Frequency and clinical determinants of dementia after ischemic stroke

African American patients have a higher probability of cognitive impairment after incident stroke: An analysis of national electronic health record data

BACKGROUND

Cognitive impairment (CI) and stroke are diseases with significant disparities in race and geography. Post stroke cognitive impairment (PSCI) can be as high as 15-70 % but few studies have utilized large administrative or electronic health records (EHR) to evaluate trends in PSCI. We utilized an EHR database to evaluate for disparities in PSCI in a large sample of patients after first recorded stroke to evaluate for disparities in race.

METHODS

This is a retrospective cohort analysis of Cerner Health Facts® EHR database, which is comprised of EHR data from hundreds of hospitals/clinics in the US from 2009-2018. We evaluated patients ≥40 years of age with a first time ischemic stroke (IS) diagnosis for PSCI using ICD9/10 codes for both conditions. Patients with first stroke in the Cerner database and no pre-existing cognitive impairment were included, we compared hazard ratios for developing PSCI for patient characteristics RESULTS: A total of 150,142 IS patients with follow-up data and no pre-existing evidence of CI were evaluated. Traditional risk factors of age, female sex, kidney injury, hypertension, and hyperlipidemia were associated with PSCI. Only African American stroke survivors had a higher probability of developing PSCI compared to White survivors (HR 1.347, 95 % CI (1.270, 1.428)) and this difference was most prominent in the South. Among those to develop PSCI, median time to documentation was 1.8 years in African American survivors.

CONCLUSION

In a large national database, African American stroke survivors had a higher probability of PSCI five years after stroke than White survivors.

Network analysis of neuropsychiatric, cognitive, and functional complications of stroke: implications for novel treatment targets

AIM

Recovery from stroke is adversely affected by neuropsychiatric complications, cognitive impairment, and functional disability. Better knowledge of their mutual relationships is required to inform effective interventions. Network theory enables the conceptualization of symptoms and impairments as dynamic and mutually interacting systems. We aimed to identify interactions of poststroke complications using network analysis in diverse stroke samples.

METHODS

Data from 2185 patients were sourced from member studies of STROKOG (Stroke and Cognition Consortium), an international collaboration of stroke studies. Networks were generated for each cohort, whereby nodes represented neuropsychiatric symptoms, cognitive deficits, and disabilities on activities of daily living. Edges characterized associations between them. Centrality measures were used to identify hub items.

RESULTS

Across cohorts, a single network of interrelated poststroke complications emerged. Networks exhibited dissociable depression, apathy, fatigue, cognitive impairment, and functional disability modules. Worry was the most central symptom across cohorts, irrespective of the depression scale used. Items relating to activities of daily living were also highly central nodes. Follow-up analysis in two studies revealed that individuals who worried had more densely connected networks than those free of worry (CASPER [Cognition and Affect after Stroke: Prospective Evaluation of Risks] study: S = 9.72, P = 0.038; SSS [Sydney Stroke Study]: S = 13.56, P = 0.069).

CONCLUSION

Neuropsychiatric symptoms are highly interconnected with cognitive deficits and functional disabilities resulting from stroke. Given their central position and high level of connectedness, worry and activities of daily living have the potential to drive multimorbidity and mutual reinforcement between domains of poststroke complications. Targeting these factors early after stroke may have benefits that extend to other complications, leading to better stroke outcomes.

Association of socioeconomic status and poststroke cognitive function: A systematic review and meta-analysis

BACKGROUND

Stroke survivors are at high risk of coping with cognitive problems after stroke. In recent decades, the relationship between socioeconomic status (SES) and health-related outcomes has been a topic of considerable interest. Learning more about the potential impact of SES on poststroke cognitive dysfunction is of great importance.

OBJECTIVE

The purpose of this systematic review and meta-analysis was to summarize the association between SES and poststroke cognitive function by quantifying the effect sizes of the existing studies.

METHOD

We searched studies from PubMed, Ovid, Embase, Cochrane, Scopus, and PsychINFO up to January 30th 2024 and the references of relevant reviews. Studies reporting the risk of poststroke cognitive dysfunction as assessed by categorized SES indicators were included. The Newcastle-Ottawa scale and the Agency for Healthcare Research and Quality were used to evaluate the study quality. Meta-analyses using fixed-effect models or random-effect models based on study heterogeneity were performed to estimate the influence of SES on cognitive function after stroke, followed by subgroup analyses stratified by study characteristics.

RESULTS

Thirty-four studies were eligible for this systematic review and meta-analysis. Of which, 19 studies reported poststroke cognitive impairment (PSCI) as the outcome, 13 reported poststroke dementia (PSD), one reported both PSCI and PSD, and one reported vascular cognitive impairment no dementia. The findings showed that individuals with lower SES levels had a higher risk of combined poststroke cognitive dysfunction (odds ratio (OR) = 1.91, 95% confidence interval (CI) = 1.59-2.29), PSCI (OR = 2.09, 95% CI = 1.57-2.78), and PSD (OR = 1.95, 95% CI = 1.48-2.57). Subgroup analyses stratified by SES indicators demonstrated the protective effects of education and occupation against the diagnoses of combined poststroke cognitive dysfunction, PSCI, and PSD.

CONCLUSIONS

Stroke survivors belonging to a low SES are at high risk of poststroke cognitive dysfunction. Our findings add evidence for public health strategies to reduce the risk of poststroke cognitive dysfunction by reducing SES inequalities.

Shared Proteins and Pathways of Cardiovascular and Cognitive Diseases: Relation to Vascular Cognitive Impairment

One of the primary goals of systems medicine is the detection of putative proteins and pathways involved in disease progression and pathological phenotypes. Vascular cognitive impairment (VCI) is a heterogeneous condition manifesting as cognitive impairment resulting from vascular factors. The precise mechanisms underlying this relationship remain unclear, which poses challenges for experimental research. Here, we applied computational approaches like systems biology to unveil and select relevant proteins and pathways related to VCI by studying the crosstalk between cardiovascular and cognitive diseases. In addition, we specifically included signals related to oxidative stress, a common etiologic factor tightly linked to aging, a major determinant of VCI. Our results show that pathways associated with oxidative stress are quite relevant, as most of the prioritized vascular cognitive genes and proteins were enriched in these pathways. Our analysis provided a short list of proteins that could be contributing to VCI: DOLK, TSC1, ATP1A1, MAPK14, YWHAZ, CREB3, HSPB1, PRDX6, and LMNA. Moreover, our experimental results suggest a high implication of glycative stress, generating oxidative processes and post-translational protein modifications through advanced glycation end-products (AGEs). We propose that these products interact with their specific receptors (RAGE) and Notch signaling to contribute to the etiology of VCI.

Age at menopause and all-cause and cause-specific dementia: a prospective analysis of the UK Biobank cohort

STUDY QUESTION

Are there associations between natural or surgical menopause and incident dementia by age at menopause?

SUMMARY ANSWER

Compared to age at menopause of 46-50 years, earlier natural menopause (≤40 and 41-45 years) was related to higher risk of all-cause dementia, while a U-shape relationship was observed between age at surgical menopause and risk of dementia.

WHAT IS KNOWN ALREADY

Menopause marks the end of female reproductive period. Age at menopause reflects the length of exposure to endogenous estrogen. Evidence on the association between age at natural, surgical menopause, and risk of dementia has been inconsistent.

STUDY DESIGN, SIZE, DURATION

A population-based cohort study involving 160 080 women who participated in the UK Biobank study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women with no dementia at baseline, and had no missing data on key exposure variables and covariates were included. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% CIs on the association of categorical menopause age with incident all-cause dementia, Alzheimer's disease (AD) and vascular dementia (VD). Restricted cubic splines were used to model the non-linear relationship between continuous age at natural, surgical menopause, and risk of dementia. In addition, we analyzed the interaction effect of ever-used menopausal hormone therapy (MHT) at baseline, income level, leisure activities, and age at menopause on risk of dementia.

MAIN RESULTS AND THE ROLE OF CHANCE

Compared to women with age at menopause of 46-50 years, women with earlier natural menopause younger than 40 years (1.36, 1.01-1.83) and 41-45 years (1.19, 1.03-1.39) had a higher risk of all-cause dementia, while late natural menopause >55 years was linked to lower risk of dementia (0.83, 0.71-0.98). Compared to natural menopause, surgical menopause was associated with 10% higher risk of dementia (1.10, 0.98-1.24). A U-shape relationship was observed between surgical menopause and risk of dementia. Women with surgical menopause before age 40 years (1.94, 1.38-2.73) and after age 55 years (1.65, 1.21-2.24) were both linked to increased risk of all-cause dementia. Women with early natural menopause without ever taking MHT at baseline had an increased risk of AD. Also, in each categorized age at the menopause level, higher income level or higher number of leisure activities was linked to a lowers risk of dementia.

