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Alphonce B, Meda J, Nyundo A. Incidence and predictors of post-stroke cognitive impairment among patients admitted with first stroke at tertiary hospitals in Dodoma, Tanzania: A prospective cohort study. PLoS One 2024; 19:e0287952. [PMID: 38598466 PMCID: PMC11006170 DOI: 10.1371/journal.pone.0287952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 02/01/2024] [Indexed: 04/12/2024] Open
Abstract
INTRODUCTION Stroke survivors develop cognitive impairment, which significantly impacts their quality of life, their families, and the community as a whole but not given attention. This study aims to determine the incidence and predictors of post-stroke cognitive impairment (PSCI) among adult stroke patients admitted to a tertiary hospital in Dodoma, Tanzania. METHODOLOGY A prospective cohort study was conducted at tertiary hospitals in the Dodoma region, central Tanzania. A sample size of 158 participants with the first stroke confirmed by CT/MRI brain aged ≥ 18 years met the criteria. At baseline, social-demographic, cardiovascular risks and stroke characteristics were acquired, and then at 30 days, participants were evaluated for cognitive functioning using Montreal Cognitive Assessment (MoCA). Key confounders for cognitive impairment, such as depression and apathy, were evaluated using the Personal Health Questionnaire (PHQ-9) and Apathy Evaluation Scale (AES), respectively. Descriptive statistics were used to summarise data; continuous data were reported as Mean (SD) or Median (IQR), and categorical data were summarised using proportions and frequencies. Univariate and multivariable logistic regression analysis was used to determine predictors of PSCI. RESULTS The median age of the 158 participants was 58.7 years; 57.6% of them were female, and 80.4% of them met the required criteria for post-stroke cognitive impairment. After multivariable logistic regression, left hemisphere stroke (AOR: 5.798, CI: 1.030-32.623, p = 0.046), a unit cm3 increase in infarct volume (AOR: 1.064, 95% CI: 1.018-1.113, p = 0.007), and apathy symptoms (AOR: 12.259, CI: 1.112-89.173, p = 0.041) had a significant association with PSCI. CONCLUSION The study revealed a significant prevalence of PSCI; early intervention targeting stroke survivors at risk may improve their outcomes. Future research in the field will serve to dictate policies and initiatives.
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Affiliation(s)
- Baraka Alphonce
- Department of Internal Medicine, School of Medicine & Dentistry, The University Dodoma, Dodoma, Tanzania
- Department of Internal Medicine, The Benjamin Mkapa Hospital, Dodoma, Tanzania
| | - John Meda
- Department of Internal Medicine, School of Medicine & Dentistry, The University Dodoma, Dodoma, Tanzania
- Department of Cardiology, The Benjamin Mkapa Hospital, Dodoma, Tanzania
| | - Azan Nyundo
- Department of Internal Medicine, The Benjamin Mkapa Hospital, Dodoma, Tanzania
- Department of Psychiatry and Mental Health, School of Medicine, The University Dodoma, Dodoma, Tanzania
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Milosevich ET, Moore MJ, Pendlebury ST, Demeyere N. Domain-specific cognitive impairment 6 months after stroke: The value of early cognitive screening. Int J Stroke 2024; 19:331-341. [PMID: 37749759 PMCID: PMC10903146 DOI: 10.1177/17474930231205787] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Cognitive screening following stroke is widely recommended, yet few studies have considered the prognostic value of acute domain-specific function for longer-term cognitive outcome. Identifying which post-stroke cognitive impairments more commonly occur, recover, and persist, and which impairments hold prognostic value, could inform care planning, and resource allocation. AIMS This study aimed to determine the prevalence of domain-specific impairment acutely and at 6 months, assess the proportion of change in cognitive performance, and examine the prognostic value of acute domain-specific cognitive screening. METHODS A prospective stroke cohort completed the Oxford Cognitive Screen acutely (⩽2 weeks) and 6 months post-stroke. We determined the prevalence of acute and 6-month domain-specific impairment and proportion of change in performance from acute to 6 months. Hierarchical multivariable regression was used to predict global and domain-specific cognitive impairment at 6 months adjusted for demographic/vascular factors, stroke severity, and lesion volume. RESULTS A total of 430 stroke survivors (mean/SD age 73.9/12.5 years, 46.5% female, median/interquartile range (IQR) National Institute of Health Stroke Scale (NIHSS) 5/2-10) completed 6-month follow-up. Acutely, domain-specific impairments were highly prevalent ranging from 26.7% (n = 112) in praxis to 46.8% (n = 183) in attention. At 6 months, the proportion of domain-specific recovery was highest in praxis (n = 73, 71%) and lowest in language (n = 89, 46%) and memory (n = 82, 48%). Severity of 6-month cognitive impairment was best predicted by the addition of acute cognitive impairment (adj R2 = 0.298, p < 0.0001) over demographic and clinical factors alone (adj R2 = 0.105, p < 0.0001). Acute cognitive function was the strongest predictor of 6-month cognitive performance (p < 0.0001). Acute domain-specific impairments in memory (p < 0.0001), language (p < 0.0001), and praxis (p < 0.0001) significantly predicted overall severity of cognitive impairment at 6 months. CONCLUSION Post-stroke cognitive impairment is highly prevalent across all domains acutely, while impairments in language, memory, and attention predominate at 6 months. Early domain-specific screening can provide valuable prognostic information for longer-term cognitive outcomes.
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Affiliation(s)
- Elise T Milosevich
- Department of Experimental Psychology, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
| | - Margaret J Moore
- Department of Experimental Psychology, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
- Queensland Brain Institute, University of Queensland, St Lucia, QLD, Australia
| | - Sarah T Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre and Departments of General Medicine and Geratology, John Radcliffe Hospital, Oxford, UK
| | - Nele Demeyere
- Department of Experimental Psychology, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Hobden G, Tang EYH, Demeyere N. A qualitative study investigating the views of stroke survivors and their family members on discussing post-stroke cognitive trajectories. Neuropsychol Rehabil 2024:1-18. [PMID: 38367002 DOI: 10.1080/09602011.2024.2314882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 01/16/2024] [Indexed: 02/19/2024]
Abstract
Cognitive impairment is common early after stroke but trajectories over the long term are variable. Some stroke survivors make a full recovery, while others retain a stable impairment or decline. This study explored the perceived advantages and disadvantages of discussing potential cognitive trajectories with stroke survivors and their family members. Stroke survivors at least six-months post-stroke were purposively sampled from an existing pool of research volunteers recruited originally for the OCS-Recovery study. They were invited, alongside a family member, to participate in a semi-structured interview. Interviews were audio recorded, transcribed, and analyzed using reflexive thematic analysis. Twenty-six stroke survivors and eleven family members participated. We identified one overarching theme and three related subthemes. The overarching theme was: One size does not fit all. The subthemes were: (1) Hearing about potential cognitive trajectories helps to develop realistic expectations; (2) Discussions about cognitive trajectories may be motivating; (3) Cognitive decline and post-stroke dementia discussions may be anxiety-provoking and depressing. Healthcare professionals should adopt a person-centred approach to sharing information about post-stroke cognitive trajectories. Discussions should be tailored to individual needs and preferences, with dementia-related topics in particular addressed with the utmost selectivity and sensitivity.
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Affiliation(s)
- Georgina Hobden
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | | | - Nele Demeyere
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Wang R, Jiao Z, Wang A, Zhang Y, Hong X, Huang S, Fu J, Zhou Y, Wang Y, Li C, Liu Y, Wei K, Meng X, Xu J. High-density lipoprotein cholesterol is associated with lowered cognitive recovery among acute ischemic stroke patients with mild cognitive impairment. Acta Neurol Belg 2024; 124:241-248. [PMID: 37752321 DOI: 10.1007/s13760-023-02375-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 06/21/2023] [Indexed: 09/28/2023]
Abstract
High-density lipoprotein (HDL) has been documented to be related to mild cognitive impairment (MCI) and dementia occurrence; however, the underlying basis behind this association remains unclear. We aimed to elucidate this basis by examining the association between HDL levels and cognitive improvements after 6 months, among acute ischemic stroke (AIS) patients with MCI. Five hundred fifty-eight AIS and MCI patients from the NICE study were enrolled, and divided into four groups, according to their baseline HDL quartiles; median HDL was 1.12 mmol/L (interquartile range 0.96-1.34 mmol/L). The primary outcome examined was the extent of cognitive improvement, defined as ΔMoCA (Montreal Cognitive Assessment) ≥ 2, while the secondary outcome was cognitive deterioration, defined as ΔADAS-cog (Alzheimer's Disease Assessment Scale-Cognitive Subscale) ≥ 4 or ΔMMSE (Mini-Mental State Examination) ≤ - 3, at 6-months post-AIS. We found that 314 (56.27%), 49 (8.78%), and 31 (5.56%) patients had ΔMoCA ≥ 2, ΔADAS-cog ≥ 4, and ΔMMSE ≤ - 3, respectively. Furthermore, cognitive improvement negatively correlated to HDL levels, with the lowest being present among patients in quartiles 4 (Q4; adjusted OR = 0.44, 95% CI 0.25-0.78, P = 0.0050) and Q3 (OR = 0.38, CI 0.23-0.65, P = 0.0004), compared to Q2 (OR = 0.57, CI 0.34-0.96, P = 0.0331). Q2 patients also had positive correlations with ΔADAS-cog ≥ 4 (OR = 5.18, CI 1.55-17.29, P = 0.0074). However, no association between HDL and ΔMMSE ≤ - 3 was observed, nor with LDL and any cognitive changes. Additionally, restricted cubic spline analysis found a nonlinear relationship between HDL and cognitive improvements. All these findings suggested that low plasma HDL was positively associated with improved cognitive functioning among AIS patients with MCI after 6 months.
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Affiliation(s)
- Rui Wang
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zhuomin Jiao
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yijun Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiangxiang Hong
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Shan Huang
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jin Fu
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yinglian Zhou
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yifei Wang
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chunyang Li
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yue Liu
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Ke Wei
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Jie Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
- Lipid Metabolism and Atherosclerosis Research Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Yu H, Zheng B, Zhang Y, Chu M, Shu X, Wang X, Wang H, Zhou S, Cao M, Wen S, Chen J. Activation changes in patients with post-stroke cognitive impairment receiving intermittent theta burst stimulation: A functional near-infrared spectroscopy study. NeuroRehabilitation 2024; 54:677-690. [PMID: 38905062 DOI: 10.3233/nre-240068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2024]
Abstract
BACKGROUND Intermittent theta burst stimulation (iTBS) has demonstrated efficacy in patients with cognitive impairment. However, activation patterns and mechanisms of iTBS for post-stroke cognitive impairment (PSCI) remain insufficiently understood. OBJECTIVE To investigate the activation patterns and potential benefits of using iTBS in patients with PSCI. METHODS A total of forty-four patients with PSCI were enrolled and divided into an iTBS group (iTBS and cognitive training) or a control group (cognitive training alone). Outcomes were assessed based on the activation in functional near-infrared spectroscopy (fNIRS), as well as Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) and the modified Barthel Index (MBI). RESULTS Thirty-eight patients completed the interventions and assessments. Increased cortical activation was observed in the iTBS group after the interventions, including the right superior temporal gyrus (STG), left frontopolar cortex (FPC) and left orbitofrontal cortex (OFC). Both groups showed significant improvements in LOTCA and MBI after the interventions (p < 0.05). Furthermore, the iTBS group augmented superior improvement in the total score of MBI and LOTCA compared to the control group, especially in visuomotor organization and thinking operations (p < 0.05). CONCLUSION iTBS altered activation patterns and improved cognitive function in patients with PSCI. The activation induced by iTBS may contribute to the improvement of cognitive function.
