European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment

Terence J Quinn; Edo Richard; Yvonne Teuschl; Thomas Gattringer; Melanie Hafdi; John T O'Brien; Niamh Merriman; Celine Gillebert; Hanne Huygelier; Ana Verdelho; Reinhold Schmidt; Emma Ghaziani; Hysse Forchammer; Sarah T Pendlebury; Rose Bruffaerts; Milija Mijajlovic; Bogna A Drozdowska; Emily Ball; Hugh S Markus

doi:10.1111/ene.15068

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.

Authors

Terence J Quinn¹, Edo Richard², Yvonne Teuschl³, Thomas Gattringer⁴, Melanie Hafdi⁵, John T O'Brien⁶, Niamh Merriman⁷, Celine Gillebert^{8

9}, Hanne Huygelier^{8

9}, Ana Verdelho¹⁰, Reinhold Schmidt¹¹, Emma Ghaziani¹², Hysse Forchammer¹³, Sarah T Pendlebury¹⁴, Rose Bruffaerts¹⁵, Milija Mijajlovic¹⁶, Bogna A Drozdowska¹, Emily Ball¹⁷, Hugh S Markus¹⁸

Affiliations

¹ Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
² Department of Neurology, Donders Institute for Brain, Behaviour and Cognition, Radboud University Medical Centre, Nijmegen, The Netherlands.
³ Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria.
⁴ Department of Neurology and Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria.
⁵ Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
⁶ Department of Psychiatry, University of Cambridge School of Clinical Medicine, Cambridge, UK.
⁷ Department of Health Psychology, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.
⁸ Department Brain and Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium.
⁹ TRACE, Centre for Translational Psychological Research (TRACE), KU Leuven - Hospital East-Limbourgh, Genk, Belgium.
¹⁰ Department of Neurosciences and Mental Health, Hospital de Santa Maria, Lisbon, Portugal.
¹¹ Department of Neurology and Medical University of Graz, Graz, Austria.
¹² Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.
¹³ Hjernesagen, The Danish Stroke Association, Taastrup, Denmark.
¹⁴ Departments of Medicine and Geratology and NIHR Oxford Biomedical Research Centre Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK.
¹⁵ Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium.
¹⁶ Neurosonology Unit, Neurology Clinic, University Clinical Center of Serbia and Faculty of Medicine University of Belgrade, Belgrade, Serbia.
¹⁷ Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
¹⁸ Stroke Research group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.

PMID: 34476868
DOI: 10.1111/ene.15068

Abstract

Background and purpose: The optimal management of post-stroke cognitive impairment (PSCI) remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making regarding prevention, diagnosis, treatment and prognosis.

Methods: Guidelines were developed according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations.

Results: There was limited randomized controlled trial (RCT) evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Lifestyle interventions and treating vascular risk factors have many health benefits, but a cognitive effect is not proven. We found no evidence regarding routine cognitive screening following stroke, but recognize the importance of targeted cognitive assessment. We describe the accuracy of various cognitive screening tests, but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognition. The association between PSCI and acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on brain magnetic resonance imaging may help predict cognitive outcomes.

Conclusions: These guidelines highlight fundamental areas where robust evidence is lacking. Further definitive RCTs are needed, and we suggest priority areas for future research.

Keywords: cognition; dementia; diagnosis; guidelines; prognosis; stroke.

MeSH terms

Cognitive Dysfunction* / diagnosis
Cognitive Dysfunction* / etiology
Cognitive Dysfunction* / therapy
Humans
Neurology*
Prognosis
Risk Factors
Stroke* / complications
Stroke* / therapy