LIMITATIONS, REASONS FOR CAUTION

Menopausal age was based on women's self-report, which might cause recall bias.

WIDER IMPLICATION OF THE FINDINGS

Women who experienced natural menopause or had surgical menopause at an earlier age need close monitoring and engagement for preventive health measures to delay the development of dementia.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by the Start-up Foundation for Scientific Research in Shandong University (202099000066), Science Fund Program for Excellent Young Scholars of Shandong Provence (Overseas) (2022HWYQ-030), and the National Natural Science Foundation of China (82273702). There are no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Associations Between Vascular Risk Factor Levels and Cognitive Decline Among Stroke Survivors

Importance

Incident stroke is associated with accelerated cognitive decline. Whether poststroke vascular risk factor levels are associated with faster cognitive decline is uncertain.

Objective

To evaluate associations of poststroke systolic blood pressure (SBP), glucose, and low-density lipoprotein (LDL) cholesterol levels with cognitive decline.

Design, Setting, and Participants

Individual participant data meta-analysis of 4 US cohort studies (conducted 1971-2019). Linear mixed-effects models estimated changes in cognition after incident stroke. Median (IQR) follow-up was 4.7 (2.6-7.9) years. Analysis began August 2021 and was completed March 2023.

Exposures

Time-dependent cumulative mean poststroke SBP, glucose, and LDL cholesterol levels.

Main Outcomes and Measures

The primary outcome was change in global cognition. Secondary outcomes were change in executive function and memory. Outcomes were standardized as t scores (mean [SD], 50 [10]); a 1-point difference represents a 0.1-SD difference in cognition.

Results

A total of 1120 eligible dementia-free individuals with incident stroke were identified; 982 (87.7%) had available covariate data and 138 (12.3%) were excluded for missing covariate data. Of the 982, 480 (48.9%) were female individuals, and 289 (29.4%) were Black individuals. The median age at incident stroke was 74.6 (IQR, 69.1-79.8; range, 44.1-96.4) years. Cumulative mean poststroke SBP and LDL cholesterol levels were not associated with any cognitive outcome. However, after accounting for cumulative mean poststroke SBP and LDL cholesterol levels, higher cumulative mean poststroke glucose level was associated with faster decline in global cognition (-0.04 points/y faster per each 10-mg/dL increase [95% CI, -0.08 to -0.001 points/y]; P = .046) but not executive function or memory. After restricting to 798 participants with apolipoprotein E4 (APOE4) data and controlling for APOE4 and APOE4 × time, higher cumulative mean poststroke glucose level was associated with a faster decline in global cognition in models without and with adjustment for cumulative mean poststroke SBP and LDL cholesterol levels (-0.05 points/y faster per 10-mg/dL increase [95% CI, -0.09 to -0.01 points/y]; P = .01; -0.07 points/y faster per 10-mg/dL increase [95% CI, -0.11 to -0.03 points/y]; P = .002) but not executive function or memory declines.

Conclusions and Relevance

In this cohort study, higher poststroke glucose levels were associated with faster global cognitive decline. We found no evidence that poststroke LDL cholesterol and SBP levels were associated with cognitive decline.

Dementia Risk Following Ischemic Stroke: A Systematic Review and Meta-Analysis of Factors Collected at Time of Stroke Diagnosis

BACKGROUND

The majority of stroke cases are ischemic in origin and ischemic stroke survivors represent a high-risk population for progression to dementia.

OBJECTIVE

To determine incidence rates and predictors of dementia after ischemic stroke.

METHODS

A systematic review and meta-analysis compliant with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA).

RESULTS

5,843 studies were screened for title and abstract. 292 eligible studies were screened for full text. A total of 22 studies met the inclusion criteria and were included, representing 55,929 ischemic stroke survivors. Cumulative incidence of dementia after stroke was 20% at 5 years, 30% at 15 years, and 48% at 25 years of follow-up. Dementia incidence rates were 1.5 times higher among patients with recurrent ischemic stroke compared to patients with first-time stroke. Predictors of dementia after ischemic stroke included female gender (OR 1.2, 95% CI (1.1, 1.4)), hypertension (1.4, (1.1, 2.0)), diabetes mellitus (1.6, (1.3, 2.1)), atrial fibrillation (1.9, (1.2, 3.0)), previous stroke (2.0, (1.6, 2.6)), presence of stroke lesion in dominant hemisphere (2.4, (1.3, 4.5)), brain stem or cerebellum (OR 0.5, (0.3, 0.9)) or frontal lobe (3.7, (1.2, 12.0)), presence of aphasia (OR 7.9, (2.4, 26.0)), dysphasia (5.8, (3.0, 11.3)), gait impairment (1.7, (1.1, 2.7)), presence of white matter hyperintensities (3.2, (2.0, 5.3)), and medial temporal lobe atrophy (3.9, (1.9, 8.3)).

CONCLUSION

Factors routinely collected for stroke patients are a useful resource for monitoring dementia progression in this population. In the present meta-analysis, cardiovascular factors, stroke location, stroke-related disability and chronic brain changes were predictors of dementia after ischemic stroke.

Association between diabetes mellitus and post-stroke cognitive impairment

Stroke survivors suffer from various physical, emotional, and cognitive impairments. These changes are dynamic and depend on multiple factors, including underlying diseases, baseline brain function and pathology, the site of the stroke and the post-stroke inflammation, neurogenesis as well as the subsequent remodeling of the neuro-network. First we review the structural and pathological changes of the brain in stroke survivors with diabetes mellitus, which may lead to post-stroke cognitive dysfunction. Second, we provide evidence of hyperglycemia, diabetes mellitus, hypoglycemia, and their relationship with post-stroke cognitive impairment (PSCI) and post-stroke dementia (PSD). In addition to conventional biomarkers, such as HbA1c, we also provide other novel tools to predict PSCI/PSD, such as glycemic variability, receptor for advanced glycation end products, and gut microbiota. Finally, we attempt to provide some modifying methods for glycemic control, focusing on the prevention of PSCI/PSD.

Poststroke Cognitive Impairment: A Longitudinal Follow-Up and Pre/Poststroke Mini-Mental State Examination Comparison

BACKGROUND

Poststroke cognitive impairment (PSCI) is a prevalent cause of disability in people with stroke. PSCI results from either lesion-dependent loss of cognitive function or augmentation of Alzheimer's pathology due to vascular insufficiency. The lack of prestroke cognitive assessments limits the clear understanding of the impact of PSCI on cognition.

OBJECTIVE

The present study aims to make a direct comparison of longitudinal cognitive assessment results to clarify the impact of ischemic stroke on PSCI and assess the cognitive decline in PSCI compared to people with Alzheimer's disease (AD).

METHODS

All study participants had their Mini-Mental State Examination (MMSE) at the chronic poststroke stage (≥6 months after stroke), which was compared with prestroke or acute poststroke (<6 months after stroke) MMSE to investigate the two aspects of PSCI. A group of patients with AD was used to reference the speed of neurodegenerative cognitive deterioration. Repeated measures analysis of variance was used to compare the longitudinal change of MMSE.

RESULTS

MMSE score between acute and chronic poststroke revealed a 1.8 ± 6.49 decline per year (n=76), which was not significantly different from the AD patients who underwent cholinesterase inhibitors treatment (-1.11 ± 2.61, p=0.35, n=232). MMSE score between prestroke and chronic poststroke (n=33) revealed a significant decline (-6.52 ± 6.86, p < 0.001). In addition, their cognitive deterioration was significantly associated with sex, age, and stroke over the white matter or basal ganglia.

CONCLUSION

Ischemic stroke substantially affects cognition with an average six-point drop in MMSE. The rate of cognitive decline in PSCI was similar to AD, and those with white matter or basal ganglia infarct were at greater risk of PSCI.

Social problem solving and trait socioemotional abilities in ambulatory stroke patients

INTRODUCTION

Stroke has been associated with sociocognitive impairment, so far well documented for emotion recognition and Theory of Mind. However, more complex abilities, such as social problem solving, which directly facilitate appropriate behavior in social situations have been neglected in previous research.

