Executive and memory dysfunction related to binge drinking in stroke survivors during a 9-year follow-up.

Background: Ischemic stroke and heavy alcohol consumption are both known risk factors for cognitive impairment. The issue gains importance because the prevalence of stroke and binge drinking have both increased among working-aged adults. Alarmingly, a recent cross-sectional study suggests the additive negative effects of binge drinking and comorbid brain disease on cognition. However, the long-term cognitive prognosis of the additive effects of stroke and binge drinking on adults remains unknown. Methods: In this prospective, two-center cohort study, we recruited consecutive 18-65-year-old patients with first-ever ischemic stroke along with demographically matched stroke-free controls. Patients participated in neuropsychological assessment at 6 months, 2 years, and 9 years after stroke, and in neurological assessment at acute care and at 9-year follow-up. Controls participated in a similar follow-up procedure. We examined the association between binge drinking, follow-up time, and long-term cognitive outcomes using repeated-measures analysis of variance. Results: We included 85 patients who had had their first-ever and only ischemic stroke (mean age 53 years at the incident stroke). Patients were divided into binge-drinking (n = 22) and non-binge-drinking groups (n = 63) based on the shortened version of the Alcohol Use Disorders Identification Test. Follow-up data in healthy controls (n = 31) was used to normalize the patients' test scores for effects of age, sex, and education. We compared cognitive changes between binge-drinking and non-binge-drinking patients over a 9-year follow-up. Non-binge-drinking patients outperformed binge-drinking patients across all follow-up points on most of the executive function tests and in one memory test: binge drinking had a significant main effect both on executive function (the phonemic fluency task, p = 0.002; the Trail Making Test, p = 0.013) and memory (the list learning task, p = 0.002). Conclusion: Binge drinking was associated with executive and memory dysfunction at three time points over a decade after a first-ever ischemic stroke. Subdiagnostic binge drinking might increase the adverse effects of a first-ever ischemic stroke on executive function and memory, evident over a decade poststroke.

Virtual reality tasks with eye tracking for mild spatial neglect assessment: a pilot study with acute stroke patients.

Objective: Increasing evidence shows that traditional neuropsychological tests are insensitive for detecting mild unilateral spatial neglect (USN), lack ecological validity, and are unable to clarify USN in all different spatial domains. Here we present a new, fully immersive virtual reality (VR) task battery with integrated eye tracking for mild visual USN and extinction assessment in the acute state of stroke to overthrow these limitations. Methods: We included 11 right-sided stroke patients and 10 healthy controls aged 18-75 years. Three VR tasks named the Extinction, the Storage and the Shoot the target tasks were developed to assess USN. Furthermore, neuropsychological assessment examining various parts of cognitive functioning was conducted to measure general abilities. We compared VR and neuropsychological task performance in stroke patients - those with (USN+, n = 5) and without USN (USN-, n = 6) - to healthy controls (n = 10) and tentatively reported the usability of VR system in the acute state of stroke. Results: Patients had mostly mild neurological and USN symptoms. Nonetheless, we found several differences between the USN+ and healthy control groups in VR task performance. Compared to controls, USN+ patients showed visual extinction and asymmetry in gaze behavior and detection times in distinct spatial locations. Extinction was most evident in the extrapersonal space and delayed detection times on the extreme left and on the left upper parts. Also, USN+ patients needed more time to complete TMT A compared with USN- patients and TMT B compared with controls. VR system usability and acceptance were rated high; no relevant adverse effects occurred. Conclusion: New VR technology with eye tracking enables ecologically valid and objective assessment methods with various exact measures for mild USN and thus could potentially improve future clinical assessments.

Memory decline in young stroke survivors during a 9-year follow-up: A cohort study.

