Development of a Swedish short version of the Montreal Cognitive Assessment for cognitive screening in patients with stroke.

OBJECTIVE: The primary objective was to develop a Swedish short version of the Montreal Cognitive Assessment (s-MoCA-SWE) for use  with patients with stroke. Secondary objectives were to identify an optimal cut-off value for the s-MoCA-SWE to screen for cognitive impairment and to compare its sensitivity with that of previously developed short forms of the Montreal Cognitive Assessment. DESIGN: Cross-sectional study. SUBJECTS/PATIENTS: Patients admitted to stroke and rehabilitation units in hospitals across Sweden. METHODS: Cognition was screened using the Montreal Cognitive Assessment. Working versions of the s-MoCA-SWE were developed using supervised and unsupervised algorithms. RESULTS: Data from 3,276 patients were analysed (40% female, mean age 71.5 years, 56% minor stroke at admission). The suggested s-MoCA-SWE comprised delayed recall, visuospatial/executive function, serial 7, fluency, and abstraction. The aggregated scores ranged from 0 to 16. A threshold for impaired cognition ≤ 12 had a sensitivity of 97.41 (95% confidence interval, 96.64-98.03) and positive predictive value of 90.30 (95% confidence interval 89.23-91.27). The s-MoCA-SWE had a higher absolute sensitivity than that of other short forms. CONCLUSION: The s-MoCA-SWE (threshold ≤ 12) can detect post-stroke cognitive issues. The high sensitivity makes it a potentially useful "rule-out" tool that may eliminate severe cognitive impairment in people with stoke.

Physical Activity Trajectories and Functional Recovery After Acute Stroke Among Adults in Sweden.

Importance: The optimum level and timing of poststroke physical activity interventions to enhance functional recovery remain unclear. Objective: To assess the level of physical activity in the first 6 months after stroke among individuals with similar physical activity patterns over time and to investigate the association between physical activity trajectories and functional recovery at 6 months after stroke. Design, Setting, and Participants: This cohort study obtained data from the Efficacy of Fluoxetine-a Randomized Controlled Trial in Stroke, which was conducted in 35 stroke and rehabilitation centers across Sweden from October 2014 to June 2019. Adult participants (aged >18 years) were recruited between 2 and 15 days after stroke onset and followed up for 6 months. Participants who withdrew or were lost to follow-up were excluded from the longitudinal analysis. Data analyses were performed between August 15 and October 28, 2022. Exposures: Physical activity was assessed at 1 week, 1 month, 3 months, and 6 months. Multiple factors associated with physical activity trajectories were investigated. Association of the distinct trajectories with functional recovery was assessed in multivariable logistic regression. Main Outcomes and Measures: The primary outcomes were the distinct physical activity trajectories over time, which were identified using group-based trajectory modeling. The secondary outcome was the functional recovery at 6 months after stroke, which was assessed using the modified Rankin Scale. Results: Of the 1367 included participants (median [IQR] age, 72 years [65-79] years; 844 males [62%]), 2 distinct trajectory groups were identified: increaser (n = 720 [53%]) and decreaser (647 [47%]). The increaser group demonstrated a significant increase in physical activity level (mean difference, 0.27; linear slope ß1 = 0.46; P < .001) and sustained it at light intensity from 1 week to 6 months, whereas the decreaser group showed a decline in physical activity and eventually became inactive (mean difference, -0.26; linear slope ß1 = 1.81; P < .001). Male participants and those with normal cognition had higher odds of being in the increaser group, regardless of stroke severity. Increasing physical activity and sustaining it at light intensity were associated with a good functional outcome at 6 months (adjusted odds ratio, 2.54; 99% CI, 1.72-3.75; P < .001). Conclusions ad Relevance: Results of this study suggest that increased physical activity was associated with functional recovery 6 months after stroke. Interventions targeting individuals with decreasing physical activity in the subacute phase of stroke may play a role in improved functional outcomes.

Prestroke physical activity is associated with admission haematoma volume and the clinical outcome of intracerebral haemorrhage.

