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Post-stroke cognitive impairment and the risk of stroke recurrence and death in patients with insulin resistance

  • Kat Schmidt
    Affiliations
    Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, George Washington University, Washington, DC, United States
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  • Melinda C. Power
    Affiliations
    Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, United States
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  • Author Footnotes
    1 These authors contributed equally to these work.
    Adam Ciarleglio
    Footnotes
    1 These authors contributed equally to these work.
    Affiliations
    Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, George Washington University, Washington, DC, United States
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  • Author Footnotes
    1 These authors contributed equally to these work.
    Zurab Nadareishvili
    Correspondence
    Corresponding author.
    Footnotes
    1 These authors contributed equally to these work.
    Affiliations
    Department of Neurology, School of Medicine and Health Sciences, The George Washington University, Washington, DC and Stroke Center, Virginia Hospital Center, 1625 North George Mason Drive, Suite #344, Arlington, VA 22205, United States
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  • on behalf of theIRIS Study Group
  • Author Footnotes
    1 These authors contributed equally to these work.

      Abstract

      Objective

      Post-stroke cognitive impairment (PSCI) is associated with etiology, severity, and functional outcome of stroke. The risks of recurrent stroke and death in patients with PSCI and insulin resistance (IR) is unknown. The goal of this study was to determine whether global and domain-specific cognitive impairment after stroke in patients with IR was associated with recurrent stroke and death.

      Materials and Methods

      We studied patients with recent stroke or transient ischemic attack (TIA) and IR with a baseline Modified Mini-Mental State Examination (3MS) cognitive exam at median of 79 days after stroke. We considered a baseline score of ≤ 88 on the 3MS to indicate global cognitive impairment, and domain-specific summary scores in the lowest quartile to indicate language, attention, orientation, memory and visuospatial impairments. The primary endpoint was fatal or non-fatal recurrent stroke, and the secondary endpoints were all-cause mortality, and fatal or non-fatal myocardial infarction (MI).

      Results

      Among studied n = 3,338 patients 13.6% had global cognitive impairment. During the median 4.96 years of follow-up, 7.4% patients experienced recurrent stroke, 3.5% MI, and 7.3% died. In the fully adjusted model, impairment in language (HR 1.35; 95% CI 1.01—1.81) and orientation (HR 1.41; 95% CI: 1.06—1.87) were associated with a higher risk of recurrent stroke, while attention impairment was associated with all-cause mortality (HR 1.34; 95% CI: 1.01—1.78).

      Discussion/Conclusion

      In patients with recent stroke/TIA and IR, post-stroke language and orientation impairments independently predicted recurrent stroke, while attention deficit was associated with increased risk of all-cause mortality.

