Skip to main content
PMC home page
Journal of Neurology, Neurosurgery, and Psychiatry logoLink to Journal of Neurology, Neurosurgery, and Psychiatry
. 1999 Dec;67(6):742–748. doi: 10.1136/jnnp.67.6.742

Clinical and radiological determinants of prestroke cognitive decline in a stroke cohort

T Pohjasvaara 1, R Mantyla 1, H Aronen 1, M Leskela 1, O Salonen 1, M Kaste 1, T Erkinjuntti 1
PMCID: PMC1736686  PMID: 10567490

Abstract

OBJECTIVES—Stroke seems to be related to dementia more often than previously assumed and vascular factors are also related to Alzheimer's disease. The pathophysiology of poststroke dementia includes ischaemic changes in the brain, a combination of degenerative and vascular changes, and changes only related to Alzheimer's disease. Some cognitive decline recognised after a stroke may be due to pre-existing cognitive decline. The aim of this study was to determine the clinical and radiological determinants of prestroke cognitive decline.
METHODS—The study group comprised 337 of 486 consecutive patients aged 55 to 85 years who 3 months after ischaemic stroke completed a comprehensive neuropsychological test battery; structured medical, neurological, and mental status examination; interview of a knowledgeable informant containing structured questions on abnormality in the cognitive functions; assessment of social functions before the index stroke; and MRI.
RESULTS—Frequency of prestroke cognitive decline including that of dementia was 9.2% (31/337). The patients with prestroke cognitive decline were older, more often had less than 6 years of education, and had history of previous stroke. Vascular risk factors did not differ significantly between these two groups. White matter changes (p=0.004), cortical entorhinal, hippocampal, and medial temporal atrophy (p<0.001), cortical frontal atrophy (p=0.008); and any central atrophy (p<0.01), but not the frequencies or volumes of old, silent, or all infarcts on MRI differentiated those with and without prestroke cognitive decline. The correlates of prestroke cognitive decline in logistic regression analysis were medial temporal cortical atrophy (odds ratio (OR) 7.5, 95% confidence interval (95%CI) 3.2-18.2), history of previous ischaemic stroke (OR 4.4, 95% CI 1.8-10.6), and education (OR 0.9, 95% CI 0.8-0.9).
CONCLUSIONS—History of previous stroke, but not volumes or frequencies was found to correlate with prestroke cognitive decline. Other associating factors were rather those usually associated with degenerative dementia: white matter changes and cerebral atrophy; and in multiple models medial temporal cortical atrophy and education. The possible overlap between two or more underlying diseases must be remembered in diagnosis and treatment of patients with vascular cognitive impairment.



