Key points for the management of cognitive impairment after stroke, see the latest joint guidelines of the European Stroke Organization and the European Society of Neurology

The optimal management of post-stroke cognitive impairment (PSCI) remains controversial
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The European Stroke Organization (ESO) and the European Academy of Neurology (EAN) jointly developed this guideline, which uses 18 PICO (Population, Intervention, Comparator, Outcome) questions and answers for clinicians to make decisions about prevention, diagnosis, treatment and prognosis help
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Prevention of PICO 1: In patients with a history of stroke, are life>➤Recommendation: Life>
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➤Expert consensus statement: Life>
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But other benefits of life>
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Further, sufficiently powered trials are needed to assess the impact of life>
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 PICO 2: Does intensive management of vascular risk factors prevent cognitive impairment and dementia more than usual care in patients with a history of stroke? ➤Recommendation: (1) Intensive blood pressure reduction cannot be recommended solely for the prevention of post-stroke cognitive decline and dementia
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(2) Dual antiplatelet therapy is not recommended to prevent cognitive decline or dementia after lacunar stroke
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(3) Intensive statin therapy cannot be recommended solely for the prevention of post-stroke cognitive decline or dementia
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➤Expert Consensus Statement: Given the benefits of vascular risk factor management for the prevention of recurrent stroke and cardiovascular disease, although the cognitive benefits are unclear, post-stroke interventions including antihypertensive, antithrombotic, and statins are warranted.
Comprehensive risk factor management
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The goals of stroke risk factor management are constantly evolving, and approaches that used to be considered "intensive" are now common practice and recommended in guidelines
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Future trials on secondary stroke prevention should include cognitive outcome measures
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 PICO 3: In patients with a history of stroke, are multiple interventions (life>➤Recommendation: Multiple interventions (life>
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➤ Expert consensus statement (all but one agreed): Multiple interventions cannot be recommended alone for the prevention of post-stroke cognitive decline or dementia, but these interventions have other potential benefits, such as prevention of cardiovascular disease Disease or stroke recurrence
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 PICO 4: In patients with a history of stroke, is cognitive training more effective in preventing cognitive impairment or dementia than usual care? ➤Recommendation: There is uncertainty regarding the benefits and harms of cognitive training for the prevention of post-stroke cognitive decline and dementia
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➤ Expert consensus statement (all but one agreed): Cognitive training after stroke can be applied to patients as part of a broad rehabilitation program
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However, there is currently no evidence that cognitive training as a single intervention has clinical significance or benefit in preventing cognitive decline or dementia after stroke
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 PICO 5: In patients with a history of post-stroke dementia, does discontinuation of vascular risk factor control medications prevent cognitive impairment or improve health-related quality of life more than continuation of medications? ➤ Recommendation: The benefits and harms of continued use of antihypertensive drugs or statins on cognition or quality of life in post-stroke dementia patients compared with discontinuation remain uncertain
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➤Expert consensus statement: Vascular risk factor management drugs are beneficial for cardiovascular disease/stroke prevention, and there is no clear evidence that these drugs impair cognitive function, and vascular risk factor management should continue in patients with mild to moderate post-stroke dementia
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For patients with more advanced dementia and shorter life expectancy, the potential harm and burden of treatment may be greater than the vasoprotective effect, and the benefit of continued stroke secondary prevention drugs is unclear
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Further studies are needed to observe the cognitive effects of drug discontinuation to guide treatment decisions in patients with advanced post-stroke dementia
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 Diagnosing PICO 6: In stroke patients, does routine use of cognitive screening improve stroke care more than no routine screening? ➤Recommendation: The benefits and harms of routine cognitive screening for stroke treatment remain uncertain
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➤Expert consensus statement: Cognitive screening should be considered as part of a comprehensive assessment of stroke survivors
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But there are insufficient data to make recommendations to patients, caregivers, and healthcare systems about the timing, content, or potential benefits of cognitive screening
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Further studies looking at the impact of routine cognitive screening after stroke are needed, and these studies should include acute stroke status, document feasibility and acceptability, consider implications for treatment approaches, and describe treatment staff outcomes and health economics outcomes
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 PICO 7: In stroke patients (acute or post-acute), how accurate is the Montreal Cognitive Assessment (MoCA) for diagnosing post-stroke cognitive impairment or dementia? ➤Recommendation: MoCA is recommended for cognitive screening after acute stroke
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MoCA should not replace comprehensive clinical assessment
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At the conventional positive threshold, MoCA screening will detect the majority of stroke survivors with important cognitive problems, but with a high number of false positives; it is recommended to consider modifying the threshold (lower) for the stroke population
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➤Expert Consensus Statement: MoCA has inherent limitations and it relies on full visuospatial and linguistic capabilities to accomplish
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While MoCA can be used as an initial screening test in the stroke population, consideration should be given to developing a more acceptable and feasible cognitive screening tool for patients with communication difficulties or spatial neglect