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Affiliation(s)
- Hong Yu
- Zhejiang Rehabilitation Medical Center (The Affiliated Rehabilitation Hospital of Zhejiang Chinese Medical University), Hangzhou, China
| | - Beisi Zheng
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Youmei Zhang
- The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Minmin Chu
- The Seconditions Hospital of Anhui Medical University, Hefei, China
| | - Xinxin Shu
- Zhejiang Rehabilitation Medical Center (The Affiliated Rehabilitation Hospital of Zhejiang Chinese Medical University), Hangzhou, China
| | - Xiaojun Wang
- Zhejiang Rehabilitation Medical Center (The Affiliated Rehabilitation Hospital of Zhejiang Chinese Medical University), Hangzhou, China
| | - Hani Wang
- Zhejiang Rehabilitation Medical Center (The Affiliated Rehabilitation Hospital of Zhejiang Chinese Medical University), Hangzhou, China
| | - Siwei Zhou
- Zhejiang Rehabilitation Medical Center (The Affiliated Rehabilitation Hospital of Zhejiang Chinese Medical University), Hangzhou, China
| | - Manting Cao
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Shilin Wen
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jianer Chen
- Zhejiang Rehabilitation Medical Center (The Affiliated Rehabilitation Hospital of Zhejiang Chinese Medical University), Hangzhou, China
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
- The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
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Kang SH, Kang M, Han JH, Lee ES, Lee KJ, Chung SJ, Suh SI, Koh SB, Eo JS, Kim CK, Oh K. Independent effect of Aβ burden on cognitive impairment in patients with small subcortical infarction. Alzheimers Res Ther 2023; 15:178. [PMID: 37838715 PMCID: PMC10576878 DOI: 10.1186/s13195-023-01307-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/17/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND The effect of amyloid-β (Aβ) on cognitive impairment in patients with small subcortical infarction remains controversial, although a growing body of evidence shows a substantial overlap between Alzheimer's disease (AD) and subcortical ischemic vascular dementia, another form of cerebral small vessel disease (cSVD). Therefore, we investigated the relationships between Aβ positivity and the development of post-stroke cognitive impairment (PSCI) in patients with small subcortical infarction. METHODS We prospectively recruited 37 patients aged ≥ 50 years, with first-ever small subcortical infarction, who underwent amyloid positron emission tomography, 3 months after stroke at Korea University Guro Hospital. We also enrolled CU participants matched for age and sex with stroke patients for comparison of Aβ positivity. Patients were followed up at 3 and 12 months after the stroke to assess cognitive decline. Logistic and linear mixed-effect regression analyses were performed to identify the effect of Aβ positivity on PSCI development and long-term cognitive trajectories. RESULTS At 3 months after stroke, 12/37 (32.4%) patients developed PSCI, and 11/37 (29.7%) patients had Aβ deposition. Aβ positivity (odds ratio [OR] = 72.2, p = 0.024) was predictive of PSCI development regardless of cSVD burden. Aβ positivity (β = 0.846, p = 0.014) was also associated with poor cognitive trajectory, assessed by the Clinical Dementia Rating-Sum of Box, for 1 year after stroke. CONCLUSIONS Our findings highlight that Aβ positivity is an important predictor for PSCI development and cognitive decline over 1 year. Furthermore, our results provide evidence that anti-AD medications may be a strategy for preventing cognitive decline in patients with small subcortical infarctions.
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Affiliation(s)
- Sung Hoon Kang
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Minwoong Kang
- Department of Biomedical Research Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Jung Hoon Han
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Eun Seong Lee
- Department of Nuclear Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Keon-Joo Lee
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Su Jin Chung
- Department of Neurology, Myongji Hospital, Hanyang University College of Medicine, Goyang, South Korea
| | - Sang-Il Suh
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Seong-Beom Koh
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Jae Seon Eo
- Department of Nuclear Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea.
| | - Chi Kyung Kim
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea.
| | - Kyungmi Oh
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
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Van Patten R, Chan L, Tocco K, Mordecai K, Altalib H, Twamley EW, Gaston TE, Grayson LP, Martin A, Fry S, Goodman A, Allendorfer JB, Correia S, Szaflarski J, LaFrance WC. Improvements in Montreal Cognitive Assessment scores after neurobehavioral therapy in adults with functional (nonepileptic) seizures and traumatic brain injury. J Psychiatr Res 2023; 165:282-289. [PMID: 37549503 DOI: 10.1016/j.jpsychires.2023.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/18/2023] [Accepted: 07/28/2023] [Indexed: 08/09/2023]
Abstract
Cognitive functioning impacts clinical symptoms, treatment response, and quality of life in adults with functional/nonepileptic seizures (FS/NES), but no study to date examines effects of behavioral FS/NES treatment on cognition in these patients. We hypothesized that there would be a reduction in cognitive symptoms in participants with FS/NES and traumatic brain injury (TBI) following neurobehavioral therapy (NBT). We also hypothesized that select seizure-related, medication, subjective cognitive, and mental health symptoms would be negatively correlated with improvements in cognitive performance after NBT. Participants were 37 adults with TBI + FS/NES and 35 adults with TBI only, recruited from medical centers in the northeastern or southeastern U.S. TBI + FS/NES participants completed a 12 session NBT intervention, and TBI without seizures participants were not treated. All participants completed pre-post assessments of cognition (Montreal Cognitive Assessment [MoCA]) and baseline sociodemographic factors and mental health symptoms. Pre-post MoCA scores increased significantly in TBI + FS/NES participants (28/37 [75.7%] improved) but not in TBI comparisons (10/35 [28.6%] improved). Language, memory, and visuospatial/executive functions, but not attention, improved over time in the TBI + FS/NES group. Gains in cognition were concentrated in those TBI + FS/NES participants with likely baseline cognitive impairments (MoCA total score <26), and 9/17 of these participants moved from the "impaired" range at baseline (<26) to the "intact" range at endpoint (≥26). Lastly, participants taking fewer medications and reporting lower subjective cognitive difficulties at baseline showed larger pre-post MoCA total score improvements. Overall, results from this study suggest the potential for positive change in cognition in FS/NES and co-occurring TBI using evidence-based psychotherapy.
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Affiliation(s)
- Ryan Van Patten
- VA Providence Healthcare System, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Lawrence Chan
- VA Providence Healthcare System, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Krista Tocco
- VA Providence Healthcare System, Providence, RI, USA; Rhode Island Hospital, Providence, RI, USA
| | | | | | - Elizabeth W Twamley
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System and UC San Diego, San Diego, CA, USA
| | - Tyler E Gaston
- University of Alabama Birmingham, Birmingham, AL, USA; Birmingham VA Medical Center, Birmingham, AL, USA
| | | | - Amber Martin
- University of Alabama Birmingham, Birmingham, AL, USA
| | - Samantha Fry
- University of Alabama Birmingham, Birmingham, AL, USA
| | - Adam Goodman
- University of Alabama Birmingham, Birmingham, AL, USA
| | | | | | | | - W Curt LaFrance
- VA Providence Healthcare System, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA; Rhode Island Hospital, Providence, RI, USA
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Bayliss L, Sandoval AM, Nava A, Diaz-Victoria AR, Espinola-Nadurille M, Ramírez-Bermúdez J, Galvez V. Cognitive follow-up in anti-N-methyl-D-aspartate receptor encephalitis: Hospital discharge, 4, 8, and 12 months. Clin Neurol Neurosurg 2023; 228:107701. [PMID: 36996670 DOI: 10.1016/j.clineuro.2023.107701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/24/2023] [Accepted: 03/26/2023] [Indexed: 03/29/2023]
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Cui M, You T, Zhao Y, Liu R, Guan Y, Liu J, Liu X, Wang X, Dong Q. Ginkgo biloba extract EGb 761® improves cognition and overall condition after ischemic stroke: Results from a pilot randomized trial. Front Pharmacol 2023; 14:1147860. [PMID: 37063270 PMCID: PMC10090660 DOI: 10.3389/fphar.2023.1147860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/20/2023] [Indexed: 03/31/2023] Open
Abstract
Background: Patients who experienced an ischemic stroke are at risk for cognitive impairment. Quantified Ginkgo biloba extract EGb 761® has been used to treat cognitive dysfunction, functional impairment and neuropsychiatric symptoms in mild cognitive impairment and dementia.Objectives: To assess the cognitive-related effects of EGb 761® treatment in patients after acute ischemic stroke, as well as the feasibility of patient selection and outcome measures.Methods: We conducted a randomized, multicentric, open-label trial at 7 centers in China. Patients scoring 20 or lower on the National Institutes of Health Stroke Scale were enrolled between 7 and 14 days after stroke onset and randomly assigned to receive 240 mg per day of EGb 761® or no additional therapy for 24 weeks in a 1:1 ratio. Both groups received standard treatments for the prevention of recurrent stroke during the trial. General cognitive function and a battery of cognitive tests for sub-domains were evaluated at 24 weeks. All patients were monitored for adverse events.Results: 201 patients ≥50 years old were included, with 100 assigned to the EGb 761® group and 101 to the reference group. The mean change from baseline on the global cognitive function as assessed by the Montreal Cognitive Assessment score was 2.92 in the EGb 761® group and 1.33 in the reference group (between-group difference: 1.59 points; 95% confidence interval [CI], 0.51 to 2.67; p < 0.005). For cognitive domains, EGb 761® showed greater effects on the Hopkins Verbal Learning Test Total Recall (EGb 761® change 1.40 vs. reference −0.49) and Form 1 of the Shape Trail Test (EGb 761® change −38.2 vs. reference −15.6). Potentially EGb 761®-related adverse events occurred in no more than 3% of patients.Conclusion: Over the 24-week period, EGb 761® treatment improved overall cognitive performance among patients with mild to moderate ischemic stroke. Our findings provide valuable recommendations for the design of future trials, including the criteria for patient selection.Clinical Trial Registration:www.isrctn.com, identifier ISRCTN11815543.
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Affiliation(s)
- Mei Cui
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Tongyao You
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuwu Zhao
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Ruozhuo Liu
- Department of Neurology, Chinese PLA General Hospital, Beijing, China
| | - Yangtai Guan
- Department of Neurology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jianren Liu
- Department of Neurology, Shanghai Jiao Tong University Affiliated Ninth People’s Hospital, Shanghai, China
| | - Xueyuan Liu
- Department of Neurology, Shanghai Tong Ji University Affiliated Tenth People’s Hospital, Shanghai, China
| | - Xin Wang
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
- *Correspondence: Qiang Dong,
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Holmes AA, Tripathi S, Katz E, Mondesire-Crump I, Mahajan R, Ritter A, Arroyo-Gallego T, Giancardo L. A novel framework to estimate cognitive impairment via finger interaction with digital devices. Brain Commun 2022; 4:fcac194. [PMID: 35950091 PMCID: PMC9356723 DOI: 10.1093/braincomms/fcac194] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 05/11/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
Measuring cognitive function is essential for characterizing brain health and tracking cognitive decline in Alzheimer’s Disease and other neurodegenerative conditions. Current tools to accurately evaluate cognitive impairment typically rely on a battery of questionnaires administered during clinical visits which is essential for the acquisition of repeated measurements in longitudinal studies. Previous studies have shown that the remote data collection of passively monitored daily interaction with personal digital devices can measure motor signs in the early stages of synucleinopathies, as well as facilitate longitudinal patient assessment in the real-world scenario with high patient compliance. This was achieved by the automatic discovery of patterns in the time series of keystroke dynamics, i.e. the time required to press and release keys, by machine learning algorithms. In this work, our hypothesis is that the typing patterns generated from user-device interaction may reflect relevant features of the effects of cognitive impairment caused by neurodegeneration. We use machine learning algorithms to estimate cognitive performance through the analysis of keystroke dynamic patterns that were extracted from mechanical and touchscreen keyboard use in a dataset of cognitively normal (n = 39, 51% male) and cognitively impaired subjects (n = 38, 60% male). These algorithms are trained and evaluated using a novel framework that integrates items from multiple neuropsychological and clinical scales into cognitive subdomains to generate a more holistic representation of multifaceted clinical signs. In our results, we see that these models based on typing input achieve moderate correlations with verbal memory, non-verbal memory and executive function subdomains [Spearman’s ρ between 0.54 (P < 0.001) and 0.42 (P < 0.001)] and a weak correlation with language/verbal skills [Spearman’s ρ 0.30 (P < 0.05)]. In addition, we observe a moderate correlation between our typing-based approach and the Total Montreal Cognitive Assessment score [Spearman’s ρ 0.48 (P < 0.001)]. Finally, we show that these machine learning models can perform better by using our subdomain framework that integrates the information from multiple neuropsychological scales as opposed to using the individual items that make up these scales. Our results support our hypothesis that typing patterns are able to reflect the effects of neurodegeneration in mild cognitive impairment and Alzheimer’s disease and that this new subdomain framework both helps the development of machine learning models and improves their interpretability.
