Understanding the extent of long-term neuropsychological deficits poststroke and their contribution to functional outcomes is essential for evidence-based rehabilitation and resource planning, and ...could improve stroke outcomes. However, most existing neuropsychological stroke data are not population-based, examine limited outcomes, and have short-term follow-up.
This population-based long-term stroke follow-up study examined associations between neuropsychological deficits (memory, executive function, information processing speed IPS, visuoperceptual/construction ability, language), depression, and a range of functional outcomes and their interrelationships 5 years poststroke.
The greatest proportion of the 307 participants exhibited neuropsychological functioning within the average range, and about 30%-50% performed at lower levels on most measures; few performed above the average range. Deficits were most common in executive functioning and IPS, and 30.4% of participants were depressed. While correlation analyses indicate all cognitive domains are significantly related to functional outcomes, multiple regression analyses showed that only IPS and visuoperceptual ability made significant independent contributions to functional outcomes over and above age, depression, and current Barthel Index. Depression also made a significant and independent contribution to functional outcomes.
A considerable proportion of 5-year stroke survivors experience neuropsychological deficits, with these being more likely to involve IPS and executive functioning. Visuoperceptual/construction abilities, visual memory, and IPS were independently associated with handicap, disability, and health-related quality of life over and above contributions made by age, depression, and stroke severity, suggesting these areas are important targets for rehabilitation to improve overall stroke recovery and should be evaluated in future randomized controlled trials.
Studying long-term stroke outcomes including body functioning (neurologic and neuropsychological impairments) and activity limitations and participation is essential for long-term evidence-based ...rehabilitation and service planning, resource allocation, and improving health outcomes in stroke. However, reliable data to address these issues is lacking.
This study (February 2007-December 2008) sourced its participants from the population-based incidence study conducted in Auckland in 2002-2003. Participants completed structured self-administered questionnaires, and a face-to-face interview including a battery of neuropsychological tests. Logistic regression analysis was used to analyze associations between and within functional outcomes and their potential predictors.
Of 418 5-year stroke survivors, two-thirds had good functional outcome in terms of neurologic impairment and disability (defined as modified Rankin Score <3), 22.5% had cognitive impairment indicative of dementia, 20% had experienced a recurrent stroke, almost 15% were institutionalized, and 29.6% had symptoms suggesting depression. Highly significant correlations were found between and within various measurements of body functioning (especially neuropsychological impairments), activity, and participation. Age, dependency, and depression were independently associated with most outcomes analyzed.
The strong associations between neuropsychological impairment and other functional outcomes and across various measurements of body functioning, activity, and participation justify utilizing a multidisciplinary approach to studying and managing long-term stroke outcomes. Observed gender and ethnic differences in some important stroke outcomes warrant further investigations.
Secondary ischaemia is a frequent cause of poor outcome in patients with subarachnoid haemorrhage (SAH). Its pathogenesis has been incompletely elucidated, but vasospasm probably is a contributing ...factor. Experimental studies have suggested that calcium antagonists can prevent or reverse vasospasm and have neuroprotective properties.
To determine whether calcium antagonists improve outcome in patients with aneurysmal SAH.
We searched the Cochrane Stroke Group Trials Register (last searched April 2006), MEDLINE (1966 to March 2006) and EMBASE (1980 to March 2006). We handsearched two Russian journals (1990 to 2003), and contacted trialists and pharmaceutical companies in 1995 and 1996.
Randomised controlled trials comparing calcium antagonists with control, or a second calcium antagonist (magnesium sulphate) versus control in addition to another calcium antagonist (nimodipine) in both the intervention and control groups.
Two review authors independently extracted the data and assessed trial quality. Trialists were contacted to obtain missing information.
Sixteen trials, involving 3361 patients, were included in the review; three of the studies were of magnesium sulphate in addition to nimodipine. Overall, calcium antagonists reduced the risk of poor outcome: the relative risk (RR) was 0.81 (95% confidence interval (CI) 0.72 to 0.92); the corresponding number of patients needed to treat was 19 (95% CI 1 to 51). For oral nimodipine alone the RR was 0.67 (95% CI 0.55 to 0.81), for other calcium antagonists or intravenous administration of nimodipine the results were not statistically significant. Calcium antagonists reduced the occurrence of secondary ischaemia and showed a favourable trend for case fatality. For magnesium in addition to standard treatment with nimodipine, the RR was 0.75 (95% CI 0.57 to 1.00) for a poor outcome and 0.66 (95% CI 0.45 to 0.96) for clinical signs of secondary ischaemia.
