment no dementia (CIND) within one year post-stroke.

Patients and methods

Pubmed, EMBASE and PsychInfo were searched for papers published in English in 1995-2017. Included studies were population or hospital-based cohort studies for first-ever/recurrent stroke, assessing CIND using standardised criteria at 1-12 months post-stroke. Abstracts were screened, followed by full text review of potentially relevant articles. Data were extracted using a standard form, and study quality was appraised using the Crowe Critical Appraisal Tool. A pooled prevalence of CIND with 95% confidence intervals (CI) was estimated using random-effects meta-analysis. Heterogeneity was measured using the I² statistic.

Results

A total of 7000 abstracts were screened, followed by 1028 full text articles. Twenty-three articles were included in the systematic review, and 21 in the meta-analysis. The pooled CIND prevalence was 38% [95% CI = 32-43%] (I²=92.5%, p < 0.01). Study quality emerged as one source of heterogeneity. The five studies with the highest quality scores had no heterogeneity (I²=0%, p = 0.99), with a similar pooled prevalence (39%, 95%CI = 35-42%). Other sources of heterogeneity were stroke type, inclusion of pre-stroke CI, and age at assessment time.Discussion and conclusion: Meta-analysis of available studies indicates that in the first year post-stroke, 4 in 10 patients display a level of cognitive impairment that does not meet the criteria for dementia.

Prevalence and short-term changes of cognitive dysfunction in young ischaemic stroke patients

BACKGROUND AND PURPOSE

Information on the prevalence and course of post-stroke cognitive impairment in young stroke patients is limited. The aim was to assess a consecutive sample of acute young ischaemic stroke patients (18-55 years) for the presence and development of neuropsychological deficits.

METHODS

Patients prospectively underwent a comprehensive clinical and cognitive assessment, examining general cognitive function, processing speed, attention, flexibility/executive function and word fluency within the first 3 weeks after hospital admission (median assessment at day 6) and at a 3 months' follow-up (FU). Cognitive dysfunction was defined in comparison to age-standardized published norms.

RESULTS

At baseline (N = 114), deficits were highly prevalent in processing speed (56.0%), flexibility/executive function (49.5%), attention (46.4%) and general cognitive function (42.1%). These frequencies were comparable for those with FU assessment (N = 87). In most domains, cognitive performance improved within 3 months, except for word fluency. However, in about one-third of patients, cognitive deficits (as defined by 1.5 standard deviations below the standardized mean) were still present 3 months after stroke. At FU, 44.0% were impaired in the domain flexibility/executive function, 35.0% in processing speed and 30.0% in attention.

CONCLUSIONS

The high prevalence of cognitive deficits in acute young patients with ischaemic stroke highlights the importance of early post-stroke cognitive assessment to capture a patient's dysfunction in a comprehensive manner and to offer adequate rehabilitation. The role of factors which promote neuropsychological deficits needs further exploration.

Sex differences in risk factors for vascular contributions to cognitive impairment & dementia

Vascular contributions to cognitive impairment and dementia (VCID) is the second most common cause of dementia. While males overall appear to be at a slightly higher risk for VCID throughout most of the lifespan (up to age 85), some risk factors for VCID more adversely affect women. These include female-specific risk factors associated with pregnancy related disorders (e.g. preeclampsia), menopause, and poorly timed hormone replacement. Further, presence of certain co-morbid risk factors, such as diabetes, obesity and hypertension, also may more adversely affect women than men. In contrast, some risk factors more greatly affect men, such as hyperlipidemia, myocardial infarction, and heart disease. Further, stroke, one of the leading risk factors for VCID, has a higher incidence in men than in women throughout much of the lifespan, though this trend is reversed at advanced ages. This review will highlight the need to take biological sex and common co-morbidities for VCID into account in both preclinical and clinical research. Given that there are currently no treatments available for VCID, it is critical that we understand how to mitigate risk factors for this devastating disease in both sexes.

Who should undergo a comprehensive cognitive assessment after a stroke? A cognitive risk score

OBJECTIVE

To validate the ability of a specifically developed cognitive risk score to identify patients at risk of poststroke neurocognitive disorders (NCDs) who are eligible for a comprehensive cognitive assessment.

METHODS

After assessing 404 patients (infarct 91.3%) in the Groupe de Réflexion pour l'Evaluation Cognitive VASCulaire (GRECogVASC) cross-sectional study with the National Institute of Neurological Disorders and Stroke-Canadian Stroke Network battery 6 months after stroke, we used multivariable logistic regression and bootstrap analyses to determine factors associated with NCDs. Independent, internally validated factors were included in a cognitive risk score.