BACKGROUND: Prestroke physical activity (PA) has been linked to improved outcomes after intracerebral haemorrhage (ICH), but its association with ICH volume is unknown. We aimed to investigate associations of prestroke PA with location-specific haematoma volume and the clinical outcome of ICH. METHODS: All patients with primary ICH, admitted to three hospitals between 2014 and 2019, were included. Patients performing light PA ≥4 hour/week the year before stroke were considered physically active. Haematoma volumes were assessed from admission brain imaging. Adjusted associations were estimated using multivariate linear and logistic regression models. Haematoma volume was explored as mediator to the relationship between prestroke PA and mild stroke severity (0-4 points on the National Institutes of Health Stroke Scale), a good 1-week functional status (0-3 points on the modified Rankin Scale) and 90-day survival. Average direct effects (ADE) and average causal mediation effects (ACME) were computed. RESULTS: Of 686 primary ICH cases, 349 were deep, 240 lobar and 97 infratentorial. Prestroke PA predicted smaller haematoma volumes in deep ICH (ß=-0.36, SE=0.09, p<0.001) and lobar ICH (ß=-0.23, SE=0.09, p=0.016). Prestroke PA was also associated with mild stroke severity (OR 2.53, 95% CI 1.59 to 4.01), a good 1-week functional status (OR 2.12, 95% CI 1.37 to 3.30) and 90-day survival (OR 3.48, 95% CI 2.06 to 5.91). Haematoma volume partly mediated the relationships between PA and stroke severity (ADE 0.08, p=0.004; ACME 0.10, p<0.001), 1-week functional status (ADE 0.07, p=0.03; ACME 0.10, p<0.001) and 90-day survival (ADE 0.14, p<0.001; ACME 0.05, p<0.001). CONCLUSIONS: Light PA ≥4 hour/week prior to ICH was associated with smaller haematoma volumes in deep and lobar locations. Physically active patients with ICH had a higher likelihood of mild stroke, a good 1-week functional status and 90-day survival, in part mediated by smaller haematoma volumes on admission.

Associations of Prestroke Physical Activity With Stroke Severity and Mortality After Intracerebral Hemorrhage Compared With Ischemic Stroke.

BACKGROUND AND OBJECTIVES: Prestroke physical activity may protect the brain from severe consequences of stroke. However, previous studies on this subject included mainly ischemic stroke cases, and the association between prestroke physical activity and outcomes after intracerebral hemorrhage is uncertain. Therefore, we sought to examine the associations between prestroke physical activity, stroke severity, and all-cause mortality after intracerebral hemorrhage in comparison with ischemic stroke. METHODS: This was a longitudinal, register-based cohort study. All adult patients with intracerebral hemorrhage or ischemic stroke admitted to 3 stroke units in Gothenburg, Sweden, between November 1, 2014, and June 30, 2019, were screened for inclusion. Physical activity was defined as light physical activity ≥4 h/wk or moderate physical activity ≥2 h/wk the year before stroke. Stroke severity was assessed on admission using the NIH Stroke Scale. All-cause mortality rates were followed up to 7 years, from the time of incident stroke until death or censoring. Ordinal logit models and Cox proportional hazards models were used to estimate adjusted associations of prestroke physical activity. RESULTS: We included 763 patients with intracerebral hemorrhage and 4,425 with ischemic stroke. Prestroke physical activity was associated with less severe strokes by an adjusted odds ratio of 3.57 (99% CI 2.35-5.47) for intracerebral hemorrhages and 1.92 (99% CI 1.59-2.33) for ischemic strokes. During a median follow-up of 4.7 (interquartile range 3.5-5.9) years, 48.5% of patients with intracerebral hemorrhage died, compared with 37.5% with ischemic stroke. Prestroke physical activity was associated with decreased short-term mortality (0-30 days) by an adjusted hazard ratio of 0.30 (99% CI 0.17-0.54) after intracerebral hemorrhage and 0.22 (99% CI 0.13-0.37) after ischemic stroke. Prestroke physical activity was further associated with decreased long-term mortality (30 days-2 years) by an adjusted hazard ratio of 0.40 (99% CI 0.21-0.77) after intracerebral hemorrhage and 0.49 (99% CI 0.38-0.62) after ischemic stroke. DISCUSSION: Prestroke physical activity was associated with decreased stroke severity and all-cause mortality after intracerebral hemorrhage and ischemic stroke, independent of other risk factors. Based on current knowledge, health care professionals should promote physical activity as part of primary stroke prevention.

