Cognitive impairment before and after intracerebral haemorrhage: a systematic review

Introduction: There is increasing interest in understanding cognitive dysfunction before and after Intracerebral haemorrhage (ICH), given the higher prevalence of dementia reported (ranging from 5 to 44%) for this stroke type. Much of the evidence to date examining cognitive impairment associated with cerebrovascular disease has tended to focus more on ischaemic stroke. The aim of this review was to identify and quantify studies that focused on cognitive dysfunction pre and post ICH. / Methods: We conducted a systematic search using databases PubMed, Science Direct, Scopus and PsycINFO to identify studies that exclusively assessed cognitive function pre and post ICH. Studies were included in the review if used a measure of global cognition and/or a neuropsychological battery to assess cognitive function. Nineteen studies were deemed relevant for inclusion, where n = 8 studies examined cognitive impairment pre ICH and n = 11 post ICH. / Results: Prevalence of cognitive impairment ranged between 9–29% for pre ICH and 14–88% for post ICH. Predictive factors identified for pre and post ICH were previous stroke, ICH volume and location and markers of cerebral amyloid angiopathy (CAA). Most common cognitive domains affected post ICH were information processing speed, executive function, memory, language and visuo-spatial abilities. Most common cognitive assessments tools were the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) for pre-existing cognitive impairment and the Mini-Mental State Examination for global cognition post ICH and the Trail Making Test where neuropsychological tests were used. / Conclusion: Cognitive impairment and dementia affected almost one-third of patients, whether assessed pre or post ICH

Reducing delays to administration of prothrombin complex concentrate in patients with vitamin K antagonist-related intracerebral haemorrhage

BACKGROUND/AIMS Four-factor prothrombin complex concentrate is the first-line treatment in vitamin K antagonist-related intracerebral haemorrhage. Early administration is associated with improved patient outcomes. A quality improvement project investigated delays in prothrombin complex concentrate administration in vitamin K antagonist-related intracerebral haemorrhage in order to reduce the time from computed tomography scan confirming intracerebral haemorrhage to prothrombin complex concentrate administration (scan-to-needle time). METHOD Twenty patients were identified by retrospective audit over a 3-year period. The median scan-to-needle time for prothrombin complex concentrate was 156 minutes. Several points of delay were identified, including contacting both haematology and transfusion departments for prothrombin complex concentrate dosing and dispensing. Following this audit, interventions were brought in which included the introduction of a protocol with a prothrombin complex concentrate dosing algorithm, negating the need to contact haematology before administration. A dedicated supply of prothrombin complex concentrate was given to the stroke unit avoiding the need to contact the transfusion service. RESULTS A re-audit showed a 68% reduction in median scan-to-needle time from 156 minutes to 49 minutes. Prospective data collection is ongoing

Memory Trajectories Before and After First and Recurrent Strokes

BACKGROUND AND OBJECTIVES: The evidence on timing of memory change after first and recurrent strokes is limited and inconsistent. We investigated memory trajectories before and after first and recurrent strokes in eighteen European countries, and tested whether the country-level acute stroke care was associated with memory change after stroke. METHODS: Data were from the Survey of Health, Ageing and Retirement in Europe (2004-2019). Incident first and recurrent strokes were identified among baseline stroke-free individuals. Within each country, each participant with incident stroke (case group) was matched with a stroke-free individual (control group) using the Propensity Score Matching. We applied multilevel segmented linear regression to quantify acute and accelerated memory changes (measured by the sum score of immediate and delayed word recall tests; 0-20 words) before and after first and recurrent strokes in both groups. Associations between stroke and memory were compared between countries with different levels of acute stroke care indicators. RESULTS: The final analytical sample included 35,164 participants who were stroke-free at baseline (≥50 years). 2,362 incident first and 341 recurrent strokes between 2004 and 2019 were identified. In case group, mean acute decreases in memory scores were 0.48 (95% confidence interval: 0.31, 0.65) and 1.14 (95% confidence interval: 0.80, 1.48) words after first and recurrent stroke, respectively, independent of a range of confounders. No such acute decreases were observed in control group after a hypothetical non-stroke onset date. In both groups, memory declined over time but decline rates were similar (-0.07 [95% confidence interval: -0.10, -0.05] versus -0.06 [95% confidence interval: -0.08, -0.05] words per year). The mean acute decreases in memory scores after first and recurrent strokes were smaller in countries with better access to endovascular treatment. DISCUSSION: We found acute decreases but not accelerated declines in memory after first and recurrent strokes. Improved endovascular therapy might be associated with smaller memory loss after stroke but more evidence based on individual-level data is needed. More effort should be made in early assessment and intensive prevention of stroke among the ageing population, and promoting access to and delivery of acute stroke care among patients with stroke