METHOD

The present study aimed to address this gap by focusing on performance-based social problem solving abilities and self-reported socioemotional abilities (i.e., empathy and alexithymia) in outpatient stroke patients (n = 36) compared to a group of healthy controls (n = 36) equivalent on age, gender, and education. In further analyses, potential lateralization effects and correlations between social problem solving/socioemotional functioning and demographic and clinical data were investigated.

RESULTS

In the main analyses, patients were impaired in their ability to freely generate appropriate solutions for challenging interpersonal situations depicted in written scenarios but performed on a comparable level as healthy controls when they had to choose the optimal solution presented amidst a range of less optimal options. While showing difficulty in identifying the awkward elements in the scenarios, the patient group nevertheless rated the degree of discomfort attributed to these elements on a level comparable to the control group. On the self-report measures, stroke patients reported overall higher degrees of alexithymia (i.e., an inability to describe and identify one's own and other persons´ emotions) and more personal distress in response to other individuals´ emotional suffering as assessed by self-report.

CONCLUSIONS

The present results suggest that stroke is associated with a broad impact on socioemotional and social problem solving abilities. As difficulties in social problem solving might be associated with increased psychosocial burden they ought to be addressed in stroke rehabilitation.

Association of periodontitis and oral microbiomes with Alzheimer’s disease: A narrative systematic review

Background/purpose

Alzheimer’s disease (AD) is a neurodegenerative disorder and the most common form of dementia. The etiology for AD includes age, genetic susceptibility, neuropathology, and infection. Periodontitis is an infectious and inflammatory disease which mainly causes alveolar bone destruction and tooth loss. The evidence of a link between AD and periodontitis remains controversial. Thus far, studies reviewing the association between AD and periodontal disease have been insufficient from the viewpoint of the oral microbiome. The aim of this review was to focus on studies that have explored the relationship between the oral microbiome and AD development by using the next-generation sequencing technique.

Materials and methods

A comprehensive electronic search of MEDLINE via PubMed, EMBASE, Scopus, and Google Scholar was conducted. The keywords included dementia, Alzheimer’s disease, cognitive impairment, periodontitis, periodontal disease, and oral microbiome.

Results

This review included 26 articles based on the eligibility criteria. Epidemiologic researches and post-mortem studies showed that the presence of periodontitis is associated with cognitive decline, suggesting a possible role of periodontal pathogens in the pathogenesis of AD. The reported microbiome was inconsistent with those in gene sequencing studies. Nevertheless, Gram-negative species may be possible candidates.

Conclusion

This review suggests that periodontal infection is associated with AD. The contributing microbiome remains unconfirmed, possibly because of different microbiome sampling sites or methods. Additional large-scale studies with periodontal intervention and longitudinal follow-up are warranted to clarify the relationship between periodontal disease and AD.

Prevalence, awareness, and treatment of depression among community-dwelling stroke survivors in Korea

Post-stroke depression (PSD), a prevalent complication of stroke, causes poor outcomes. However, little is known about its prevalence and management among community-dwelling stroke survivors. Thus, we investigated the prevalence, awareness, and treatment of PSD in a community setting. A cross-sectional study was performed using representative data from the Korea National Health and Nutrition Surveys 2014, 2016, and 2018. A total of 11,122 participants aged ≥ 40 years were categorized, including 343 stroke survivors and 10,779 non-stroke survivors. We then calculated and compared the prevalence, awareness (formal diagnosis of depression by a doctor), and treatment rates of depression between the two groups. Depression was defined as a score ≥ 10 in the nine-item Patient Health Questionnaire (PHQ-9). Depression was significantly more prevalent among stroke survivors than in non-stroke survivors (22.2% vs. 8.5%, respectively), while the differences in the awareness and treatment rates were insignificant. However, only 46.8% of stroke survivors with PSD were aware of their condition, and only 20.5% were receiving treatment. These results suggest that clinicians should more actively screen for and treat depression among stroke survivors.

A Novel Perspective on the Proactive and Reactive Controls of Executive Function in Chronic Stroke Patients

Objectives

To investigate the proactive and reactive control process when executing a complex task in patients with stroke. Proactive control is the preparatory process before the target stimulus, whereas reactive control is an imperative resolution of interference after the target stimulus.

Methods

In total, 17 patients with chronic stroke and 17 healthy individuals were recruited. The proactive and reactive control of executive function was assessed by the task-switching paradigm and the AX version of the Continuous Performance Task (AX-CPT). The general executive function was assessed by Color Trial Test (CTT) and Stroop Test. The behavioral data of the task-switching paradigm were analyzed by a three-way repeated-measures ANOVA, and the AX-CPT data were analyzed by two-way repeated-measures ANOVA.

Results

For efficiency scores in the task-switching paradigm, trial (repeat vs. switch) × group (stroke or control group) interaction effect was significant. Post-hoc analysis on trial × group effect showed a significant between-trial difference in accuracy rates in the repeat trial in the control group regardless of 100 or 50% validity. For the AX-CPT, the main effects of condition and group on response time were statistically significant. The interaction effect of condition (AY or BX) × group (stroke or control group) was also significant. Post-hoc analysis for condition × group indicated that the stroke group had a significantly longer response time in the BX condition than the control group and longer completion time in CTT2 and larger word interference for completion time in the Stroop test than the control cohort.

Conclusions

Post-stroke survivors showed deficits in the performance of proactive control but not in the performance of reactive control. Deficits in proactive control may be related to the impairment of working memory. Interventions that focus on proactive control may result in improved clinical outcomes.

Association of Ischemic Stroke Incidence, Severity, and Recurrence With Dementia in the Atherosclerosis Risk in Communities Cohort Study

IMPORTANCE

Ischemic stroke is associated with increased risk of dementia, but the association of stroke severity and recurrence with risk of impaired cognition is not well known.

OBJECTIVE

To examine the risk of dementia after incident ischemic stroke and assess how it differed by stroke severity and recurrence.

DESIGN, SETTING, AND PARTICIPANTS

The Atherosclerosis Risk in Communities (ARIC) study is an ongoing prospective cohort of 15 792 community-dwelling individuals from 4 US states (Mississippi, Maryland, Minnesota, and North Carolina). Among them, 15 379 participants free of stroke and dementia at baseline (1987 to 1989) were monitored through 2019. Data were analyzed from April to October 2021. Associations between dementia and time-varying ischemic stroke incidence, frequency, and severity were studied across an average of 4.4 visits over a median follow-up of 25.5 years with Cox proportional hazards models adjusted for sociodemographic characteristics, apolipoprotein E, and vascular risk factors.

EXPOSURES

Incident and recurrent ischemic strokes were classified by expert review of hospital records, with severity defined by the National Institutes of Health Stroke Scale (NIHSS; minor, ≤5; mild, 6-10; moderate, 11-15; and severe, ≥16).

MAIN OUTCOMES AND MEASURES

Dementia cases adjudicated through expert review of in-person evaluations, informant interviews, telephone assessments, hospitalization codes, and death certificates. In participants with stroke, dementia events in the first year after stroke were not counted.

RESULTS

At baseline, the mean (SD) age of participants was 54.1 (5.8) years, and 8485 of 15 379 participants (55.2%) were women. A total of 4110 participants (26.7%) were Black and 11 269 (73.3%) were White. A total of 1378 ischemic strokes (1155 incident) and 2860 dementia cases were diagnosed 1 year or more after incident stroke in participants with stroke, or at any point after baseline in participants without stroke, were identified through December 31, 2019. NIHSS scores were available for 1184 of 1378 ischemic strokes (85.9%). Risk of dementia increased with both the number and severity of strokes. Compared with no stroke, risk of dementia by adjusted hazard ratio was 1.76 (95% CI, 1.49-2.00) for 1 minor to mild stroke, 3.47 (95% CI, 2.23-5.40) for 1 moderate to severe stroke, 3.48 (95% CI, 2.54-4.76) for 2 or more minor to mild strokes, and 6.68 (95% CI, 3.77-11.83) for 2 or more moderate to severe strokes.

CONCLUSIONS AND RELEVANCE

In this study, risk of dementia significantly increased after ischemic stroke, independent of vascular risk factors. Results suggest a dose-response association of stroke severity and recurrence with risk of dementia.

Efficacy of sequential N-butylphthalide therapy on psychiatric and behavioral functions in acute ischemic stroke

BACKGROUND

Stroke can cause physical and mental problems. This study examined how the sequential therapy of N-butylphthalide (NBP) could effectively improve physical movement, life activities, and psychological disorders in stroke patients.