Introduction: A decade after stroke, young stroke survivors continue to suffer from cognitive impairment. However, it is not known whether this long-term cognitive outcome is caused in part by further cognitive decline or solely by incomplete recovery from the acute effects of ischemic stroke. We studied changes in three cognitive domains over a 9-year follow-up period after first-ever and only ischemic stroke. Patients and methods: In this prospective, two-center cohort study, we recruited consecutive 18-65 year-old patients with acute stroke between 2007 and 2009, along with demographically matched stroke-free controls. We performed comprehensive neuropsychological assessments at 3 months, 2, and 9 years after stroke, and we also performed neurological examinations at the time of inclusion and at the 9-year follow-up. We assessed the associations among stroke, follow-up time and long-term cognitive outcomes using repeated-measures analysis of variance. Results: The subjects comprised 85 patients who had had their first-ever and only ischemic stroke (mean age 53 years at inclusion), along with 31 stroke-free demographic controls. We compared the cognitive changes in patients to those in controls over a 9-year follow-up. After initial recovery between 3 months and 2 years after stroke, patients showed a decline in memory between 2 and 9 years after stroke compared to controls within the same time interval (immediate recall p < 0.001; delayed recall p < 0.001; list learning p < 0.001). Other than memory, we found no difference in cognitive changes between poststroke patients and controls. Discussion: Our main finding was memory decline over a decade in young first-ever stroke patients with no further stroke or neurodegenerative disease. Our study extends the previous results of further memory decline in elderly stroke survivors to young stroke survivors. Conclusion: Young stroke survivors might be at risk of memory decline over the decade following the stroke.

Associations between cognition and employment outcomes after epilepsy surgery.

OBJECTIVES: Previous studies have shown that younger age, higher education, and seizure freedom after epilepsy surgery are associated with employment. However, very few studies have investigated associations with cognition and employment status in epilepsy surgery patients. METHODS: This retrospective study consists of 46 adult patients, who underwent resective epilepsy surgery in the Helsinki University Hospital between 2010 and 2018 and who had been assessed by a neuropsychologist prior to surgery and 6 months after surgery using a systematic test battery. In addition to neuropsychological evaluation, neurologists assessed the patients prior to surgery and followed up the patients up to 24 months after the surgery and evaluated work status of the patients. Logistic regression models were used to assess the effects of cognition on changes in employment status, while controlling for age and education. RESULTS: Out of the 46 patients 38 (82.6%) were seizure free and 7 (15.2%) had their seizures reduced 2 years postsurgically. From prior to surgery to 2 years postsurgery, use of antiseizure medication was reduced in most of the patients, mean reduction of the dosage being 26.9%. Employment status improved in 10 (21.7%) patients, remained unchanged in 27 (58.7%) and worsened in 3 (6.5%). An additional 6 patients were already not working prior to surgery. Subsequent analyses are based on the subsample of 37 patients whose employment status improved or remained unchanged. Mistakes in executive function tasks (p = 0.048) and working memory performance (p = 0.020) differentiated between the group whose employment status remained similar and those who were able to improve their employment status. Epilepsy surgery outcome or changes in antiseizure medication (ASM) use were not associated with changes in employment status. CONCLUSIONS: In the subsample of 37 patients, errors in executive function tasks and poorer working memory differentiated patients whose employment status did not change from those patients who could improve their employment status. Problems in executive function and working memory tasks might hinder performance in a complex work environment. When assessing the risks and opportunities in returning to work after surgery, difficulties in working memory and executive function performance should be taken into consideration as they may predispose the patient to challenges at work.

Executive Dysfunction Related to Binge Drinking in Ischemic Stroke.

BACKGROUND: Recent evidence has shown that cognitive dysfunction is associated with a history of binge drinking in adolescents who do not have an alcohol use disorder. Most previous studies with adults, however, have failed to show a link between cognitive dysfunction and subdiagnostic binge drinking, nor have any studies investigated the additive cognitive effect of binge drinking to ischemic stroke. OBJECTIVE: To examine whether a pattern of cognitive dysfunction, especially executive and memory dysfunction, in patients with a first-ever ischemic stroke is associated with a history of subdiagnostic binge drinking. METHODS: We studied 206 first-ever ischemic stroke patients (18-65 years) and 50 healthy, demographically comparable adults-both groups with no alcohol use disorder. After exclusion by matching, 189 patients and 39 healthy participants were included in our study (228 participants). The binge-drinking group included 76 participants; the non-binge-drinking group included 152. A multivariate analysis of covariance was used to compare nine cognitive functions between the two groups, with age, education, and stroke severity used as covariates. RESULTS: Binge drinking had a significant negative effect on executive functions (P<0.001). The non-binge-drinking group outperformed the binge-drinking group on the Stroop Test (P=0.001), Trail Making Test (P=0.002), and a phonemic fluency test (P=0.005). The Binge×Stroke Severity interaction (P=0.037) indicated that a history of binge drinking increased the negative effect of stroke on executive functions. CONCLUSIONS: Subdiagnostic binge drinking may exacerbate the adverse effects of ischemic stroke on executive dysfunction.