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Affiliation(s)
| | - Shikha Tripathi
- Center for Precision Health, School of Biomedical Informatics, University of Texas Health Science Center at Houston , Houston, TX 77030 , USA
| | | | | | - Rahul Mahajan
- nQ Medical , Cambridge, MA 02142 , USA
- Division of Neurocritical Care, Department of Neurology, Brigham & Women’s Hospital , Boston, MA 02115 , USA
| | - Aaron Ritter
- Cleveland Clinic Lou Ruvo Center for Brain Health, Cleveland Clinic , Las Vegas, NV 89106 , USA
| | | | - Luca Giancardo
- Center for Precision Health, School of Biomedical Informatics, University of Texas Health Science Center at Houston , Houston, TX 77030 , USA
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11
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Ramirez-Garcia G, Galvez V, Diaz R, Campos-Romo A, Fernandez-Ruiz J. Montreal Cognitive Assessment (MoCA) performance in Huntington's disease patients correlates with cortical and caudate atrophy. PeerJ 2022; 10:e12917. [PMID: 35402100 PMCID: PMC8988933 DOI: 10.7717/peerj.12917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 01/20/2022] [Indexed: 01/11/2023] Open
Abstract
Huntington's Disease (HD) is an autosomal neurodegenerative disease characterized by motor, cognitive, and psychiatric symptoms. Cognitive impairment develops gradually in HD patients, progressing later into a severe cognitive dysfunction. The Montreal Cognitive Assessment (MoCA) is a brief screening test commonly employed to detect mild cognitive impairment, which has also been useful to assess cognitive decline in HD patients. However, the relationship between MoCA performance and brain structural integrity in HD patients remains unclear. Therefore, to explore this relationship we analyzed if cortical thinning and subcortical nuclei volume differences correlated with HD patients' MoCA performance. Twenty-two HD patients and twenty-two healthy subjects participated in this study. T1-weighted images were acquired to analyze cortical thickness and subcortical nuclei volumes. Group comparison analysis showed a significantly lower score in the MoCA global performance of HD patients. Also, the MoCA total score correlated with cortical thinning of fronto-parietal and temporo-occipital cortices, as well as with bilateral caudate volume differences in HD patients. These results provide new insights into the effectiveness of using the MoCA test to detect cognitive impairment and the brain atrophy pattern associated with the cognitive status of prodromal/early HD patients.
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Affiliation(s)
- Gabriel Ramirez-Garcia
- Departamento de Fisiología, Universidad Nacional Autónoma de Mexico, Ciudad de Mexico, Mexico
| | - Victor Galvez
- Escuela de Psicología, Universidad Panamericana, Ciudad de Mexico, Mexico
| | - Rosalinda Diaz
- Departamento de Fisiología, Universidad Nacional Autónoma de Mexico, Ciudad de Mexico, Mexico
| | - Aurelio Campos-Romo
- Facultad de Medicina, Unidad Periférica de Neurociencias, Universidad Nacional Autónoma de México/Instituto Nacional de Neurologia y Neurocirugia, Ciudad de Mexico, Mexico
| | - Juan Fernandez-Ruiz
- Departamento de Fisiología, Universidad Nacional Autónoma de Mexico, Ciudad de Mexico, Mexico
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12
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Shen W, Fan X, Wang L, Zhang Y. Traditional Chinese Medicine for Post-Stroke Cognitive Impairment: A Systematic Review and Meta-Analysis. Front Pharmacol 2022; 13:816333. [PMID: 35237166 PMCID: PMC8883343 DOI: 10.3389/fphar.2022.816333] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/18/2022] [Indexed: 12/29/2022] Open
Abstract
Background: Post-stroke cognitive impairment (PSCI) affects more than one-third of stroke patients, and causes much greater harm to long-term function than the initial brain damage. No conventional Western medications have shown convincing clinical effectiveness for treating PSCI. Research shows that Traditional Chinese medicine (TCM) can improve cognitive function in patients. However, the clinical efficacy and safety remain controversial. The aim of this study was to examine the effectiveness and harmful effects of TCMs in the treatment of PSCI. Method: We searched seven databases and two clinical registration websites for randomized controlled trials (RCTs). The revised Cochrane risk of bias tool (RoB 2.0) was used to evaluate the methodological quality and RevMan 5.4 was used for data analysis. This study has been submitted to PROSPERO with registration number is CRD42020149299. Results: We included 34 studies in this review. The results of this study showed that TCM adjuvant therapy improved scores on the MoCA [MD = 2.55, 95% CI (1.56, 3.53), p < 0.00001; MD = 3.07, 95% CI (1.98, 4.17), p < 0.00001 at treatment duration of <3 and 3 months, respectively], MMSE [MD = 2.55, 95% CI (1.99, 3.10), p < 0.00001; MD = 2.53, 95% CI (1.59, 3.47), p < 0.00001; MD = 2.91, 95% CI (1.26, 4.56), p = 0.0006; MD = 3.11, 95% CI (-0.04, 6.27), p = 0.05 at treatment duration of <3, 3, 4, and 6 months, respectively], and BI [MD = 7.34, 95% CI (3.83, 10.85), p < 0.0001; MD = 8.98, 95% CI (4.76, 13.21), p < 0.0001 at treatment duration of <3 and 3 months, respectively] and reduced scores on the ADL (MD = -8.64, 95% CI (-9.83, -7.45), p < 0.00001; MD = -2.00, 95% CI (-2.94, -1.06), p < 0.0001 at treatment duration of 3 and 4 months, respectively], NIHSS [MD = -2.48, 95% CI (-4.97, 0.00), p = 0.05; MD = -3.81, 95% CI (-6.21, -1.40), p = 0.002 at treatment duration of <3 and 3 months, respectively], and CSS [MD = -2.47, 95% CI (-3.49, -1.45), p < 0.00001 at a treatment duration of 3 months]. No serious adverse reactions were observed. Conclusion: Despite the significant positive results, the present evidence supports, to a limited extent because of the methodological flaws and herbal heterogeneity, that TCM adjuvant therapy can be used for patients with PSCI. While, further rigorous RCTs are warranted to confirm the efficacy and safety of TCM. Systematic Review Registration: https://www.crd.york.ac.uk/prospero, identifier CRD42020149299.
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Affiliation(s)
- Wei Shen
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xueming Fan
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Liuding Wang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yunling Zhang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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13
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Lu W, Richards M, Werring D, Bobak M. Memory Trajectories Before and After First and Recurrent Strokes. Neurology 2022; 98:e589-e600. [PMID: 34893555 PMCID: PMC8829961 DOI: 10.1212/wnl.0000000000013171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 11/19/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Evidence on timing of memory change after first and recurrent strokes is limited and inconsistent. We investigated memory trajectories before and after first and recurrent strokes in 18 European countries and tested whether the country-level acute stroke care was associated with memory change after stroke. METHODS Data were from the Survey of Health, Ageing and Retirement in Europe (2004-2019). Incident first and recurrent strokes were identified among baseline stroke-free individuals. Within each country, each participant with incident stroke (case group) was matched with a stroke-free individual (control group) using propensity score matching. We applied multilevel segmented linear regression to quantify acute and accelerated memory changes (measured by the sum score of immediate and delayed word recall tests; 0-20 words) before and after first and recurrent strokes in both groups. Associations between stroke and memory were compared between countries with different levels of acute stroke care indicators. RESULTS The final analytical sample included 35,164 participants who were stroke-free at baseline (≥50 years). A total of 2,362 incident first and 341 recurrent strokes between 2004 and 2019 were identified. In case groups, mean acute decreases in memory scores were 0.48 (95% confidence interval [CI] 0.31, 0.65) and 1.14 (95% CI 0.80, 1.48) words after first and recurrent stroke, respectively, independent of a range of confounders. No such acute decreases were observed in the control group after a hypothetical nonstroke onset date. In both groups, memory declined over time but decline rates were similar (-0.07 [95% CI -0.10, -0.05] vs -0.06 [95% CI -0.08, -0.05] words per year). The mean acute decreases in memory scores after first and recurrent strokes were smaller in countries with better access to endovascular treatment. DISCUSSION We found acute decreases but not accelerated declines in memory after first and recurrent strokes. Improved endovascular therapy might be associated with smaller memory loss after stroke but more evidence based on individual-level data is needed. More effort should be made in early assessment and intensive prevention of stroke among the ageing population and promoting access to and delivery of acute stroke care among patients with stroke.
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Affiliation(s)
- Wentian Lu
- From the Research Department of Epidemiology and Public Health (W.L., M.B.), MRC Unit for Lifelong Health & Ageing (M.R.), and Stroke Research Centre, UCL Queen Square Institute of Neurology (D.W.), University College London, UK.
| | - Marcus Richards
- From the Research Department of Epidemiology and Public Health (W.L., M.B.), MRC Unit for Lifelong Health & Ageing (M.R.), and Stroke Research Centre, UCL Queen Square Institute of Neurology (D.W.), University College London, UK
| | - David Werring
- From the Research Department of Epidemiology and Public Health (W.L., M.B.), MRC Unit for Lifelong Health & Ageing (M.R.), and Stroke Research Centre, UCL Queen Square Institute of Neurology (D.W.), University College London, UK
| | - Martin Bobak
- From the Research Department of Epidemiology and Public Health (W.L., M.B.), MRC Unit for Lifelong Health & Ageing (M.R.), and Stroke Research Centre, UCL Queen Square Institute of Neurology (D.W.), University College London, UK
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14
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Klinkhammer S, Horn J, Visser-Meilij JMA, Verwijk E, Duits A, Slooter AJC, van Heugten CM. Dutch multicentre, prospective follow-up, cohort study comparing the neurological and neuropsychological sequelae of hospitalised non-ICU- and ICU-treated COVID-19 survivors: a study protocol. BMJ Open 2021; 11:e054901. [PMID: 34620676 PMCID: PMC8507410 DOI: 10.1136/bmjopen-2021-054901] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Owing to the novelty of COVID-19, there are still large knowledge gaps concerning its effect on the brain and the resulting impact on peoples' lives. This large-scale prospective follow-up study investigates COVID-19-associated brain damage, neuropsychological dysfunction and long-term impact on the well-being of patients and their close ones. It is hypothesised that structural brain damage and cognitive dysfunction primarily occur in severely ill patients, as compared with moderately ill patients. Cognitive complaints, emotional distress and impact on well-being are hypothesised to be less dependent on illness severity. METHODS AND ANALYSIS For this multicentre study, 200 patients with COVID-19 (100 intensive care unit (ICU) patients and 100 non-ICU patients) formerly hospitalised in one of the six recruiting hospitals during the first European infection wave (ie, March to June 2020) and their close ones will be recruited. At minimally 6 months posthospital discharge, patients will perform a set of neuropsychological tests and are subjected to a 3T MRI scan. Patients and close ones will fill out a set of questionnaires, also at minimally 6 months posthospital discharge and again another 6 months thereafter. Data related to COVID-19 hospitalisation will be extracted from the patients' medical records. MRI abnormalities will ultimately be related to neuropsychological test performance and questionnaire outcomes. ETHICS AND DISSEMINATION Ethics approval was granted by the medical research ethics committee of Maastricht University Medical Centre and Maastricht University (NL75102.068.20). The project is sponsored by The Brain Foundation Netherlands. Findings will be presented at national and international conferences, as well as published in peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER NCT04745611.
