Welcome to the WSC 2021 Interactive Program
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INTRACRANIAL CALCIFICATION – A MARKER FOR BRAIN ATROPHY AND FUTURE POST STROKE COGNITIVE DECLINE, DATA FROM THE TABASCO PROSPECTIVE COHORT
Abstract
Background and Aims
Vascular calcifications are considered to be part of active atherosclerosis. Coronary calcification have long become a prognostic marker. Calcifications of intracranial vessels(ICC) are frequently observed on non-contrast CT and their effect on post-stroke cognitive impairment(PSCI) remains unclear. Our aim was to explore the association of ICC with long-term cognitive and advanced MRI measures in a large prospective cohort of mild stroke/transient ischemic attack(TIA) patients
Methods
Data from the Tel Aviv brain acute stroke cohort(TABASCO) was analyzed. This prospective cohort study(n=575)aimed to identify predictors of PSCI. The ICC score(ICCS) on initial NCCT was calculated using a calcium quantification application. Participants underwent a 3T-MRI and comprehensive cognitive assessments at enrollment, 6, 12 and 24 months thereafter
Results
Baseline data were available for 531 subjects(mean age 67.4 years,59.5% males). The incidence of cognitive impairment at the two-year time mark was doubled in the high ICCS group(26% vs.13.7%,p<0.001).On multiple regression analysis higher ICCS was associated with brain atrophy manifested by lower normalized white matter(WM), gray matter(GM), hippocampal and thalamic volumes(β=-0.178,β=-0.200,β=-0.137,β=-0.157;p<0.05)and with lower cognitive scores at baseline,6- and 12-month post-stroke (β-0.14,β=-0.12, β=-0.12,respectively;p<0.05). Microstructural damage, defined by DTI analysis of the normal appearing white matter(NAWM), as well as all small vessel disease(SVD) markers were significantly increased in the high ICCS group(p<0.001, p=0.002, respectively).
Conclusions
Our findings suggest that the ICCS correlates with brain atrophy, the extent of SVD and long-term PSCI. This score, which is a readily available imaging marker, can assist in post-stroke prognostication and help provide individually tailored therapy by adjusting treatment targets in stroke survivors.
PREVALENCE OF PERSISTENT DOMAIN-SPECIFIC COGNITIVE IMPAIRMENTS AT 6 MONTHS POST STROKE
Abstract
Background and Aims
Understanding the long-term cognitive outcomes of stroke is vital in guiding appropriate individualized care for stroke patients, yet this is often not prioritized. With the advent of stroke-specific cognitive screening, such as the Oxford Cognitive Screen (OCS), it is clear that solely screening for general cognitive impairment overlooks crucial domain-specific impairments. Identifying domain-specific impairments over time and the prevalence of persistent impairments will allow for a better understanding of the longitudinal effect of stroke on cognition.
Methods
The cognitive profiles of 458 stroke survivors (216 female, mean age 74 years) were examined during acute recovery and at six-month follow-up. Domain-specific cognitive impairments were assessed using the OCS. The prevalence of impairments at acute recovery (<2 weeks) and six months were examined, and more crucially, the rates of individuals suffering persistent cognitive impairments (i.e. impaired acutely and remained impaired at follow-up).
Results
Persistent impairment after six-months was most common for tests related to aphasia, such as picture naming (42.7%) and sentence reading (35.3%). For memory, 24-27% remained impaired, while executive function remained impaired in 20% of participants. The lowest rates of persistent impairment was a in measure of semantic understanding at 3.85%, followed by basic arithmetic ability (15%).
Conclusions
Although some domain-specific impairments improve, many patients experience lasting impairments. This emphasizes the need to better understand the specific challenges for individuals recovering from stroke and importantly, this further highlights the clear need for domain-specific assessments in order to provide tailored interventions and support to patients.
INCIDENCE OF DEMENTIA IN ATRIAL FIBRILLATION CLINIC: A PROSPECTIVE ASSESSMENT
Abstract
Background and Aims
In atrial fibrillation (AF), anticoagulation helps prevent ischemic stroke but poses higher risk of intracranial hemorrhage (ICH) in the elderly and those with dementia. Cerebral Amyloid Angiopathy (CAA) is a subtype of dementia with a brain MRI revealing cerebral micro-bleeds (CMB) that may convert into ICH. Outcomes are poor for ICH patients on anticoagulation, which complicates AF treatment decision-making in the elderly.