Domain-Specific Cognitive Recovery after First-Ever Stroke: A 2-Year Follow-Up.

OBJECTIVES: The aim of this work was to study the change in different cognitive domains after stroke during a 2-year follow-up. METHOD: We evaluated both neuropsychologically and neurologically a consecutive cohort of working-age patients with a first-ever stroke at baseline (within the first weeks), 6 months, and 2 years after stroke-onset. A total of 153 patients participated in all examinations and were compared to 50 healthy controls. RESULTS: Forty-nine percent of the patients were cognitively impaired at baseline, 41% at 6 months, and 39% at 2-year follow-up. We analyzed seven cognitive domains (impairment rates at baseline and 2-year follow-up): psychomotor speed (34%; 23%), executive functions (27%; 17%), visual memory (21%; 4%), visuospatial function (20%; 14%), verbal memory (18%; 12%), basic language processing (baseline 11%; 6 months 5%), and reasoning (2 years 14%). The patients who were cognitively impaired at baseline improved more within 6 months, than either the controls or cognitively intact patients in all cognitive domains (all p<.05). Later on, between 6 months and 2 years, the domain-specific change scores did not differ between patients who were cognitively intact and impaired at 6 months. Also, the cognitive status (intact or impaired) remained the same in 90% of patients between 6-month and 2-year follow-ups. At 2 years, half of the patients, who were categorized cognitively impaired, were rated as well-recovered according to neurological evaluation. CONCLUSIONS: Most of the cognitive improvement took place within 6 months. Long-lasting cognitive impairment was common even after good neurological recovery. An early neuropsychological examination is essential in evaluating cognitive dysfunction and need for rehabilitation. (JINS, 2018, 24, 117-127).

Executive Impairment Is Associated with Impaired Memory Performance in Working-Aged Stroke Patients.

OBJECTIVES: Executive dysfunction is associated with impaired memory performance, but controversies remain about which aspects of memory are involved and how general intelligence influences these connections. We aimed to clarify these connections in stroke patients by comparing various memory measures in patients with and without executive impairment. METHODS: Our consecutive cohort included patients with a first-ever ischemic stroke. Neuropsychological assessments were completed 6 months and 2 years after stroke. We classified patients as executively impaired, when at least two of five executive measures were defective at 6 months. At both 6 months and 2 years, we compared list learning of unrelated words, story recall, and recall of geometric figures in patients with and without executive impairment, while controlling for general intelligence. RESULTS: Patients with executive impairment (n=66; 37%) performed worse in list learning (p=.001; partial η2=.058) and immediate recall of a logical passage (p=.010; partial η2=.037) 6 months after stroke compared to executively intact patients (n=113). At the end of the 2-year follow-up period, the patients who were executively impaired at 6 months (n=53; 37%) still performed worse than executively intact patients (n=92) in list learning (p<.001; partial η2=.096), and additionally in delayed recall of the list (p=.006; partial η2=.052) and immediate recall of geometric figures (p=.007; partial η2=.050). CONCLUSIONS: In our working-aged stroke patients, executive impairment was common. Executive impairment was associated with memory tasks that provided less inherent structure and required the use of active memory strategies. Clinicians should remember this role of executive dysfunction when interpreting memory performance.

Use of Stroke-Related Income Supplements and Predictors of Use in a Working-Aged Finnish Ischemic Stroke Cohort.