METHODS

This double-blind, randomized controlled trial included middle-aged or elderly patients with acute ischemic stroke that had commenced within 48 hours before enrolment in the study. The experimental group was administered 100 mL NBP injections twice a day in the first 14 days, and a sequential 200 mg NBP soft capsule 3 times a day for the next 76 days. The control group was administered 100 mL NBP placebo injections twice a day in the first 14 days and 200 mg sequential NBP placebo soft capsule 3 times a day for the next 76 days. Primary outcomes were the National Institutes of Health Stroke Scale, the Barthel Index of activities of daily living, and Modified Rankin Scale which were evaluated at day 0, day 14, and month 1 or at day 14, month 3, and month 6. Secondary outcomes included the Hamilton Anxiety Scale and the Hamilton Depression Scale, all were evaluated on day 0, month 3, and month 6. Moreover, the adverse reaction of NBP or other serious adverse events were evaluated at each time.

RESULTS

Our therapy significantly increased the Barthel Index of activities of daily living scores, decreased the National Institutes of Health Stroke Scale and Modified Rankin Scale scores, and the incidence of the Hamilton Anxiety Scale and the Hamilton Depression Scale of ischemic stroke patients (P < .05).

CONCLUSION

Our results indicated that 90 days' sequential therapy with NBP as an additional therapy in the treatment of ischemic stroke can better improve patients' psychological and behavioral functions without significant side effects.

Long-Term Cognitive Decline After Stroke: An Individual Participant Data Meta-Analysis

BACKGROUND AND PURPOSE

Poststroke cognitive impairment is common, but the trajectory and magnitude of cognitive decline after stroke is unclear. We examined the course and determinants of cognitive change after stroke using individual participant data from the Stroke and Cognition Consortium.

METHODS

Nine longitudinal hospital-based cohorts from 7 countries were included. Neuropsychological test scores and normative data were used to calculate standardized scores for global cognition and 5 cognitive domains. One-step individual participant data meta-analysis was used to examine the rate of change in cognitive function and risk factors for cognitive decline after stroke. Stroke-free controls were included to examine rate differences. Based on the literature and our own data that showed short-term improvement in cognitive function after stroke, key analyses were restricted to the period beginning 1-year poststroke to focus on its long-term effects.

RESULTS

A total of 1488 patients (mean age, 66.3 years; SD, 11.1; 98% ischemic stroke) were followed for a median of 2.68 years (25th-75th percentile: 1.21-4.14 years). After an initial period of improvement through up to 1-year poststroke, decline was seen in global cognition and all domains except executive function after adjusting for age, sex, education, vascular risk factors, and stroke characteristics (-0.053 SD/year [95% CI, -0.073 to -0.033]; P<0.001 for global cognition). Recurrent stroke and older age were associated with faster decline. Decline was significantly faster in patients with stroke compared with controls (difference=-0.078 SD/year [95% CI, -0.11 to -0.045]; P<0.001 for global cognition in a subgroup analysis).

CONCLUSIONS

Patients with stroke experience cognitive decline that is faster than that of stroke-free controls from 1 to 3 years after onset. An increased rate of decline is associated with older age and recurrent stroke.

Structural and Functional Deficits in Patients with Poststroke Dementia: A Multimodal MRI Study

Although many neuroimaging studies have reported structural and functional abnormalities in the brains of patients with cognitive impairments following stroke, little is known about the pattern of such brain reorganization in poststroke dementia (PSD). The present study was aimed at investigating alterations in spontaneous brain activity and gray matter volume (GMV) in PSD patients. We collected T1-weighted and resting-state functional magnetic resonance imaging data from 20 PSD patients, 24 poststroke nondementia (PSND) patients, and 21 well-matched normal controls (NCs). We compared the differences among the groups in GMV and the fractional amplitude of low-frequency fluctuations (fALFF). Then, we evaluated the relationship between these brain measures and cognitive assessments and explored the possible distinguisher for PSD by receiver operating characteristic (ROC) curve analysis. PSD patients showed smaller GMV in the right superior temporal gyrus and lower fALFF values in the right inferior frontal gyrus than both PSND patients and NCs, but such differences were not observed between PSND patients and NCs. Moreover, GMV in the left medial prefrontal cortex showed a significant positive correlation with the Mini-Cog assessment in PSD patients, and GMV in the left CPL displayed the highest area under the ROC curve among all the features for classifying PSD versus PSND patients. Our findings suggest that PSD patients show dementia-specific structural and functional alteration patterns, which may help elucidate the pathophysiological mechanisms underlying PSD.

Current view on post-stroke dementia

Dementia is one of the leading complications after stroke affecting about one third of survivors. Prevalence of post-stroke dementia (PSD) differs between studies due to variability in methodology, characteristics of included patients, type of stroke, diagnostic tools used to identify patients with dementia, or time when the assessment was performed. Patients diagnosed with PSD are at higher risk of mortality, disability, and institutionalization. Aetiology of PSD may include mixed overlapping processes such as vascular brain pathology or Alzheimer's disease. Several risk factors have been found to increase PSD incidence, involving demographics, vascular factors, stroke characteristics, abnormalities on neuroimaging, and stroke complications. However, the influence of some other factors still remains unclear. PSD may coexist with other neuropsychiatric disorders and its association with post-stroke depression seems to be the most significant. There is a strong need for further research on possible genetic, biological, and inflammatory biomarkers. Also, there are no unambiguously efficacious methods of management. Continuing to address these issues will help to find more effective interventions directly targeting prevention and treatment of PSD in the future.

Lack of association between acute stroke, post-stroke dementia, race, and β-amyloid status

INTRODUCTION

Stroke and Alzheimer disease share risk factors and often co-occur, and both have been reported to have a higher prevalence in African Americans as compared to non-Hispanic whites. However, their interaction has not been established. The objective of this study was to determine if preclinical Alzheimer disease is a risk factor for stroke and post-stroke dementia and whether racial differences moderate this relationship.

METHODS

This case-control study was analyzed in 2019 using retrospective data from 2007 to 2013. Participants were adults age 65 and older with and without acute ischemic stroke. Recruitment included word of mouth and referrals in Saint Louis, MO, with stroke participants recruited from acutely hospitalized patients and non-stroke participants from community living older adults who were research volunteers. Our assessment included radiologic reads of infarcts, microbleeds, and white matter hyperintensitites (WMH); a Pittsburgh Compound B PET measure of cortical β-amyloid binding; quantitative measures of hippocampal and WMH volume; longitudinal Mini Mental State Examination (MMSE) scores; and Clinical Dementia Rating (CDR) 1 year post-stroke.

RESULTS

A total of 243 participants were enrolled, 81 of which had a recent ischemic stroke. Participants had a mean age of 75, 57% were women, and 52% were African American. Cortical amyloid did not differ significantly by race, stroke status, or CDR post-stroke. There were racial differences in MMSE scores at baseline (mean 26.8 for African Americans, 27.9 for non-Hispanic whites, p = 0.03), but not longitudinally. African Americans were more likely to have microbleeds (32.8% vs 22.6%, p = 0.04), and within the acute stroke group, African Americans were more likely to have small infarcts (75.6% vs 56.8%, p = 0.049).

CONCLUSION

Preclinical Alzheimer disease did not show evidence of being a risk factor for stroke nor predictive of post-stroke dementia. We did not observe racial differences in β-amyloid levels. However, even after controlling for several vascular risk factors, African Americans with clinical stroke presentations had greater levels of vascular pathology on MRI.

[Poststroke motor and cognitive impairments: clinical features and current approaches to rehabilitation]

Stroke is one of the most common neurological diseases with high morbidity, disability and mortality, which is an urgent medical and social problem. Clinically, stroke, depending on its nature and location, causes a wide range of neurological disorders, including movement disorders, as well as a variety of cognitive and neuropsychiatric disorders. There is an emerging need for new approaches to manage patients with cerebrovascular diseases during the pandemic of COVID-19. Rehabilitation measures for the correction of motor and cognitive impairments are very diverse. The use of drugs stimulating the production of neurotrophic factors is considered as a promising direction of pharmacotherapy. Cerebrolysin promotes significant regression of motor and cognitive impairments in the acute and recovery period of ischemic stroke. Based on the data of clinical studies, Cerebrolysin is included in the guidelines for the rehabilitation of patients with stroke in Canada and Germany.

