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Overman MJ, Binns E, Milosevich ET, Demeyere N. Recovery of Visuospatial Neglect With Standard Treatment: A Systematic Review and Meta-Analysis. Stroke 2024; 55:2325-2339. [PMID: 39016005 PMCID: PMC11346719 DOI: 10.1161/strokeaha.124.046760] [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: 02/02/2024] [Revised: 06/05/2024] [Accepted: 06/21/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND Visuospatial neglect is a common consequence of stroke and is characterized by impaired attention to contralesional space. Currently, the extent and time course of recovery from neglect are not clearly established. This systematic review and meta-analysis aimed to determine the recovery trajectory of poststroke neglect with standard treatment. METHODS PsycInfo, Embase, and MEDLINE were searched for articles reporting recovery rates of neglect after stroke. Time since stroke was categorized into early (0-3 months), mid (3-6 months), and late (>6 months) recovery phases. Random-effects models for pooled prevalence were generated for each phase, and potential sources of heterogeneity were explored with metaregressions. Methodological quality of each study was assessed using the Joanna Briggs Institute checklist, with low-quality studies excluded in sensitivity analyses. RESULTS The search captured 4130 articles including duplicates, and 111 full-text reviews were undertaken. A total of 27 studies reporting data from 839 stroke survivors with neglect were included for review. Meta-analyses indicated a recovery rate of 42% in the early phase, which increased to 53% in the mid-recovery phase. Additional recovery in the late phase was minimal, with an estimated 56% recovery rate. Heterogeneity of studies was high (I2>75%) in all 3 phases of recovery. Estimates were robust to sensitivity analyses. Metaregressions showed significantly greater recovery in studies that included patients with left-hemisphere lesions (β=0.275, P<0.05, I2=84%). CONCLUSIONS Most recovery from neglect occurs in the first 3 months, although additional gains can be expected up to 6 months poststroke. While a large proportion of patients recover from neglect, over 40% show persistent symptoms. Further research is needed on effective rehabilitation interventions, particularly focusing on patients most at risk of chronic visuospatial neglect. REGISTRATION URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42023388763.
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Affiliation(s)
- Margot Juliëtte Overman
- Department of Experimental Psychology (M.J.O., E.B., E.T.M.), University of Oxford, United Kingdom
| | - Elena Binns
- Department of Experimental Psychology (M.J.O., E.B., E.T.M.), University of Oxford, United Kingdom
| | - Elise T. Milosevich
- Department of Experimental Psychology (M.J.O., E.B., E.T.M.), University of Oxford, United Kingdom
| | - Nele Demeyere
- Nuffield Department of Clinical Neurosciences (N.D.), University of Oxford, United Kingdom
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2
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Sloane KL, Hamilton RH. Transcranial Direct Current Stimulation to Ameliorate Post-Stroke Cognitive Impairment. Brain Sci 2024; 14:614. [PMID: 38928614 PMCID: PMC11202055 DOI: 10.3390/brainsci14060614] [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: 04/22/2024] [Revised: 06/04/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
Post-stroke cognitive impairment is a common and disabling condition with few effective therapeutic options. After stroke, neural reorganization and other neuroplastic processes occur in response to ischemic injury, which can result in clinical improvement through spontaneous recovery. Neuromodulation through transcranial direct current stimulation (tDCS) is a promising intervention to augment underlying neuroplasticity in order to improve cognitive function. This form of neuromodulation leverages mechanisms of neuroplasticity post-stroke to optimize neural reorganization and improve function. In this review, we summarize the current state of cognitive neurorehabilitation post-stroke, the practical features of tDCS, its uses in stroke-related cognitive impairment across cognitive domains, and special considerations for the use of tDCS in the post-stroke patient population.