A cohort study on longitudinal changes in postural balance during the first year after stroke.

INTRODUCTION: Many patients with strokes report increased incidence of fall that can be due to impaired postural balance. The recovery of balance in patients with varying degrees of impairments and activity limitations is less studied, and whether individuals with mild paresis can recover their balance faster is unclear. Better knowledge about factors influencing the recovery of postural balance can be used to guide clinical management after stroke to provide the right rehabilitation to the right person at the right time, and thus to avoid potential fall incidences. OBJECTIVE: This study aims to examine longitudinal changes in postural balance during the first year after stroke. METHODS: Postural balance was assessed using the Berg Balance Scale (BBS) within 5 days, 1, 2, and 3 months and 1-year post-stroke. Stroke severity was stratified using a cluster analysis by including multidimensional baseline measures. A longitudinal mixed-effect model was constructed to analyze changes in proportional balance impairment by stroke severity over time. Individuals with a cut-off of BBS below 45 scores were identified through a classification algorithm using baseline predictors. RESULTS: A total of 135 patients were stratified to mild stroke (77 [57%] patients) or moderate stroke (58 [43%] patients). Ninety-three patients were included in the longitudinal analysis. Significant recovery was found at 1-year for moderate stroke (48% recovery from the initial impaired postural balance, adjusted P < 0.001), but not for mild stroke, after adjusting for age and cognition. Both stroke severities had a maximal recovery in postural balance at 3 months post-stroke, but the moderate stroke group deteriorated after that. Patients with higher age and worse cognition had more severe balance impairments. The classification model achieved a sensitivity of 0.95 (95% confidence interval [CI]: 0.91-0.98) and a specificity of 0.99 (95% CI: 0.98-1.0) for classifying individuals with BBS below 45 points. CONCLUSIONS: This study indicates that continuous improvements in postural balance ends at 3 months regardless for mild or moderate stroke groups, and patients with moderate stroke significantly deteriorate in postural balance after 3 months.

Prestroke physical activity and outcomes after intracerebral haemorrhage in comparison to ischaemic stroke: protocol for a matched cohort study (part of PAPSIGOT).

INTRODUCTION: Piling evidence suggests that a higher level of prestroke physical activity can decrease stroke severity, and reduce the risk of poststroke mortality. However, prior studies have only included ischaemic stroke cases, or a majority of such. We aim to investigate how premorbid physical activity influences admission stroke severity and poststroke mortality in patients with intracerebral haemorrhage, compared with ischaemic stroke. A prespecified analysis plan counteract some inherent biases in observational studies, and promotes transparency. METHODS AND ANALYSIS: This is a statistical analysis protocol for a matched cohort study, including all adult patients with intracerebral haemorrhage, and matched ischaemic stroke controls, treated at Sahlgrenska University Hospital in Sweden between 1 November 2014 and 30 June 2019. All patients have been identified in the Väststroke register, and the data file has been sent for merging with national registries. The follow-up of time for survival will be approximately 2-7 years. The sample size calculation indicates that a minimum of 628 patients with intracerebral haemorrhage is needed for power of 80% at an alpha level of 0.01. Multiple imputation by chained equations will be used to handle missing data. The entire cohort of patients with intracerebral haemorrhage will be matched with consecutive ischaemic stroke controls (1:3 ratio) using nearest neighbour propensity score matching. The association between prestroke physical activity and admission stroke severity will be evaluated using multivariable ordinal regression models, and risk for all-cause mortality will be analysed using multivariable Cox proportional-hazards models. Potential confounders include age, ethnicity, income, educational level, comorbidity, medical treatments, alcohol-related disorders, drug abuse and smoking. ETHICS: Data collection for the Physical Activity Pre-Stroke In GOThenburg project was approved by the Regional Ethical Board on 4 May 2016. An additional application was approved by the National Ethical Review Authority on 7 July 2021.

Barriers to cognitive screening in acute stroke units.

