To diagnose delayed cognitive impairment after stroke, these 3 conditions need to be met

*For medical professionals only

Core features, exclusion criteria, support criteria

At the "Expert Consensus on Poststroke Cognitive Impairment Management (2021 Edition) National Online Tour - Central China Station", Professor Qu Qiumin of the First Affiliated Hospital of Xi'an Jiaotong University brought a wonderful lecture "Late Cognitive Impairment after Stroke - From Concept to Practice", let's follow the steps of Professor Qu Qiumin to learn together

Recognition of delayed cognitive impairment after stroke

       

Post-stroke cognitive impairment (PSCI) refers to a clinical syndrome
characterized by cognitive impairment that occurs after a stroke event and persists until 6 months.

Professor Qu Qiumin said that stroke patients are prone to cognitive impairment, the degree of injury to PSCI standard is called PSCI, to achieve the dementia standard is called post-stroke dementia, the vast majority of PSCI occurs in the early stage of stroke, commonly found in thalamic infarction, medial temporal lobe infarction, horn trapetic infarction, frontotemporal lobe infarction and so on
.


In addition, there is a process of cognitive function change after stroke, Professor Qu Qiumin explained: "Stroke patients have a sharp decline in cognitive function in the early stage, similar to the change process of hemiplegia symptoms, over time, with rehabilitation treatment and neural function compensation, the patient's limb disability will be restored, and cognitive function will gradually recover
.
" At the

same time, Qu Qiumin introduced to us that in 2009, their team found that researchers assessed the cognitive function
of patients with MMSE and MoCA in the acute phase of stroke (within 2 weeks after stroke), 6 weeks, and 12 weeks, respectively.

Using MMSE as a criterion for judging cognitive dysfunction, the incidence of cognitive impairment in the acute phase of stroke is 24%, drops to 12% at 6 weeks, and drops to 9.
9%
at 12 weeks.
When MoCA is used as the standard for screening, it can be reduced to 86.
8% in the acute phase, 68% at 6 weeks, and 38%
at 12 weeks.
It can be found that over time, the cognitive impairment that occurs early in stroke patients will gradually recover
.

However, Professor Qu Qiumin mentioned that some stroke patients may not have obvious cognitive impairment in the early stage
.

In the case shown in the figure above, the patient's cognitive impairment progresses slowly, can it be considered late-onset PSCI?
The "Expert Consensus on the Prevention and Treatment of Post-stroke Cognitive Impairment in China" published in 2020 pointed out that PSCI can be divided into early-onset PSCI (early-onset PSCI) (3 to 6 months after stroke event) and delayed-onset PSCI (6 months after stroke event)
according to the time of occurrence of cognitive impairment after stroke events.

Reflections, explorations and practices on late-onset PSCI

       

Professor Qu Qiumin said that this has caused us to think:
1.
As a PSCI subtype, should late-onset PSCI meet the definition of PSCI?
2.
Most of the post-stroke delirium and neurological deficits are stable
from January to March3, stroke-induced secondary neurodegeneration mainly occurs in
June 4, cognitive impairment occurs after 6 months of stroke, and the relationship with stroke is difficult to determine
Faced with these thoughts, Professor Qu Qiumin introduced to us the definition and clinical features of late-onset PSCI.
.
.

▌ Definition of late-onset PSCI The definition
of late-onset PSCI should be that there is no obvious cognitive impairment in the acute phase of stroke, and cognitive function decline that slowly onsets within 6 months after stroke meets the criteria
of MCI or dementia.

▌Clinical features
of late-onset PSCI (1) Cognitive function is basically normal
in the acute stage of stroke (2) Slow decline
in cognitive function within 6 months after stroke (3) Executive dysfunction is the main manifestation
(4) Secondary brain tissue degeneration is the main cause (5) There is no other cause
of cognitive impairment [such as stroke recurrence, Other brain diseases, systemic factors (electrolyte disorders, vitamin deficiencies, drugs, etc.
)
▌ Diagnosis
of delayed PSCI Qu Qiumin introduced that the diagnosis of delayed PSCI needs to meet 3 conditions: (1) have all core characteristics; (2) No exclusion criteria; (3) There is a support standard for "the presence of obvious cerebral small vascular disease"
.