Potential role of exosome in post-stroke reorganization and/or neurodegeneration

Currently, stroke is a common and devastating condition, which is sometimes associated with permanent cerebral damages. Although in early time after stroke, the related treatments are mainly focused on the restoration of cerebral blood flow (CBF), at the same time, some changes are commencing that continue for a long time and need to be specially noticed. Previous studies have proposed several molecular mechanisms in these post-stroke events. Exosomes are a type of vesicle, which are formed and secreted by most cells as a mean to transfer cellular constituents such as proteins, DNA and/or RNA to distant cells. Therefore, they are considered as a novel mechanism of cellular communication. Herein, we reviewed the current knowledge on cascades, which are activated after stroke and consequently lead to the reorganization and/or continuance of tissue damage and development of other disorders such as Neurodegenerative diseases (ND). Thereafter, we summarized the latest proofs about the possible participation of exosomes in transferring some components such as proteins and micro-RNAs (miRs), from the affected areas to other parts of the brain and eventually cause the above-mentioned post-stroke events.

CHA2DS2-VASc Stroke Risk Index and Executive Functioning in Older Adults

OBJECTIVE

CHA2DS2-VASc is a stroke risk classification system developed to improve the precision of stroke risk classification. The current study examined the validity of CHA2DS2-VASc in a sample of healthy older adults using executive function measures of processing speed, working memory, and cognitive flexibility that are sensitive to cerebrovascular risk factors.

METHODS

Participants included 51 community-dwelling, healthy older adults (ages 53-86) recruited from both the community and cardiology clinics. CHA2DS2-VASc was utilized as a measure of stroke risk. Measures of executive functioning and processing speed included the Paced Auditory Serial Addition Test (PASAT), Delis-Kaplan Executive Function System (DKEFS) Number-Letter Switching, and Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) Coding.

RESULTS

CHA2DS2-VASc scores significantly predicted scores on the PASAT, DKEFS Number-Letter Switching, and RBANS Coding, such that greater stroke risk was associated with poorer performances on tests of executive functioning and processing speed. These relationships were observed over and above the potential influence of educational attainment and symptoms of depression.

CONCLUSION

Significant relations between stroke risk classification and performance on several measures of executive functioning provide support for a wider and more generalized use of CHA2DS2-VASc with healthy older adults. These findings further highlight the importance of early identification and treatment of stroke risk factors associated with cognitive decline. Findings suggest that CHA2DS2-VASc is a practical and useful tool for patients and their providers in the early detection of stroke risk and development of individualized treatment plans.

Assessing the Predictive Validity of Simple Dementia Risk Models in Harmonized Stroke Cohorts

Supplemental Digital Content is available in the text.

Stroke is associated with an increased risk of dementia. To assist in the early identification of individuals at high risk of future dementia, numerous prediction models have been developed for use in the general population. However, it is not known whether such models also provide accurate predictions among stroke patients. Therefore, the aim of this study was to determine whether existing dementia risk prediction models that were developed for use in the general population can also be applied to individuals with a history of stroke to predict poststroke dementia with equivalent predictive validity.

Eligibility, Enrollment, and Completion of Exercise-Based Cardiac Rehabilitation Following Stroke Rehabilitation: What Are the Barriers?

BACKGROUND

People after stroke benefit from comprehensive secondary prevention programs including cardiac rehabilitation (CR), yet there is little understanding of eligibility for exercise and barriers to use.

OBJECTIVE

The aim of this study was to examine eligibility for CR; enrollment, adherence, and completion; and factors affecting use.

DESIGN

This was a prospective study of 116 consecutive people enrolled in a single outpatient stroke rehabilitation (OSR) program located in Toronto, Ontario, Canada.

METHODS

Questionnaires were completed by treating physical therapists for consecutive participants receiving OSR and included reasons for CR ineligibility, reasons for declining participation, demographics, and functional level. CR eligibility criteria included the ability to walk ≥100 m (no time restriction) and the ability to exercise at home independently or with assistance. People with or without hemiplegic gait were eligible for adapted or traditional CR, respectively. Logistic regression analyses were used to examine factors associated with use indicators.

RESULTS

Of 116 participants receiving OSR, 82 (70.7%) were eligible for CR; 2 became eligible later. Sixty (71.4%) enrolled in CR and 49 (81.7%) completed CR, attending 87.1% (SD = 16.6%) of prescribed sessions. The primary reasons for ineligibility included being nonambulatory or having poor ambulation (52.9%; 18/34 patients) and having severe cognitive deficits and no home exercise support (20.6%; 7/34). Frequently cited reasons for declining CR were moving or travel out of country (17.2%; 5/29 reasons), lack of interest (13.8%; 4/29), transportation issues (10.3%; 3/29), and desiring a break from therapy (10.3%; 3/29). In a multivariate analysis, people who declined CR were more likely to be women, have poorer attendance at OSR, and not diabetic. Compared with traditional CR, stroke-adapted CR resulted in superior attendance (66.1% [SD = 22.9%] vs 87.1% [SD = 16.6%], respectively) and completion (66.7% vs 89.7%, respectively). The primary reasons for dropping out were medical (45%) and moving (27%).

LIMITATIONS

Generalizability to other programs is limited, and other, unmeasured factors may have affected outcomes.

CONCLUSIONS

An OSR-CR partnership provided an effective continuum of care, with approximately 75% of eligible people participating and more than 80% completing. However, just over 1 of 4 eligible people declined participation; therefore, strategies should target lack of interest, transportation, women, and people without diabetes. An alternative program model is needed for people who have severe ambulatory or cognitive deficits and no home exercise support.

Serum cystatin C levels are negatively correlated with post-stroke cognitive dysfunction

Stroke is the leading cause of death and long-term disability worldwide, and cognitive impairment and dementia are major complications of ischemic stroke. Cystatin C (CysC) has been found to be a neuroprotective factor in animal studies. However, the relationship between CysC levels and cognitive dysfunction in previous studies has revealed different results. This prospective observational study investigated the correlation between serum CysC levels and post-stroke cognitive dysfunction at 3 months. Data from 638 patients were obtained from the China Antihypertensive Trial in Acute Ischemic Stroke (CATIS). Cognitive dysfunction was assessed using the Mini-Mental State Examination (MMSE) at 3 months after stroke. According to the MMSE score, 308 patients (52.9%) had post-stroke cognitive dysfunction. After adjusting for potential confounding factors, the odds ratio (95% CI) of post-stroke cognitive dysfunction for the highest quartile of serum CysC levels was 0.54 (0.30–0.98), compared with the lowest quartile. The correlation between serum CysC and cognitive dysfunction was modified by renal function status. We observed a negative linear dose-response correlation between CysC and cognitive dysfunction in patients with normal renal function (P_linearity = 0.044), but not in those with abnormal renal function. Elevated serum CysC levels were correlated with a low risk of 3-month cognitive dysfunction in patients with acute ischemic stroke, especially in those with normal renal function. The current results suggest that CysC is a protective factor for post-stroke cognitive dysfunction, and could be used to treat post-stroke cognitive dysfunction. The CATIS study was approved by the Institutional Review Boards at Soochow University from China (approval No. 2012-02) on December 30, 2012, and was registered at ClinicalTrials.gov (identifier No. NCT01840072) on April 25, 2013.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Genetics of cognitive trajectory in Brazilians: 15 years of follow-up from the Bambuí-Epigen Cohort Study of Aging

Age-related cognitive decline (ACD) is the gradual process of decreasing of cognitive function over age. Most genetic risk factors for ACD have been identified in European populations and there are no reports in admixed Latin American individuals. We performed admixture mapping, genome-wide association analysis (GWAS), and fine-mapping to examine genetic factors associated with 15-year cognitive trajectory in 1,407 Brazilian older adults, comprising 14,956 Mini-Mental State Examination measures. Participants were enrolled as part of the Bambuí-Epigen Cohort Study of Aging. Our admixture mapping analysis identified a genomic region (3p24.2) in which increased Native American ancestry was significantly associated with faster ACD. Fine-mapping of this region identified a single nucleotide polymorphism (SNP) rs142380904 (β = -0.044, SE = 0.01, p = 7.5 × 10-5) associated with ACD. In addition, our GWAS identified 24 associated SNPs, most in genes previously reported to influence cognitive function. The top six associated SNPs accounted for 18.5% of the ACD variance in our data. Furthermore, our longitudinal study replicated previous GWAS hits for cognitive decline and Alzheimer's disease. Our 15-year longitudinal study identified both ancestry-specific and cosmopolitan genetic variants associated with ACD in Brazilians, highlighting the need for more trans-ancestry genomic studies, especially in underrepresented ethnic groups.