Full Text

The Full Text of this article is available as a PDF (105.0 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Blessed G., Tomlinson B. E., Roth M. The association between quantitative measures of dementia and of senile change in the cerebral grey matter of elderly subjects. Br J Psychiatry. 1968 Jul;114(512):797–811. doi: 10.1192/bjp.114.512.797. [DOI] [PubMed] [Google Scholar]
  2. Breteler M. M., van Amerongen N. M., van Swieten J. C., Claus J. J., Grobbee D. E., van Gijn J., Hofman A., van Harskamp F. Cognitive correlates of ventricular enlargement and cerebral white matter lesions on magnetic resonance imaging. The Rotterdam Study. Stroke. 1994 Jun;25(6):1109–1115. doi: 10.1161/01.str.25.6.1109. [DOI] [PubMed] [Google Scholar]
  3. Cohen D. L., Hedera P., Premkumar D. R., Friedland R. P., Kalaria R. N. Amyloid-beta protein angiopathies masquerading as Alzheimer's disease? Ann N Y Acad Sci. 1997 Sep 26;826:390–395. doi: 10.1111/j.1749-6632.1997.tb48490.x. [DOI] [PubMed] [Google Scholar]
  4. Copeland J. R., Kelleher M. J., Kellett J. M., Gourlay A. J., Gurland B. J., Fleiss J. L., Sharpe L. A semi-structured clinical interview for the assessment of diagnosis and mental state in the elderly: the Geriatric Mental State Schedule. I. Development and reliability. Psychol Med. 1976 Aug;6(3):439–449. doi: 10.1017/s0033291700015889. [DOI] [PubMed] [Google Scholar]
  5. Davis P. B., White H., Price J. L., McKeel D., Robins L. N. Retrospective postmortem dementia assessment. Validation of a new clinical interview to assist neuropathologic study. Arch Neurol. 1991 Jun;48(6):613–617. doi: 10.1001/archneur.1991.00530180069019. [DOI] [PubMed] [Google Scholar]
  6. Erkinjuntti T., Sulkava R., Kovanen J., Palo J. Suspected dementia: evaluation of 323 consecutive referrals. Acta Neurol Scand. 1987 Nov;76(5):359–364. doi: 10.1111/j.1600-0404.1987.tb03594.x. [DOI] [PubMed] [Google Scholar]
  7. Fazekas F., Chawluk J. B., Alavi A., Hurtig H. I., Zimmerman R. A. MR signal abnormalities at 1.5 T in Alzheimer's dementia and normal aging. AJR Am J Roentgenol. 1987 Aug;149(2):351–356. doi: 10.2214/ajr.149.2.351. [DOI] [PubMed] [Google Scholar]
  8. Folstein M. F., Folstein S. E., McHugh P. R. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975 Nov;12(3):189–198. doi: 10.1016/0022-3956(75)90026-6. [DOI] [PubMed] [Google Scholar]
  9. Foulkes M. A., Wolf P. A., Price T. R., Mohr J. P., Hier D. B. The Stroke Data Bank: design, methods, and baseline characteristics. Stroke. 1988 May;19(5):547–554. doi: 10.1161/01.str.19.5.547. [DOI] [PubMed] [Google Scholar]
  10. Frisoni G. B., Geroldi C., Bianchetti A., Trabucchi M., Govoni S., Franceschini G., Calabresi L. Apolipoprotein E epsilon 4 allele frequency in vascular dementia and Alzheimer's disease. Stroke. 1994 Aug;25(8):1703–1704. doi: 10.1161/01.str.25.8.1703. [DOI] [PubMed] [Google Scholar]
  11. Gold G., Giannakopoulos P., Bouras C. Re-evaluating the role of vascular changes in the differential diagnosis of Alzheimer's disease and vascular dementia. Eur Neurol. 1998 Oct;40(3):121–129. doi: 10.1159/000007968. [DOI] [PubMed] [Google Scholar]
  12. Hachinski V. Preventable senility: a call for action against the vascular dementias. Lancet. 1992 Sep 12;340(8820):645–648. doi: 10.1016/0140-6736(92)92177-h. [DOI] [PubMed] [Google Scholar]
  13. Hofman A., Rocca W. A., Brayne C., Breteler M. M., Clarke M., Cooper B., Copeland J. R., Dartigues J. F., da Silva Droux A., Hagnell O. The prevalence of dementia in Europe: a collaborative study of 1980-1990 findings. Eurodem Prevalence Research Group. Int J Epidemiol. 1991 Sep;20(3):736–748. doi: 10.1093/ije/20.3.736. [DOI] [PubMed] [Google Scholar]
