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Introduction my country is the country with the highest lifetime risk of stroke and the heaviest disease burden.
Among them, about one-third of stroke patients will experience post-stroke cognitive impairment (PSCI), and the quality of life and survival time will be severely affected, which is an important reason for the current burden of stroke disease.
In order to further increase the importance of PSCI in clinical work, and to more effectively guide physicians in the standardized management of PSCI, experts from the Vascular Cognitive Impairment Branch of the Chinese Stroke Society have written the 2021 version of the Expert Consensus on Post-stroke Cognitive Impairment Management for reference.
.
The concept of PSCI PSCI refers to a clinical syndrome characterized by cognitive impairment that appears after a stroke event and persists until 6 months.
The establishment of PSCI diagnosis should have three elements: ➤Clear stroke diagnosis: stroke diagnosis supported by clinical or imaging evidence, including transient ischemic attack, hemorrhagic stroke and ischemic stroke.
➤Present cognitive impairment: The patient's chief complaint or the insider's report or the experienced clinician judges that the cognitive impairment occurred after the stroke event, and neuropsychological evidence confirms that there is more than one cognitive domain function impairment or evidence of cognitive decline compared with the past.
➤Sequential relationship between stroke and cognitive impairment: Appears after a stroke event and lasts for 3 to 6 months.
PSCI risk factors PSCI risk factors can be divided into two categories, namely non-intervention factors and intervenable factors.
Non-intervention factors mainly include demographic characteristics, stroke-related factors and imaging characteristics; interventionable factors mainly include vascular risk factors, pre-stroke cognitive impairment and stroke complications.
See Table 1 for details.
Table 1 Assessment of PSCI Risk Factors of Cognitive Impairment After Stroke The clear diagnosis of PSCI requires clinical, imaging, and neuropsychological evaluation.
Clinical evaluation should focus on the diagnosis of stroke through medical history and physical examination, as well as whether there is cognitive impairment and decline in living and working abilities.
At the same time, on the one hand, collecting information that can rule out cognitive impairment caused by other reasons; on the other hand, collecting PSCI risk factors to identify high-risk groups of PSCI.
MRI is the gold standard for imaging evaluation.
The evaluation content includes at least brain atrophy (location and degree), cerebral infarction (location, size, number), white matter lesions (range) and cerebral hemorrhage (location, size, number), which will be clear Provide basis for diagnosis, differential diagnosis, clinical classification and prediction of the occurrence of PSCI.
Neuropsychological assessment to establish cognitive impairment and its degree should include at least five core cognitive domains: executive function, attention, memory, language ability, and visual space ability.
In addition, comorbid conditions such as psycho-behavioral symptoms and affective disorders need to be evaluated.
Prevention of PSCI At this stage, more and more studies suggest that 90% of strokes and 1/3 of dementia are preventable.
PSCI prevention strategies require a comprehensive and holistic approach and cross-professional cooperation: primary prevention for interventions with adjustable risk factors for stroke and cognitive impairment, as well as interventions for acute stroke treatment, prevention of stroke recurrence and early cognitive dysfunction interventions Secondary prevention.
Recommendations: ➤Active control of vascular risk factors can not only reduce the occurrence of stroke events, but also be beneficial to the prevention of dementia (level I recommendation, level B evidence).
➤Patients with hypertension actively control blood pressure, and patients with diabetes actively control blood sugar to prevent PSCI (level I recommendation, level B evidence).
➤Active control of hyperlipidemia may be beneficial to the prevention of PSCI (level IIb recommendation, level C evidence).
➤It is recommended to improve the level of education, actively participate in physical exercise, and increase social participation to enhance cognitive reserve (level I recommendation, level C evidence).
➤Intravenous thrombolysis and/or mechanical thrombectomy in the acute phase of stroke and active prevention of stroke recurrence are beneficial to prevent PSCI (level I recommendation, level B evidence).
