Abstract
BackgroundMany studies have highlighted the high prevalence of executive disorders in stroke. However, major uncertainties remain due to use of variable and non-validated methods. The objectives of this study were: 1) to characterize the executive disorder profile in stroke using a standardized battery, validated diagnosis criteria of executive disorders and validated framework for the interpretation of neuropsychological data and 2) examine the sensitivity of the harmonization standards protocol proposed by the National Institute of Neurological Disorders and Stroke and Canadian Stroke Network (NINDS-CSN) for the diagnosis of Vascular Cognitive Impairment.Methods237 patients (infarct: 57; cerebral hemorrhage: 54; ruptured aneurysm of the anterior communicating artery (ACoA): 80; cerebral venous thrombosis (CVT): 46) were examined by using the GREFEX battery. The patients’ test results were interpreted with a validated framework derived from normative data from 780 controls.ResultsDysexecutive syndrome was observed in 88 (55.7%; 95%CI: 48–63.4) out of the 156 patients with full cognitive and behavioral data: 40 (45.5%) had combined behavioral and cognitive syndromes, 29 (33%) had a behavioral disorder alone and 19 (21.6%) had a cognitive syndrome alone. The dysexecutive profile was characterized by prominent impairments of initiation and generation in the cognitive domain and by hypoactivity with disinterest and anticipation loss in the behavioral domain. Cognitive impairment was more frequent (p = 0.014) in hemorrhage and behavioral disorders were more frequent (p = 0.004) in infarct and hemorrhage. The harmonization standards protocol underestimated (p = 0.007) executive disorders in CVT or ACoA.ConclusionsThis profile of executive disorders implies that the assessment should include both cognitive tests and a validated inventory for behavioral dysexecutive syndrome. Initial assessment may be performed with a short cognitive battery, such as the harmonization standards protocol. However, administration of a full cognitive battery is required in selected patients.
Highlights
Executive disorders and action slowing are the most prevalent impairments in stroke patients [1,2,3,4,5,6,7] including cerebral hemorrhage [8], cerebral venous thrombosis (CVT) [9] and CADASIL [10]
The dysexecutive profile was characterized by prominent impairments of initiation and generation in the cognitive domain and by hypoactivity with disinterest and anticipation loss in the behavioral domain
The few studies of the behavioral domain of executive function have focused on apathy, which was found in 20% to 40% of stroke patients ([11,12,13,14]) and 40% of CADASIL patients [15]
Summary
Executive disorders and action slowing are the most prevalent impairments in stroke patients [1,2,3,4,5,6,7] including cerebral hemorrhage [8], cerebral venous thrombosis (CVT) [9] and CADASIL [10]. A major confounder is action slowing which has been demonstrated to be more frequently due to sensory-motor disorders than attentional and executive disorder in stroke patients [6] except for postaneurysmal frontal stroke [19] Another major limitation of previous studies concerns the evaluation of executive functions, which is variable, frequently incomplete and does not control for the impairment of other cognitive functions. The criteria for impairment varied from one study to another and this has been shown to have a major impact on the functions assessed by several performance scores [23] These observations emphasize the need to use a systematic battery designed according to a theoretical framework defining both behavioral and cognitive aspects of executive functions and controlling for the impairment of instrumental functions.
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