  14. Hughes C. P., Berg L., Danziger W. L., Coben L. A., Martin R. L. A new clinical scale for the staging of dementia. Br J Psychiatry. 1982 Jun;140:566–572. doi: 10.1192/bjp.140.6.566. [DOI] [PubMed] [Google Scholar]
  15. Huppert F. A., Tym E. Clinical and neuropsychological assessment of dementia. Br Med Bull. 1986 Jan;42(1):11–18. doi: 10.1093/oxfordjournals.bmb.a072089. [DOI] [PubMed] [Google Scholar]
  16. Hénon H., Pasquier F., Durieu I., Godefroy O., Lucas C., Lebert F., Leys D. Preexisting dementia in stroke patients. Baseline frequency, associated factors, and outcome. Stroke. 1997 Dec;28(12):2429–2436. doi: 10.1161/01.str.28.12.2429. [DOI] [PubMed] [Google Scholar]
  17. Hénon H., Pasquier F., Durieu I., Pruvo J. P., Leys D. Medial temporal lobe atrophy in stroke patients: relation to pre-existing dementia. J Neurol Neurosurg Psychiatry. 1998 Nov;65(5):641–647. doi: 10.1136/jnnp.65.5.641. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Kalaria R. N. Cerebrovascular degeneration is related to amyloid-beta protein deposition in Alzheimer's disease. Ann N Y Acad Sci. 1997 Sep 26;826:263–271. doi: 10.1111/j.1749-6632.1997.tb48478.x. [DOI] [PubMed] [Google Scholar]
  19. Kase C. S., Wolf P. A., Kelly-Hayes M., Kannel W. B., Beiser A., D'Agostino R. B. Intellectual decline after stroke: the Framingham Study. Stroke. 1998 Apr;29(4):805–812. doi: 10.1161/01.str.29.4.805. [DOI] [PubMed] [Google Scholar]
  20. Katz S., Downs T. D., Cash H. R., Grotz R. C. Progress in development of the index of ADL. Gerontologist. 1970 Spring;10(1):20–30. doi: 10.1093/geront/10.1_part_1.20. [DOI] [PubMed] [Google Scholar]
  21. Kokmen E., Whisnant J. P., O'Fallon W. M., Chu C. P., Beard C. M. Dementia after ischemic stroke: a population-based study in Rochester, Minnesota (1960-1984) Neurology. 1996 Jan;46(1):154–159. doi: 10.1212/wnl.46.1.154. [DOI] [PubMed] [Google Scholar]
  22. Kuller L. H., Shemanski L., Manolio T., Haan M., Fried L., Bryan N., Burke G. L., Tracy R., Bhadelia R. Relationship between ApoE, MRI findings, and cognitive function in the Cardiovascular Health Study. Stroke. 1998 Feb;29(2):388–398. doi: 10.1161/01.str.29.2.388. [DOI] [PubMed] [Google Scholar]
  23. Lawton M. P., Brody E. M. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969 Autumn;9(3):179–186. [PubMed] [Google Scholar]
  24. Loeb C., Gandolfo C., Croce R., Conti M. Dementia associated with lacunar infarction. Stroke. 1992 Sep;23(9):1225–1229. doi: 10.1161/01.str.23.9.1225. [DOI] [PubMed] [Google Scholar]
  25. Marcusson J., Rother M., Kittner B., Rössner M., Smith R. J., Babic T., Folnegovic-Smalc V., Möller H. J., Labs K. H. A 12-month, randomized, placebo-controlled trial of propentofylline (HWA 285) in patients with dementia according to DSM III-R. The European Propentofylline Study Group. Dement Geriatr Cogn Disord. 1997 Sep-Oct;8(5):320–328. doi: 10.1159/000106650. [DOI] [PubMed] [Google Scholar]
  26. Mäntylä R., Erkinjuntti T., Salonen O., Aronen H. J., Peltonen T., Pohjasvaara T., Standertskjöld-Nordenstam C. G. Variable agreement between visual rating scales for white matter hyperintensities on MRI. Comparison of 13 rating scales in a poststroke cohort. Stroke. 1997 Aug;28(8):1614–1623. doi: 10.1161/01.str.28.8.1614. [DOI] [PubMed] [Google Scholar]
  27. Nyenhuis D. L., Gorelick P. B. Vascular dementia: a contemporary review of epidemiology, diagnosis, prevention, and treatment. J Am Geriatr Soc. 1998 Nov;46(11):1437–1448. doi: 10.1111/j.1532-5415.1998.tb06015.x. [DOI] [PubMed] [Google Scholar]
  28. Pasquier F. Early diagnosis of dementia: neuropsychology. J Neurol. 1999 Jan;246(1):6–15. doi: 10.1007/s004150050299. [DOI] [PubMed] [Google Scholar]
