Stroke occurring in patients with cognitive impairment or dementia

Abstract

Stroke survivors are at risk for (i) new vascular events such as recurrent stroke 1 , myocardial infarction 2 or vascular death 3 ; (ii) complications of treatments 4 ; and (iii) delayed neurological complications, such as epileptic seizures 5,6 , cognitive impairment 7,8 , depression 9 , and pain 10 . Cognitive impairment is one of the major causes of dependency after stroke 7,8 .It is quite frequent that cognitive impairment, or even dementia, was already present before the stroke 7,8 . Stroke and cognitive impairment are both common, occur in the same age category, and share similar risk factors 11 . Moreover, stroke lesions can lead to cognitive impairment, alone or in association with Alzheimer pathology 11 . Most studies on the relationship between stroke and cognitive impairment have focused on cognitive impairment occurring after stroke, or on patients with cognitive impairment who have "apparently silent" brain lesions of vascular origin. However, although one patient in six admitted for a stroke was already demented before the stroke 7,12,13,14 , and probably many more were cognitively impaired, little is known about the characteristics of stroke occurring in patients with pre-existing cognitive decline, and about the optimal management of stroke in these patients. ABSTRACTOne in six patients admitted for stroke was previously demented. These patients have less access to appropriate stroke care, although little is known about their optimal management. Objective: To determine how pre-stroke cognitive impairment can be detected, its mechanism, and influence on outcome and management. Methods: Literature search. Results: (i) A systematic approach with the Informant Questionnaire of Cognitive Decline in the Elderly is recommended; (ii) Pre-stroke cognitive impairment may be due to brain lesions of vascular, degenerative, or mixed origin; (iii) Patients with pre-stroke dementia, have worse outcomes, more seizures, delirium, and depression, and higher mortality rates; they often need to be institutionalised after their stroke; (iv) Although the safety profile of treatment is not as good as that of cognitively normal patients, the risk:benefit ratio is in favour of treating these patients like others. Conclusion: Patients with cognitive impairment who develop a stroke have worse outcomes, but should be treated like others.Keywords: stroke; cerebral infarction; cerebral hemorrhage; dementia; mild cognitive impairment. RESUMOUm em cada seis pacientes internados em decorrência de acidente vascular cerebral (AVC) apresenta diagnóstico prévio de demência. Estes indivíduos têm menor acesso à assistência recomendada para pacientes com AVC, mas pouco ainda se sabe em relação aos cuidados médicos ideais que devem receber. (ii) O comprometimento cognitivo preexistente pode ser devido a lesões cerebrais de origem vascular, degenerativa ou mista; (iii) Pacientes com demência prévia ao AVC têm pior prognóstico, maior frequência de crises epilépticas, de delirium e depressão, além de taxas de mortalidade mais altas; eles ...

The role of pre-stroke cognitive disorders in the formation of post-stroke cognitive impairment

“…В свою очередь взаимодействие этих двух патологических состояний приводит к ухудшению когнитивных функций и прогрессированию их дальнейшего снижения, что отрицательно сказывается на про-цессе восстановления пациента после инсульта. У больных с доинсультными когнитивными нарушениями в остром периоде инсульта чаще наблюдаются расстройства сознания, судорожные приступы и летальные исходы, а в последующем нередко присоединяются депрессивные растройства [28].…”

Stroke as a Cause of Death in Death Certificates of Patients with Dementia: A Cohort Study from the Swedish Dementia Registry

“…Different definitions of stroke as a cause of death in literature make comparisons between studies challenging. Beside this, it is well-known among clinicians that the diagnosis of stroke in a patient with severe dementia is complicated due to impaired communication and cooperation at examination [27]. However, generally high error rates appeared in death certification - approximately 33-41% of…”

Age-related immune alterations and cerebrovascular inflammation

“…Other SASP components secreted by senescent CECs can also promote fibrosis and collagen deposition. [ 4 ] Senescent CECs secrete pro-inflammatory substances (IL-1, IL-6, IL-8) into the vasculature lumen that impair tight junctions between CEC, and [ 5 ] facilitate the infiltration of immune cells and monocytes through the CEC layer. [ 6 ] Infiltrating monocytes reach the internal elastic lamina and change their phenotype to macrophages, [ 7 ] which phagocytize oxidized lipoproteins.…”

“…Although the hallmark of both CAA and AD is amyloid pathology, these diseases are clinically distinct. Less than 50% of CAA cases meet the pathologic criteria for AD and over 75% of patients with AD have only mild or no CAA [ 5 , 51 ]. In CAA, vascular amyloid deposits cause inflammation, hemorrhage, and degradation of vascular smooth muscle cells and pericytes [ 52 , 53 ].…”

“…Age is a risk factor for stroke-related complications such as infections, cardiac events, and delirium, as well as mortality [ 4 ]. Elderly patients also have higher rates of post-stroke depression and cognitive decline [ 5 ]. Stroke accelerates the progression of neurodegenerative diseases, such as Alzheimer’s disease (AD), and is a significant contributor to vascular dementia [ 6 , 7 ].…”