Cognitive impairment is common after stroke. However, not all patients with stroke undergo cognitive screening, despite recommendations. The aim of this retrospective, explorative study was to examine the barriers to cognitive screening in acute stroke units. Data were retrieved from two Swedish Stroke registries. The outcome variable was cognitive screening during the stay at acute stroke units. Forty-three candidate explanatory variables were considered for analysis, encompassing sociodemographic factors and stroke-related outcomes during the stay at acute stroke units. The Least Absolute Shrinkage and Selection Operator and decision-tree methods were used. Of the 1120 patients (56% male, mean age: 72 years, 50% with mild stroke), 44% did not undergo cognitive screening. Walking 10 m post-stroke was the most important attribute for decisions regarding cognitive screening. The classification accuracy, sensitivity, and specificity of the model were 70% (95% CI 63-75%), 71% (63-78%), and 67% (55-77%), respectively. Patient-related parameters that influenced cognitive screening with a valid and reliable screening instrument in acute stroke units included new stroke during the hospitalisation, aphasia at admission, mobility problems, impaired verbal output skills, and planned discharge to another care facility. The barriers to cognitive screening were both patient- and organisation-related, suggesting the need for patient-tailored cognitive screening tools as well as the implementation and systematic adherence to guidelines.

A prospective cohort study on longitudinal trajectories of cognitive function after stroke.

The study aimed to determine longitudinal trajectories of cognitive function during the first year after stroke. The Montreal Cognitive Assessment (MoCA) was used to screen cognitive function at 36-48 h, 3-months, and 12-months post-stroke. Individuals who shared similar trajectories were classified by applying the group-based trajectory models. Data from 94 patients were included in the analysis. Three cognitive functioning groups were identified by the trajectory models: high [14 patients (15%)], medium [58 (62%)] and low [22 (23%)]. For the high and medium groups, cognitive function improved at 12 months, but this did not occur in the low group. After age, sex and education matching to the normative MoCA from the Swedish population, 52 patients (55%) were found to be cognitively impaired at baseline, and few patients had recovered at 12 months. The impact on memory differs between cognitive functioning groups, whereas the impact on activities of daily living was not different. Patients with the poorest cognitive function did not improve at one-year poststroke and were prone to severe memory problems. These findings may help to increase focus on long-term rehabilitation plans for those patients, and more accurately assess their needs and difficulties experienced in daily living.

Physical inactivity after stroke: Incidence and early predictors based on 190 individuals in a 1-year follow-up of the Fall Study of Gothenburg.

OBJECTIVE: To determine the incidence of physical inactivity and factors prior to stroke and in acute stroke that are associated with physical inactivity 1 year after stroke Design: Prospective longitudinal cohort Patients: A total of 190 consecutively included individuals with acute stroke Methods: A follow-up questionnaire, relating to physical activity level using the Saltin-Grimby Physical Activity Scale, was sent to participants in The Fall Study of Gothenburg 1 year after stroke. Predictors of physical inactivity at baseline were identified using univariable and multivariable logistic regression analyses. RESULTS: Physical inactivity 1 year after stroke was reported by 70 (37%) of the 190 patients who answered the questionnaire and was associated with physical inactivity before the stroke, odds ratio (OR) 4.07 (95% confidence interval (95% CI) 1.69-9.80, p = 0.002); stroke severity (assessed by National Institutes of Health Stroke Scale (NIHSS), score 1-4), OR 2.65 (95% CI) 1.04-6.80, p = 0.042) and fear of falling in acute stroke, OR 2.37 (95% CI 1.01-5.60, p = 0.048). CONCLUSION: Almost 4 in 10 participants reported physical inactivity 1 year after stroke. Physical inactivity before the stroke, stroke severity and fear of falling in acute stroke are the 3 main factors that predict physical inactivity 1 year after stroke.

Development of a short-form Swedish version of the Montreal Cognitive Assessment (s-MoCA-SWE): protocol for a cross-sectional study.