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Affiliation(s)
- Kelly L. Sloane
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Roy H. Hamilton
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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3
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Schellekens MMI, Springer RCS, Boot EM, Verhoeven JI, Ekker MS, van Alebeek ME, Brouwers PJAM, Arntz RM, van Dijk GW, Gons RAR, van Uden IWM, den Heijer T, van Tuijl JH, de Laat KF, van Norden AGW, Vermeer SE, van Zagten MSG, Van Oostenbrugge RJ, Wermer MJH, Nederkoorn PJ, van Rooij FG, van den Wijngaard IR, de Kort PLM, De Leeuw FE, Kessels RPC, Tuladhar AM. Cognitive trajectory in the first year after first-ever ischaemic stroke in young adults: the ODYSSEY study. J Neurol Neurosurg Psychiatry 2024; 95:571-579. [PMID: 38160045 PMCID: PMC11103341 DOI: 10.1136/jnnp-2023-332104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 12/07/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Limited data exists on cognitive recovery in young stroke patients. We aimed to investigate the longitudinal course of cognitive performance during the first year after stroke at young age and identify predictors for cognitive recovery. METHODS We conducted a multicentre prospective cohort study between 2013 and 2021, enrolling patients aged 18-49 years with first-ever ischaemic stroke. Cognitive assessments were performed within 6 months and after 1 year following the index event, covering seven cognitive domains. Composite Z-scores using normative data determined cognitive impairment (Z-score<-1.5). A Reliable Change Index (RCI) assessed cognitive recovery (RCI>1.96) or decline (RCI<-1.96). RESULTS 393 patients (median age 44.3 years, IQR 38.4-47.2) completed cognitive assessments with a median time interval of 403 days (IQR 364-474) between assessments. Based on RCI, a similar proportion of patients showed improvement and decline in each cognitive domain, while the majority exhibited no cognitive change. Among cognitively impaired patients at baseline, improvements were observed in processing speed (23.1%), visuoconstruction (40.1%) and executive functioning (20.0%). Younger age was associated with better cognitive recovery in visuoconstruction, and larger lesion volume was related to cognitive recovery in processing speed. No other predictors for cognitive recovery were identified. CONCLUSIONS Cognitive impairment remains prevalent in young stroke even 1 year after the event. Most patients showed no cognitive change, however, recovery may have occurred in the early weeks after stroke, which was not assessed in our study. Among initially cognitively impaired patients, cognitive recovery is observed in processing speed, visuoconstruction and executive functioning. It is still not possible to predict cognitive recovery in individual patients.
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Affiliation(s)
- Mijntje M I Schellekens
- Neurology, Radboudumc, Nijmegen, The Netherlands
- Radboud University Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
| | | | - Esther M Boot
- Neurology, Radboudumc, Nijmegen, The Netherlands
- Radboud University Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
| | - Jamie I Verhoeven
- Neurology, Radboudumc, Nijmegen, The Netherlands
- Radboud University Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
| | - Merel S Ekker
- Neurology, Radboudumc, Nijmegen, The Netherlands
- Radboud University Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
| | | | | | - Renate M Arntz
- Neurology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Gert W van Dijk
- Neurology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Rob A R Gons
- Neurology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Tom den Heijer
- Neurology, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | | | | | | | | | | | - Robert J Van Oostenbrugge
- Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands
- University Maastricht School for Mental Health and Neuroscience, Maastricht, The Netherlands
| | - Marieke J H Wermer
- Neurology, Leiden University Medical Centre, Leiden, The Netherlands
- Neurology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Paul J Nederkoorn
- Neurology, Amsterdam University Medical Centre, location AMC, Amsterdam, The Netherlands
| | | | | | - Paul L M de Kort
- Neurology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Frank-Erik De Leeuw
- Neurology, Radboudumc, Nijmegen, The Netherlands
- Radboud University Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
| | - Roy P C Kessels
- Radboud University Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
- Vincent Van Gogh Instituut for Psychiatry, Venray, The Netherlands
- Department of Medical Psychology and Radboudumc Alzheimer Center, Radboudumc, Nijmegen, The Netherlands
| | - Anil M Tuladhar
- Neurology, Radboudumc, Nijmegen, The Netherlands
- Radboud University Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
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Guo X, Phan C, Batarseh S, Wei M, Dye J. Risk factors and predictive markers of post-stroke cognitive decline-A mini review. Front Aging Neurosci 2024; 16:1359792. [PMID: 38414631 PMCID: PMC10896992 DOI: 10.3389/fnagi.2024.1359792] [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: 12/22/2023] [Accepted: 01/22/2024] [Indexed: 02/29/2024] Open
Abstract
Stroke is one of the top causes of death and disability worldwide. Cognitive impairments are found in more than 70% of individuals who have survived a stroke. Cognitive decline is a major contributor to disability, dependency, and morbidity. The prevalence and severity of dementia vary depending on different characteristics of the stroke and other clinical risk factors. Here we discuss the effects of stroke territory, patients' age, sex, cerebral blood flow, acute reperfusion therapy, and cognitive reserve of post-stroke cognitive decline. Potential predictive molecular and genetic biomarkers of post-stroke cognitive impairments are also discussed.