Pre-Stroke Frailty Is Independently Associated With Post-Stroke Cognition: A Cross-Sectional Study

OBJECTIVE

Post-stroke cognitive impairment is common, but mechanisms and risk factors are poorly understood. Frailty may be an important risk factor for cognitive impairment after stroke. We investigated the association between pre-stroke frailty and acute post-stoke cognition.

METHODS

We studied consecutively admitted acute stroke patients in a single urban teaching hospital during three recruitment waves between May 2016 and December 2017. Cognition was assessed using the Mini-Montreal Cognitive Assessment (min=0; max=12). A Frailty Index was used to generate frailty scores for each patient (min=0; max=100). Clinical and demographic information were collected, including pre-stroke cognition, delirium, and stroke-severity. We conducted univariate and multiple-linear regression analyses with covariates forced in (covariates included were: age, sex, stroke severity, stroke-type, pre-stroke cognitive impairment, delirium, previous stroke/transient ischemic attack) to investigate the association between pre-stroke frailty and post-stroke cognition.

RESULTS

Complete data were available for 154 stroke patients. Mean age was 68 years (SD=11; range=32-97); 93 (60%) were male. Median mini-Montreal Cognitive Assessment score was 8 (IQR=4-12). Mean Frailty Index score was 18 (SD=11). Pre-stroke cognitive impairment was apparent in 13/154 (8%) patients. Pre-stroke frailty was significantly associated with lower post-stroke cognition (Standardized-Beta=-0.40; p&lt;0.001) and this association was independent of covariates (Unstandardized-Beta=-0.05; p=0.005). Additional significant variables in the multiple regression model were age (Unstandardized-Beta=-0.05; p=0.002), delirium (Unstandardized-Beta=-2.81; p&lt;0.001), pre-stroke cognitive impairment (Unstandardized-Beta=-2.28; p=0.001), and stroke-severity (Unstandardized-Beta=-0.20; p&lt;0.001).

CONCLUSIONS

Pre-stroke frailty may be a moderator of post-stroke cognition, independent of other well-established post-stroke cognitive impairment risk factors. (JINS, 2019, 25, 501-506).

Vinpocetine in the treatment of poststroke cognitive dysfunction: A protocol for systematic review and meta-analysis

BACKGROUND

Previous clinical trials have reported that vinpocetine can be used for the treatment of cognitive dysfunction. However, its efficacy is still inconclusive. In this systematic review study, we aim to assess its efficacy and safety for the treatment of poststroke cognitive dysfunction (PSCD).

METHODS

We will search the following electronic databases from the inception to the present to evaluate the efficacy and safety of vinpocetine for patients with PSCD. These databases include CENTRAL, EMBASE, MEDILINE, CINAHL, AMED, and four Chinese databases. All randomized controlled trials (RCTs) of vinpocetine for PSCD will be considered for inclusion without the language restrictions. The methodological quality of all included RCTs will be evaluated by the Cochrane risk of bias tool. The 95% confidence intervals will be utilized to calculate the continuous data, the mean difference or standard mean difference, and dichotomous data with risk ratio.

DISSEMINATION AND ETHICS

The results of this review will be disseminated through peer-reviewed journals. Its results may provide important evidence for the clinical practice, as well as the future studies. It does not require ethical approval, because this systematic review will not involve the individual data.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018115224.

Deep Brain Stimulation Rescues Memory and Synaptic Activity in a Rat Model of Global Ischemia

Deep brain stimulation (DBS) is remarkably effective in treating Parkinson's disease and is currently under investigation for the treatment of neuropsychiatric disorders including Alzheimer's disease. Until now, DBS has not been examined for its cognitive benefits in the context of hypoxic-ischemic injuries. Here, we investigated the effect of DBS in a rat model of global ischemia (GI) that mimics the neurological consequences occurring after a cardiac arrest. We show that DBS rescues memory deficits induced by GI and produces changes in synaptic activity in the hippocampus. Novel approaches to improve neurological outcomes after stroke are urgently needed; therefore, the present study highlights a possible role for DBS in the treatment of cognitive impairment associated with ischemia.

Progressive treadmill cognitive dual-task gait training on the gait ability in patients with chronic stroke

The purpose of this study was to investigate the effects of progressive treadmill cognitive dual-task training on gait performance in individuals with chronic stroke patients. Twenty-six participants with chronic hemiparesis were recruited to this study and randomly distributed into two groups: progressive treadmill cognitive dual-task gait training (PTCDG group, 13 patients), conventional treadmill gait training (CTG group, 13 patients). All patients underwent 20 sessions of treadmill gait training with a harness (5 times per week, for a total of 4 weeks). The GAITRite was used to analyze gait kinematics, and 10-m walking test (10MWT) wear used as the clinical evaluation indicators. After training, PTCDG group showed significant improvement in gait velocity, cadence, single support time, and 10MWT compared to the control group. However there was no significant difference between the groups in the stride lengths in the affected and unaffected sides. The study verified that progressive treadmill cognitive dual-task gait training had a positive influence on the gait and clinical gait index in chronic stroke patients.

Clinical observation of 60 cases of treating cognitive disorder after cerebral injury in combination with scalp acupuncture and cognitive training

To observe the clinical effect of scalp acupuncture combined with cognitive training on cognitive disorder after cerebral injury.Around 60 cases of cerebral injury patients for hospitalization in rehabilitation department of Chongqing Three Gorges Central Hospital from July in 2015 to June in 2017 are divided into control group and treatment group of 30 cases for each at random. The control group received routine treatment and cognitive rehabilitation training for 12 weeks. The treatment group received conventional treatment, cognitive rehabilitation training, and scalp acupuncture. Acupuncture with a scalp acupuncture is provided for the treatment group besides adopting above conventional treatment and rehabilitation training method.Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) score of both groups increases obviously after treatment compared with that before treatment, and there is difference (P < .01) through contrast. And LOTCA score of treatment group is higher than that of control group (P < .05) after treatment.Scalp acupuncture in combination with cognitive training can effectively improve cognitive disorder degree of patients with cerebral injury, and the effect is more significant compared with simple cognitive rehabilitation training, thus it is worth of research and application.

Infarct topography and functional outcomes

Acute ischemic stroke represents a major cause of long-term adult disability. Accurate prognostication of post-stroke functional outcomes is invaluable in guiding patient care, targeting early rehabilitation efforts, selecting patients for clinical research, and conveying realistic expectations to families. The involvement of specific brain regions by acute ischemia can alter post-stroke recovery potential. Understanding the influences of infarct topography on neurologic outcomes holds significant promise in prognosis of functional recovery. In this review, we discuss the recent evidence of the contribution of infarct location to patient management decisions and functional outcomes after acute ischemic stroke.

Effects of cognitive-motor dual-task training combined with auditory motor synchronization training on cognitive functioning in individuals with chronic stroke: A pilot randomized controlled trial

BACKGROUND

Preservation and enhancement of cognitive function are essential for the restoration of functional abilities and independence following stroke. While cognitive-motor dual-task training (CMDT) has been utilized in rehabilitation settings, many patients with stroke experience impairments in cognitive function that can interfere with dual-task performance. In the present study, we investigated the effects of CMDT combined with auditory motor synchronization training (AMST) utilizing rhythmic cues on cognitive function in patients with stroke.

METHODS

The present randomized controlled trial was conducted at a single rehabilitation hospital. Thirty patients with chronic stroke were randomly divided an experimental group (n = 15) and a control group (n = 15). The experimental group received 3 CMDT + AMST sessions per week for 6 weeks, whereas the control group received CMDT only 3 times per week for 6 weeks. Changes in cognitive function were evaluated using the trail making test (TMT), digit span test (DST), and stroop test (ST).

RESULTS

Significant differences in TMT-A and B (P = .001, P = .001), DST-forward (P = .001, P = .001), DST-backward (P = .000, P = .001), ST-word (P = .001, P = .001), and ST-color (P = .002, P = .001) scores were observed in both the control and experimental groups, respectively. Significant differences in TMT-A (P = .001), DST-forward (P = .027), DST-backward (P = .002), and ST-word (P = .025) scores were observed between the 2 groups. Performance speed on the TMT-A was faster in the CMDT + AMST group than in the CMDT group. Moreover, DST-forward and DST-backward scores were higher in the CMDT + AMST group than in the CDMT group. Although ST-color results were similar in the 2 groups, ST-word scores were higher in the CMDT + AMST group than in the CMDT group.

CONCLUSION

This finding indicates that the combined therapy CMDT and AMST can be used to increase attention, memory, and executive function for people with stroke.