Methods
In an interdepartmental collaboration, the University of South Florida Neuro-Cardiac Program designed the DAME-Detect (Dementia in Atrial fibrillation with Micro-bleeds Early Detection) prospective observational study. University of South Florida cardiology clinics were pre-screened based on AF status and age>65. Qualified subjects were screened with a validated test called “Symptoms of Early Dementia-11 Questionnaire” (SED-11Q).
Results
Pre-screening of 2,682 patients in 7 cardiology clinics identified 323 eligible subjects over 65 years old with confirmed AF. From this population, 100 agreed to consent, were enrolled into DAME-Detect, and received the Q11-SED. Of these, 19% screened positive by scoring 4 or higher on the Q11-SED.
Conclusions
About 1 in 5 elderly patients with AF in the outpatient cardiology office may have dementia, and hence represent high risk of ICH on anticoagulation. Thus, dementia screening of this vulnerable population may be warranted. Ongoing data review of DAME-Detect will examine referral requests, MRI-confirmed incidence of CMB/CAA, and anticoagulation patterns. A larger, future study may identify pathways to mitigate ICH risk with non-pharmacologic alternatives to stroke prevention in elderly patients with AF and dementia.
SEX AND RACIAL/ETHNIC ASSOCIATIONS WITH POST-STROKE COGNITIVE DECLINE: LONGITUDINAL ANALYSES FROM THE HEALTH AND RETIREMENT STUDY
Abstract
Background and Aims
Evidence on sex and race/ethnic disparities in post-stroke cognitive decline have largely been inconclusive. We investigate these disparities using a series of quasi-experimental models.
Methods
Using the Health and Retirement Study (HRS), a biennial survey of a nationally representative sample of community dwellers in the US aged 51 years and older, we applied the two-way fixed effects model, event study design, and Bacon’s weighted difference-in-differences (DiD) estimation for survey panel data(1996−2016), to evaluate the differences in the modified Telephone Interview for Cognitive Status (TICS-m) score (lower scores representing lower cognitive functioning) between patients with and without self-reported incident stroke, while controlling for observed and unobserved time-invariant baseline participant characteristics such as age and education, as well as time-specific confounders.
Results
Of the 35,451 HRS participants that met the inclusion criteria (Figure.1), 4,620 (13.03%) had incident stroke. The mean (SD) TICS-m score post vs pre incident stroke was 12.8 (0.02) vs. 15.5 (0.07). The two-way fixed effects estimator for the relationship between incident stroke and cognitive decline was −1.21(95% CI:−1.32,−1.10), which was similar to the weighted DiD estimate of −1.25(95% CI:−1.38,−1.13). Event study revealed a continuous decline in TICS-m score, up to 10 years after stroke incidence in the overall sample, as well as among females and white non-Hispanics (Figure.1). However, the decline in TICS-m score plateaued from the third wave post-stroke for males and second wave post-stroke for black non-Hispanics.
Conclusions
Sex and race differences may illuminate variations in cognitive decline associated with stroke.
PREDICTABILITY OF EARLY COGNITIVE SCREENING ON SELF-REPORTED COGNITIVE DIFFICULTIES THREE MONTHS AFTER STROKE: A REGISTER-BASED LONGITUDINAL STUDY
Abstract
Background and Aims
Cognitive deficits are common after stroke, and they have been linked with later cognitive decline and dementia. Subjective cognitive complaints (SCC) have been identified as further risk factor for post-stroke dementia. Our aim was to study early cognitive screening at acute stroke unit and if this could predict self-reported cognitive difficulties at three months after stroke. A secondary aim was to study if stroke severity and age could influence this prediction.
Methods
Data were taken from three Swedish registers (Riksstroke, Väststroke, Statistics Sweden) between November 2014 – June 2019. Information about SCC was retrieved from the Riksstroke 3-month follow-up questionnaire, while the Montreal Cognitive Assessment (MoCA) was used as cognitive screening tool at the acute stroke units. Stroke severity at admission was assessed using the National Institutes of Health Stroke Scale (NIHSS).