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Affiliation(s)
- Xiaofan Guo
- Department of Neurology, Loma Linda University, Loma Linda, CA, United States
| | - Cattien Phan
- Department of Neurology, Loma Linda University, Loma Linda, CA, United States
| | - Sanad Batarseh
- Department of Neurology, Loma Linda University, Loma Linda, CA, United States
| | - Miao Wei
- Department of Neurology, Loma Linda University, Loma Linda, CA, United States
| | - Justin Dye
- Department of Neurosurgery, Loma Linda University, Loma Linda, CA, United States
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Stulberg EL, Sachdev PS, Murray AM, Cramer SC, Sorond FA, Lakshminarayan K, Sabayan B. Post-Stroke Brain Health Monitoring and Optimization: A Narrative Review. J Clin Med 2023; 12:7413. [PMID: 38068464 PMCID: PMC10706919 DOI: 10.3390/jcm12237413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/10/2023] [Accepted: 11/21/2023] [Indexed: 01/22/2024] Open
Abstract
Significant advancements have been made in recent years in the acute treatment and secondary prevention of stroke. However, a large proportion of stroke survivors will go on to have enduring physical, cognitive, and psychological disabilities from suboptimal post-stroke brain health. Impaired brain health following stroke thus warrants increased attention from clinicians and researchers alike. In this narrative review based on an open timeframe search of the PubMed, Scopus, and Web of Science databases, we define post-stroke brain health and appraise the body of research focused on modifiable vascular, lifestyle, and psychosocial factors for optimizing post-stroke brain health. In addition, we make clinical recommendations for the monitoring and management of post-stroke brain health at major post-stroke transition points centered on four key intertwined domains: cognition, psychosocial health, physical functioning, and global vascular health. Finally, we discuss potential future work in the field of post-stroke brain health, including the use of remote monitoring and interventions, neuromodulation, multi-morbidity interventions, enriched environments, and the need to address inequities in post-stroke brain health. As post-stroke brain health is a relatively new, rapidly evolving, and broad clinical and research field, this narrative review aims to identify and summarize the evidence base to help clinicians and researchers tailor their own approach to integrating post-stroke brain health into their practices.
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Affiliation(s)
- Eric L. Stulberg
- Department of Neurology, University of Utah, Salt Lake City, UT 84112, USA;
| | - Perminder S. Sachdev
- Centre for Healthy Brain Ageing (CHeBA), University of New South Wales, Sydney, NSW 2052, Australia;
- Neuropsychiatric Institute, Prince of Wales Hospital, Sydney, NSW 2031, Australia
| | - Anne M. Murray
- Berman Center for Outcomes and Clinical Research, Minneapolis, MN 55415, USA;
- Department of Medicine, Geriatrics Division, Hennepin Healthcare Research Institute, Minneapolis, MN 55404, USA
| | - Steven C. Cramer
- Department of Neurology, University of California Los Angeles, Los Angeles, CA 90095, USA;
- California Rehabilitation Institute, Los Angeles, CA 90067, USA
| | - Farzaneh A. Sorond
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Kamakshi Lakshminarayan
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Behnam Sabayan
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA;
- Department of Neurology, Hennepin Healthcare Research Institute, Minneapolis, MN 55404, USA
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6
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Berger N, Brunner A, Wünsch G, Nistl O, Pinter D, Fandler-Höfler S, Haidegger M, Pichler A, Hatab I, Mokry M, Wolfsberger S, Enzinger C, Gattringer T, Kneihsl M. Long-term outcome after decompressive hemicraniectomy for malignant middle cerebral artery infarction. J Neurol 2023:10.1007/s00415-023-11679-1. [PMID: 37004558 PMCID: PMC10066964 DOI: 10.1007/s00415-023-11679-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/15/2023] [Accepted: 03/18/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Although decompressive hemicraniectomy (DHC) is a lifesaving treatment strategy for patients with malignant middle cerebral artery infarction (mMCAi), only one in four patients achieves low to moderate post-stroke disability according to previous studies. However, the short follow-up periods in prior studies could have overestimated the poor clinical prognosis. This study therefore examined the long-term outcome after DHC for mMCAi. METHODS We retrospectively included all patients who had undergone DHC after mMCAi at the University Hospital Graz between 2006 and 2019. Demographics, clinical data and complications were collected from electronic clinical patient records. To investigate long-term prognosis, all patients were followed up to 14 years after stroke including quality of life (QOL) assessment. Post-stroke disability was rated according to the modified Rankin Scale (mRS). RESULTS Of 47 patients that had undergone DHC for mMCAi, follow-up data were available in 40 patients (mean age: 48 years; 40% female). Six months after the mMCAi, 14 patients had died (35%) and nine (23%) had a low to moderate post-stroke disability (mRS 0-3). Of 26 stroke survivors, half (50%) showed further mRS improvement (≥ 1 point) during the long-term follow-up period (mean follow-up time: 8 years). At last follow-up, 17 patients had achieved an mRS score of ≤ 3 (65% versus 35% after 6 months; p = 0.008) and 55% had no signs of depression and anxiety, and 50% no signs of pain or discomfort in QOL assessment. CONCLUSION This study shows substantial long-term improvement of functional disability and reasonable QOL in mMCAi patients after DHC.
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Affiliation(s)
- Natalie Berger
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Anna Brunner
- Department of Neurosurgery, Medical University of Graz, Graz, Austria
| | - Gerit Wünsch
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Oliver Nistl
- Division of Neuroradiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Daniela Pinter
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | | | | | - Isra Hatab
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Michael Mokry
- Department of Neurosurgery, Medical University of Graz, Graz, Austria
| | | | | | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Markus Kneihsl
- Department of Neurology, Medical University of Graz, Graz, Austria.