  29. Patel S. V. Pharmacotherapy of cognitive impairment in Alzheimer's disease: a review. J Geriatr Psychiatry Neurol. 1995 Apr;8(2):81–95. doi: 10.1177/089198879500800202. [DOI] [PubMed] [Google Scholar]
  30. Pfeffer R. I., Kurosaki T. T., Harrah C. H., Jr, Chance J. M., Filos S. Measurement of functional activities in older adults in the community. J Gerontol. 1982 May;37(3):323–329. doi: 10.1093/geronj/37.3.323. [DOI] [PubMed] [Google Scholar]
  31. Pohjasvaara T., Erkinjuntti T., Vataja R., Kaste M. Correlates of dependent living 3 months after ischemic stroke. Cerebrovasc Dis. 1998 Sep-Oct;8(5):259–266. doi: 10.1159/000015863. [DOI] [PubMed] [Google Scholar]
  32. Pohjasvaara T., Erkinjuntti T., Ylikoski R., Hietanen M., Vataja R., Kaste M. Clinical determinants of poststroke dementia. Stroke. 1998 Jan;29(1):75–81. doi: 10.1161/01.str.29.1.75. [DOI] [PubMed] [Google Scholar]
  33. RANKIN J. Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J. 1957 May;2(5):200–215. doi: 10.1177/003693305700200504. [DOI] [PubMed] [Google Scholar]
  34. Saunders A. M., Roses A. D. Apolipoprotein E4 allele frequency, ischemic cerebrovascular disease, and Alzheimer's disease. Stroke. 1993 Sep;24(9):1416–1417. doi: 10.1161/01.str.24.9.1416. [DOI] [PubMed] [Google Scholar]
  35. Skoog I., Berg S., Johansson B., Palmertz B., Andreasson L. A. The influence of white matter lesions on neuropsychological functioning in demented and non-demented 85-year-olds. Acta Neurol Scand. 1996 Feb-Mar;93(2-3):142–148. doi: 10.1111/j.1600-0404.1996.tb00190.x. [DOI] [PubMed] [Google Scholar]
  36. Skoog I., Nilsson L., Palmertz B., Andreasson L. A., Svanborg A. A population-based study of dementia in 85-year-olds. N Engl J Med. 1993 Jan 21;328(3):153–158. doi: 10.1056/NEJM199301213280301. [DOI] [PubMed] [Google Scholar]
  37. Skoog I., Palmertz B., Andreasson L. A. The prevalence of white-matter lesions on computed tomography of the brain in demented and nondemented 85-year-olds. J Geriatr Psychiatry Neurol. 1994 Jul-Sep;7(3):169–175. doi: 10.1177/089198879400700308. [DOI] [PubMed] [Google Scholar]
  38. Tatemichi T. K., Desmond D. W., Stern Y., Paik M., Sano M., Bagiella E. Cognitive impairment after stroke: frequency, patterns, and relationship to functional abilities. J Neurol Neurosurg Psychiatry. 1994 Feb;57(2):202–207. doi: 10.1136/jnnp.57.2.202. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Tatemichi T. K., Foulkes M. A., Mohr J. P., Hewitt J. R., Hier D. B., Price T. R., Wolf P. A. Dementia in stroke survivors in the Stroke Data Bank cohort. Prevalence, incidence, risk factors, and computed tomographic findings. Stroke. 1990 Jun;21(6):858–866. doi: 10.1161/01.str.21.6.858. [DOI] [PubMed] [Google Scholar]
  40. Tatemichi T. K. How acute brain failure becomes chronic: a view of the mechanisms of dementia related to stroke. Neurology. 1990 Nov;40(11):1652–1659. doi: 10.1212/wnl.40.11.1652. [DOI] [PubMed] [Google Scholar]
  41. Terry J. G., Howard G., Mercuri M., Bond M. G., Crouse J. R., 3rd Apolipoprotein E polymorphism is associated with segment-specific extracranial carotid artery intima-media thickening. Stroke. 1996 Oct;27(10):1755–1759. doi: 10.1161/01.str.27.10.1755. [DOI] [PubMed] [Google Scholar]
  42. Vinters H. V. Cerebral amyloid angiopathy. A critical review. Stroke. 1987 Mar-Apr;18(2):311–324. doi: 10.1161/01.str.18.2.311. [DOI] [PubMed] [Google Scholar]
  43. Yerby M. S., Sundsten J. W., Larson E. B., Wu S. A., Sumi S. M. A new method of measuring brain atrophy: the effect of aging in its application for diagnosing dementia. Neurology. 1985 Sep;35(9):1316–1320. doi: 10.1212/wnl.35.9.1316. [DOI] [PubMed] [Google Scholar]

Articles from Journal of Neurology, Neurosurgery, and Psychiatry are provided here courtesy of BMJ Publishing Group

RESOURCES