      Keywords

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      References

        • Pendlebury S.T.
        • Rothwell PM.
        Incidence and prevalence of dementia associated with transient ischaemic attack and stroke: analysis of the population-based oxford vascular study.
        Lancet Neurol. 2019; 18: 248-258
        • Jacova C.
        • Pearce L.A.
        • Costello R.
        • et al.
        Cognitive impairment in lacunar strokes: the SPS3 trial.
        Ann Neurol. 2012; 72: 351-362
        • Moroney J.T.
        • Bagiella E.
        • Tatemichi T.K.
        • et al.
        Dementia after stroke increases the risk of long-term stroke recurrence.
        Neurology. 1997; 48: 1317-1325
        • Kwon H.S.
        • Lee D.
        • Lee M.H.
        • et al.
        Post-stroke cognitive impairment as an independent predictor of ischemic stroke recurrence: PICASSO sub-study.
        J Neurol. 2020; 267: 688-693
        • Tatemichi T.
        • Paik M.
        • Bagiella E.
        • et al.
        Dementia after stroke is a predictor of long-term survival.
        Stroke. 1994; 25: 1915-1919
        • Melkas S.
        • Oksala N.K.
        • Jokinen H.
        • et al.
        Poststroke dementia predicts poor survival in long-term follow-up: influence of prestroke cognitive decline and previous stroke.
        J Neurol Neurosurg Psychiatry. 2009; 80: 865-870
        • Narasimhalu K.
        • Ang S.
        • De Silva D.A.
        • et al.
        The prognostic effects of poststroke cognitive impairment no dementia and domain-specific cognitive impairments in nondisabled ischemic stroke patients.
        Stroke. 2011; 42: 883-888
        • Sibolt G.
        • Curtze S.
        • Melkas S.
        • et al.
        Poststroke dementia is associated with recurrent ischaemic stroke.
        J Neurol Neurosurg Psychiatry. 2013; 84: 722-726
        • Woo J.
        • Kay R.
        • Yuen Y.
        • Nicholls M.
        Factors influencing long-term survival and disability among three-month stroke survivors.
        Neuroepidemiology. 1992; 11: 143-150
        • Oksala N.K.
        • Jokinen H.
        • Melkas S.
        • et al.
        Cognitive impairment predicts poststroke death in long-term follow-up.
        J Neurol Neurosurg Psychiatry. 2009; 80: 1230-1235
        • Patel M.D.
        • Coshall C.
        • Rudd A.G.
        • et al.
        Cognitive impairment after stroke: clinical determinants and its associations with long-term stroke outcomes.
        J Am Geriatr Soc. 2002; 50: 700-706
        • Desmond D.W.
        • Moroney J.T.
        • Bagiella E.
        • et al.
        Dementia as a predictor of adverse outcomes following stroke: an evaluation of diagnostic methods.
        Stroke. 1998; 29: 69-74
        • Yaghi S.
        • Cotsonis G.
        • de Havenon A.
        • et al.
        Poststroke montreal cognitive assessment and recurrent stroke in patients with symptomatic intracranial atherosclerosis.
        J Stroke Cerebrovasc Dis. 2020; 29104663
        • Henon H.
        • Vroylandt P.
        • Durieu I.
        • et al.
        Leukoaraiosis more than dementia is a predictor of stroke recurrence.
        Stroke. 2003; 34: 2935-2940
        • Béjot Y.
        • Jacquin A.
        • Rouaud O.
        • et al.
        One-year survival of demented stroke patients: data from the Dijon stroke registry, France (1985–2008).
        Eur J Neurol. 2012; 19: 712-717
        • Kwan A.
        • Wei J.
        • Dowling N.M.
        • et al.
        Cognitive impairment after lacunar stroke and the risk of recurrent stroke and death.
        Cerebrovasc Dis. 2021; 50: 383-389
        • Kernan W.N.
        • Inzucchi S.E.
        • Viscoli C.M.
        • et al.
        Insulin resistance and risk for stroke.
        Neurology. 2002; 59: 809-815
        • Kernan W.N.
        • Viscoli C.M.
        • Furie K.L.
        • et al.
        Pioglitazone after ischemic stroke or transient ischemic attack.
        N Engl J Med. 2016; 374: 1321-1331
        • Furie K.L.
        • Viscoli C.M.
        • Gorman M.
        • et al.
        Effects of pioglitazone on cognitive function in patients with a recent ischaemic stroke or TIA: a report from the IRIS trial.
        J Neurol Neurosurg Psychiatry. 2018; 89: 21-27
        • Viscoli C.M.
        • Brass L.M.
        • Carolei A.
        • et al.
        Pioglitazone for secondary prevention after ischemic stroke and transient ischemic attack: rationale and design of the insulin resistance intervention after stroke trial.
        Am Heart J. 2014; 168: 823-829
        • Kernan W.N.
        • Viscoli C.M.
        • Dearborn J.L.
        • et al.
        Targeting pioglitazone hydrochloride therapy after stroke or transient ischemic attack according to pretreatment risk for stroke or myocardial infarction.
        JAMA Neurol. 2017; 74: 1319-1327
        • Teng E.L.
        • Chui HC.
        The modified mini mental state (3MS) examination.