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Affiliation(s)
- Simona Klinkhammer
- Department of Psychiatry and Neuropsychology, Maastricht University Faculty of Health Medicine and Life Sciences, Maastricht, The Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Janneke Horn
- Department of Intensive Care, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Johanna M A Visser-Meilij
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht, Utrecht, The Netherlands
- UMC Utrecht Brain Center, UMC Utrecht, Utrecht, The Netherlands
| | - Esmée Verwijk
- Department of Medical Psychology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
- Department of Psychology, Brain and Cognition, University of Amsterdam, Amsterdam, The Netherlands
| | - Annelien Duits
- Department of Psychiatry and Neuropsychology, Maastricht University Faculty of Health Medicine and Life Sciences, Maastricht, The Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
- Department of Medical Psychology, Maastricht UMC+, Maastricht, The Netherlands
| | - Arjen J C Slooter
- UMC Utrecht Brain Center, UMC Utrecht, Utrecht, The Netherlands
- Department of Intensive Care, UMC Utrecht, Utrecht, The Netherlands
| | - Caroline M van Heugten
- Department of Psychiatry and Neuropsychology, Maastricht University Faculty of Health Medicine and Life Sciences, Maastricht, The Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
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15
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Dong Y, Ding M, Cui M, Fang M, Gong L, Xu Z, Zhang Y, Wang X, Xu X, Liu X, Li G, Zhao Y, Dong Q. Development and validation of a clinical model (DREAM-LDL) for post-stroke cognitive impairment at 6 months. Aging (Albany NY) 2021; 13:21628-21641. [PMID: 34506303 PMCID: PMC8457606 DOI: 10.18632/aging.203507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 08/17/2021] [Indexed: 01/31/2023]
Abstract
Introduction: This multicenter, retrospective study assessed the prevalence of post-stroke cognitive impairment (PSCI) 6 months after acute ischemic stroke (AIS) and its risk factors to build a bedside early predictive model for PSCI using the Montreal Cognitive Assessment (MoCA). Methods: Records of consecutive patients with AIS treated at 4 stroke centers in Shanghai had MoCA assessments within 2 weeks after AIS onset and 6 months later were reviewed. Prevalence of PSCI (MoCA<22) was calculated and risk factors were identified by multivariate logistic regression analysis. The modeling and validation and identified risk factors were included in a predictive model using multivariate regression. Results: There were 383 patients included and prevalence of PSCI 6 months after AIS was 34.2%, significantly lower than prevalence of patients with acute cognitive impairment (49.6%). Aging, less education, higher glucose level and severe stroke were PSCI risk factors, while level of low-density lipoprotein cholesterol (LDL-C) had a paradox effect on the risk of PSCI. 40.0% of the patients with cognitive impairment at acute phase reverted to normal, and patients with LDL-C 1.8-2.5 mmol/L were more likely to revert. The predictive model we built, DREAM-LDL (Diabetes [fasting blood glucose level], Rating [NIHSS], level of Education, Age, baseline MoCA and LDL-C level), had an AUROC of 0.93 for predicting PSCI at 6 months. Conclusion: PSCI was common among AIS patients 6 months after AIS. We provided a practical tool to predict PSCI based on MoCA and risk factors present during acute phase of AIS.
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Affiliation(s)
- Yi Dong
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Fudan University, Shanghai, China
| | - Mengyuan Ding
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Fudan University, Shanghai, China
| | - Mei Cui
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Fudan University, Shanghai, China
| | - Min Fang
- Department of Neurology, The Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
| | - Li Gong
- Department of Neurology, The Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
| | - Zhuojun Xu
- Department of Neurology, The East Hospital Affiliated to Tongji University, Shanghai, China
| | - Yue Zhang
- Department of Neurology, The East Hospital Affiliated to Tongji University, Shanghai, China
| | - Xiuzhe Wang
- Department of Neurology, The Six People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Xiaofeng Xu
- Department of Neurology, The Six People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Xueyuan Liu
- Department of Neurology, The Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
| | - Gang Li
- Department of Neurology, The East Hospital Affiliated to Tongji University, Shanghai, China
| | - Yuwu Zhao
- Department of Neurology, The Six People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Fudan University, Shanghai, China
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Verdelho A, Wardlaw J, Pavlovic A, Pantoni L, Godefroy O, Duering M, Charidimou A, Chabriat H, Biessels GJ. Cognitive impairment in patients with cerebrovascular disease: A white paper from the links between stroke ESO Dementia Committee. Eur Stroke J 2021; 6:5-17. [PMID: 33817330 PMCID: PMC7995319 DOI: 10.1177/23969873211000258] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/04/2021] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Many daily-life clinical decisions in patients with cerebrovascular disease and cognitive impairment are complex. Evidence-based information sustaining these decisions is frequently lacking. The aim of this paper is to propose a practical clinical approach to cognitive impairments in patients with known cerebrovascular disease. METHODS The document was produced by the Dementia Committee of the European Stroke Organisation (ESO), based on evidence from the literature where available and on the clinical experience of the Committee members. This paper was endorsed by the ESO. FINDINGS Many patients with stroke or other cerebrovascular disease have cognitive impairment, but this is often not recognized. With improvement in acute stroke care, and with the ageing of populations, it is expected that more stroke survivors and more patients with cerebrovascular disease will need adequate management of cognitive impairment of vascular etiology. This document was conceived for the use of strokologists and for those clinicians involved in cerebrovascular disease, with specific and practical hints concerning diagnostic tools, cognitive impairment management and decision on some therapeutic options.Discussion and conclusions: It is essential to consider a possible cognitive deterioration in every patient who experiences a stroke. Neuropsychological evaluation should be adapted to the clinical status. Brain imaging is the most informative biomarker concerning prognosis. Treatment should always include adequate secondary prevention.
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Affiliation(s)
- Ana Verdelho
- Department of Neurosciences and Mental Health, CHLN-Hospital de Santa Maria, Instituto de Medicina Molecular – IMM e Instituto de Saúde Ambiental –ISAMB, Faculdade de Medicina, University of Lisbon, Lisbon, Portugal
| | - Joanna Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Aleksandra Pavlovic
- Faculty for Special Education and Rehabilitation, University of Belgrade, Belgrade, Serbia
| | - Leonardo Pantoni
- Stroke and Dementia Lab, "Luigi Sacco" Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Olivier Godefroy
- Department of Neurology, Amiens University Hospital, Laboratory of Functional Neurosciences1,6 (UR UPJV 4559), Jules Verne Picardy University, Amiens, France
| | - Marco Duering
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Germany
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Andreas Charidimou
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Hugues Chabriat
- Department of Neurology, FHU NeuroVasc, Hôpital Lariboisiere, University of Paris, Paris, France
| | - Geert Jan Biessels
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, the Netherlands
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17
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Gans SD, Michaels E, Thaler DE, Leung LY. Detection of symptoms of late complications after stroke in young survivors with active surveillance versus usual care. Disabil Rehabil 2021; 44:4023-4028. [PMID: 33605166 DOI: 10.1080/09638288.2021.1883749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE Stroke survivors develop late complications after stroke (LCAS) that impair return to pre-stroke responsibilities. Optimal strategies for detection have not been developed. We assessed differences in LCAS symptom detection among young stroke survivors undergoing active surveillance versus usual care. METHODS This was a retrospective cohort study including patients age 18-50 with ischemic stroke, transient ischemic attack, or intracerebral hemorrhage evaluated in a Stroke Clinic between 1/1/2016-12/31/2017 with at least one outpatient evaluation during the first year after stroke. "Active surveillance" involved a semi-structured interview to elicit LCAS symptoms including headache, seizures, lethargy, mood disorders, cognitive impairment, central pain, insomnia, spasticity, dystonia, and orthostasis. "Usual care" did not involve the interview. Rates of LCAS symptom detection were assessed at 0-3 months and 3-12 months. RESULTS One hundred twenty-one stroke survivors were included, of which 37% (45) underwent active surveillance. There were no differences in baseline characteristics except hospitalization location. Patients undergoing active surveillance were more likely to have at least one LCAS symptom detected (77% vs 49% at 0-3 months, p = 0.02; 81% vs. 54% at 3-12 months, p = 0.008). Active surveillance was more likely to detect symptoms of non-motor LCAS. There were no differences for motor LCAS. CONCLUSIONS Active surveillance leads to higher rates of early symptom detection of non-motor LCAS in young stroke survivors.Implications for rehabilitationYoung stroke survivors frequently have late complications after stroke (LCAS) that impair return to pre-stroke responsibilities.Active surveillance for LCAS symptoms with a semi-structured interview increases detection of non-motor late complications.A bundled approach to screening for LCAS symptoms is pragmatic as a majority of young stroke survivors have at least one symptom but no single symptom is present in all stroke survivors.
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Affiliation(s)
- Sarah D Gans
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Tufts Medical Center, Boston, MA, USA
| | - Elena Michaels
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Tufts Medical Center, Boston, MA, USA
| | - David E Thaler
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Tufts Medical Center, Boston, MA, USA
| | - Lester Y Leung
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Tufts Medical Center, Boston, MA, USA
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18
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D'Souza CE, Greenway MRF, Graff-Radford J, Meschia JF. Cognitive Impairment in Patients with Stroke. Semin Neurol 2021; 41:75-84. [PMID: 33418591 DOI: 10.1055/s-0040-1722217] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Despite substantial advances in stroke care, vascular cognitive impairment remains a prominent source of disability. Unlike sensorimotor impairments, cognition often continues to decline after stroke. An aging population will increase the prevalence of vascular cognitive impairment, with stroke playing an important role. Ten percent of patients presenting with stroke have pre-stroke dementia; an additional 10% will develop incident dementia with a first stroke, and 30% with a recurrent stroke. While stroke increases the risk of cognitive impairment, the presence of cognitive impairment also impacts acute stroke treatment and increases risk of poor outcome by nearly twofold. There is substantial overlap in the clinical and pathological aspects of vascular and degenerative dementias in many patients. How they relate to one another is controversial. The treatment of vascular cognitive impairment remains supportive, focusing on treating vascular risk factors. Cognitive rehabilitation after stroke is an area of active research, and existing pharmacologic treatments have limited benefit. Heightened awareness of cognitive impairment in the setting of stroke is imperative for prognostication and management, impetus for research and, ultimately, the discovery of efficacious treatments.