- Division of Neuroradiology, Department of Radiology, Medical University of Graz, Graz, Austria.
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7
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Eriksson J, Nyberg L, Elgh E, Hu X. Improvement of cognition across a decade after stroke correlates with the integrity of functional brain networks. Neuroimage Clin 2023; 37:103356. [PMID: 36842348 PMCID: PMC9984887 DOI: 10.1016/j.nicl.2023.103356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 02/08/2023] [Accepted: 02/19/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND AND OBJECTIVE We recently reported improvements of working memory across 10 years post stroke among middle-aged individuals. However, the mechanisms underlying working-memory recovery are largely unknown. This study investigated the associations between long-term improvement of working memory and resting-state functional connectivity in two frontoparietal networks: the frontoparietal network and the dorsal attention network. METHODS Working memory was repeatedly assessed by the Digit Span Backwards task in 21 persons, within 1 year after stroke onset and again 10 years post stroke onset. Brain functional connectivity was examined by resting state functional magnetic resonance imaging at the 10-year follow-up. RESULTS A significant improvement of working memory was found among 21 persons after stroke (median age = 64) at the 10-year follow-up compared to the within-one-year assessment. The magnitude of performance improvement on the Digit Span Backwards task was significantly positively correlated with stronger brain connectivity in the frontoparietal network (r = 0.51, p = 0.018) measured at the 10-year follow-up only. A similar association was observed in the dorsal attention network (r = 0.43, p = 0.052) but not in a visual network (r = -0.17, p = 0.46) that served as a control network. The association between functional connectivity within the above-mentioned networks and Digit Span Backwards scores at 10-year after stroke was in the same direction but did not reach significance. CONCLUSIONS The present work relate stronger long-term performance improvement on the Digit Span Backwards task with higher integrity of frontoparietal network connectivity.
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Affiliation(s)
- Johan Eriksson
- Umeå center for Functional Brain Imaging (UFBI) and Department of Integrative Medical Biology, Umeå University, 901 87 Umeå, Sweden
| | - Lars Nyberg
- Umeå center for Functional Brain Imaging (UFBI) and Department of Integrative Medical Biology, Umeå University, 901 87 Umeå, Sweden; Department of Radiation Sciences, Umeå University, 901 87 Umeå, Sweden
| | - Eva Elgh
- Department of Psychology, Umeå University, 901 87 Umeå, Sweden
| | - Xiaolei Hu
- Department of Community Medicine and Rehabilitation, Umeå University, 901 87 Umeå, Sweden.
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Mayorova LA, Grechko AV, Fateeva VV. [A two-year prospective longitudinal study of the dynamics of cognitive functions in different periods of stroke]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:36-42. [PMID: 38148696 DOI: 10.17116/jnevro202312312236] [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: 12/28/2023]
Abstract
OBJECTIVE To examine the dynamics of cognitive functions 3, 6, 12, and 24 months after ischemic stroke (IS). MATERIAL AND METHODS The study included 32 patients (women 21.4%), aged 40-71 years (mean age 58.7 years), with IS less than 3 months old and a moderately pronounced decrease in activity in everyday life. At four visits (baseline, after 12, 36, 84 weeks), a neuropsychological examination of cognitive functions was carried out using a 10-point system (1 point - maximum impairment, 10 points - no impairment), testing according to the Barthel scale, the National Institutes of Health Stroke Scale (NIHSS), the modified Rankin scale (mRs). During the study, patients received unified basic therapy and underwent multimodal rehabilitation courses. RESULTS When assessing cognitive functions in the period 3-6 months after IS, there was a significant (p<0.05) improvement in memory (6.5±0.62 to 8.0±0.74 points), attention (5.7±0.58 to 7.2±0.73 points), praxis (7.9±0.78 to 9.1±0.85 points), speech (6.5±0.67 to 7.5±0.87 points); a significant increase in the average Barthel score (65.8±5.4 to 89.2±8.6) was accompanied by a significant decrease in neurological deficit (7.7±0.51 to 5.3±0.33 NIHSS points and 3.9±0.28 to 2.6±0.15 mRs points). In the period 6-12 months after IS, significant disturbances were detected in the areas of memory, attention and thinking. Cognitive function continued to deteriorate 12-24 months after IS. In the period 6-24 months after IS, no significant changes in the average values on the Barthel, NIHSS, and mRs were detected. CONCLUSION The most favorable interval for the recovery of cognitive functions in patients after IS is the early recovery period. As the time after a stroke increases, the ability to recovery cognitive functions decreases.