        J Clin Psychiatry. 1987; 48: 314-318
        • Espeland M.A.
        • Rapp S.R.
        • Robertson J.
        • et al.
        Benchmarks for designing two-stage studies using modified mini-mental state examinations: experience from the Women's health initiative memory study.
        Clin Trials. 2006; 3: 99-106
        • van Buuren S.
        • Groothuis-Oudshoorn K.
        mice: Multivariate imputation by chained equations in R.
        J Stat Softw. 2011; 45: 1-67
        • Veltkamp R.
        • Pearce L.A.
        • Korompoki E.
        • et al.
        Characteristics of recurrent ischemic stroke after embolic stroke of undetermined source: secondary analysis of a randomized clinical trial.
        JAMA Neurol. 2020; 77: 1233-1240
        • Hyafil F.
        • Schindler A.
        • Sepp D.
        • et al.
        High-risk plaque features can be detected in non-stenotic carotid plaques of patients with ischaemic stroke classified as cryptogenic using combined (18)F-FDG PET/MR imaging.
        Eur J Nucl Med Mol Imaging. 2016; 43: 270-279
        • Ferris S.H.
        • Farlow M.
        Language impairment in Alzheimer's disease and benefits of acetylcholinesterase inhibitors.
        Clin Interv Aging. 2013; 8: 1007-1014
        • McKhann G.M.
        • Knopman D.S.
        • Chertkow H.
        • et al.
        The diagnosis of dementia due to Alzheimer's disease: recommendations from the national institute on aging-alzheimer's association workgroups on diagnostic guidelines for Alzheimer's disease.
        Alzheimers Dement. 2011; 7: 263-269
        • Greenberg S.M.
        • Bacskai B.J.
        • Hernandez-Guillamon M.
        • et al.
        Cerebral amyloid angiopathy and Alzheimer disease - one peptide, two pathways.
        Nat Rev Neurol. 2020; 16: 30-42
        • Shoamanesh A.
        • Pearce L.A.
        • Bazan C.
        • et al.
        Microbleeds in the secondary prevention of small subcortical strokes trial: stroke, mortality, and treatment interactions.
        Ann Neurol. 2017; 82: 196-207
        • Peer M.
        • Salomon R.
        • Goldberg I.
        • et al.
        Brain system for mental orientation in space, time, and person.
        Proc Natl Acad Sci U S A. 2015; 1 (112): 11072-11077
        • Peer M.
        • Lyon R.
        • Arzy S.
        Orientation and disorientation: Lessons from patients with epilepsy.
        Epilepsy Behav. 2014; 41: 149-157
        • Spiers H.J.
        • Burgess N.
        • Maguire E.A.
        • et al.
        Unilateral temporal lobectomy patients show lateralized topographical and episodic memory deficits in a virtual town.
        Brain. 2001; 124: 2476-2489
        • Greicius M.D.
        • Srivastava G.
        • Reiss A.L.
        • et al.
        Default-mode network activity distinguishes Alzheimer's disease from healthy aging: evidence from functional MRI.
        Proc Natl Acad Sci U S A. 2004; 101: 4637-4642
        • Buckner R.L.
        • Snyder A.Z.
        • Shannon B.J.
        • et al.
        Molecular, structural, and functional characterization of Alzheimer's disease: evidence for a relationship between default activity, amyloid, and memory.
        J Neurosci. 2005; 25: 7709-7717
        • McCabe D.P.
        • Roediger H.L.
        • McDaniel M.A.
        • et al.
        The relationship between working memory capacity and executive functioning: evidence for a common executive attention construct.
        Neuropsychology. 2010; 24: 222-243
        • Graham N.L.
        • Emery T.
        • Hodges JR.
        Distinctive cognitive profiles in Alzheimer's disease and subcortical vascular dementia.
        J Neurol Neurosurg Psychiatry. 2004; 75: 61-71
        • Berry C.
        • Sidik N.
        • Pereira A.C.
        • et al.
        Small-vessel disease in the heart and brain: current knowledge, unmet therapeutic need, and future directions.
        J Am Heart Assoc. 2019; 8e011104
        • Toyoda K.
        Cerebral small vessel disease and chronic kidney disease.
        J Stroke. 2015; 17: 31
        • Spence J.D.
        • Viscoli C.M.
        • Inzucchi S.E.
        • et al.
        Pioglitazone therapy in patients with stroke and prediabetes: a post hoc analysis of the IRIS randomized clinical trial.
        JAMA Neurol. 2019; 76: 526-535
        • Quinn T.J.
        • Richard E.
        • Teuschl Y.
        • et al.
        European stroke organisation and European academy of neurology joint guidelines on post-stroke cognitive impairment.
        Eur Stroke J. 2021; 6: 1-38
        • Duering M.
        • Gesierich B.
        • Seiler S.
        • et al.
        Strategic white matter tracts for processing speed deficits in age-related small vessel disease.
        Neurology. 2014; 82 (Jun 3): 1946-1950
        • Corriveau R.A.
        • Koroshetz W.J.
        • Gladman J.T.
        • et al.
        Alzheimer's disease-related dementias summit 2016: national research priorities.
        Neurology. 2017; 89: 2381-2391