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Affiliation(s)
- Caitlin E D'Souza
- Department of Neurology, Mayo Clinic Florida, Jacksonville, Florida.,Department of Neurology, Baptist Health, Jacksonville, Florida
| | | | | | - James F Meschia
- Department of Neurology, Mayo Clinic Florida, Jacksonville, Florida
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19
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Huang LC, Hsieh SW, Tsai CC, Chen CH, Yang YH. The Role of Cilostazol and Inflammation in Cognitive Impairment After Ischemic Stroke. Am J Alzheimers Dis Other Demen 2021; 36:15333175211016185. [PMID: 34008421 PMCID: PMC10624089 DOI: 10.1177/15333175211016185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE The aim of this study is to examine the potential effect of cilostazol and inflammation on cognitive impairment after stroke in an Asian population. METHODS Forty-five patients with cognitive impairment after ischemic stroke using cilostazol were enrolled as the study group and 45 patients using aspirin or clopidogrel were enrolled as the control group. Neuropsychiatric assessments were administered at the start of the study and after 6 months. Multiple logistic regression analysis was used to estimate the association between the cognitive change and cilostazol use. Macrophage polarization were assessed using flow cytometry in 7 patients. RESULTS There were a significantly higher number of patients with peripheral arterial occlusive disease in the cilostazol group. No significant differences were observed in the cognitive change between the cilostazol and control groups. M1 macrophage subset increment were observed in the patient having a declined cognitive change. CONCLUSION Cilostazol did not make a significant difference in cognitive change after ischemic stroke. M1 macrophage subset increment may indicate post stroke cognitive decline. Due to limited number of subjects, these findings should be examined further in large-scale randomized clinical trials.
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Affiliation(s)
- Ling-Chun Huang
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
| | - Sun-Wung Hsieh
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
- Department of Neurology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Chia-Chan Tsai
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
| | - Chun-Hung Chen
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
- Department of Neurology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Yuan-Han Yang
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
- Department of Master’s Program in Neurology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
- Neuroscience Research Center, Kaohsiung Medical University, Kaohsiung City, Taiwan
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20
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Sharma R, Mallick D, Llinas RH, Marsh EB. Early Post-stroke Cognition: In-hospital Predictors and the Association With Functional Outcome. Front Neurol 2020; 11:613607. [PMID: 33424761 PMCID: PMC7787003 DOI: 10.3389/fneur.2020.613607] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/07/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose: To characterize and predict early post-stroke cognitive impairment by describing cognitive changes in stroke patients 4-8 weeks post-infarct, determining the relationship between cognitive ability and functional status at this early time point, and identifying the in-hospital risk factors associated with early dysfunction. Materials and Methods: Data were collected for 214 patients with ischemic stroke and 39 non-stroke controls. Montreal Cognitive Assessment (MoCA) exams were administered at post-hospitalization clinic visits approximately 4-8 weeks after infarct. MoCA scores were compared for patients with: no stroke, minor stroke [NIH Stroke Scale (NIHSS) < 5], and major stroke. Ordinal logistic regression was performed to assess the relationship between MoCA score and functional status [modified Rankin Scale score (mRS)] at follow-up. Predictors of MoCA < 26 and < 19 (cutoffs for mild and severe cognitive impairment, respectively) at follow-up were identified by multivariable logistic regression using variables available during hospitalization. Results: Post stroke cognitive impairment was common, with 66.8% of patients scoring < 26 on the MoCA and 22.9% < 19. The average total MoCA score at follow-up was 18.7 (SD 7.0) among major strokes, 23.6 (SD 4.8) among minor strokes, and 27.2 (SD 13.0) among non-strokes (p = <0.0001). The follow-up MoCA score was associated with the follow-up mRS in adjusted analysis (OR 0.69; 95% C.I. 0.59-0.82). Among patients with no prior cognitive impairment (N = 201), a lack of pre-stroke employment, admission NIHSS > 6, and left-sided infarct predicted a follow-up MoCA < 26 (c-statistic 0.75); while admission NIHSS > 6 and infarct volume > 17 cc predicted a MoCA < 19 (c-statistic 0.75) at follow-up. Conclusion: Many patients experience early post-stroke cognitive dysfunction that significantly impacts function during a critical time period for decision-making regarding return to work and future independence. Dysfunction measured at 4-8 weeks can be predicted during the inpatient hospitalization. These high-risk individuals should be identified for targeted rehabilitation and counseling to improve longer-term post-stroke outcomes.
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Affiliation(s)
- Richa Sharma
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Dania Mallick
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Rafael H. Llinas
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Elisabeth B. Marsh
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
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21
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Mohamed Fuad Z, Mahadzir H, Syed Zakaria SZ, Mohamed Ibrahim N. Frequency of Cognitive Impairment Among Malaysian Elderly Patients Following First Ischaemic Stroke—A Case Control Study. Front Public Health 2020; 8:577940. [PMID: 33282811 PMCID: PMC7689266 DOI: 10.3389/fpubh.2020.577940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/09/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Stroke is highly prevalent globally and is an important cause of cognitive impairment and dementia. Aims: We determined the frequency of post-stroke cognitive impairment (PSCI) at 1, 3, and 6 months among patients with first clinical ischemic stroke compared to risk and age-matched controls. Methods: This study involved 32 cases and 32 controls, and was conducted over 6 months. Cases were inpatients aged >60 with first clinical ischemic stroke. Controls were age-matched subjects without prior stroke. Montreal Cognitive Assessment (MoCA) was performed in all patients at 1, 3, and 6 month post stroke. A MoCA score of <26 was used for mild PSCI and <22 for moderate PSCI (post stroke dementia). Results: Post-stroke dementia was detected in 12 patients (37.5%) at 1st month, in 13 (40.6%) at 3rd month and 15 (48.4%) at 6th months. Mild PSCI was present in 7 patients (21.6%) at 1 month, 16 patients (50%) at 3 months, and 15 patients (48%) at 6 months. The odds ratio (OR) for post-stroke dementia was 3.2 (95%CI 0.98–10.68; p = 0.05) at 1 month; 3.69(95% CI 1.13–12.11; p = 0.031) at 3 months, and 4.88 (95% CI 1.49–15.99; p = 0.009) at 6 months. Years of education was an independent predictor for dementia (OR 0.60; p = 0.046). The OR for post-stroke dementia at 6th month was 7.23 with education level adjusted (95%CI 1.46–35.86, p = 0.015). Conclusion: The frequency of PSCI was high as early as 1 month after stroke. Stroke alone conferred a 7.2 times risk for post-stroke dementia compared to controls.
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Affiliation(s)
- Zeena Mohamed Fuad
- Department of Medicine, Universiti Kebangsaan Medical Centre, Kuala Lumpur, Malaysia
| | - Hazlina Mahadzir
- Department of Medicine, Universiti Kebangsaan Medical Centre, Kuala Lumpur, Malaysia
| | | | - Norlinah Mohamed Ibrahim
- Department of Medicine, Universiti Kebangsaan Medical Centre, Kuala Lumpur, Malaysia
- *Correspondence: Norlinah Mohamed Ibrahim
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22
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Ahmed T, Kumar R, Bahurupi Y. Factors Affecting Quality of Life among Post-Stroke Patients in the Sub-Himalayan Region. J Neurosci Rural Pract 2020; 11:616-622. [PMID: 33144800 PMCID: PMC7595802 DOI: 10.1055/s-0040-1716927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background
Stroke is one of the most debilitating conditions contributing to significant disability and death globally. Identifying risk factors for quality of life (QoL) will enable to improve home-based rehabilitation in post-stroke phase.
Objective
This study was aimed to identify the risk factors of QoL in stroke patients in the sub-Himalayan region.
Materials and Methods
A cross-sectional hospital-based study assessed the QoL among stroke patients within a week after the onset of acute stroke and then re-evaluated at 3 months. World Health Organization QoL-BREF, Beck Depression Inventory, the Barthel Index, and Montreal Cognitive Assessment (MOCA) were used to seek data on QoL, depression, cognitive, and functional dependence status, respectively. Appropriate statistics were used to compute the results.
Results
In total, 129 stroke patients recruited, out of which 102 returned to a 3-month follow-up. QoL, MOCA, disability index, and depression score were compared using Wilcoxon Singed-rank test. In multivariate analysis, depression and disability together predicted 60% of the variance for physical QoL (
p
< 0.0001). Similarly, poststroke depression and disability together predicted 61% of the variance for psychological QoL (
p
< 0.0001) in stroke patients.
Conclusion
Findings indicated that depression and disability are leading risk factors of QoL in stroke patients. Early identification of poststroke depression and functional dependence status is, therefore, essential to devise screening procedure and to develop targeted intervention to improve rehabilitation outcomes.
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Affiliation(s)
- Tarannum Ahmed
- College of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | | | - Rajesh Kumar
- College of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Yogesh Bahurupi
- Department of Community & Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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23
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Draaisma LR, Wessel MJ, Hummel FC. Neurotechnologies as tools for cognitive rehabilitation in stroke patients. Expert Rev Neurother 2020; 20:1249-1261. [DOI: 10.1080/14737175.2020.1820324] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Laurijn R. Draaisma
- Defitech Chair of Clinical Neuroengineering, Center for Neuroprosthetics (CNP) and Brain Mind Institute (BMI), Swiss Federal Institute of Technology (EPFL), Geneva, Switzerland
- Defitech Chair of Clinical Neuroengineering, Clinique Romande de Réadaptation, Center for Neuroprosthetics (CNP) and Brain Mind Institute (BMI, Swiss Federal Institute of Technology (EPFL Valais), Sion, Switzerland
| | - Maximilian J. Wessel
- Defitech Chair of Clinical Neuroengineering, Center for Neuroprosthetics (CNP) and Brain Mind Institute (BMI), Swiss Federal Institute of Technology (EPFL), Geneva, Switzerland
- Defitech Chair of Clinical Neuroengineering, Clinique Romande de Réadaptation, Center for Neuroprosthetics (CNP) and Brain Mind Institute (BMI, Swiss Federal Institute of Technology (EPFL Valais), Sion, Switzerland
| | - Friedhelm C. Hummel
- Defitech Chair of Clinical Neuroengineering, Center for Neuroprosthetics (CNP) and Brain Mind Institute (BMI), Swiss Federal Institute of Technology (EPFL), Geneva, Switzerland
- Defitech Chair of Clinical Neuroengineering, Clinique Romande de Réadaptation, Center for Neuroprosthetics (CNP) and Brain Mind Institute (BMI, Swiss Federal Institute of Technology (EPFL Valais), Sion, Switzerland
- Clinical Neuroscience, University of Geneva Medical School, Geneva, Switzerland
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24
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Feng L, He W, Huang G, Lin S, Yuan C, Cheng H, He J, Liu Y. Reduced thiamine is a predictor for cognitive impairment of cerebral infarction. Brain Behav 2020; 10:e01709. [PMID: 32755028 PMCID: PMC7507112 DOI: 10.1002/brb3.1709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/21/2020] [Accepted: 05/17/2020] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE Reduced thiamine (vitamin B1 ) had been reported to be associated with cognitive impairment caused by Alzheimer disease. Our study is to explore the association between thiamine and cognitive impairment after acute ischemic stroke. MATERIALS AND METHODS One hundred and eighty two patients with acute cerebral infarction were recruited within the first 24 hr after admission. Thiamine and other vitamin Bs of peripheral blood samples were measured. Patients were divided into with poststroke cognitive impairment (PSCI) and non-PSCI according to the score of MMSE and the degree of education. RESULTS Reduced thiamine (<1.0 ng/ml) was independently associated with PSCI (OR: 2.033, 95% CI: 1.017-4.067, p = .045) after adjusting for potential confounding factors. Advanced age, lower education, diabetes mellitus, left hemisphere infarction, and higher National Institute of Health Stroke Scale (NIHSS) were also independent risk factors for PSCI. CONCLUSIONS Reduced thiamine is one of the predictors for early cognitive impairment in patients with acute cerebral infarction.