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Affiliation(s)
- L A Mayorova
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
- Institute of Higher Nervous Activity and Neurophysiology, Moscow, Russia
| | - A V Grechko
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
- Patrice Lumumba Peoples' Friendship University of Russia, Moscow, Russia
| | - V V Fateeva
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
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Laari S, Turunen K, Kauranen T, Mustanoja S, Lahti-Pulkkinen M, Tatlisumak T, Poutiainen E. Memory decline in young stroke survivors during a 9-year follow-up: A cohort study. Front Neurol 2022; 13:1069686. [PMID: 36504659 PMCID: PMC9732240 DOI: 10.3389/fneur.2022.1069686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/10/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction A decade after stroke, young stroke survivors continue to suffer from cognitive impairment. However, it is not known whether this long-term cognitive outcome is caused in part by further cognitive decline or solely by incomplete recovery from the acute effects of ischemic stroke. We studied changes in three cognitive domains over a 9-year follow-up period after first-ever and only ischemic stroke. Patients and methods In this prospective, two-center cohort study, we recruited consecutive 18-65 year-old patients with acute stroke between 2007 and 2009, along with demographically matched stroke-free controls. We performed comprehensive neuropsychological assessments at 3 months, 2, and 9 years after stroke, and we also performed neurological examinations at the time of inclusion and at the 9-year follow-up. We assessed the associations among stroke, follow-up time and long-term cognitive outcomes using repeated-measures analysis of variance. Results The subjects comprised 85 patients who had had their first-ever and only ischemic stroke (mean age 53 years at inclusion), along with 31 stroke-free demographic controls. We compared the cognitive changes in patients to those in controls over a 9-year follow-up. After initial recovery between 3 months and 2 years after stroke, patients showed a decline in memory between 2 and 9 years after stroke compared to controls within the same time interval (immediate recall p < 0.001; delayed recall p < 0.001; list learning p < 0.001). Other than memory, we found no difference in cognitive changes between poststroke patients and controls. Discussion Our main finding was memory decline over a decade in young first-ever stroke patients with no further stroke or neurodegenerative disease. Our study extends the previous results of further memory decline in elderly stroke survivors to young stroke survivors. Conclusion Young stroke survivors might be at risk of memory decline over the decade following the stroke.
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Affiliation(s)
- Siiri Laari
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland,HUS Neurocenter, Helsinki University Hospital and University of Helsinki, Helsinki, Finland,*Correspondence: Siiri Laari
| | - Katri Turunen
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Tatu Kauranen
- Department of Neurology and Clinical Neurophysiology, Lapland Central Hospital, Rovaniemi, Finland
| | - Satu Mustanoja
- HUS Neurocenter, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marius Lahti-Pulkkinen
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Turgut Tatlisumak
- Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Erja Poutiainen
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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Zhao X, Chong EJY, Qi W, Pang T, Xu X, Chen C. Domain-Specific Cognitive Trajectories Among Patients with Minor Stroke or Transient Ischemic Attack in a 6-Year Prospective Asian Cohort: Serial Patterns and Indicators. J Alzheimers Dis 2021; 83:557-568. [PMID: 34334410 DOI: 10.3233/jad-210619] [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: 12/18/2022]
Abstract
BACKGROUND Long-term post-stroke cognitive impairment (PSCI) has often been overlooked, especially among patients with minor stroke or transient ischemic attack (TIA). OBJECTIVE To assess 6-year domain-specific cognitive trajectories among survivors of minor stroke or TIA and to identify possible indicators associated with cognitive trajectories, as well as long-term and incident PSCI. METHODS Eligible participants completed cognitive and clinical assessments at baseline (2 weeks after stroke) and up to 5 follow-up visits in 6 years. Mixed linear models and generalized estimating equations were adopted to analyze longitudinal data and survival analysis to explore incident PSCI, controlling for demographic, clinical, and vascular indicators. RESULTS The prevalence of PSCI and mortality rate ranged from 34.6% to 53.7%, and 0 to 7.7% respectively, among 244 patients. Incidence of PSCI was 21.9%. While visual memory demonstrated a significant improvement (p < 0.05), other cognitive domains showed a fluctuating yet stable pattern across visits (all ps > 0.05). Besides age, baseline IQCODE (attention: -0.218 SD/y, executive function: -0.238 SD/y, visual memory: -0.266 SD/y), and MoCA improvement within 1 year (visuoconstruction: 0.007 SD/y, verbal memory: 0.012 SD/y) were associated with longitudinal cognitive changes. Baseline MoCA (OR = 0.66, 95% CI = [0.59-0.74]), MoCA improvement within 3-6 months (OR = 0.79, 95% CI = [0.71-0.89], and within 1 year (OR = 0.86, 95% CI = [0.76-0.96]) were associated with long-term PSCI, while baseline MoCA (OR = 0.76, 95% CI = [0.61-0.96]) was also associated with incident PSCI. CONCLUSION While most domains remained stable across-time, visual memory demonstrated an overall improvement. Short-term cognitive improvement could be an early indicator of long-term cognitive trajectory to identify individuals who may be resilient to PSCI.