INTRODUCTION: Short forms of the Montreal Cognitive Assessment (MoCA) have allowed quick cognitive screening. However, none of the available short forms has been created or validated in a Swedish sample of patients with stroke.The aim is to develop a short-form Swedish version of the MoCA (s-MoCA-SWE) in a sample of patients with acute and subacute stroke. The specific objectives are: (1) to identify a subgroup of MoCA items that have the potential to form the s-MoCA-SWE; (2) to determine the optimal cut-off value of s-MoCA-SWE for predicting cognitive impairment and (3) and to compare the psychometric properties of s-MoCA-SWE with those of previously developed MoCA short forms. METHODS AND ANALYSIS: This is a statistical analysis protocol for a cross-sectional study. The study sample will comprise patients from Väststroke, a local stroke registry from Gothenburg, Sweden and Efficacy oF Fluoxetine-a randomisEd Controlled Trial in Stroke (EFFECTS), a randomised controlled trial in Sweden. The s-MoCA-SWE will be developed by using exploratory factor analysis and the boosted regression tree algorithm. The cut-off value of s-MoCA-SWE for impaired cognition will be determined based on binary logistic regression analysis. The psychometric properties of s-MoCA-SWE will be compared with those of other MoCA short forms by using cross-tabulation and area under the receiving operating characteristic curve analyses. ETHICS AND DISSEMINATION: The Väststroke study has received ethical approval from the Regional Ethical Review Board in Gothenburg (346-16) and the Swedish Ethical Review Authority (amendment 2019-04299). The handling of data generated within the framework of quality registers does not require written informed consent from patients. The EFFECTS study has received ethical approval from the Stockholm Ethics Committee (2013/1265-31/2 on 30 September 2013). All participants provided written consent. Results will be published in an international, peer-reviewed journal, presented at conferences and communicated to clinical practitioners in local meetings and seminars.

Preoperative Patient-Reported Outcomes in Suspected Low-Grade Glioma: Markers of Disease Severity and Correlations with Molecular Subtypes.

This prospective study aims to determine the overall health-related quality of life (HRQoL), functioning, fatigue, and psychological distress preoperatively in patients with suspected diffuse low-grade glioma (dLGG). We were particularly interested if these parameters differed by molecular tumor subtypes: oligodendroglioma, IDHmut astrocytoma and IDHwt astrocytoma. Fifty-one patients answered self-assessed questionnaires prior to operation (median age 51 years; range 19-75; 19 females [37%]). Thirty-five (69%) patients had IDH-mutated tumors, of which 17 were 1p/19q codeleted (i.e., oligodendroglioma) and 18 non-1p/19q codeleted (i.e., IDHmut astrocytoma). A lower overall generic HRQoL was associated with a high level of fatigue (rs = -0.49, p < 0.001), visual disorder (rs = -0.5, p < 0.001), motor dysfunction (rs = -0.51, p < 0.001), depression (rs = -0.54, p < 0.001), and reduced functioning. Nearly half of the patients reported high fatigue (23 out of 51 patients) and anxiety (26/51 patients). Patients with IDHwt had worse generic HRQoL, worse functioning, and more severe fatigue, though differences were not statistically significant between the molecular subtypes. In conclusion, fatigue and anxiety are prominent self-assessed symptoms of patients with suspected dLGG in a preoperative setting, but do not seem to be a reliable method to make assumptions of underlying biology or guide treatment decisions.

Classification of Adverse Events Following Surgery in Patients With Diffuse Lower-Grade Gliomas.

BACKGROUND: Recently, the Therapy-Disability-Neurology (TDN) was introduced as a multidimensional reporting system to detect adverse events in neurosurgery. The aim of this study was to compare the novel TDN score with the Landriel-Ibanez classification (LIC) grade in a large cohort of patients with diffuse lower-grade glioma (dLGG). Since the TDN score lacks validation against patient-reported outcomes, we described health-related quality of life (HRQoL) change in relation to TDN scores in a subset of patients. METHODS: We screened adult patients with a surgically treated dLGG World Health Organization (WHO) grade 2 and 3 between 2010 and 2020. Up until 2017, it consists of a retrospective cohort (n = 158). From 2017 and onwards, HRQoL was registered using EuroQoL-5-dimension, three levels of response (EQ-5D 3L) questionnaire at baseline and 3 months follow-up, in a prospectively recruited cohort (n = 102). Both the LIC grade and TDN score were used to classify adverse events. RESULTS: In total, 231 patients were included. In 110/231 (47.6%) of the surgical procedures, a postoperative complication was registered. When comparing the TDN score to LIC grades, only a minor shift towards complications of higher order could be observed. EQ-5D 3L was reported for 45 patients. Patients with complications related to surgery had pre- to postoperative changes in EQ-5D 3L index values (n = 27; mean 0.03, 95% CI -0.06 to 0.11) that were comparable to patients without complications (n = 18; mean -0.06, 95% CI -0.21 to 0.08). In contrast, patients with new-onset neurological deficit had a deterioration in HRQoL at follow-up, with a mean change in the EQ-5D 3L index value of 0.11 (n = 13, 95% CI 0.0 to 0.22) compared to -0.06 (n = 32, 95% CI -0.15 to 0.03) for all other patients. CONCLUSIONS: In patients with dLGG, TDN scores compared to the standard LIC tend to capture more adverse events of higher order. There was no clear relation between TDN severity and HRQoL. However, new-onset neurological deficit caused impairment in HRQoL. For the TDN score to better align with patient-reported outcomes, more emphasis on neurological deficit and function should be considered.