Factors predicting community participation in patients living with stroke, in the Western Cape, South Africa

Purpose: An important focus of poststroke rehabilitation is the attainment of community participation. However, several factors may influence participation some of which vary from setting to setting. The aim of this study is to investigate the factors influencing community participation among community-dwelling stroke survivors in the Western Cape, South Africa. Materials and methods: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) and the Social Support Questionnaire 6 (SSQ6) were the instruments used to collect data. Participant demographics, clinical features and domain-specific scores of the WHODAS 2.0 were used as potential predictors. Correlation analysis and multiple regression models were used to examine determinants of community participation. All assessments were conducted using face-to-face interviews. Results: One hundred and six stroke survivors enrolled in this cross-sectional study. Risk factors, cognition, mobility, self-care, getting along with people, household activities and total WHODAS 2.0 score were associated with participation. Four predictors of community participation were identified from multiple regression, namely mobility (38%), cognition (11%), life activities (4%) and stroke risk factors (1%). Determinants varied by gender and age group. Mobility predominated in males and younger adults, while cognition was more pronounced in females and the elderly. Lastly, the influence of social support on community participation was largely defined by the gender and age of stroke survivors. Conclusion: The findings suggest focusing stroke rehabilitation on important factors such as mobility, cognition, life activities and risk factors to advance patients' participation. It also emphasizes giving specific consideration to key factors specific for gender and age of stroke survivors. Implications for Rehabilitation Community participation in the general population of stroke survivors' is largely determined by their mobility function. Determinants of community participation among stroke survivors essentially vary according to age and gender. Clinically, this study suggests that focusing on specific determinants of improved community participation according to stroke patients' demographic categories (gender and age) may be an important impetus to enhance rehabilitation outcome.

Can Better Management of Periodontal Disease Delay the Onset and Progression of Alzheimer's Disease?

A risk factor relationship exists between periodontal disease and Alzheimer's disease (AD) via tooth loss, and improved memory following dental intervention. This links the microbial contribution from indigenous oral periodontal pathogens to the manifestation of chronic conditions, such as AD. Here, we use Porphyromonas gingivalis infection to illustrate its effect on mental health. P. gingivalis infection, in its primary sub-gingival niche, can cause polymicrobial synergy and dysbiosis. Dysbiosis describes the residency of select commensals from the oral cavity following co-aggregation around the dominant keystone pathogen, such as P. gingivalis, to gain greater virulence. The initial process involves P. gingivalis disturbing neutrophil mediated innate immune responses in the healthy gingivae and then downregulating adaptive immune cell differentiation and development to invade, and subsequently, establish new dysbiotic bacterial communities. Immune responses affect the host in general and functionally via dietary adjustments caused by tooth loss. Studies from animals orally infected with P. gingivalis confirm this bacterium can transmigrate to distant organ sites (the brain) and contribute toward peripheral and intracerebral inflammation, and compromise vascular and microvascular integrity. In another study, P. gingivalis infection caused sleep pattern disturbances by altering glial cell light/dark molecular clock activity, and this, in turn, can affect the clearance of danger associated molecular patterns, such as amyloid-β, via the glymphatic system. Since P. gingivalis can transmigrate to the brain and modulate organ-specific inflammatory innate and adaptive immune responses, this paper explores whether better management of indigenous periodontal bacteria could delay/prevent the onset and/or progression of dementia.

Prediabetes is associated with post-stroke cognitive impairment in ischaemic stroke patients

AIM

Diabetes mellitus is associated with post-stroke cognitive impairment. To the best of our knowledge, no study has explored the relationship between prediabetes and post-stroke cognitive impairment. The purpose of this study is to explore the association between prediabetes and cognitive impairment in ischaemic stroke patients at 1 month.

METHODS

Two hundred one acute ischaemic stroke patients were consecutively recruited within the first 24 h after admission and were followed up for 1 month. Patients were divided into a diabetes mellitus group, prediabetes group and non-diabetes mellitus group by fasting glucose levels, 2-h postprandial blood glucose levels and glycosylated haemoglobin levels at admission. Cognitive function was evaluated by the Mini-Mental State Examination at 1 month after stroke.

RESULTS

The prediabetes group had a higher risk of post-stroke cognitive impairment than the non-diabetes group (35.7% vs. 18.1%, χ² = 4.252, P = .039). In logistical analyses, prediabetes was associated with post-stroke cognitive impairment after adjusting for potential confounding factors (odds ratio 3.062, 95% confidence interval 1.130-8.299, P = .028).

CONCLUSIONS

Our findings show that prediabetes is associated with post-stroke cognitive impairment and may predict its development at 1 month post-stroke.

A Clinical Research Study of Cognitive Dysfunction and Affective Impairment after Isolated Brainstem Stroke

Although the function of the cerebellum in neurocognition has been well-documented, the similar role of the brainstem has yet to be fully elucidated. This clinical research study aimed to combine data relating to neuropsychological assessments and P300 to explore cognitive dysfunction and affective impairment following brainstem stroke. Thirty-four patients with isolated brainstem stroke and twenty-six healthy controls were recruited; for each patient, we collated data pertaining to the P300, Addenbrooke's Cognitive Examination III (ACE-III), Montreal Cognitive Assessment Chinese version (MoCA), trail-making test (TMT), Symbol Digit Modalities Test (SDMT), Wechsler Adult Intelligence Scale-Digit Spans (DS), Stroop test, Self Rating Depression Scale (SDS), and Self Rating Anxiety Scale (SAS). Significance was analyzed using an independent T-test or the Mann-Whitney U-test. Correlation was analyzed using Pearson's correlation analysis or Spearman's correlation analysis. Collectively, data revealed that brainstem stroke caused mild cognitive impairment (MCI), and that visuospatial, attention, linguistic, and emotional disturbances may occur after isolated brainstem stroke. Cognitive decline was linked to P300 latency, ACE-III, and MoCA; P300 latency was correlated with ACE-III. Patients with right brainstem lesions were more likely to suffer memory decline. The present study provides initial data relating to the role of the brainstem in neurocognition, and will be useful for further understanding of vascular cognitive and affective impairment.

Ginkgo biloba extract improved cognitive and neurological functions of acute ischaemic stroke: a randomised controlled trial

Purpose

To evaluate the efficacy and safety of Ginkgo biloba extract (GBE) in acute ischaemic stroke and its impact on the recurrence of vascular events.

Methods

We conducted a multicentre, prospective, randomised, open label, blinded, controlled clinical trial enrollingpatients with an onset of acute stroke within 7 days from five hospitals in China Jiangsu Province. Participants were assigned to the GBE group (450 mg GBE with 100 mg aspirin daily) or the control group (100 mg aspirin daily) for 6 months. The primary outcome was the decline in the Montreal Cognitive Assessment score at 6 months. Secondary outcomes were other neuropsychological tests of cognitive and neurological function, the the incidence of adverse events and vascular events.

Results

348 patients were enrolled: 179 in the GBE group and 169 in the control group. With 18 patients lost to follow-up, the dropout rate was 5.17%. Admission data between two groups were similar, but in the GBE group there was a marked slow down in the decline in the Montreal Cognitive Assessment scores (-2.77±0.21 vs -1.99±0.23, P=0.0116 (30 days); -3.34±0.24 vs -2.48±0.26, P=0.0165 (90 days); -4.00±0.26 vs -2.71±0.26, P=0.0004 (180 days)) compared with controls. The National Institutes of Health Stroke Scale scores at 12 and 30 days, the modified Rankin Scale scores for independent rate at 30, 90 and 180 days, and the Barthel Index scores at 30, 90 and 180 days in the GBE group were significantly improved compared with controls. Improvements were also observedin GBE groups for Mini-Metal State Examination scores of 30, 90 and 180 days, Webster's digit symbol test scores at 30 days and Executive Dysfunction Index scores at 30 and 180 days. No significant differences were seen in the incidence of adverse events or vascular events.

Conclusions

We conclude that GBE in combination with aspirin treatment alleviated cognitive and neurological deficits after acute ischaemic stroke without increasing the incidence of vascular events.

Trial registration number

ChiCTR-TRC-12002688.