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Persons using the MoCA cognitive screening test should receive comprehensive administrative training
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If MoCA is positive, further comprehensive cognitive assessment is recommended and results should be shared with the stroke care team
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 PICO 8: How accurate is MMSE for diagnosing post-stroke cognitive impairment or dementia in stroke patients (acute or post-acute)? ➤Recommendation: MMSE is recommended for cognitive screening after acute stroke
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MMSE should not replace a comprehensive clinical assessment
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At the conventional positive threshold, MMSE screening will exclude most stroke survivors without significant cognitive problems, but there are many false negatives
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➤Expert Consensus Statement: MMSE has inherent limitations and it relies on full visuospatial and linguistic capabilities to accomplish
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While the MMSE can be used as an initial screening test in the stroke population, consideration should be given to developing a more acceptable and feasible cognitive screening tool for patients with communication difficulties or spatial neglect
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Persons using the MMSE cognitive screening test should receive comprehensive management training
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If MMSE is positive, further comprehensive cognitive assessment is recommended and results should be shared with the stroke care team
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 PICO 9: How accurate is the Addenbrooke Cognitive Test (ACE) for diagnosing post-stroke cognitive impairment or dementia in stroke patients (acute or post-acute)? ➤Recommendation: One of the ACE versions is recommended for acute post-stroke cognitive screening
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ACE should not replace a comprehensive clinical assessment
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The optimal threshold for ACE screening for stroke patients has not been established
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➤Expert Consensus Statement: The various versions of ACE have inherent limitations and all rely on full visuospatial and language capabilities to do so
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ACE has not been identified as an initial screening test for the stroke population, and consideration should be given to developing more acceptable and feasible cognitive screening tools for patients with communication difficulties or spatial neglect
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Persons using the ACE Cognitive Screening Test should receive comprehensive administrative training
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If ACE is positive, further comprehensive cognitive evaluation is recommended and results should be shared with the stroke care team
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 PICO 10: How accurate is the Oxford Cognitive Screening (OCS) for diagnosing post-stroke cognitive impairment or dementia in stroke patients (acute or post-acute)? ➤ Recommendation: There is insufficient evidence to assess the accuracy of OCS in diagnosing dementia after stroke
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➤Expert consensus statement: OCS has the advantage over other screening tools that it is easy to complete and applicable to stroke survivors with physical, language, or visuospatial impairments
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Research is needed to observe the accuracy of OCS as a screening function for post-stroke dementia
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Persons using the OCS Cognitive Screening Test should receive comprehensive management training
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If OCS is positive, further comprehensive cognitive assessment is recommended and results should be shared with the stroke care team
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 PICO 11: For stroke patients (acute or post-acute), how accurate is remote assessment for diagnosing post-stroke cognitive impairment or dementia? ➤Recommendation: It is recommended that cognitive screening by telephone be considered after acute stroke
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Telephone-based cognitive screening should not replace comprehensive clinical assessment
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At the conventional positive threshold, phone-based screening would detect most people with significant cognitive problems, but with more false positives
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The optimal threshold for screening stroke patients has not been established
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➤Expert Consensus Statement: Telephone-based cognitive screening has inherent limitations, but telephone screening is useful in situations where in-person assessment is not possible
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Video call-based cognitive screening is promising, but further research and best practice guidance on the application and interpretation of results is needed
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Development and validation of specific telephone or video call cognitive screening tools or protocols should be considered
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Those using remote cognitive screening tests should receive comprehensive administrative training
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If the screening test results are positive, further comprehensive cognitive assessment is recommended and results should be shared with the stroke care team
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Treatment of PICO 12: Are cholinesterase inhibitors more effective than placebo in delaying cognitive decline or progression to dementia, improving behavioral and psychological symptoms, reducing healthcare worker burden, and/or causing adverse effects in patients with post-stroke cognitive impairment event? ➤ Recommendation: In patients with post-stroke cognitive impairment, the benefits and harms of cholinesterase inhibitors on cognitive, behavioral, and psychological symptoms, activities of daily living (ADL), and caregiver burden remain uncertain
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➤Expert Consensus Statement: Any beneficial effect of cholinesterase inhibitors is likely to be modest and likely not clinically relevant in patients with post-stroke cognitive impairment, and the risk of adverse events should also be considered
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In vascular cognitive impairment, these drugs have a small role, but many elderly stroke patients with other neurodegenerative diseases may benefit from cholinesterase inhibitors
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Excluding coexisting Alzheimer's disease or other neurodegenerative disorders in elderly stroke patients can be difficult, and cholinesterase inhibitors may be considered if the diagnosis is likely to be mixed pathology