BACKGROUND: Compared with the direct costs, the indirect costs of stroke may be larger contributors to the socioeconomic burden of stroke, and the need to better understand the indirect costs of stroke is well established. We investigated the indirect costs of stroke according to a novel outcome, the use of stroke-related income supplements, in a Finnish cohort of working-aged patients. METHODS: Consecutive patients (n = 230) who experienced a first-ever ischemic stroke were recruited. Demographic, clinical, and cognitive function data (which were measured using clinical neuropsychological assessments) were collected at baseline and at 6-month and 2-year follow-ups. Data on the use of income supplements within the first 3 years of the stroke were retrieved from national insurance registry files and used to construct survival models. RESULTS: Stroke patients used a mean of 11 months of stroke-related income supplements; this use was associated with atrial fibrillation, cognitive impairment, prestroke income supplement use, higher National Institutes of Health Stroke Scale scores, lower Barthel Index scores, and increased lesion sizes. In multivariate survival models, atrial fibrillation and cognitive impairment were the factors most strongly associated with the use of stroke-related income supplements. CONCLUSIONS: Using stroke-related income supplement data to quantify poststroke productivity losses allowed a working-aged cohort to be investigated without inclusion restrictions based on occupational status or other factors; the use of these data as an outcome emphasized the well-known detrimental effects of atrial fibrillation and cognitive impairment on stroke outcome. The results support stroke-related income supplement use as a complementary outcome for understanding stroke-related productivity losses.

The cognitive burden of stroke emerges even with an intact NIH Stroke Scale Score: a cohort study.

BACKGROUND: We aim to facilitate recognition of the cognitive burden of stroke by describing the parallels between cognitive deficits and the National Institutes of Health Stroke Scale (NIHSS), a widely used measure of stroke severity. METHODS: A consecutive cohort of 223 working-age patients with an acute first-ever ischaemic stroke was assessed neuropsychologically within the first weeks after stroke and at a 6-months follow-up visit and compared with 50 healthy demographic controls. The NIHSS was administered at the time of hospital admittance and upon discharge from the acute care unit. The associations between total NIHSS scores and domain-specific cognitive deficits were analysed correlatively and with a binary logistic regression. RESULTS: Of the NIHSS measurements (admittance median=3, range 0-24; discharge median=1, range 0-13), the total score at the time of discharge had systematically stronger correlations with cognitive impairment. Adjusted for demographics, the NIHSS discharge score stably predicted every cognitive deficit with ORs ranging from 1.4 (95% CI 1.2 to 1.6) for episodic memory to 1.9 (95% CI 1.5 to 2.3) for motor skills. The specificities of the models ranged from 89.5-97.7%, but the sensitivities were as low as 11.6-47.9%. Cognitive deficits were found in 41% of patients with intact NIHSS scores and in all patients with NIHSS scores ≥4, a finding that could not be accounted for by confounding factors. CONCLUSIONS: Cognitive deficits were common even in patients with the lowest NIHSS scores. Thus, low NIHSS scores are not effective indicators of good cognitive outcomes after stroke.

The severity of cognitive deficits predicts return to work after a first-ever ischaemic stroke.

BACKGROUND: The inability of stroke patients to return to work contributes disproportionately to the socioeconomic impact of stroke and is best predicted by the severity of stroke. However, the role of cognitive deficits in stroke severity has not been scrutinised. We studied whether the initial cognitive severity of stroke, compared with other influential factors, predicts the inability to return to work after stroke. METHODS: Consecutive patients aged 18--65 with a first-ever ischaemic stroke, working full time previously, were assessed neuropsychologically within the first weeks after stroke and at the 6-month follow-up. Similarly, 50 healthy demographic controls were assessed twice. The cognitive severity of stroke was operationalised as the number of initial cognitive deficits. Cognitive severity as a predictor of the inability to return to work was compared with demographic, occupational, neurological, radiological and functional data, vascular risk factors and mood state. RESULTS: The mean age of the 140 patients assessed both initially and at follow-up was 52 years. They had a mean of 13 years of education and 59% were men. At 6 months, only 41% of the patients had returned to work despite the relatively minor neurological and functional impairments of the cohort. In our model, the number of early cognitive deficits (OR=2.252, CI 1.294 to 3.918) was the only significant predictor of the inability to return to work. CONCLUSIONS: The initial cognitive severity of stroke predicts the later inability to return to work. The benefits of neuropsychological assessments within the first weeks after stroke are emphasised.