Treatment of PSCI The main purpose of treatment of PSCI is to delay the further decline of cognitive impairment, improve cognitive level, improve mental behavior symptoms and improve the ability of daily living.
At present, the treatment methods of PSCI include drug treatment, psycho-behavioral symptom treatment and rehabilitation treatment.
Drug treatment recommendations: ➤ Cholinesterase inhibitors donepezil and rivastigmine can be used in the treatment of PSCI to improve patients' cognitive function and ability of daily living (level I recommendation, level A evidence).
➤The cholinesterase inhibitor galantamine may be effective against PSCI, but its safety and tolerance are poor (level IIa recommendation, level A evidence).
➤Memantine is safe and well tolerated, and may be effective for post-stroke aphasia (level IIa recommendation, level B evidence).
➤Deproteinized calf blood extract and Oxiracetam may be effective in improving the cognitive function of PSCI, but it still needs to be confirmed by large-scale clinical trials (level IIb recommendation, level B evidence).
Recommendations for the treatment of psycho-behavioral symptoms: ➤Non-drug treatment should be the first choice for the treatment of mild psycho-behavioral symptoms (level IIb recommendation, level B evidence).
➤Selective serotonin reuptake inhibitors are recommended for depression treatment (level IIb recommendation, level C evidence).
➤Antipsychotics are the first choice for low-dose atypical antipsychotics, and the clinical benefits and potential risks of the patient must be fully considered (level IIb recommendation, level C evidence).
Rehabilitation treatment recommendations: ➤ Cognitive training intervention studies may be effective in improving PSCI (level IIa recommendation, level B evidence).
➤Rehabilitation treatment should be individualized, and a long-term goal is needed to enable the patient to restore some living abilities as much as possible, such as self-care, family and economic management, psychological balance and return to work, etc.
(Level IIa recommendation, Level C evidence).
Yimaitong compiled from: Wang Kai, Dong Qiang, Yu Jintai, Hu Panpan.
Expert consensus on the management of cognitive impairment after stroke 2021[J].
Chinese Journal of Stroke,2021,16(04):376-389.
Among them, about one-third of stroke patients will experience post-stroke cognitive impairment (PSCI), and the quality of life and survival time will be severely affected, which is an important reason for the current burden of stroke disease.
In order to further increase the importance of PSCI in clinical work, and to more effectively guide physicians in the standardized management of PSCI, experts from the Vascular Cognitive Impairment Branch of the Chinese Stroke Society have written the 2021 version of the Expert Consensus on Post-stroke Cognitive Impairment Management for reference.
.
The concept of PSCI PSCI refers to a clinical syndrome characterized by cognitive impairment that appears after a stroke event and persists until 6 months.
The establishment of PSCI diagnosis should have three elements: ➤Clear stroke diagnosis: stroke diagnosis supported by clinical or imaging evidence, including transient ischemic attack, hemorrhagic stroke and ischemic stroke.
➤Present cognitive impairment: The patient's chief complaint or the insider's report or the experienced clinician judges that the cognitive impairment occurred after the stroke event, and neuropsychological evidence confirms that there is more than one cognitive domain function impairment or evidence of cognitive decline compared with the past.
➤Sequential relationship between stroke and cognitive impairment: Appears after a stroke event and lasts for 3 to 6 months.
PSCI risk factors PSCI risk factors can be divided into two categories, namely non-intervention factors and intervenable factors.
Non-intervention factors mainly include demographic characteristics, stroke-related factors and imaging characteristics; interventionable factors mainly include vascular risk factors, pre-stroke cognitive impairment and stroke complications.
See Table 1 for details.
Table 1 Assessment of PSCI Risk Factors of Cognitive Impairment After Stroke The clear diagnosis of PSCI requires clinical, imaging, and neuropsychological evaluation.
Clinical evaluation should focus on the diagnosis of stroke through medical history and physical examination, as well as whether there is cognitive impairment and decline in living and working abilities.