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If concomitant Alzheimer's disease or dementia with Lewy bodies is suspected, stroke should not be a barrier to consideration of cholinesterase inhibitor therapy
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 PICO 13: In patients with post-stroke cognitive impairment, is memantine more effective than placebo in delaying cognitive decline or progression to dementia, improving behavioral and psychological symptoms, reducing healthcare worker burden, and/or causing adverse events? ➤Recommendation: The benefits and harms of memantine on cognitive, behavioral, and psychological symptoms, ADL, and caregiver burden in patients with post-stroke cognitive impairment remain uncertain
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➤Expert consensus statement: In patients with post-stroke cognitive impairment, any beneficial effect of memantine is likely to be modest and likely not clinically relevant, and the risk of adverse events should also be considered
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In vascular cognitive impairment, these drugs have a small role, but many elderly stroke patients with other neurodegenerative diseases may benefit from memantine
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Excluding coexisting Alzheimer's disease or other neurodegenerative diseases in elderly stroke patients can be difficult, and memantine may be considered if the diagnosis is likely to be mixed pathology
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If moderate-to-severe Alzheimer's disease is suspected, stroke should not be a barrier to consideration of memantine therapy
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 PICO 14: Whether actovegin or cerebrolysin is more effective than placebo in delaying cognitive decline or progression to dementia, improving behavioral and psychological symptoms, reducing health care providers, in patients with post-stroke cognitive impairment Burden and/or cause adverse events? ➤Recommendation: In patients with post-stroke cognitive impairment, the benefits and harms of Avicel or cerebrolysin on cognitive, behavioral, and psychological symptoms, ADL, and caregiver burden remain uncertain
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➤Expert Consensus Statement: Any cognitive benefit of Avegizine or Cerebrolysin is likely to be modest, and there is a risk of serious adverse events from the treatment
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Given the balance of risks and harms, these drugs are not recommended for patients with post-stroke cognitive impairment
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Further research is needed to observe the efficacy of Aiweizhi or cerebrolysin
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 PICO 15: Does cognitive rehabilitation (cognitive skills training or compensatory strategies) delay cognitive decline or progression to dementia, improve behavioral and psychological symptoms, improve ADL performance, or Reduce caregiver burden? ➤ Recommendation: The benefits and harms of most cognitive rehabilitation interventions for stroke survivors remain uncertain
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➤Expert consensus statement: There is growing evidence that cognitive rehabilitation, especially compensatory strategies, may be beneficial for patients with post-stroke cognitive impairment
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Further research is needed to observe the efficacy of cognitive rehabilitation interventions
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 Prognosis PICO 16: Can a multiitem prognostic tool performed shortly after stroke predict cognitive decline or dementia in patients with a history of stroke? ➤Recommendation: The advantages and disadvantages of using a multiitem prognostic tool to predict cognitive outcomes after stroke remain uncertain
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➤Expert consensus statement: The quality of supporting evidence for tools to predict cognitive syndromes (delirium or dementia) is insufficient to recommend their use in routine stroke care
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Further research on prognostic tools for post-stroke cognitive syndrome should follow best practice guidelines for prognostic methods, with particular attention to ensuring appropriate sample sizes, handling of missing data, and external validation in independent populations
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 PICO 17: Can structural features on acute brain CT images predict (at least 1 year after stroke) cognitive decline or dementia in patients with a history of stroke? ➤Recommendation: The value of acute brain CT imaging findings in predicting cognitive outcomes beyond 1 year after stroke remains uncertain
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➤Expert consensus statement: Since CT is the most widely available and commonly used imaging modality for acute stroke, it would be useful to better understand the value of imaging findings for cognitive outcomes
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Further research on the predictive value of CT imaging-based variables should use standardized measures and validated tools
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The population for inclusion needs to be considered, preferably an unselected sample with a low rate of loss to follow-up
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The results of these studies need to be adjusted appropriately to distinguish the additional prognostic value of CT imaging features relative to standard clinical factors such as age, sex, and stroke severity
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 PICO 18: Can acute brain MRI structural features predict (at least 1 year after the stroke event) cognitive decline or dementia in patients with a history of stroke? ➤Recommendation: The presence of presumed white matter lesions of vascular origin (WHM) on acute brain MRI may help predict cognitive outcomes beyond 1 year after stroke
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With the exception of WMH, the value of imaging variables of acute brain MRI for predicting cognitive outcomes beyond 1 year after stroke remains uncertain
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➤Expert consensus statement: Currently, WHM is the most convincing prognostic role in predicting cognitive decline after stroke
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Further research on the predictive value of MRI-based imaging variables should use standardized measures and validated tools
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The population for inclusion needs to be considered, preferably an unselected sample with a low rate of loss to follow-up
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The results of these studies need to be adjusted appropriately to distinguish the additional prognostic value of MRI features relative to standard clinical factors such as age, sex, and stroke severity
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 Index of the original text: European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment.
Eur J Neurol.
2021 Dec;28(12):3883-3920.
doi: 10.
1111/ene.
15068.
Epub 2021 Sep 13.