Case Report: Auditory Neuropathy and Central Auditory Processing Deficits in a Neuro-Otological Case-Study of Infratentorial Superficial Siderosis

Hearing and balance impairment are the most frequently reported features of infratentorial (classical) superficial siderosis (iSS). There are few comprehensive descriptions of audiovestibular function in iSS and therefore limited understanding of the affected segment(s) of the audiovestibular pathway. In addition, monitoring disease progression and response to treatment is challenging and currently mainly guided by subjective patient reports and magnetic resonance imaging. To the best of our knowledge, there have been no previous reports assessing central auditory function in iSS. We describe such findings in a patient with iSS in an attempt to precisely localize the site of the audiovestibular dysfunction, determine its severity and functional impact. We confirm the presence of (asymmetrical) auditory neuropathy and identify central auditory processing deficits, suggesting involvement of the central auditory pathway beyond the brainstem. We correlate the audiological and vestibular findings with self-report measures and the siderosis appearances on brain magnetic resonance images

Auditory Rehabilitation after Stroke: Treatment of Auditory Processing Disorders in Stroke Patients with Personal Frequency-Modulated (FM) Systems

Purpose: Auditory disability due to impaired auditory processing (AP) despite normal pure-tone thresholds is common after stroke, and it leads to isolation, reduced quality of life and physical decline. There are currently no proven remedial interventions for AP deficits in stroke patients. This is the first study to investigate the benefits of personal frequency-modulated (FM) systems in stroke patients with disordered AP. Methods: Fifty stroke patients had baseline audiological assessments, AP tests and completed the (modified) Amsterdam Inventory for Auditory Disability (AIAD) and Hearing Handicap Inventory for Elderly (HHIE) questionnaires. Nine out of these fifty patients were diagnosed with disordered AP based on severe deficits in understanding speech in background noise but with normal pure-tone thresholds. These nine patients underwent spatial speech-in-noise testing in a sound-attenuating chamber (the “crescent of sound”) with and without FM systems. Results: The signal-to-noise-ratio (SNR) for 50% correct speech recognition performance was measured with speech presented from 0° azimuth and competing babble from ±90° azimuth. Spatial release from masking (SRM) was defined as the difference between SNRs measured with co-located speech and babble and SNRs measured with spatially separated speech and babble. The SRM significantly improved when babble was spatially separated from target speech, while the patients had the FM systems in their ears compared to without the FM systems. Conclusions: Personal FM systems may substantially improve speech-in-noise deficits in stroke patients who are not eligible for conventional hearing aids. FMs are feasible in stroke patients and show promise to address impaired AP after stroke

Efficacy and Safety of Intravenous rtPA in Ischemic Strokes Due to Small-Vessel Occlusion: Systematic Review and Meta-Analysis