At the same time, on the one hand, collecting information that can rule out cognitive impairment caused by other reasons; on the other hand, collecting PSCI risk factors to identify high-risk groups of PSCI.
MRI is the gold standard for imaging evaluation.
The evaluation content includes at least brain atrophy (location and degree), cerebral infarction (location, size, number), white matter lesions (range) and cerebral hemorrhage (location, size, number), which will be clear Provide basis for diagnosis, differential diagnosis, clinical classification and prediction of the occurrence of PSCI.
Neuropsychological assessment to establish cognitive impairment and its degree should include at least five core cognitive domains: executive function, attention, memory, language ability, and visual space ability.
In addition, comorbid conditions such as psycho-behavioral symptoms and affective disorders need to be evaluated.
Prevention of PSCI At this stage, more and more studies suggest that 90% of strokes and 1/3 of dementia are preventable.
PSCI prevention strategies require a comprehensive and holistic approach and cross-professional cooperation: primary prevention for interventions with adjustable risk factors for stroke and cognitive impairment, as well as interventions for acute stroke treatment, prevention of stroke recurrence and early cognitive dysfunction interventions Secondary prevention.
Recommendations: ➤Active control of vascular risk factors can not only reduce the occurrence of stroke events, but also be beneficial to the prevention of dementia (level I recommendation, level B evidence).
➤Patients with hypertension actively control blood pressure, and patients with diabetes actively control blood sugar to prevent PSCI (level I recommendation, level B evidence).
➤Active control of hyperlipidemia may be beneficial to the prevention of PSCI (level IIb recommendation, level C evidence).
➤It is recommended to improve the level of education, actively participate in physical exercise, and increase social participation to enhance cognitive reserve (level I recommendation, level C evidence).
➤Intravenous thrombolysis and/or mechanical thrombectomy in the acute phase of stroke and active prevention of stroke recurrence are beneficial to prevent PSCI (level I recommendation, level B evidence).
Treatment of PSCI The main purpose of treatment of PSCI is to delay the further decline of cognitive impairment, improve cognitive level, improve mental behavior symptoms and improve the ability of daily living.
At present, the treatment methods of PSCI include drug treatment, psycho-behavioral symptom treatment and rehabilitation treatment.
Drug treatment recommendations: ➤ Cholinesterase inhibitors donepezil and rivastigmine can be used in the treatment of PSCI to improve patients' cognitive function and ability of daily living (level I recommendation, level A evidence).
➤The cholinesterase inhibitor galantamine may be effective against PSCI, but its safety and tolerance are poor (level IIa recommendation, level A evidence).
➤Memantine is safe and well tolerated, and may be effective for post-stroke aphasia (level IIa recommendation, level B evidence).
➤Deproteinized calf blood extract and Oxiracetam may be effective in improving the cognitive function of PSCI, but it still needs to be confirmed by large-scale clinical trials (level IIb recommendation, level B evidence).
Recommendations for the treatment of psycho-behavioral symptoms: ➤Non-drug treatment should be the first choice for the treatment of mild psycho-behavioral symptoms (level IIb recommendation, level B evidence).
➤Selective serotonin reuptake inhibitors are recommended for depression treatment (level IIb recommendation, level C evidence).
➤Antipsychotics are the first choice for low-dose atypical antipsychotics, and the clinical benefits and potential risks of the patient must be fully considered (level IIb recommendation, level C evidence).
Rehabilitation treatment recommendations: ➤ Cognitive training intervention studies may be effective in improving PSCI (level IIa recommendation, level B evidence).
➤Rehabilitation treatment should be individualized, and a long-term goal is needed to enable the patient to restore some living abilities as much as possible, such as self-care, family and economic management, psychological balance and return to work, etc.
(Level IIa recommendation, Level C evidence).
Yimaitong compiled from: Wang Kai, Dong Qiang, Yu Jintai, Hu Panpan.
Expert consensus on the management of cognitive impairment after stroke 2021[J].
Chinese Journal of Stroke,2021,16(04):376-389.