RESULTS

Cognitive impairment was present in 170 of the 320 patients with a Rankin Scale score ≥1. The backward logistic regression selected 4 factors (≥73% of the permutations): NIH Stroke Scale score on admission ≥7 (odds ratio [OR] 2.73, 95% confidence interval [CI] 1.29-4.3, p = 0.005), multiple strokes (OR 3.78, 95% CI 1.6-8, p = 0.002), adjusted Mini-Mental State Examination (MMSEadj) score ≤27 (OR 6.69, 95% CI 3.9-11.6, p = 0.0001), and Fazekas score ≥2 (OR 2.34, 95% CI 1.3-4.2, p = 0.004). The cognitive risk score computed with these 4 factors provided good calibration, discrimination (overoptimism-corrected C = 0.793), and goodness of fit (Hosmer-Lemeshow test p = 0.99). A combination of Rankin Scale score ≥1, cognitive risk score ≥1, and MMSEadj score ≥21 selected 230 (56.9%) of the 404 patients for a comprehensive assessment. This procedure yielded good sensitivity (96.5%) and moderate specificity (43%; positive predictive value 0.66, negative predictive value 0.91) and was more accurate (p ≤ 0.03 for all) than the sole use of screening tests (MMSE or Montréal Cognitive Assessment).

CONCLUSION

The GRECogVASC cognitive risk score comprises 4 easily documented factors; this procedure helps to identify patients at risk of poststroke NCDs who must therefore undergo a comprehensive assessment.

CLINICALTRIALSGOV IDENTIFIER

NCT01339195.

Effects of Blood Pressure in the Early Phase of Ischemic Stroke and Stroke Subtype on Poststroke Cognitive Impairment

BACKGROUND AND PURPOSE

Blood pressure (BP) control in the early phase of stroke is controversial to reduce the risk of poststroke cognitive impairment (PSCI). This study was to investigate the impact of BP levels in the early phase of ischemic stroke and stroke subtype on PSCI.

METHODS

Seven hundred and ninety-six patients with acute ischemic stroke were included. Cognitive function was assessed after stroke onset using the Montreal Cognitive Assessment. Patients were divided into quintiles according to systolic BP and diastolic BP levels in the early phase. Subtype analyses were according to Trial of ORG 10172 in Acute Stroke Treatment classification (infarct cause) and Oxfordshire Community Stroke Project classification (infarct location).

RESULTS

After adjusting for multiple variables, the quintiles with the lowest systolic BP (Q1, 102-127 mm Hg) and with the highest systolic BP (Q5, 171-215 mm Hg) were associated with increased PSCI risk (odds ratio, 1.83; 95% confidence interval, 1.64-2.28; P=0.007 in Q1; odds ratio, 2.32; 95% confidence interval, 1.74-2.90; P<0.001 in Q5) at 3 months as compared with the middle quintile (Q3, 143-158 mm Hg). Similar association was found in diastolic BP quintiles. The analysis of cerebral infarction subtype demonstrated that both large artery atherosclerosis and total anterior circulation infarct were associated with increased risk of PSCI at 3 months after adjusting for multiple variables (large artery atherosclerosis: odds ratio, 1.42; 95% confidence interval, 1.06-1.90; P=0.031; total anterior circulation infarct: odds ratio, 1.68; 95% confidence interval, 1.32-2.15; P=0.001).

CONCLUSIONS

Lower or higher BP in the early phase of ischemic stroke was correlated with increased PSCI risk at 3 months. Maintaining systolic/diastolic BP in the levels of 143 to 158/93 to 102 mm Hg might be beneficial to reduce the occurrence of PSCI. Moreover, large artery atherosclerosis subtype and total anterior circulation infarct subtype were correlated with increased PSCI risk at 3 months.

CLINICAL TRIAL REGISTRATION

URL: https://www.chictr.org. Unique identifier: ChiCTR-TRC-14004804.

Prevalence of Poststroke Neurocognitive Disorders Using National Institute of Neurological Disorders and Stroke-Canadian Stroke Network, VASCOG Criteria (Vascular Behavioral and Cognitive Disorders), and Optimized Criteria of Cognitive Deficit

BACKGROUND AND PURPOSE

The prevalence of poststroke neurocognitive disorder (NCD) has yet to be accurately determined. The primary objective of the present study was to optimize operationalization of the criterion for NCD by using an external validity criterion.