Predicting Longitudinal Progression in Functional Mobility After Stroke: A Prospective Cohort Study.

BACKGROUND AND PURPOSE: A majority of people with stroke remain impaired in their functional mobility. The aim of the study was to determine longitudinal changes in functional mobility after stroke. METHODS: The study was of a longitudinal and prospective design. The functional mobility was assessed using the Timed Up-and-Go test on 5 different occasions: 5 days after onset, within 24 hours after discharge, 1 month after discharge, 3 months, and 1 year poststroke. Stroke severity was stratified based on impairments and activity limitations using a baseline cluster analysis. A multilevel model was developed to predict longitudinal progression in functional mobility based on stroke severity. RESULTS: One-hundred-thirty-five patients were included at baseline. Two distinct subgroups (moderate stroke [52%] and mild stroke [48%]) were identified based on impairments and activity limitations using clustering. Ninety-one patients were included in the longitudinal analysis. After controlling for age and cognition, significant improvements in functional mobility were found in the moderate stroke group between baseline and 1 year poststroke (mean difference in Timed Up-and-Go test time, -6.4 s, adjusted P<0.001). Patients with moderate stroke had a maximum rate of improvement in functional mobility during the first 3 months poststroke and then declined significantly at 1 year (12% increase in Timed Up-and-Go test time, adjusted P=0.025). Younger patients had better functional mobility. Although there was also a slight improvement in the mild stroke group, it was not statistically significant. CONCLUSIONS: The recovery of functional mobility differs between mild and moderate stroke. Patients with moderate stroke improved their functional mobility during the first 3 months, after which it decreased significantly. These findings suggest that long-term rehabilitation is desirable to maintain and perhaps increase the gained functional mobility. Older patients and those with moderate impairments and activity limitations have particular needs. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01622205.

A multiple motion sensors index for motor state quantification in Parkinson's disease.

AIM: To construct a Treatment Response Index from Multiple Sensors (TRIMS) for quantification of motor state in patients with Parkinson's disease (PD) during a single levodopa dose. Another aim was to compare TRIMS to sensor indexes derived from individual motor tasks. METHOD: Nineteen PD patients performed three motor tests including leg agility, pronation-supination movement of hands, and walking in a clinic while wearing inertial measurement unit sensors on their wrists and ankles. They performed the tests repeatedly before and after taking 150% of their individual oral levodopa-carbidopa equivalent morning dose.Three neurologists blinded to treatment status, viewed patients' videos and rated their motor symptoms, dyskinesia, overall motor state based on selected items of Unified PD Rating Scale (UPDRS) part III, Dyskinesia scale, and Treatment Response Scale (TRS). To build TRIMS, out of initially 178 extracted features from upper- and lower-limbs data, 39 features were selected by stepwise regression method and were used as input to support vector machines to be mapped to mean reference TRS scores using 10-fold cross-validation method. Test-retest reliability, responsiveness to medication, and correlation to TRS as well as other UPDRS items were evaluated for TRIMS. RESULTS: The correlation of TRIMS with TRS was 0.93. TRIMS had good test-retest reliability (ICC = 0.83). Responsiveness of the TRIMS to medication was good compared to TRS indicating its power in capturing the treatment effects. TRIMS was highly correlated to dyskinesia (R = 0.85), bradykinesia (R = 0.84) and gait (R = 0.79) UPDRS items. Correlation of sensor index from the upper-limb to TRS was 0.89. CONCLUSION: Using the fusion of upper- and lower-limbs sensor data to construct TRIMS provided accurate PD motor states estimation and responsive to treatment. In addition, quantification of upper-limb sensor data during walking test provided strong results.