Calcium antagonists reduce the risk of poor outcome and secondary ischaemia after aneurysmal SAH. The results for 'poor outcome' depend largely on a single large trial of oral nimodipine; the evidence for other calcium antagonists is inconclusive. The evidence for nimodipine is not beyond all doubt, but given the potential benefits and modest risks of this treatment, oral nimodipine is currently indicated in patients with aneurysmal SAH. Intravenous administration of calcium antagonists cannot be recommended for routine practice on the basis of the present evidence. Magnesium sulphate is a promising agent but more evidence is needed before definite conclusions can be drawn.
Background and purpose
Enzogenol, a flavonoid‐rich extract from Pinus radiata bark with antioxidant and anti‐inflammatory properties has been shown to improve working memory in healthy adults. In ...traumatic brain injury (TBI), oxidation and inflammation have been linked to poorer cognitive outcomes. Hence, this phase II, randomized controlled trial investigated safety, compliance and efficacy of Enzogenol for improving cognitive functioning in people following mild TBI.
Methods
Sixty adults, who sustained a mild TBI, 3–12 months prior to recruitment, and who were experiencing persistent cognitive difficulties Cognitive Failures Questionnaire (CFQ) score > 38, were randomized to receive Enzogenol (1000 mg/day) or matching placebo for 6 weeks. Subsequently, all participants received Enzogenol for a further 6 weeks, followed by placebo for 4 weeks. Compliance, side‐effects, cognitive failures, working and episodic memory, post‐concussive symptoms and mood were assessed at baseline, 6, 12 and 16 weeks. Simultaneous estimation of treatment effect and breakpoint was effected, with confidence intervals (CIs) obtained through a treatment–placebo balance‐preserving bootstrap procedure.
Results
Enzogenol was found to be safe and well tolerated. Trend and breakpoint analyses showed a significant reduction in cognitive failures after 6 weeks mean CFQ score, 95% CI, Enzogenol versus placebo −6.9 (−10.8 to −4.1). Improvements in the frequency of self‐reported cognitive failures were estimated to continue until week 11 before stabilizing. Other outcome measures showed some positive trends but no significant treatment effects.
Conclusions
Enzogenol supplementation is safe and well tolerated in people after mild TBI, and may improve cognitive functioning in this patient population. This study provides Class IIB evidence that Enzogenol is well tolerated and may reduce self‐perceived cognitive failures in patients 3–12 months post‐mild TBI.
Background and purpose
Treatments to facilitate recovery after traumatic brain injury (TBI) are urgently needed. We conducted a 9‐month pilot, randomized placebo‐controlled clinical trial to examine ...the safety and potential effects of the herbal supplement MLC901 (NeuroAiD II™) on cognitive functioning following TBI.
Methods
Adults aged 18–65 years at 1–12 months after mild or moderate TBI were randomized to receive MLC901 (0.8 g capsules 3 times daily) or placebo for 6 months. The primary outcome was cognitive functioning as assessed by the CNS Vital Signs online neuropsychological test. Secondary outcomes included the Cognitive Failures Questionnaire, the Rivermead Post‐concussion Symptom Questionnaire (neurobehavioral sequelae), Quality of Life after Brain Injury, Hospital Anxiety and Depression Scale, Modified Fatigue Impact Scale and extended Glasgow Outcome Scale (physical disability). Assessments were completed at baseline and at 3‐, 6‐ and 9‐month follow‐up. Linear mixed‐effects models were conducted, with the primary outcome time‐point of 6 months.
Results
A total of 78 participants mean age 37.5 ± 14.8 years, 39 (50%) female were included in the analysis. Baseline variables were similar between groups (treatment group, n = 36; control group, n = 42). Linear mixed‐effects models controlling for time, group allocation, repeated measurements, adherence and baseline assessment scores revealed significant improvements in complex attention (P = 0.04, d = 0.6) and executive functioning (P = 0.04, d = 0.4) at 6 months in the MLC901 group compared with controls. There were no significant differences between the groups for neurobehavioral sequelae, mood, fatigue, physical disability or overall quality of life at 6 months. No serious adverse events were reported.
Conclusions
MLC901 was safe and well tolerated post‐TBI. This study provided Class I/II evidence that, for patients with mild to moderate TBI, 6 months of MLC901 improved cognitive functioning.
Corticosteroids, particularly dexamethasone, are commonly used for treatments in patients with subarachnoid haemorrhage (SAH) and primary intracerebral haemorrhage (PICH) despite the lack of ...evidence.
This review aimed: (1) to determine whether corticosteroid therapy reduces the proportion of patients who die or have a poor outcome at one to six months after the onset of SAH or PICH; (2) to determine whether corticosteroid therapy reduces the frequency of delayed cerebral ischaemia (DCI) in patients with SAH; (3) to determine the frequency of adverse effects of corticosteroid therapy in patients with SAH or PICH within six months of the onset of the event.