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Affiliation(s)
- Liang Feng
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Weilei He
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Guiqian Huang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Shasha Lin
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chengxiang Yuan
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Haoran Cheng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jincai He
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yiming Liu
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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25
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Zhu Y, Zhao S, Fan Z, Li Z, He F, Lin C, Topatana W, Yan Y, Liu Z, Chen Y, Zhang B. Evaluation of the Mini-Mental State Examination and the Montreal Cognitive Assessment for Predicting Post-stroke Cognitive Impairment During the Acute Phase in Chinese Minor Stroke Patients. Front Aging Neurosci 2020; 12:236. [PMID: 32848712 PMCID: PMC7424073 DOI: 10.3389/fnagi.2020.00236] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/08/2020] [Indexed: 11/22/2022] Open
Abstract
Objective: To assess the value of the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) during acute phase in predicting post-stroke cognitive impairment (PSCI) at 3–6 months. Methods: We prospectively recruited 229 patients who had suffered their first-ever ischemic stroke. PSCI was determined in 104 of these patients by a comprehensive neuropsychological battery performed at 3–6 months. Receiver operating characteristic (ROC) curve analysis was then performed to compare the discriminatory ability of the MMSE and MoCA. Also, we applied a decision tree generated by the classification and regression tree methodology. Results: In total, 66 patients had PSCI when evaluated 3–6 months after the onset of minor stroke. Logistic regression analysis revealed that education, body mass index (BMI), and baseline MoCA scores were independently associated with PSCI. ROC curve analysis showed that the ability to predict PSCI was similar when compared between baseline MoCA scores [area under curve (AUC), 0.821; 95% confidence interval (CI), 0.743–0.898] and baseline MMSE scores (AUC, 0.809; 95% CI, 0.725–0.892, P = 0.75). Both MMSE and MoCA exhibited similar predictive values at their optimal cut-off points (MMSE ≤27; sensitivity, 0.682; specificity, 0.816; MoCA ≤21; sensitivity, 0.636; specificity, 0.895). Classification and regression tree-derived analysis yielded an AUC of 0.823 (sensitivity, 0.803; specificity, 0.842). Conclusion: When applied within 2 weeks of stroke, the MMSE and MoCA are both useful and have similar predictive value for PSCI 3–6 months after the onset of minor stroke.
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Affiliation(s)
- Yueli Zhu
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shuai Zhao
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ziqi Fan
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zheyu Li
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Fan He
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Caixiu Lin
- Department of Neurology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Win Topatana
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yaping Yan
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhirong Liu
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yanxing Chen
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Baorong Zhang
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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26
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de Graaf JA, Nijsse B, Schepers VPM, van Heugten CM, Post MWM, Visser-Meily JMA. Which approach to measure cognitive functioning should be preferred when exploring the association between cognitive functioning and participation after stroke? Neuropsychol Rehabil 2020; 31:1207-1223. [PMID: 32496877 DOI: 10.1080/09602011.2020.1769687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
A variety of approaches are currently used to explore the relationship between cognitive functioning and participation after stroke. We aimed to gain insight into the preferred approach to measure cognitive functioning when exploring the association between cognitive functioning and participation in the long term after stroke. In this inception cohort study 128 individuals with stroke participated and were assessed at a single time point three to four years after the event. Participation was measured using the Restrictions subscale of the Utrecht Scale for Evaluation of Rehabilitation-Participation. Subjective cognitive complaints were assessed using the Cognition subscale of the Checklist for Cognitive and Emotional Consequences (CLCE-24-C). Objective cognitive performance was measured using the Montreal Cognitive Assessment (MoCA) and a neuropsychological test battery (NTB) testing multiple cognitive domains. Participation showed a strong correlation (r = 0.51) with the CLCE-24-C and moderate correlations with the domains of visuospatial perception (r = 0.37) and mental speed (r = 0.36). Backward linear regression analyses showed that participation restrictions were best explained by the combination of the CLCE-24-C and a test for visuospatial perception (R2 = 0.31). Our findings suggest the use of a combination of subjective cognitive complaints and objective cognitive performance to explore the relationship between cognitive functioning and participation after stroke.
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Affiliation(s)
- J A de Graaf
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - B Nijsse
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - V P M Schepers
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, The Netherlands.,Department of Rehabilitation, Physical Therapy Science & Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, The Netherlands
| | - C M van Heugten
- Faculty of Psychology and Neuroscience, Department of Neuropsychology and Psychopharmacology, Maastricht University, Maastricht, The Netherlands.,Faculty of Health, Medicine and Life Sciences, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - M W M Post
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, The Netherlands.,University of Groningen, University Medical Center Groningen, Center for Rehabilitation, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - J M A Visser-Meily
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, The Netherlands.,Department of Rehabilitation, Physical Therapy Science & Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, The Netherlands
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27
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Chi NF, Hu HH, Chan L, Wang CY, Chao SP, Huang LK, Ku HL, Hu CJ. Impaired cerebral autoregulation is associated with poststroke cognitive impairment. Ann Clin Transl Neurol 2020; 7:1092-1102. [PMID: 32468721 PMCID: PMC7359112 DOI: 10.1002/acn3.51075] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/25/2020] [Accepted: 05/10/2020] [Indexed: 01/11/2023] Open
Abstract
Objective To investigate whether dynamic cerebral autoregulation (CA) and neuroimaging characteristics are determinants of poststroke cognitive impairment (PSCI). Methods Eighty patients within 7 days of acute ischemic stroke and 35 age‐ and sex‐matched controls were enrolled. In the patients with stroke, brain magnetic resonance imaging and dynamic CA were obtained at baseline, and dynamic CA was followed up at 3 months and 1 year. Montreal Cognitive Assessment (MoCA) was performed at 3 months and 1 year. Patients with a MoCA score <23 at 1 year were defined as having PSCI, and those with a MoCA score that decreased by 2 points or more between the 3‐month and 1‐year assessments were defined as having progressive cognitive decline. Results In total, 65 patients completed the study and 16 developed PSCI. The patients with PSCI exhibited poorer results for all cognitive domains than did those without PSCI. The patients with PSCI also had poorer CA (lower phase shift between cerebral blood flow and blood pressure waveforms in the very low frequency band) compared with that of the patients without PSCI and controls at baseline and 1 year. CA was not different between the patients without PSCI and controls. In the multivariate analysis, low education level, lobar microbleeds, and impaired CA (very low frequency phase shift [≤46°] within 7 days of stroke), were independently associated with PSCI. In addition, impaired CA was associated with progressive cognitive decline. Interpretation Low education level, lobar microbleeds, and impaired CA are involved in the pathogenesis of PSCI.
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Affiliation(s)
- Nai-Fang Chi
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Han-Hwa Hu
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Lung Chan
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Yen Wang
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Shu-Ping Chao
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Li-Kai Huang
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Hsiao-Lun Ku
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Deaparmtent of Psychiatry, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Brain and Consciousness Research Center, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Chaur-Jong Hu
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan.,The Ph.D. Program for Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
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28
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Yang YM, Zhao ZM, Wang W, Dong FM, Wang PP, Jia YJ, Han N, Jia YL, Wang JH. Trends in cognitive function assessed by a battery of neuropsychological tests after mild acute ischemic stroke. J Stroke Cerebrovasc Dis 2020; 29:104887. [PMID: 32402720 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/15/2020] [Accepted: 04/12/2020] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE The aim of this study is to investigate the domain-specific trends of cognitive function up to 12 months after mild acute ischemic stroke. METHODS Enrolment of consecutive cohort of patients with mild acute ischemic stroke with recorded clinical characteristics and extensive neuropsychological assessments, including five cognitive domains. The Montreal cognitive assessment of the Beijing version (MoCA-Bj) was used to assess overall cognition. All patients completed all domain-specific examinations were categorised into three groups according to the time between the stroke onset and neuropsychological profiling, the time duration including less than one month (n = 174), one month to six months (n = 65) and over six months (n = 39). RESULTS The final cohort consisted of 278 patients. The executive (χ2 = 6.95, P<0.05) and memory dysfunctions (χ2 = 9.6, P<0.01) showed strong improvement, especially in executive function, which prevalence was 48.85% at <1- month group and 25.64% at >6 months group. The prevalence of attention and information processing also had a declining trend, the differences, however, were not statistically significant (χ2 = 0.23 and 2.25, respectively, P>0.05). There was no significant change in language function (χ2 = 0.46, P>0.05) and the MoCA (χ2 = 0.59, P>0.05) at 3-time point groups. In 195 first-ever stroke patients, the results of memory (χ2 = 6.94 P<0.05) and executive dysfunctions (χ2 = 6.25 P<0.05) also showed significant improvement. CONCLUSION There is varying degree of improvement tendency in executive and memory dysfunctions after mild acute ischemic stroke. Early cognitive assessments after mild acute ischemic stroke do not reflect the cognitive level of stable period.
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Affiliation(s)
- Yi-Ming Yang
- Graduate School of Hebei North University, Zhangjiakou, China; The Department of Neurology, Hebei General Hospital, Shijiazhuang, China.
| | - Zhong-Min Zhao
- Graduate School of Hebei Medical University, Shijiazhuang, China; The Department of Neurology, Hebei General Hospital, Shijiazhuang, China.
| | - Wei Wang
- Graduate School of Hebei Medical University, Shijiazhuang, China; The Department of Neurology, Hebei General Hospital, Shijiazhuang, China.
| | - Fang-Ming Dong
- Graduate School of Hebei Medical University, Shijiazhuang, China; The Department of Neurology, Hebei General Hospital, Shijiazhuang, China.
| | - Pan-Pan Wang
- The Department of Neurology, Hebei General Hospital, Shijiazhuang, China.
| | - Yang-Juan Jia
- The Department of Neurology, Hebei General Hospital, Shijiazhuang, China.
| | - Ning Han
- The Department of Neurology, Hebei General Hospital, Shijiazhuang, China.
| | - Yan-Li Jia
- The Department of Neurology, Hebei General Hospital, Shijiazhuang, China.
| | - Jian-Hua Wang
- The Department of Neurology, Hebei General Hospital, Shijiazhuang, China.
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29
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Cox V, Schepers V, Ketelaar M, van Heugten C, Visser-Meily A. Participation Restrictions and Satisfaction With Participation in Partners of Patients With Stroke. Arch Phys Med Rehabil 2020; 101:464-471. [DOI: 10.1016/j.apmr.2019.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 09/25/2019] [Accepted: 09/25/2019] [Indexed: 11/15/2022]
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30
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de Graaf JA, Kuijpers MMT, Visser-Meily JMA, Kappelle LJ, Post MWM. Validity of an enhanced EQ-5D-5L measure with an added cognitive dimension in patients with stroke. Clin Rehabil 2020; 34:545-550. [DOI: 10.1177/0269215520907990] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Objective: The 5-level EuroQoL (EQ-5D-5L) is a patient-reported outcome measure frequently used in stroke research. However, it does not assess the cognitive problems many patients with stroke experience. The aim of this article is to compare the content validity, internal consistency and discriminative ability of the EQ-5D-5L with and without an additional cognitive domain (EQ-5D-5L+C), administered three months post-stroke. Design: Cross-sectional study. Setting: Six general hospitals in the Netherlands. Subjects: In all, 360 individuals with stroke three months after the event. Interventions: Not applicable. Main measures: The modified Rankin Scale and EQ-5D-5L+C were administered in telephone interviews three months post-stroke. Results: A total of 360 patients with stroke were included. Mean age was 68.8 years (standard deviation (SD) = 11.7), 143 (40%) were female, 334 (93%) had had an ischemic stroke, 165 (46%) had a National Institutes of Health Stroke Scale (NIHSS) score ⩽ 4 at presentation and the Barthel Index was 17.2 (SD = 4) four days post-stroke. Cognitive problems were reported by 199 (55%) patients three months post-stroke. Internal consistencies of the EQ-5D-5L and EQ-5D-5L+C were 0.75 and 0.77, respectively. Adding a cognitive domain resulted in a decrease of the ceiling effect from 22% to 14%. Both EQ-5D-5L and EQ-5D-5L+C showed good discriminative ability, but differences between patients with different modified Rankin Scale scores and with/without reported decrease in health and daily activities were slightly larger with the EQ-5D-5L+C compared to the EQ-5D-5L. Conclusions: The EQ-5D-5L+C, which includes a cognitive domain that is highly significant for stroke patients, showed increased content validity and good discriminative ability, without losing internal consistency.