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Affiliation(s)
- Xuhao Zhao
- School of Public Health & the 2nd Affiliated Hospital of School of Medicine, Zhejiang University, China
| | - Eddie Jun Yi Chong
- Memory, Ageing and Cognition Centre (MACC), Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Wei Qi
- School of Public Health & the 2nd Affiliated Hospital of School of Medicine, Zhejiang University, China
| | - Ting Pang
- School of Public Health & the 2nd Affiliated Hospital of School of Medicine, Zhejiang University, China
| | - Xin Xu
- School of Public Health & the 2nd Affiliated Hospital of School of Medicine, Zhejiang University, China.,Memory, Ageing and Cognition Centre (MACC), Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Christopher Chen
- Memory, Ageing and Cognition Centre (MACC), Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Memory, Ageing and Cognition Centre (MACC), Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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11
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Lee KP, Chang AYW, Sung PS. Association between Blood Pressure, Blood Pressure Variability, and Post-Stroke Cognitive Impairment. Biomedicines 2021; 9:773. [PMID: 34356837 PMCID: PMC8301473 DOI: 10.3390/biomedicines9070773] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/23/2021] [Accepted: 06/29/2021] [Indexed: 12/18/2022] Open
Abstract
After stroke, dynamic changes take place from necrotic-apoptotic continuum, inflammatory response to poststroke neurogenesis, and remodeling of the network. These changes and baseline brain pathology such as small vessel disease (SVD) and amyloid burden may be associated with the occurrence of early or late poststroke cognitive impairment (PSCI) or dementia (PSD), which affect not only stroke victims but also their families and even society. We reviewed the current concepts and understanding of the pathophysiology for PSCI/PSD and identified useful tools for the diagnosis and the prediction of PSCI in serological, CSF, and image characteristics. Then, we untangled their relationships with blood pressure (BP) and blood pressure variability (BPV), important but often overlooked risk factors for PSCI/PSD. Finally, we provided evidence for the modifying effects of BP and BPV on PSCI as well as pharmacological and non-pharmacological interventions and life style modification for PSCI/PSD prevention and treatment.
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Affiliation(s)
- Kang-Po Lee
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan;
- Department of Neurology, E-DA Hospital, Kaohsiung 824, Taiwan
| | - Alice Y. W. Chang
- Department of Physiology, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan;
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Pi-Shan Sung
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan;
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
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12
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Elgh E, Hu X. Visuospatial Function at Sub-Acute Phase Predicts Fatigue 10 Years After Stroke. Front Neurol 2020; 11:562706. [PMID: 33192997 PMCID: PMC7649767 DOI: 10.3389/fneur.2020.562706] [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: 05/15/2020] [Accepted: 09/24/2020] [Indexed: 01/07/2023] Open
Abstract
Background and Objective: Fatigue is common among stroke survivors; and has significant negative consequences. However, long-term follow-up on post-stroke fatigue and it's association with cognitive and physiological parameters remains vague. Methods: A prospective cohort study was carried out on 38 young stroke survivors (aged 18-65 at stroke onset) living in the community 10 years after first-ever stroke. Fatigue was assessed by Fatigue assessment scale (FAS). Global cognition and cognitive sub-domains were assessed repeatedly at 1 week, 7 months, and 10 years after their first-ever stroke. Univariate correlation analysis was used to investigate associations and multivariate regression was used to investigate predictors and association with fatigue. Results: At 10-years follow-up after stroke onset, more than half of the 38 participants suffered from fatigue [with median score 25 on FAS with 25-75% percentile (21-28)]. Most of them were independent in their everyday life [mRS median score 1 (0-2)]. In univariate correlation analyses, higher fatigue score was significantly correlated to higher independence in the daily activity, higher BMI, anxiety, higher scores on global cognition and better working memory at 10-years follow-up as well as better visuospatial functions after 7 months and 10-years. In a multiple regression analysis, only visuospatial function at 7-months follow-up was a significant predictor of fatigue 10 years after stroke onset [F = 23.07, p < 0.009], with adjusted (R 2 = 0.815) i.e., higher scores on Block design were associated with more fatigue. Conclusion: Our results extended the time course of post-stroke fatigue up to 10 years after stroke onset. The participants with more fatigue performed better in cognitive assessments and daily activity, which indicated dissociation between fatigue and fatigability among stroke patients. Visuospatial function at the sub-acute phase predicted independently late post-stroke fatigue. This may offer a broad time window for rehabilitation and information about fatigue. The clinical implications of the current findings are worth to be studied further.