In addition, Professor Qu Qiumin said that regarding cognitive impairment, these points should be known: (1) cognitive function decline; (2) Lasts for more than 3 months; (3) Non-aging, depression, etc.
; (4) It is not only the delirium period; (5) It is divided into MCI and dementia (the difference is shown in the table below
).

▌ The mechanism
of late-onset PSCI First, Professor Qu Qiumin introduced some related research:
in 2017, studies have shown that the relationship between late-onset PSCI and cerebral small angiopathy is strong
.

In 2015, studies showed that secondary degeneration of the attached white matter fibers and the distal cortex in June after cerebral infarction can occur, regardless of whether a softening foci
is formed after infarction.

A 2019 study showed that patients with cerebral infarction experienced secondary degeneration of white matter on the ipsilateral side of the infarction, despite the gradual recovery of limb disability and improved NIHSS scores over time, which can also explain why patients with cerebral infarction have secondary cognitive dysfunction and mental behavior abnormalities; Other studies have come to similar conclusions
.

.
.
.
.
.
.

Then, Professor Qu Qiumin concluded that the mechanism of late-onset PSCI may be based on cerebral small vascular disease, stroke events induce disorders of cerebral blood flow regulation function, induce inflammatory response, chronic ischemia of brain tissue, damage of the brain barrier, and then lead to degeneration of cerebral white matter, secondary cerebral atrophy, these mechanisms together lead to patients with delayed PSCI, manifested as no cognitive impairment in the early stage of stroke.
After three or four months of stroke, cognitive decline gradually occurred
.

▌ Prevention and control strategy
of late-onset PSCI For such a mechanism, Professor Qu Qiuming said that for the prevention and treatment of late-onset PSCI, there are mainly 2 aspects:
First, improve cognitive function, including cholinesterase inhibitors (CHEIs), non-competitive NMDA receptor antagonists Memantle, cognitive training, brain stimulation, etc.
;
The second is to reduce pathological damage, such as improving cerebral circulation, reducing inflammation, protecting mitochondria, and multi-target therapy
.

Summary: At the end of the lecture, Professor Qu Qiumin made a simple summary:
1.
Delayed
PSCI is a stroke-induced, slow-progressing cognitive decline
.

2.
Late-onset PSCI mainly occurs in patients with cerebral small vascular disease, which may be related
to stroke-induced chronic ischemia of brain tissue, inflammatory response, blood-brain barrier destruction, etc.
, causing leukospermia and brain atrophy.

3.
Improving cerebral microcirculation and protecting the blood-brain barrier may be an important strategy
for the prevention and treatment of delayed PSCI.

Expert profile

Professor Qu Qiumin

• Director of the Department of Neurology, Doctor of Medicine, Chief Physician, Second-level Professor and Doctoral Supervisor of the First Affiliated Hospital of Xi'an Jiaotong University
• Vice President of Cognitive Impairment Branch of Chinese Geriatrics Society
• Vice Chairman of Alzheimer's Disease Branch of China Geriatric Health Care Association
• Member of the Standing Committee of the Vascular Cognitive Impairment Branch of the Chinese Society of Stroke
• Dean of the Northwest HHC School of Cognition
• Leader of the Northwest Parkinson's Disease Prevention and Control Alliance
• His research interests include cognitive impairment and Parkinson's disease

Where to see more wonderful lectures?
Come to the "Doctor's Station" and take a look 👇

Source of this articleMedical Neurology ChannelHope this article is reviewQu Qiumin, Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Responsible Editor
Mr.
Lu Li Xiang Yu

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