Early Cognitive Impairment after Intracerebral Hemorrhage in the INTERACT1 Study

Background: Data on cognitive impairment after acute intracerebral hemorrhage (ICH) are limited. This study is aimed at determining the frequency and predictors of cognitive impairment among participants of the pilot phase, Intensive Blood Pressure (BP) Reduction in Acute Cerebral Hemorrhage Trial (INTERACT1). Methods: INTERACT1 was an open randomized trial of early intensive (target systolic BP <140 mm Hg) compared with contemporaneous guideline-recommended BP lowering in 404 patients with elevated systolic BP (150–220 mm Hg) within 6 h of ICH onset. Cognitive impairment was defined by scores ≤24 on the Mini-Mental State Examination (MMSE) assessed by interview on follow-up at 90 days. Results: A total of 231 (64.5%) of 358 90-day survivors had MMSE scores for analyses, and 75 (32.5%) had cognitive impairment. In multivariable analysis, older age (OR 2.48, 95% CI 1.73–3.56 per 10-year increase; p < 0.001), female sex (OR 2.06, 95% CI 1.00–4.23; p = 0.049), prior ICH (OR 2.87, 95% CI 1.08–7.65; p = 0.035), high baseline National Institute of Health Stroke Scale score (OR 1.06, 95% CI 1.00–1.13; p = 0.044), and high mean systolic BP over the first 24 h post-randomization (OR 1.34, 95% CI 1.07–1.68/10 mm Hg increase; p = 0.011) were independently associated with cognitive impairment. Conclusions: One third of patients have significant cognitive impairment early after ICH, which is more frequent in the elderly, females, those with prior ICH, and more severe initial neurological deficit and with persistently high early systolic BP.

Cognitive Function and Prognosis of Multimodal Neuroimage-Guided Thrombectomy on Mild to Moderate Anterior Circulation Infarction Patients with Broadened Therapeutic Window: A Prospective Study

BACKGROUND AND OBJECTIVES

Endovascular mechanical thrombectomy is an important approach for acute ischemic stroke (AIS) treatment. Multimodal neuroimaging methods ideally provide the exact localization, extent, and metabolic activity of target tissues. Post-stroke cognitive impairment has recently been realized to be another major concern except for neurological function impairment. The aim of our study was to carry out a prospective study to compare neurological and cognitive functions after thrombectomy in mild to moderate anterior circulation infarction patients selected by multimodal neuroimaging.

METHODS

Ninety patients were recruited from January 2016 to March 2017 consecutively. Neurological function was assessed by NIHSS before thrombectomy, and 6 h, 24 h, 7 days, 90 days after mechanical thrombectomy. Cognitive functions were evaluated by Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA) and Hachinski Ischemic Scale.

RESULTS

Patients who received mechanical thrombectomy had significantly better neurological functions at 6 h (p < 0.001), 24 h (p < 0.001), 7 days (p < 0.001), and 90 days (p < 0.001), as well as cognitive functions evaluated by MoCA (26.23 ± 3.85 vs. 24.62 ± 2.25, p = 0.022, n = 85) and MMSE (26.65 ± 2.77 vs. 25.10 ± 2.36, p = 0.023, n = 85) compared to the standard therapy group.

CONCLUSIONS

The current prospective study demonstrated that mechanical thrombectomy can significantly improve neurological and cognitive functions in patients with mild to moderate AIS at broadened therapeutic window under multimodal CT and multimodal MRI imaging.

Racial Differences in Neurocognitive Outcomes Post-Stroke: The Impact of Healthcare Variables

OBJECTIVES

The present study examined differences in neurocognitive outcomes among non-Hispanic Black and White stroke survivors using the NIH Toolbox-Cognition Battery (NIHTB-CB), and investigated the roles of healthcare variables in explaining racial differences in neurocognitive outcomes post-stroke.

METHODS

One-hundred seventy adults (91 Black; 79 White), who participated in a multisite study were included (age: M=56.4; SD=12.6; education: M=13.7; SD=2.5; 50% male; years post-stroke: 1-18; stroke type: 72% ischemic, 28% hemorrhagic). Neurocognitive function was assessed with the NIHTB-CB, using demographically corrected norms. Participants completed measures of socio-demographic characteristics, health literacy, and healthcare use and access. Stroke severity was assessed with the Modified Rankin Scale.

RESULTS

An independent samples t test indicated Blacks showed more neurocognitive impairment (NIHTB-CB Fluid Composite T-score: M=37.63; SD=11.67) than Whites (Fluid T-score: M=42.59, SD=11.54; p=.006). This difference remained significant after adjusting for reading level (NIHTB-CB Oral Reading), and when stratified by stroke severity. Blacks also scored lower on health literacy, reported differences in insurance type, and reported decreased confidence in the doctors treating them. Multivariable models adjusting for reading level and injury severity showed that health literacy and insurance type were statistically significant predictors of the Fluid cognitive composite (p<.001 and p=.02, respectively) and significantly mediated racial differences on neurocognitive impairment.

CONCLUSIONS

We replicated prior work showing that Blacks are at increased risk for poorer neurocognitive outcomes post-stroke than Whites. Health literacy and insurance type might be important modifiable factors influencing these differences. (JINS, 2017, 23, 640-652).

Structural MRI markers of brain aging early after ischemic stroke

Objective:

To examine associations between ischemic stroke, vascular risk factors, and MRI markers of brain aging.

Methods:

Eighty-one patients (mean age 67.5 ± 13.1 years, 31 left-sided, 61 men) with confirmed first-ever (n = 66) or recurrent (n = 15) ischemic stroke underwent 3T MRI scanning within 6 weeks of symptom onset (mean 26 ± 9 days). Age-matched controls (n = 40) completed identical testing. Multivariate regression analyses examined associations between group membership and MRI markers of brain aging (cortical thickness, total brain volume, white matter hyperintensity [WMH] volume, hippocampal volume), normalized against intracranial volume, and the effects of vascular risk factors on these relationships.

Results:

First-ever stroke was associated with smaller hippocampal volume (p = 0.025) and greater WMH volume (p = 0.004) relative to controls. Recurrent stroke was in turn associated with smaller hippocampal volume relative to both first-ever stroke (p = 0.017) and controls (p = 0.001). These associations remained significant after adjustment for age, sex, education, and, in stroke patients, infarct volume. Total brain volume was not significantly smaller in first-ever stroke patients than in controls (p = 0.056), but the association became significant after further adjustment for atrial fibrillation (p = 0.036). Cortical thickness and brain volumes did not differ as a function of stroke type, infarct volume, or etiology.

Conclusions:

Brain structure is likely to be compromised before ischemic stroke by vascular risk factors. Smaller hippocampal and total brain volumes and increased WMH load represent proxies for underlying vascular brain injury.

Factors associated with improvement or decline in cognitive function after an ischemic stroke in Korea: the Korean stroke cohort for functioning and rehabilitation (KOSCO) study

BACKGROUND

We conducted a prospective cohort study to investigate prevalence of poststroke cognitive impairment at 3 and 12 months after stroke onset and identify clinical and demographic factors associated with improvement or decline in cognitive function between 3 months and 12 months.

METHODS

We analyzed the cognitive assessments of total patients and patients older than 65 years separately. All patients with an ischemic stroke were divided into normal cognitive group (NCG) and impaired cognition group (ICG) by using a cutoff score on the Korean Mini-Mental State Examination (K-MMSE). Patients were additionally classified into 3 subgroups according to the changes in their K-MMSE scores between 3 and 12 months: Stable group with K-MMSE scores changes ranging from -2 to +2 points (-2 ≤ △MMSE ≤ +2); converter group with increase more than 3 points (3 ≤ △MMSE); and reverter group with decrease more than 3 points (-3 ≤ △MMSE). We also analyzed factors affecting cognitive change from 3 months to 12 months among the 3 groups including baseline medical record, stroke and treatment characteristics, and various functional assessments after 3 months.

RESULTS

This study included 2,625 patients with the first time ischemic stroke. Among these patients, 1,735 (66.1%) were classified as NCG, while 890 patients (33.9%) were belonged to the ICG at 3 month. Within the NCG, 1,460 patients (82.4%) were stable group, 93 patients (5.4%) were converter group, and 212 patients (12.2%) were reverter group at 12 months onset. Within the ICG group, 472 patients (53.0%) were stable group, 321 patients (36.1%) were converter group, and 97 patients (10.9%) were reverter group. When different factors were investigated, the three subgroups in NCG and ICG showed significant different factors affecting cognitive function from 3 to 12 month.

CONCLUSIONS

The prevalence of cognitive impairment showed difference between 3,12 months. To analyze the cognitive change from 3 month to 12 month, the proportion stable group was dominant in NCG and converter group was higher in ICG. By investigating the influencing factors from each group, we were able to identify the predictors including the age factor.