Results
A total of 1969 patients were included (median age, 73 [range 20-99] years; male, 58.6%). 59.9% of patients had impaired cognition at acute stroke unit (MoCA score, < 26) and 37% reported at least one SCC. MoCA was a significant predictor for SCC at three months after stroke (OR .74, 95% CI .61 - .91, p = .004). This effect was seen regardless of age and for minor strokes (NIHSS score, ≤ 3).
Conclusions
Early cognitive screening can predict SCC three months post-stroke. Cognitive screening should be done routinely in stroke units to identify patients at risk of future cognitive decline.
FEMALE SEX IS A RISK FACTOR FOR COGNITIVE DECLINE IN CEREBRAL SMALL-VESSEL DISEASE
Abstract
Background and Aims
Although female sex has been implied as a negative predictor of stroke outcome in general, the long-term cognitive outcome in female compared to male survivors of acute lacunar stroke has been rarely reported. We aimed to investigate sex impact on long-term cognitive decline (CD) after the first-ever lacunar stroke.
Methods
Cognitive status was assessed in a cohort of patients with small vessel disease (SVD) four years after the qualifying event. Demographic, clinical, neuropsychological, and MRI data were compared between female and male patients.
Results
A total of 294 patients were included, 46.2% females. No difference was detected between groups regarding age or frequency of common vascular risk factors (p>0.1 for all). Brain MRI markers of SVD comprising severity scores of white matter hyperintensities and a total number of lacunar infarcts (LI) were more pronounced in female subjects (p<0.0001 for all). On follow-up, the CD was more frequently detected in women than men (78.7% vs 51.2%, p<0.0001). Multivariate regression analysis revealed that female sex was independently associated with baseline severity of MRI lesions (OR 1.38, 95%CI 1.17-1.62; p<0.0001), CD (OR 1.85, 95%CI 1.06-3.24; p=0.032), the total number of LI (OR 0.74, 95%CI 0.59-0.92; p=0.008) and modified Rankin scale score (OR 8.35, 95%CI 5.04-13.84; p<0.0001).
Conclusions
In our dataset of SVD patients, female sex was associated with more severe brain lesions, as well as an increased risk of CD and functional disability. This association could not be attributed to differences in risk factor distribution.
ASSOCIATIONS BETWEEN CEREBRAL SMALL VESSEL DISEASE, OBSTRUCTIVE SLEEP APNEA AND COGNITION IN PATIENTS WITH ISCHEMIC STROKE AND TIA
Abstract
Background and Aims
Cerebral small vessel disease (SVD) is the most common cause of vascular dementia. On MRI SVD manifests as White Matter Hyperintensities (WMH), lacunes, enlarged perivascular spaces and microbleeds. Obstructive Sleep Apnea (OSA) is the most common sleep disorder and meta-analytic data supports a relationship between OSA and SVD. The purpose of this study is to examine relationships between: (1) OSA severity and SVD (2) OSA severity, SVD and cognition.
Methods
Patients with ischemic stroke/TIA were prospectively recruited across three independent cohort studies. Years of education, vascular risk factors, stroke severity and Montreal Cognitive Assessment scores were collected. All patients completed MRI and either an in-laboratory polysomnography (PSG) or Home Sleep Apnea Test (HSAT). OSA severity was quantified using the Apnea Hypopnea Index (AHI). The burden of small vessel disease was quantified using validated visual rating scales. Ordinal logistic regression models examined relationships between OSA and SVD, while controlling for covariates.
Results
In 237 patients increasing AHI was associated with a greater burden of periventricular WMH (pWMH) OR=1.02 (CI:1.01 to 1.04, p=0.02), deep microbleeds OR=1.03 (CI:1.01 to 1.05, p=0.002) and lobar microbleeds OR=1.02 (CI:1.01 to 1.04, p=0.03). Finally, in an ordinal logistic regression model, lower cognitive scores were related to cerebral microbleeds OR=1.09 (CI:1.01 to 1.18, p = 0.03) while controlling for covariates.
Conclusions
OSA severity is associated with greater periventricular WMH and cerebral microbleeds. Cerebral microbleeds are predictive of lower cognitive scores. The relationship between OSA and both lobar and deep microbleeds suggests potential associations with nocturnal hypertension and cerebral amyloid clearance.