METHODS

The GRECOG-VASC cohort (Groupe de Réflexion pour l'Évaluation Cognitive Vasculaire) of 404 stroke patients with cerebral infarct (91.3%) or hemorrhage (18.7%) was assessed 6 months poststroke and 1003 healthy controls, with the National Institute of Neurological Disorders and Stroke-Canadian Stroke Network standardized battery. Three dimensions of the criterion for cognitive impairment were systematically examined by using the false-positive rate as an external validity criterion. Diagnosis of mild and major NCD was based on the VASCOG criteria (Vascular Behavioral and Cognitive Disorders). The mechanisms of functional decline were systematically assessed.

RESULTS

The optimal criterion for cognitive impairment was the shortened summary score (ie, averaged performance for action speed, executive functions, and language) because it was associated with the highest (P=0.0001) corrected true-positive rate (43.5%) and a false-positive rate ≤5%. Using this criterion, the mean (95% confidence interval) prevalence of poststroke NCD was 49.5% (44.6-54.4), most of which corresponded to mild NCD (39.1%; 95% confidence interval, 34.4-43.9) rather than dementia (10.4%; 95% confidence interval, 7.4-13.4).

CONCLUSIONS

This study is the first to have optimized the operationalization of the criterion for poststroke cognitive impairment. It documented the prevalence of poststroke NCD in the GRECOG-VASC cohort and showed that mild cognitive impairment accounts for 80% of the affected patients. Finally, the method developed in the present study offers a means of harmonizing the diagnosis of NCD.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01339195.

A Systematic Review of the Definitions of Vascular Cognitive Impairment, No Dementia in Cohort Studies

BACKGROUND/AIMS

No set operational criteria for vascular cognitive impairment, no dementia (VCI-ND) have yet been established. The aim of this study is to undertake a systematic review to compare definitions of VCI-ND that have been used in cohort studies.

METHODS

Medline, PsycINFO and Embase were searched from inception to October 13, 2015. Initially, 3,142 records were screened, and 30 were included in this review.

RESULTS

No single set of criteria for defining VCI-ND was identified. VCI-ND was broadly defined as an absence of dementia, cognitive impairment in at least one cognitive domain with signs of vascular involvement, and intact activities of daily living.

CONCLUSION

Defining criteria will enable individuals with VCI-ND to be efficiently compared across cohort studies to more accurately determine the prevalence and risk of dementia.

Predictors of early-onset post-ischemic stroke depression: a cross-sectional study

BACKGROUND

Post-stroke depression (PSD) seriously affects the rehabilitation of nerve function and quality of life. However, the pathogenesis of PSD is still not clear. This study aimed to investigate the demographic, clinical, and biochemical factors in patients with PSD.

METHODS

Patients with an acute ischemic stroke, who met the inclusion criteria at Shanghai Tenth People's Hospital from April 2016 to September 2016, were recruited for this study. The stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS), and the mental state was assessed using Mini-Mental State Examination (MMSE), Hamilton Depression Scale (HAMD), and Hamilton Anxiety Scale (HAMA) at 1 week of admission. The patients were divided into PSD and non-PSD groups. The demographic and clinical characteristics, as well as the biochemical factors, were compared between the two groups. A logistic regression analysis was performed to identify the risk factors for depression following stroke.

RESULTS

A total of 83 patients with acute ischemic stroke were recruited. Of these, 36 (43.4%) developed depression. The multivariate logistic regression analysis indicated that high NIHSS [odds ratio (OR): 1.84, 95% confidence interval (CI): 1.09-3.12, P = 0.023] and high HAMD scores (OR: 2.38, 95% CI: 1.61-3.50, P < 0.001) were independent risk predictors for PSD and so were lower dopamine level (OR: 0.64, 95% CI: 0.45-0.91, P = 0.014), lower 5-hydroxytryptamine level (OR: 0.99, 95% CI: 0.98-1.00, P = 0.046), higher tumor necrosis factor-α level (OR: 1.05, 95% CI: 1.00-1.09, P = 0.044), and lower nerve growth factor level (OR: 0.06, 95% CI: 0.01-0.67, P = 0.022).

CONCLUSIONS

The identification of higher NIHSS scores, higher HAMD scores, lower dopamine level, lower 5-hydroxytryptamine level, higher tumor necrosis factor-α level, and lower nerve growth factor level might be useful for clinicians in recognizing and treating depression in patients after a stroke.