We searched the Cochrane Stroke Group Trials Register (last searched November 2003). In addition, we searched MEDLINE (1966 to March 2004) and EMBASE (1980 to March 2004), and searched reference lists of relevant studies identified. We also made an attempt to identify any relevant ongoing and published or unpublished studies by contacting trialists and pharmaceutical companies.
We sought to identify all randomised or quasi-randomised clinical trials of corticosteroid therapy, in patients with SAH or PICH, that have a placebo or standard strategy arm as control. Patients of any age and either gender with clinically (bed-side) diagnosed PICH and cerebrospinal fluid documented SAH were included in the analysis. The data were analysed both separately and combined for computed tomography (CT)/magnetic resonance imaging (MRI)/autopsy/angiography verified patients.
Data extracted from eligible clinical trials included: (1) death and poor outcome (death, severe disability, or vegetative state) within the first one to six months of the event onset (primary outcomes); (2) development of delayed cerebral ischaemia (as defined by the trialists) in patients with SAH; and (3) adverse effects of the treatment during the scheduled treatment or follow-up period (secondary outcomes). A pooled estimate of the effect size was computed, and the test for heterogeneity between trial results was carried out using The Cochrane Collaboration's Review Manager software, RevMan 4.2. Intention-to-treat analysis was carried out whenever possible.
Eight trials that fulfilled the eligibility criteria were identified, with a total of 256 randomised patients in three SAH trials, and 206 patients in five PICH trials. The studies differed substantially with regard to the study populations and drugs, and methodological quality. The number of patients allocated to either hydrocortisone or fludrocortisone acetate treatment in patients with SAH, or to dexamethasone treatment in patients with PICH, was too small to make any definitive conclusions (confidence intervals were wide for any of the outcome estimates).
Overall, there is no evidence of a beneficial or adverse effect of corticosteroids in patients with either SAH or PICH. Confidence intervals are wide and include clinically significant effects in both directions.
This study aimed to apply the generalizability theory (G-theory) to investigate dynamic and enduring patterns of subjective cognitive complaints (SCC), and reliability of two widely used SCC ...assessment tools.
G-theory was applied to assessment scales using longitudinal measurement design with five assessments spanning 10 years of follow-up.
Community-dwelling older adults aged 70-90 years and their informants, living in Sydney, Australia, participated in the longitudinal Sydney Memory and Ageing Study.
The sample included 232 participants aged 70 years and older, and 232 associated informants. Participants were predominantly White Europeans (97.8%). The sample of informants included 76 males (32.8%), 153 females (65.9%), and their age ranged from 27 to 86 years, with a mean age of 61.3 years (SD = 14.38).
The Memory Complaint Questionnaire (MAC-Q) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).
The IQCODE demonstrated strong reliability in measuring enduring patterns of SCC with G = 0.86. Marginally acceptable reliability of the 6-item MAC-Q (G = 0.77-0.80) was optimized by removing one item resulting in G = 0.80-0.81. Most items of both assessments were measuring enduring SCC with exception of one dynamic MAC-Q item. The IQCODE significantly predicted global cognition scores and risk of dementia incident across all occasions, while MAC-Q scores were only significant predictors on some occasions.
While both informants' (IQCODE) and self-reported (MAC-Q) SCC scores were generalizable across sample population and occasions, self-reported (MAC-Q) scores may be less accurate in predicting cognitive ability and diagnosis of each individual.
To explore whether an interaction between smoking and serum total cholesterol (TC) and/or decreased levels of serum high-density lipoprotein cholesterol (HDLC) exists for any major subtype of ...cardiovascular disease.
An individual participant overview of 34 cohort studies.
The Asia-Pacific region.
People aged >or=20 years without a particular condition or risk factor.
Hazard ratios (HRs) and 95% confidence intervals (CIs) for both TC and HDLC by smoking status were estimated using Cox proportional hazard models adjusted for age and systolic blood pressure and stratified by study and sex.
During follow-up (median 4.0 years), 3298 coronary heart disease (CHD) and 4318 stroke events were recorded. For CHD, the HR (95% CI) for an additional 1.06 mmol/l increment in TC was greater in current smokers than in non-smokers: 1.54 (1.43 to 1.66) versus 1.38 (1.30 to 1.47); p = 0.02. Similarly, the HR (95% CI) for an additional 0.40 mmol/l decrement in HDLC was greater in current smokers than in non-smokers: 1.67 (1.35 to 2.07) versus 1.28 (1.10 to 1.49); p = 0.04. The positive association of TC with ischaemic stroke, and the negative association of TC with haemorrhagic stroke, were broadly similar for current smokers and non-smokers. Similarly, the risks of both the subtypes of stroke remained broadly unchanged as HDLC decreased in both current smokers and non-smokers.
Smoking exacerbated the effects of both TC and HDLC on CHD, although no interaction between smoking and TC or HDLC existed for either of the subtypes of stroke.
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