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Affiliation(s)
- JA de Graaf
- Center of Excellence for Rehabilitation Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht University, Utrecht, The Netherlands
| | - MMT Kuijpers
- Center of Excellence for Rehabilitation Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht University, Utrecht, The Netherlands
| | - JMA Visser-Meily
- Center of Excellence for Rehabilitation Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht University, Utrecht, The Netherlands
- Department of Rehabilitation, Physical Therapy Science & Sports, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - LJ Kappelle
- UMC Utrecht Brain Center and Department of Neurology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - MWM Post
- Center of Excellence for Rehabilitation Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht University, Utrecht, The Netherlands
- Center for Rehabilitation, University Medical Center Groningen and University of Groningen, Groningen, The Netherlands
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Non-invasive brain stimulation to enhance cognitive rehabilitation after stroke. Neurosci Lett 2020; 719:133678. [DOI: 10.1016/j.neulet.2018.06.047] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 06/26/2018] [Indexed: 11/19/2022]
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Treatable causes of adult-onset rapid cognitive impairment. Clin Neurol Neurosurg 2019; 187:105575. [PMID: 31715517 DOI: 10.1016/j.clineuro.2019.105575] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 10/26/2019] [Accepted: 10/27/2019] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Acute and subacute cognitive decline, defined collectively as rapid cognitive impairment (RCI), is attributed to diverse disorders and brings great challenges for differential diagnosis. In this study we investigated the RCI patients to determine the underlying causes and the cognitive outcome of the treatable RCI. PATIENTS AND METHODS We reviewed medical records of consecutively hospitalized patients (n = 346) with significant and new cognitive dysfunction between January 2014 and December 2015. Based on the duration of their cognitive dysfunction, patients were divided into two groups with the RCI (< 12 months) and the chronic cognitive impairment (CCI, ≥ 12 months), respectively. Etiologies of the RCI and the CCI were analyzed; the cognitive outcomes of the RCI patients with the treatable disorders were assessed in the follow-up visits. RESULTS Potentially treatable or reversible causes were identified in 134 (72%) of 187 RCI patients and in 34 (21%) of 159 CCI patients. The causes in the 134 (72%) RCI patients were immune/inflammation (50, 37%), infection (30, 22%), vascular diseases (29, 22%), neoplasm (16, 12%), metabolic/toxic disorders (7, 5%), and others (2, 1%). The treatable disorders found in both the RCI and the CCI patients were vascular diseases, autoimmune encephalitis, viral encephalitis, inflammatory demyelinating diseases, Hashimoto encephalopathy, neurosyphilis, hydrocephalus, and Vitamin B12 deficiency. Total 114 RCI patients with the treatable disorders were followed up for 6∼39 (median 21) months. Poor cognitive outcomes were found in 24 (21%) of the 114 followed-up patients, comprising patients with infection (1, 3%), immune/inflammation (12, 25%), vascular diseases (8, 28%), and metabolic/toxic disorders (3, 43%). CONCLUSIONS Treatable or reversible causes are common underlying RCI. Poor outcomes with severe cognitive deficits are considerably present in the treatable RCI patients and result in permanent dementia.
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Chi NF, Chao SP, Huang LK, Chan L, Chen YR, Chiou HY, Hu CJ. Plasma Amyloid Beta and Tau Levels Are Predictors of Post-stroke Cognitive Impairment: A Longitudinal Study. Front Neurol 2019; 10:715. [PMID: 31312178 PMCID: PMC6614443 DOI: 10.3389/fneur.2019.00715] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 06/17/2019] [Indexed: 01/24/2023] Open
Abstract
Objectives: Post-stroke cognitive impairment (PSCI) is a common disease that may occur within 3 months after a stroke or even later. However, the mechanism of PSCI development is unclear. The present study investigated whether the levels of plasma amyloid beta-42 (Aβ42) and tau are associated with the onset of PSCI. Methods: Fifty-five patients admitted within 7 days of acute ischemic stroke were enrolled and followed up for 1 year. Montreal Cognitive Assessment (MoCA) was administered at 3 months and 1 year, and plasma Aβ42 and tau levels were determined using an ultrasensitive immunoassay (immunomagnetic reduction) within 7 days of the stroke event and 3 months later. Results: In this study, 13 of 55 patients developed PSCI (MoCA score <23) at 3 months. Seven patients with PSCI at 3 months recovered to a cognitively normal state at 1 year, whereas seven cognitively normal patients developed PSCI at 1 year. The patients with PSCI at 1 year had a higher incidence of cognitive function deterioration between 3 months and 1 year compared with those without PSCI at 1 year. Plasma Aβ42 and tau levels at 3 months were lower in the patients with PSCI at 1 year than in those without PSCI (Aβ42: 15.1 vs. 17.2 pg/mL, P = 0.013; tau: 16.7 vs. 19.9 pg/mL, P = 0.018). Low education levels and pre-existing white matter disease were the most significant predictors of PSCI at 3 months, and poor cognitive performance at 3 months and low plasma Aβ42 and tau levels at 3 months were the most significant predictors of PSCI at 1 year. Conclusion: The pathogenesis of PSCI is complex and changes with time. Ischemia-induced Aβ42/tau pathology might be involved in PSCI development.
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Affiliation(s)
- Nai-Fang Chi
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, Stroke Center, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan.,Department of Neurology, Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shu-Ping Chao
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, Stroke Center, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan
| | - Li-Kai Huang
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, Stroke Center, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan
| | - Lung Chan
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, Stroke Center, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan
| | - Yih-Ru Chen
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Hung-Yi Chiou
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Chaur-Jong Hu
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, Stroke Center, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan.,Graduate Institute of Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
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Banerjee G, Chan E, Ambler G, Wilson D, Cipolotti L, Shakeshaft C, Cohen H, Yousry T, Lip GYH, Muir KW, Brown MM, Jäger HR, Werring DJ. Effect of small-vessel disease on cognitive trajectory after atrial fibrillation-related ischaemic stroke or TIA. J Neurol 2019; 266:1250-1259. [PMID: 30847646 PMCID: PMC6469837 DOI: 10.1007/s00415-019-09256-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/16/2019] [Accepted: 02/19/2019] [Indexed: 01/12/2023]
Abstract
Post-stroke dementia is common but has heterogenous mechanisms that are not fully understood, particularly in patients with atrial fibrillation (AF)-related ischaemic stroke or TIA. We investigated the relationship between MRI small-vessel disease markers (including a composite cerebral amyloid angiopathy, CAA, score) and cognitive trajectory over 12 months. We included patients from the CROMIS-2 AF study without pre-existing cognitive impairment and with Montreal Cognitive Assessment (MoCA) data. Cognitive impairment was defined as MoCA < 26. We defined “reverters” as patients with an “acute” MoCA (immediately after the index event) score < 26, who then improved by ≥ 2 points at 12 months. In our cohort (n = 114), 12-month MoCA improved overall relative to acute performance (mean difference 1.69 points, 95% CI 1.03–2.36, p < 0.00001). 12-month cognitive impairment was associated with increasing CAA score (per-point increase, adjusted OR 4.09, 95% CI 1.36–12.33, p = 0.012). Of those with abnormal acute MoCA score (n = 66), 59.1% (n = 39) were “reverters”. Non-reversion was associated with centrum semi-ovale perivascular spaces (per-grade increase, unadjusted OR 1.83, 95% CI 1.06–3.15, p = 0.03), cerebral microbleeds (unadjusted OR 10.86, 95% CI 1.22–96.34, p = 0.03), and (negatively) with multiple ischaemic lesions at baseline (unadjusted OR 0.11, 95% CI 0.02–0.90, p = 0.04), as well as composite small-vessel disease (per-point increase, unadjusted OR 2.91, 95% CI 1.23–6.88, p = 0.015) and CAA (per-point increase, unadjusted OR 6.71, 95% CI 2.10–21.50, p = 0.001) scores. In AF-related acute ischaemic stroke or TIA, cerebral small-vessel disease is associated both with cognitive performance at 12 months and failure to improve over this period.
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Affiliation(s)
- Gargi Banerjee
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology and National Hospital for Neurology and Neurosurgery, Russell Square House, 10-12 Russell Square, London, WC1B 5EH, UK
| | - Edgar Chan
- Department of Neuropsychology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, Gower Street, London, UK
| | - Duncan Wilson
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology and National Hospital for Neurology and Neurosurgery, Russell Square House, 10-12 Russell Square, London, WC1B 5EH, UK.,New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Lisa Cipolotti
- Department of Neuropsychology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Clare Shakeshaft
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology and National Hospital for Neurology and Neurosurgery, Russell Square House, 10-12 Russell Square, London, WC1B 5EH, UK
| | - Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, 51 Chenies Mews, London, UK
| | - Tarek Yousry
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, Queen Square, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Martin M Brown
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology and National Hospital for Neurology and Neurosurgery, Russell Square House, 10-12 Russell Square, London, WC1B 5EH, UK
| | - Hans Rolf Jäger
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, Queen Square, London, UK
| | - David J Werring
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology and National Hospital for Neurology and Neurosurgery, Russell Square House, 10-12 Russell Square, London, WC1B 5EH, UK.
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Li J, You SJ, Xu YN, Yuan W, Shen Y, Huang JY, Xiong KP, Liu CF. Cognitive impairment and sleep disturbances after minor ischemic stroke. Sleep Breath 2018; 23:455-462. [PMID: 30145676 DOI: 10.1007/s11325-018-1709-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 07/26/2018] [Accepted: 08/15/2018] [Indexed: 12/23/2022]
Abstract
PURPOSE Post-stroke cognitive impairment (PSCI) is common among stroke survivors, although its risk factors are not well understood. Here, we assessed cognitive function in patients within 14 days after minor stroke and investigated the risk factors of PSCI, including sleep-related factors. METHODS Patients with minor acute ischemic stroke (n = 86) were continuously recruited from November 2015 to October 2016. Demographic and clinical data were collected, and cognitive assessment and polysomnography were performed. Based on their cognitive performance, stroke patients were divided into PSCI and no PSCI groups. Age-, sex-, and education-matched participants (n = 36) were included as a healthy control (HC) group. RESULTS Stroke patients showed impairments in multiple cognitive domains relative to HC participants (p < 0.01). Among stroke patients, the prevalence of PSCI and obstructive sleep apnea was 81.4 and 74.4%, respectively. Impairments in attention and working memory (87.1%) and executive function (84.3%) were the most common among stroke patients. Compared with no PSCI patients, PSCI patients showed a higher prevalence of obstructive sleep apnea (50.0 vs. 80.0%, p = 0.030) and shorter total sleep time (435.1 ± 104.0 vs. 347.3 ± 98.1 min, p = 0.002). Logistic regression analysis showed that education duration, total sleep time, and lowest SaO2 were independent risk factors for PSCI. CONCLUSIONS The prevalence of PSCI is high after minor ischemic stroke. In particular, attention and working memory and executive function are most commonly impaired. Although the risk factors for PSCI are numerous, shorter total sleep time and degree of hypoxia at night warrant further attention.
