Who should undergo a comprehensive cognitive assessment after a stroke?

Abstract

ObjectiveTo validate the ability of a specifically developed cognitive risk score to identify patients at risk of poststroke neurocognitive disorders (NCDs) who are eligible for a comprehensive cognitive assessment.MethodsAfter assessing 404 patients (infarct 91.3%) in the Groupe de Réflexion pour l'Evaluation Cognitive VASCulaire (GRECogVASC) cross-sectional study with the National Institute of Neurological Disorders and Stroke–Canadian Stroke Network battery 6 months after stroke, we used multivariable logistic regression and bootstrap analyses to determine factors associated with NCDs. Independent, internally validated factors were included in a cognitive risk score.ResultsCognitive impairment was present in 170 of the 320 patients with a Rankin Scale score ≥1. The backward logistic regression selected 4 factors (≥73% of the permutations): NIH Stroke Scale score on admission ≥7 (odds ratio [OR] 2.73, 95% confidence interval [CI] 1.29–4.3, p = 0.005), multiple strokes (OR 3.78, 95% CI 1.6–8, p = 0.002), adjusted Mini-Mental State Examination (MMSEadj) score ≤27 (OR 6.69, 95% CI 3.9–11.6, p = 0.0001), and Fazekas score ≥2 (OR 2.34, 95% CI 1.3–4.2, p = 0.004). The cognitive risk score computed with these 4 factors provided good calibration, discrimination (overoptimism-corrected C = 0.793), and goodness of fit (Hosmer-Lemeshow test p = 0.99). A combination of Rankin Scale score ≥1, cognitive risk score ≥1, and MMSEadj score ≥21 selected 230 (56.9%) of the 404 patients for a comprehensive assessment. This procedure yielded good sensitivity (96.5%) and moderate specificity (43%; positive predictive value 0.66, negative predictive value 0.91) and was more accurate (p ≤ 0.03 for all) than the sole use of screening tests (MMSE or Montréal Cognitive Assessment).ConclusionThe GRECogVASC cognitive risk score comprises 4 easily documented factors; this procedure helps to identify patients at risk of poststroke NCDs who must therefore undergo a comprehensive assessment.ClinicalTrials.gov identifier:NCT01339195.

Association Between Fatigue and Cognitive Impairment at 6 Months in Patients With Ischemic Stroke Treated With Acute Revascularization Therapy

“…A comprehensive neuropsychological assessment was performed by a neuropsychologist according to the GRECoGVASC battery (15, 16), a French-language adaptation and standardization of the National Institute of Neurological Disorders and Stroke–Canadian Stroke Network comprehensive battery (17). Several cognitive domains were explored: visuospatial and visuoconstructive skills assessed by the Rey Figure, episodic memory (verbal and visual) evaluated by the RL/RI-16 test [French adaptation of the Free and Cued Selective Reminding Test of Gruber and Buschke (18)] for the verbal modality and memory reproduction of the Rey figure for the visual modality (19), executive functions evaluated by the Trail Making Test (TMT) (20), the Subtest of Codes from Wechsler adult intelligence scale (WAIS-IV) (21), and the Verbal Fluences (categorical and lexical) (22).…”

Cognitive impairment in patients with cerebrovascular disease: A white paper from the links between stroke ESO Dementia Committee

“…Although this is always a clinical indication, and should, in the end, based on the individual level, some cues can be given: this objective can be achieved using a recently explored strategy based on risk factors of PSCI (Table 1 provided in supplementary material, and “Predictors” section). 21 Several factors have been found to be associated with PSCI, major CI, in particular. 10,16,22 A recent study has identified a minimal set of factors for selecting patients at risk of full-spectrum PSCI.…”

“…10,16,22 A recent study has identified a minimal set of factors for selecting patients at risk of full-spectrum PSCI. 21 The Rankin score represents an important step provided it is graded with a reliable informant, using a structured interview (including difficulties in instrumental activities of daily living). 23 Except in specific situations (e.g.…”

“…Still concerning stroke survivors, a combined cognitive risk score based on four easily documented factors (severity of neurological deficit, presence of multiple strokes, multiple deep WMH corresponding to Fazekas score ≥2 and a mild decrease of MMSE score, i.e., adjusted MMSE score from 21 to 27) provided a very good screening strategy 21 but remains to be tested independently and more widely in other cohorts before adoption into practice.…”

Reply to: “Diagnostic test accuracy of the Montreal Cognitive Assessment in the detection of post-stroke cognitive impairment under different stages and cutoffs: a systematic review and meta-analysis”

“…For example, the MoCA, (or other short tests) may be appropriate in the assessment of patients with mild cerebrovascular events (TIA and minor non-disabling stroke) [12], or in the detection of longer-term post stroke cognitive impairment when the number of survivors with severe stroke and problems interfering with the use of brief tests, is small [13]. Short screening tests including the MoCA may also help as an initial screening tool after acute stroke in pragmatic large-scale studies in predicting longer-term cognitive and functional outcome, or to guide need for further in-depth assessment [14,15]. In contrast, the OCS is more appropriate for informing the management of patients with acute severe stroke who will require extensive rehabilitation.…”