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 Huyglier; Ana Verdelho; Reinhold Schmidt; Emma Ghaziani; Hysse Forchammer; Sarah T Pendlebury; Rose Bruffaerts; Milija Mijajlovic; Bogna A Drozdowska; Emily Ball; Hugh S Markus

doi:10.1177/23969873211042192

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

Eur Stroke J. 2021 Sep;6(3):I-XXXVIII. doi: 10.1177/23969873211042192. Epub 2021 Oct 8.

Authors

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

9}, Hanne Huyglier^{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, der Donau, 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 Deptartment of Health Psychology, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.
⁸ Department Brain & 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, Medical University of Graz, Graz, Austria.
¹² Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.
¹³ The Danish Stroke Association, Hjernesagen, Denmark, Denmark.
¹⁴ Departments of Medicine and Geratology and NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
¹⁵ Biomedical Research Institute, Hasselt University, Hasselt, 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, Scotland.
¹⁸ Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.

Abstract

The optimal management of post-stroke cognitive impairment 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 around prevention, diagnosis, treatment and prognosis. These guidelines were developed according to ESO standard operating procedure and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and, where possible, meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. There was limited randomised controlled trial evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Interventions to improve lifestyle and treat vascular risk factors may have many health benefits but a beneficial effect on cognition is not proven. We found no evidence around routine cognitive screening following stroke but recognise the importance of targeted cognitive assessment. We described 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 cognitive syndromes (cognitive impairment, dementia and delirium). The association between post-stroke cognitive impairment and most acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on acute MRI brain may help predict cognitive outcomes. These guidelines have highlighted fundamental areas where robust evidence is lacking. Further, definitive randomised controlled trials are needed, and we suggest priority areas for future research.

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