Abstract
The optimal management of post-stroke cognitive impairment (PSCI) remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making regarding prevention, diagnosis, treatment and prognosis. Guidelines were developed according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations. There was limited randomized controlled trial (RCT) evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Lifestyle interventions and treating vascular risk factors have many health benefits, but a cognitive effect is not proven. We found no evidence regarding routine cognitive screening following stroke, but recognize the importance of targeted cognitive assessment. We describe the accuracy of various cognitive screening tests, but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognition. The association between PSCI and acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on brain magnetic resonance imaging may help predict cognitive outcomes. These guidelines highlight fundamental areas where robust evidence is lacking. Further definitive RCTs are needed, and we suggest priority areas for future research.
Highlights
The optimal management of post stroke cognitive impairment remains controversial
We downgraded the evidence on prevention of cognitive c decline to low quality evidence for imprecision, as the effect came from one single study and the e confidence intervals included both beneficialas harmfuleffects. pt Additional Information e We found limited evidence on the effectiveness of multicomponent interventions for the prevention d of cognitive decline and dementia in post-stroke patients
We c differentiate screening from more comprehensiveassessments or diagnostic formulations. ep We pre-specified threequestions with separate outcomes of interest, (1) does cognitive screening increase the detection of later cognitive syndromes in clinical practice?; t (2) does cognitive screening change subsequent care pathways? and (3) does cognitive screening translate into health economic benefits? For this PICO, we only e considered studies that used randomised or quasi-randomised trial designs. d there are many papers describing the diagnostic properties of cognitive screening tools in stroke, we found relatively few papers that assessed whether this M cognitive screening made a difference to patient care pathways or outcomes
Summary
The optimal management of post stroke cognitive impairment remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making aroundA prevention, diagnosis, treatment, and prognosis. u Methods: These guidelines were developed according to ESO standard operating procedure and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.thThe working group identified relevant clinical questions, performed systematic reviews and, where opossible, meta-analyses of the literature, assessed the quality of the available evidence, and made r specific recommendations. The optimal management of post stroke cognitive impairment remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making around. There was limited randomised controlled trial evidence regarding single or multicomponent c interventions to prevent post stroke cognitive decline. Despite the importance of post stroke cognitive problems, this is an area u of stroke care where there are substantial rates of underdiagnosis in clinical practice, and a tdisproportionate lack of research activity. There is substantial variation in management hof post stroke cognitive issues across Europe. It is noticeable that post stroke cognitive impairment is omentioned in only a small number of the many national and internationalguidelines available for r stroke care. The apparent disconnect between clinical relevance and available evidence is thankfully changing, large cohorts and other studies are underway which should help us better understand and
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