The Cognition and Affect after Stroke - a Prospective Evaluation of Risks (CASPER) study: rationale and design

BACKGROUND

Cognitive impairment and neuropsychiatric syndromes, like depression and apathy, are frequent residual consequences of stroke. These have a large impact on quality of life and long-term prognosis. Several factors are involved in the development of these residual syndromes, although their exact role and their interrelationships remain still rather unclear. The Cognition and Affect after Stroke: a Prospective Evaluation of Risks (CASPER) study has been primarily designed to examine whether stroke-specific (e.g. lesion location, volume, type, severity), cerebrovascular and neurodegenerative (e.g. white matter changes, atrophy, microbleeds, perivascular spaces), inflammatory, endothelial, and (epi)genetic markers are associated with cognitive impairment, post-stroke depression, and post-stroke apathy, and whether they predict their course over 12 months. The secondary aims are to investigate how the above-mentioned markers interact with each other, and to determine if patients with apathy and depression after stroke differ in pathogenesis, course, and outcome (e.g. functional outcome, neurocognitive performance, quality of life).

METHODS/DESIGN

CASPER is a 1-year prospective clinical cohort follow-up study in 250 stroke patients recruited at the neurological in- and outpatient services at Maastricht University Medical Center (MUMC+, Maastricht, The Netherlands), and Zuyderland Medical Center (Sittard and Heerlen, The Netherlands). At baseline (3 months post-stroke), a neuropsychological assessment, neuropsychiatric interview, blood sample, and brain magnetic resonance imaging (MRI) scan are conducted. Assessment of neuropsychiatric and neurocognitive status are repeated 6 and 12 months later.

DISCUSSION

The CASPER study investigates stroke-specific, vascular, neurodegenerative, inflammatory, and genetic markers of the development of vascular cognitive impairment, depression, and apathy after stroke. This creates the possibility to study not only the contribution of these individual markers but also their joint contribution, which differentiates this study from earlier stroke cohorts who lacked long-term follow-up data, a large sample size, an extensive MRI protocol, and markers from the blood. The knowledge we derive from this study might help in identifying markers that are associated with, or can predict the onset, maintenance, and progression of vascular cognitive impairment, depression, and apathy after stroke, and could provide new insights into possibilities for treatment and rehabilitation that result in better functional outcome after stroke.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02585349.

Application of knowledge discovery process on the prediction of stroke

OBJECTIVE

Stroke is a prominent life-threatening disease in the world. The current study was performed to predict the outcome of stroke using knowledge discovery process (KDP) methods, artificial neural networks (ANN) and support vector machine (SVM) models.

MATERIALS AND METHODS

The records of 297 (130 sick and 167 healthy) individuals were acquired from the databases of the department of emergency medicine. Nine predictors (coronary artery disease, diabetes mellitus, hypertension, history of cerebrovascular disease, atrial fibrillation, smoking, the findings of carotid Doppler ultrasonography [normal, plaque, plaque+stenosis≥50%], the levels of cholesterol and C-reactive protein) were used for predicting the stroke. Feature selection based on the Cramer's V test was carried out for reducing the predictors. Multilayer perceptron (MLP) ANN and SVM with radial basis function (RBF) kernel were used for the prediction based on the selected predictors.

RESULTS

The accuracy values were 81.82% for ANN and 80.38% for SVM in the training dataset (n=209), and 85.9% for ANN and 84.62% for SVM in the testing dataset (n=78), respectively. ANN and SVM models yielded area under curve (AUC) values of 0.905 and 0.899 in the training dataset, and 0.928 and 0.91 in the testing dataset, consecutively.

CONCLUSION

The findings of the current study pointed out that ANN had more predictive performance when compared with SVM in predicting stroke. The proposed ANN model would be useful when making clinical decisions regarding stroke.

Depression and cerebrovascular disease: could vortioxetine represent a valid treatment option?

INTRODUCTION

Depression and cerebrovascular atherosclerosis often occur in comorbidity showing neuropsychological impairment and poor response to antidepressant treatment. Objective is to evaluate if new antidepressant vortioxetine may be a potential treatment option. Mechanism of Action : Vortioxetine has 5-HT3, 5-HT7 and 5-HT1D antagonists, 5-HT1B partial agonist and a 5-HT1A agonist and serotonin transporter inhibitor property. Efficacy and safety in Major Depressive Disorders and in cognitive impairment : The majority of trials (one of them in older people) showed efficacy for vortioxetine against placebo and no differences against other active treatments. The Adverse Effects ranged from 15.8% more to 10.8% less than placebo. In the elderly, only nausea was found higher than placebo. Effects on arterial blood pressure and cardiac parameters including the ECG-QT segment were similar to placebo. Elderly depressive patients on vortioxetine showed improvement versus placebo and other active comparators in Auditory Verbal Learning Test and Digit Symbol Substitution Test scores. The inclusion criteria admitted cases with middle cerebrovascular disease. Conclusion : The mechanism of action, the efficacy on depression and safety profile and early data on cognitive impairment make Vortioxetine a strong candidate for use in depression associated with cerebrovascular disease. This information must be supported by future randomized controlled trials.