Intravenous recombinant tissue plasminogen activator (iv-rtPA) has been routinely used to treat ischemic stroke for 25 years, following large clinical trials. However, there are few prospective studies on the efficacy and safety of this therapy in strokes attributed to cerebral small vessel disease (SVD). We evaluated functional outcome (modified Rankin scale, mRS) and symptomatic intracerebral hemorrhage (sICH) using all available data on the effects of iv-rtPA in SVD-related ischemic stroke (defined either using neuroimaging, clinical features, or both). Using fixed-effect and random-effects models, we calculated the pooled effect estimates with regard to excellent and favorable outcomes (mRS=0-1 and 0-2 respectively, at 3 months), and the rate of sICH. Twenty-three studies fulfilled the eligibility criteria, 11 of which were comparative, and there were only 3 randomized clinical trials. In adjusted analyses, there was an increased odds of excellent outcome (adjusted OR=1.53, 95% CI: 1.29-1.82, I2: 0%) or favorable outcome (adjusted OR=1.68, 95% CI: 1.31-2.15,I2: 0%) in patients who received iv-rtPA compared with placebo. Across the six studies which reported it, the incidence of sICH was higher in the treatment group (M-H RR = 8.83, 95% CI: 2.76-28.27). The pooled rate of sICH in patients with SVD administered iv-rtPA was only 0.72% (95% CI: 0.12%-1.64%). We conclude that when ischemic stroke attributed to SVD is considered separately, available data on the effects of iv-rtPA therapy are insufficient for the highest level of recommendation, but it seems to be safe. Although further therapeutic trials in SVD-related ischemic stroke appear to be justified, our findings should not prevent its continued use for this group of patients in clinical practice

Antithrombotic therapy in patients with cerebral microbleeds

PURPOSE OF REVIEW: Cerebral microbleeds (CMBs) are a radiological marker of cerebral small vessel disease corresponding to small haemosiderin foci identified by blood-sensitive MRI. CMBs are common in older community populations, and in individuals with ischaemic stroke or transient ischaemic attack (TIA), and intracerebral haemorrhage (ICH). We summarize how CMBs might contribute to assessing the future risk of ischaemic stroke and ICH to inform antithrombotic (antiplatelet or anticoagulant) decisions. RECENT FINDINGS: CMBs are a risk factor for future ischaemic stroke and ICH in all community and hospital populations studied. Following ischaemic stroke/TIA treated with antithrombotics, increasing CMB burden increases the risk of ICH more steeply than that of ischaemic stroke. In ICH populations the risk of recurrent ICH increases with CMB burden, and is highest in those with strictly lobar CMBs or other haemorrhagic findings (e.g. cortical superficial siderosis) suggesting cerebral amyloid angiopathy (CAA). SUMMARY: In ischaemic stroke or patients with TIA less than five CMBs should not affect antithrombotic decisions, although with more than five CMBs the risks of future ICH and ischaemic stroke are finely balanced, and antithrombotics might cause net harm. In lobar ICH populations, a high burden of strictly lobar CMBs is associated with CAA and high ICH risk; antithrombotics should be avoided unless there is a compelling indication

Acute Stroke Treatment in an Anticoagulated Patient: When Is Thrombolysis an Option?

Purpose of Review: Direct oral anticoagulants (DOACs: the factor Xa inhibitors rivaroxaban, apixaban, and edoxaban and the direct thrombin inhibitor dabigatran) are the mainstay of stroke prevention in patients with non-valvular atrial fibrillation (AF). Nevertheless, there is a residual stroke risk of 1–2% per year despite DOAC therapy. Intravenous thrombolysis (IVT) reduces morbidity in patients with ischemic stroke and improves functional outcome. Prior DOAC therapy is a (relative) contraindication for IVT but emerging evidence supports its use in selected patients. // Recent Findings: Recent observational studies highlighted that IVT in patients on prior DOAC therapy seems feasible and did not yield major safety issues. Different selection criteria and approaches have been studied including selection by DOAC plasma levels, non-specific coagulation assays, time since last intake, and prior reversal agent use. The optimal selection process is however not clear and most studies comprised few patients. // Summary: IVT in patients taking DOAC is a clinically challenging scenario. Several approaches have been proposed without major safety issues but current evidence is weak. A patient-oriented approach balancing potential benefits of IVT (i.e., amount of salvageable penumbra) against expected bleeding risk including appropriate monitoring of anticoagulant activity seem justified