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Affiliation(s)
- Eva Elgh
- Department of Psychology, Umeå University, Umeå, Sweden
| | - Xiaolei Hu
- Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden
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13
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Drag LL, Mlynash M, Nassar H, Osborn E, Kim DE, Angst MS, Aghaeepour N, Buckwalter M, Lansberg MG. A longitudinal study of the post-stroke immune response and cognitive functioning: the StrokeCog study protocol. BMC Neurol 2020; 20:313. [PMID: 32847540 PMCID: PMC7448308 DOI: 10.1186/s12883-020-01897-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stroke increases the risk of cognitive impairment even several years after the stroke event. The exact mechanisms of post-stroke cognitive decline are unclear, but the immunological response to stroke might play a role. The aims of the StrokeCog study are to examine the associations between immunological responses and long-term post-stroke cognitive trajectories in individuals with ischemic stroke. METHODS StrokeCog is a single-center, prospective, observational, cohort study. Starting 6-12 months after stroke, comprehensive neuropsychological assessment, plasma and serum, and psychosocial variables will be collected at up to 4 annual visits. Single cell sequencing of peripheral blood monocytes and plasma proteomics will be conducted. The primary outcome will be the change in global and domain-specific neuropsychological performance across annual evaluations. To explain the differences in cognitive change amongst participants, we will examine the relationships between comprehensive immunological measures and these cognitive trajectories. It is anticipated that 210 participants will be enrolled during the first 3 years of this 4-year study. Accounting for attrition, an anticipated final sample size of 158 participants with an average of 3 annual study visits will be available at the completion of the study. Power analyses indicate that this sample size will provide 90% power to detect an average cognitive change of at least 0.23 standard deviations in either direction. DISCUSSION StrokeCog will provide novel insight into the relationships between immune events and cognitive change late after stroke.
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Affiliation(s)
- Lauren L Drag
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, 213 Quarry Rd, Palo Alto, CA, 94305, USA.
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, 213 Quarry Rd, Palo Alto, CA, 94305, USA
| | - Huda Nassar
- Department of Anesthesiology, Perioperative, & Pain Medicine, Stanford University Medical Center, 300 N. Pasteur Dr, Stanford, CA, 94305, USA
| | - Elizabeth Osborn
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, 213 Quarry Rd, Palo Alto, CA, 94305, USA
| | - Da E Kim
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, 213 Quarry Rd, Palo Alto, CA, 94305, USA
| | - Martin S Angst
- Department of Anesthesiology, Perioperative, & Pain Medicine, Stanford University Medical Center, 300 N. Pasteur Dr, Stanford, CA, 94305, USA
| | - Nima Aghaeepour
- Department of Anesthesiology, Perioperative, & Pain Medicine, Stanford University Medical Center, 300 N. Pasteur Dr, Stanford, CA, 94305, USA
| | - Marion Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, 213 Quarry Rd, Palo Alto, CA, 94305, USA
- Department of Neurosurgery, Stanford University Medical Center, 300 N. Pasteur Dr, Stanford, CA, 94305, USA
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, 213 Quarry Rd, Palo Alto, CA, 94305, USA
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14
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Assessing executive function following the early stage of mild Ischemic stroke with three brief screening tests. J Stroke Cerebrovasc Dis 2020; 29:104960. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104960] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/07/2020] [Accepted: 05/09/2020] [Indexed: 12/27/2022] Open
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15
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Kotov SV, Isakova EV, Zaitseva EV. [Poststroke cognitive impairment and the possibility of its nonpharmacological treatment with vestibular stimulation based on biological feedback to supporting reaction]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:16-22. [PMID: 32307425 DOI: 10.17116/jnevro202012003216] [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: 11/17/2022]
Abstract
Cognitive impairment is common in poststroke patients. Today in rehabilitation programs the specialists use the vestibular stimulation including biological feedback to supporting reaction for treatment poststroke cognitive impairment. These studies show the relationship of vestibular function with memory, attention, spatial orientation, navigation, mental representation of three-dimensional space and other cognitive functions. It makes possible to build rehabilitation programs for patients with stroke.
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Affiliation(s)
- S V Kotov
- Vladimirsky Moscow Regional Scientific Research Clinical Institute, Moscow, Russia
| | - E V Isakova
- Vladimirsky Moscow Regional Scientific Research Clinical Institute, Moscow, Russia
| | - E V Zaitseva
- Vladimirsky Moscow Regional Scientific Research Clinical Institute, Moscow, Russia
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16
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Shin M, Sohn MK, Lee J, Kim DY, Lee SG, Shin YI, Oh GJ, Lee YS, Joo MC, Han EY, Han J, Ahn J, Chang WH, Shin MA, Choi JY, Kang SH, Kim Y, Kim YH. Effect of Cognitive Reserve on Risk of Cognitive Impairment and Recovery After Stroke: The KOSCO Study. Stroke 2019; 51:99-107. [PMID: 31822247 PMCID: PMC6924936 DOI: 10.1161/strokeaha.119.026829] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Supplemental Digital Content is available in the text. The theory of cognitive reserve (CR) was introduced to account for individual differences in the clinical manifestation of neuropathology. This study investigated whether CR has a modulating effect on cognitive impairment and recovery after stroke.