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Affiliation(s)
- Jie Li
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, China
| | - Shou-Jiang You
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, China
| | - Ya-Nan Xu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, China
| | - Wen Yuan
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, China
| | - Yun Shen
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, China
| | - Jun-Ying Huang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, China
| | - Kang-Ping Xiong
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, China
| | - Chun-Feng Liu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, China.
- Institute of Neuroscience, Soochow University, Suzhou, 215123, China.
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Non-invasive Cerebellar Stimulation: a Promising Approach for Stroke Recovery? THE CEREBELLUM 2017; 17:359-371. [DOI: 10.1007/s12311-017-0906-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Sagnier S, Catheline G, Dilharreguy B, Munsch F, Bigourdan A, Poli M, Debruxelles S, Olindo S, Renou P, Rouanet F, Dousset V, Tourdias T, Sibon I. Admission Brain Cortical Volume. Stroke 2017. [DOI: 10.1161/strokeaha.117.017646] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sharmila Sagnier
- From the Unité Neuro-vasculaire (S.S., M.P., S.D., S.O., P.R., F.R., I.S.) and Neuroradiologie (F.M., A.B., V.D., T.T.), CHU de Bordeaux, France; UMR 5287 CNRS, Université de Bordeaux, EPHE PSL Research University, France (S.S., G.C., B.D., I.S.); and INSERM-U862, Neurocentre Magendie, Bordeaux, France (F.M., A.B., V.D., T.T.)
| | - Gwenaëlle Catheline
- From the Unité Neuro-vasculaire (S.S., M.P., S.D., S.O., P.R., F.R., I.S.) and Neuroradiologie (F.M., A.B., V.D., T.T.), CHU de Bordeaux, France; UMR 5287 CNRS, Université de Bordeaux, EPHE PSL Research University, France (S.S., G.C., B.D., I.S.); and INSERM-U862, Neurocentre Magendie, Bordeaux, France (F.M., A.B., V.D., T.T.)
| | - Bixente Dilharreguy
- From the Unité Neuro-vasculaire (S.S., M.P., S.D., S.O., P.R., F.R., I.S.) and Neuroradiologie (F.M., A.B., V.D., T.T.), CHU de Bordeaux, France; UMR 5287 CNRS, Université de Bordeaux, EPHE PSL Research University, France (S.S., G.C., B.D., I.S.); and INSERM-U862, Neurocentre Magendie, Bordeaux, France (F.M., A.B., V.D., T.T.)
| | - Fanny Munsch
- From the Unité Neuro-vasculaire (S.S., M.P., S.D., S.O., P.R., F.R., I.S.) and Neuroradiologie (F.M., A.B., V.D., T.T.), CHU de Bordeaux, France; UMR 5287 CNRS, Université de Bordeaux, EPHE PSL Research University, France (S.S., G.C., B.D., I.S.); and INSERM-U862, Neurocentre Magendie, Bordeaux, France (F.M., A.B., V.D., T.T.)
| | - Antoine Bigourdan
- From the Unité Neuro-vasculaire (S.S., M.P., S.D., S.O., P.R., F.R., I.S.) and Neuroradiologie (F.M., A.B., V.D., T.T.), CHU de Bordeaux, France; UMR 5287 CNRS, Université de Bordeaux, EPHE PSL Research University, France (S.S., G.C., B.D., I.S.); and INSERM-U862, Neurocentre Magendie, Bordeaux, France (F.M., A.B., V.D., T.T.)
| | - Mathilde Poli
- From the Unité Neuro-vasculaire (S.S., M.P., S.D., S.O., P.R., F.R., I.S.) and Neuroradiologie (F.M., A.B., V.D., T.T.), CHU de Bordeaux, France; UMR 5287 CNRS, Université de Bordeaux, EPHE PSL Research University, France (S.S., G.C., B.D., I.S.); and INSERM-U862, Neurocentre Magendie, Bordeaux, France (F.M., A.B., V.D., T.T.)
| | - Sabrina Debruxelles
- From the Unité Neuro-vasculaire (S.S., M.P., S.D., S.O., P.R., F.R., I.S.) and Neuroradiologie (F.M., A.B., V.D., T.T.), CHU de Bordeaux, France; UMR 5287 CNRS, Université de Bordeaux, EPHE PSL Research University, France (S.S., G.C., B.D., I.S.); and INSERM-U862, Neurocentre Magendie, Bordeaux, France (F.M., A.B., V.D., T.T.)
| | - Stéphane Olindo
- From the Unité Neuro-vasculaire (S.S., M.P., S.D., S.O., P.R., F.R., I.S.) and Neuroradiologie (F.M., A.B., V.D., T.T.), CHU de Bordeaux, France; UMR 5287 CNRS, Université de Bordeaux, EPHE PSL Research University, France (S.S., G.C., B.D., I.S.); and INSERM-U862, Neurocentre Magendie, Bordeaux, France (F.M., A.B., V.D., T.T.)
| | - Pauline Renou
- From the Unité Neuro-vasculaire (S.S., M.P., S.D., S.O., P.R., F.R., I.S.) and Neuroradiologie (F.M., A.B., V.D., T.T.), CHU de Bordeaux, France; UMR 5287 CNRS, Université de Bordeaux, EPHE PSL Research University, France (S.S., G.C., B.D., I.S.); and INSERM-U862, Neurocentre Magendie, Bordeaux, France (F.M., A.B., V.D., T.T.)
| | - François Rouanet
- From the Unité Neuro-vasculaire (S.S., M.P., S.D., S.O., P.R., F.R., I.S.) and Neuroradiologie (F.M., A.B., V.D., T.T.), CHU de Bordeaux, France; UMR 5287 CNRS, Université de Bordeaux, EPHE PSL Research University, France (S.S., G.C., B.D., I.S.); and INSERM-U862, Neurocentre Magendie, Bordeaux, France (F.M., A.B., V.D., T.T.)
| | - Vincent Dousset
- From the Unité Neuro-vasculaire (S.S., M.P., S.D., S.O., P.R., F.R., I.S.) and Neuroradiologie (F.M., A.B., V.D., T.T.), CHU de Bordeaux, France; UMR 5287 CNRS, Université de Bordeaux, EPHE PSL Research University, France (S.S., G.C., B.D., I.S.); and INSERM-U862, Neurocentre Magendie, Bordeaux, France (F.M., A.B., V.D., T.T.)
| | - Thomas Tourdias
- From the Unité Neuro-vasculaire (S.S., M.P., S.D., S.O., P.R., F.R., I.S.) and Neuroradiologie (F.M., A.B., V.D., T.T.), CHU de Bordeaux, France; UMR 5287 CNRS, Université de Bordeaux, EPHE PSL Research University, France (S.S., G.C., B.D., I.S.); and INSERM-U862, Neurocentre Magendie, Bordeaux, France (F.M., A.B., V.D., T.T.)
| | - Igor Sibon
- From the Unité Neuro-vasculaire (S.S., M.P., S.D., S.O., P.R., F.R., I.S.) and Neuroradiologie (F.M., A.B., V.D., T.T.), CHU de Bordeaux, France; UMR 5287 CNRS, Université de Bordeaux, EPHE PSL Research University, France (S.S., G.C., B.D., I.S.); and INSERM-U862, Neurocentre Magendie, Bordeaux, France (F.M., A.B., V.D., T.T.)
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Sagnier S, Renou P, Olindo S, Debruxelles S, Poli M, Rouanet F, Munsch F, Tourdias T, Sibon I. Gait Change Is Associated with Cognitive Outcome after an Acute Ischemic Stroke. Front Aging Neurosci 2017; 9:153. [PMID: 28572768 PMCID: PMC5435741 DOI: 10.3389/fnagi.2017.00153] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 05/03/2017] [Indexed: 11/13/2022] Open
Abstract
Background: Cognition and gait have often been studied separately after stroke whereas it has been suggested that these two domains could interact through a cognitive-motor interference. Objective: To evaluate the influence of gait changes on cognitive outcome after an ischemic stroke (IS). Methods: We conducted a prospective and monocentric study including patients admitted for an acute supratentorial IS with a National Institute of Health Stroke Score ≤ 15. Cognition, gait and motor disability were evaluated at baseline, 3 months and 1 year post-stroke, using the Montreal Cognitive Assessment (MoCA), the 10-m walking test (10-MWT) and the Fugl-Meyer motor assessment (FMMA). The effect of changes in 10-MWT over the year of follow-up on MoCA changes was estimated using a generalized linear mixed model with FMMA, age and gender as covariates. Results: Two hundred and Twelve patients were included (71% male, age 64 ± 13 years old). 10-MWT improved from baseline to 1 year (p < 0.001), as did MoCA (p < 0.001) and FMMA (p < 0.001) scores. Ninety-nine patients (47%) had a MoCA <26 at 1 year. Changes in 10-MWT were independently associated with changes in MoCA (β = -0.2, 95% CI -0.24 to -0.07, Bonferroni-corrected p-value = 0.002). Analyses of MoCA sub-scores suggested that changes in gait performance was associated with changes in executive functions and recall. Conclusion: Gait performance is associated with cognitive outcome after a mild to moderate IS, suggesting that they should be managed together to improve post-stroke independence.
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Affiliation(s)
- Sharmila Sagnier
- CHU Pasteur 2, Unité Neuro-VasculaireNice, France.,UMR 5287 Centre National de la Recherche Scientifique, Université de Bordeaux, EPHE PSL Research UniversityBordeaux, France
| | - Pauline Renou
- CHU de Bordeaux, Unité Neuro-VasculaireBordeaux, France
| | | | | | - Mathilde Poli
- CHU de Bordeaux, Unité Neuro-VasculaireBordeaux, France
| | | | - Fanny Munsch
- CHU de Bordeaux, Neuroradiologie Diagnostique et ThérapeutiqueBordeaux, France
| | - Thomas Tourdias
- CHU de Bordeaux, Neuroradiologie Diagnostique et ThérapeutiqueBordeaux, France.,Health and Human Sciences Department, Université de BordeauxBordeaux, France
| | - Igor Sibon
- UMR 5287 Centre National de la Recherche Scientifique, Université de Bordeaux, EPHE PSL Research UniversityBordeaux, France.,CHU de Bordeaux, Unité Neuro-VasculaireBordeaux, France
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van der Kemp J, Kruithof WJ, Nijboer TCW, van Bennekom CAM, van Heugten C, Visser-Meily JMA. Return to work after mild-to-moderate stroke: work satisfaction and predictive factors. Neuropsychol Rehabil 2017; 29:638-653. [DOI: 10.1080/09602011.2017.1313746] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Jet van der Kemp
- Department of Rehabilitation, Physical Therapy Science & Sports, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, the Netherlands
- De Hoogstraat Rehabilitation, Utrecht, the Netherlands
| | - Willeke J. Kruithof
- Department of Rehabilitation, Physical Therapy Science & Sports, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, the Netherlands
- De Hoogstraat Rehabilitation, Utrecht, the Netherlands
| | - Tanja C. W. Nijboer
- Department of Rehabilitation, Physical Therapy Science & Sports, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, the Netherlands
- De Hoogstraat Rehabilitation, Utrecht, the Netherlands
- Department of Experimental Psychology, Helmholtz Institute, Utrecht University, Utrecht, the Netherlands
| | - Coen A. M. van Bennekom
- Department of Research and Development, Heliomare Rehabilitation Centre, Wijk aan Zee, the Netherlands
- Coronel Institute of Occupational Health, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Caroline van Heugten
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, the Netherlands
- Department of Neuropsychology and Psychopharmacology, Maastricht University, Maastricht, the Netherlands
| | - Johanna M. A. Visser-Meily
- Department of Rehabilitation, Physical Therapy Science & Sports, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, the Netherlands
- De Hoogstraat Rehabilitation, Utrecht, the Netherlands
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