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Affiliation(s)
- Minyoung Shin
- From the Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (M.S., W.H.C., M.A.S., Y.-H.K.).,Department of Counseling Psychology, Yongmoon Graduate School of Counseling Psychology, Seoul, Republic of Korea (M.S.)
| | - Min Kyun Sohn
- Department of Rehabilitation Medicine, School of Medicine, Chungnam National University, Daejeon, Republic of Korea (M.K.S.)
| | - Jongmin Lee
- Department of Rehabilitation Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea (J.L.)
| | - Deog Young Kim
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (D.Y.K.)
| | - Sam-Gyu Lee
- Department of Physical and Rehabilitation Medicine, Chonnam National University Medical School, Kwangju, Republic of Korea (S.-G.L.)
| | - Yong-Il Shin
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Republic of Korea (Y.-I.S.)
| | - Gyung-Jae Oh
- Department of Preventive Medicine, Wonkwang University, School of Medicine, Iksan, Republic of Korea (G.-J.O.)
| | - Yang-Soo Lee
- Department of Rehabilitation Medicine, Kyungpook National University, School of Medicine, Daegu, Republic of Korea (Y.-S.L.)
| | - Min Cheol Joo
- Department of Rehabilitation Medicine, Wonkwang University School of Medicine, Iksan, Republic of Korea (M.C.J.)
| | - Eun Young Han
- Department of Rehabilitation Medicine, Jeju National University School of Medicine, Republic of Korea (E.Y.H.)
| | | | - Jeonghoon Ahn
- Department of Statistics, Hallym University, Chuncheon, Republic of Korea (J.A.).,Department of Health Convergence, Ewha Womans University, Seoul, Republic of Korea (J.A,)
| | - Won Hyuk Chang
- From the Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (M.S., W.H.C., M.A.S., Y.-H.K.)
| | - Min A Shin
- From the Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (M.S., W.H.C., M.A.S., Y.-H.K.)
| | - Ji Yoo Choi
- Division of Chronic Disease Prevention, Center for Disease Prevention, Korea Centers for Disease Control and Prevention, Osong, Republic of Korea (J.Y.C., S.H.K.)
| | - Sung Hyun Kang
- Division of Chronic Disease Prevention, Center for Disease Prevention, Korea Centers for Disease Control and Prevention, Osong, Republic of Korea (J.Y.C., S.H.K.)
| | - Youngtaek Kim
- Public Health Medical Service, Chungnam National University Hospital, Daejeon, Republic of Korea (Y.K.)
| | - Yun-Hee Kim
- From the Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (M.S., W.H.C., M.A.S., Y.-H.K.).,Department of Health Science and Technology, Department of Medical Device Management and Research, Department of Digital Healthcare, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea (Y.-H.K.)
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17
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Johnen A, Räthe S, Lohmann H, Philipp K, Minnerup J, Wiendl H, Meuth SG, Duning T. [Frequency and risk factors associated with post-stroke dementia-an observational study on stroke patients without premorbid cognitive impairment]. DER NERVENARZT 2019; 91:131-140. [PMID: 31712835 DOI: 10.1007/s00115-019-00830-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Longitudinal studies on cognitive outcomes after stroke revealed heterogeneous results and the underlying pathology and risk factors for so-called post-stroke dementia are unclear. OBJECTIVE To assess long-term cognitive performance changes in patients after the first ischemic stroke and to evaluate possible risk factors for post-stroke dementia. MATERIAL AND METHODS In this study 66 clinically mildly affected patients aged 54-87 years without a history of dementia underwent extensive neuropsychological assessment after first ever ischemic stroke and again 6 months after the event (follow-up assessment). Demographic, clinical and paraclinical parameters were assessed as potential predictors for long-term cognitive outcome. RESULTS At the group level significant performance improvements were found for most of the neurocognitive domains at the follow-up assessment. The greatest cognitive improvement was found in visuospatial processing. Immediately after stroke 54.5% of patients were considered cognitively impaired (z-scores < -2 in at least 2 neurocognitive domains). At follow-up only 16.7% were considered cognitively impaired according to this criterion and among these only 2 patients (3%) had developed a new, clinically relevant cognitive impairment (i.e. post-stroke dementia). Patients with inferior cognitive performance improvements at follow-up had on average larger brain lesions caused by the stroke as well as a prediabetic metabolic status. DISCUSSION The probability of developing a post-stroke dementia syndrome is lower than previously assumed in patients with first ever stroke, with only mild clinical disability and without premorbid cognitive impairment. Long-term cognitive impairment could primarily be determined by the size of the lesioned brain area as well as the premorbid (pre)diabetic status.
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Affiliation(s)
- A Johnen
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland.
| | - S Räthe
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - H Lohmann
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - K Philipp
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - J Minnerup
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - H Wiendl
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - S G Meuth
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - T Duning
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
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