Functional, Cognitive and Physical Outcomes 3 Years After Minor Lacunar or Cortical Ischaemic Stroke

Cerebrovascular disease
J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp-2018-319134 on 15 December 2018. Downloaded from http://jnnp.bmj.com/ on September 5, 2019 by guest. Protected by
Research paper
Functional, cognitive and physical outcomes 3 years

after minor lacunar or cortical ischaemic stroke
Caroline A McHutchison,1,2 Vera Cvoro,1,3 Stephen Makin,1,4 Francesca M Chappell,1
Kirsten Shuler,1 Joanna M Wardlaw1,2,5,6
1
Centre for Clinical Brain Abstract (IQ), lower education and more vascular risk factors
Sciences, University of Objective Many studies examining stroke outcomes (eg, atrial fibrillation (AF) and diabetes).5 7
Edinburgh, Edinburgh, UK
2
Centre for Cognitive Ageing focus on more severe strokes or have short follow-up Although many studies have documented
and Cognitive Epidemiology, periods, so the long-term outcomes post-minor ischaemic stroke risk factors and outcomes, most have short
Department of Psychology, stroke are unclear. follow-up periods and do not focus on minor
University of Edinburgh, Methods We recruited participants from inpatient stroke. Pendlebury and colleagues5 found that in 21
Edinburgh, UK hospital-based studies of post-stroke dementia, only
3
NHS Fife Victoria Hospital,
and outpatient services with a lacunar or minor cortical
Kirkcaldy, UK ischaemic stroke (National Institutes of Health Stroke 4 (19%) had a follow-up period of 2 or more years,
4
Institute of Cardiovascular and Scale score <8) and assessed current and premorbid 7 (33.33%) were longitudinal and most included
Medical Science, University of cognitive functioning (Addenbrooke’s Cognitive patients with varying severities, mainly moderate
Glasgow, Glasgow, UK Examination–Revised (ACE-R), National Adult Reading strokes.5 8 Patients with minor stroke, while less
5
UK Dementia Research
Institute, University of Test (NART)), physical functioning (Timed Get Up likely to be physically disabled, may have cognitive
Edinburgh, Edinburgh, UK and Go (TUG), 9-Hole Peg Test (9HPT)), dependency impairment that restricts their return to full inde-
6
Edinburgh Imaging, University (modified Rankin Scale (mRS)), depression (Beck’s pendent function,9 but their long-term outcomes
of Edinburgh, Edinburgh, UK Depression Inventory) in-person and remotely (Stroke are unclear. Furthermore, data on associations
Impact Scale). between cognitive and physical function, depen-
Correspondence to dency and post-stroke comorbidities like depression
Professor Joanna M Wardlaw,
Results We followed up 224/264 participants at 3 years
Centre for Clinical Brain (mean age at index stroke=67, 126 (56%) men, 25 non- are also limited, restricting long-term planning for
Sciences, University of contactable, 15 declined): 66/151 (44%) had cognitive minor ischaemic stroke.
copyright.
Edinburgh, Edinburgh, EH16 impairment, mean ACE-R 88 (SD 9, range 54–100/100), We aimed to document physical and cognitive
4SB, UK; joanna.wardlaw@ed. 61/156 (39%) had depression and 26/223 (12%) were impairment and dependency outcomes at 3 years
ac.uk post-minor ischaemic stroke, including any associ-
dependent (mRS=3–5). Cognitive impairment at 3 years
Received 2 July 2018 affected all ACE-R subdomains and was associated with ations between outcomes and specific independent
Revised 1 October 2018 ACE-R 1 year (β=1.054, p<0.001) and NART (β=1.023, risk factors. We also compared direct in-person
Accepted 29 October 2018 p<0.05). Poor physical function was associated with with indirect (postal/phone) assessments of several
Published Online First 15 domains.
December 2018 stroke severity (TUG, β=1.064, p<0.01) and recurrent
stroke (9HPT, β=1.130, p<0.05 right, β=1.214, p<0.05
left). Higher ACE-R scores were associated with faster Methods
TUG (β=−0.279, p<0.05) and 9HPT (right β=−0.257, Participants
p<0.05; left β=−0.302, p=0.05) and inversely with In this prospective study, we recruited patients with
jnnp.bmj.com dependency (mRS=3–5, OR 0.88, 95% CI 0.80 to 0.97). minor ischaemic stroke (details described previ-
We adjusted analyses for demographic, stroke and ously).6 Briefly, we recruited inpatients and outpa-
known risk factors. In-person and remote assessments tients consecutively assessed by the Lothian Stroke
were highly correlated. Services, Scotland, and diagnosed with minor isch-
Conclusions Cognitive, physical impairments and aemic stroke between May 2010 and May 2012
depression are common and interrelated 3 years after into the Mild Stroke Study 2 (MSS2).
minor stroke. Cognitive and physical impairments require Minor ischaemic stroke was defined as a focal
rehabilitation after minor stroke and argue for better onset of neurological symptoms lasting >24 hours,
integration of stroke and dementia services. with no other explanation, a National Institutes of
Health Stroke Scale (NIHSS) score of <8 and not
expected to result in dependency (modified Rankin
Stroke is a common cause of disability in adults in Scale (mRS) score <3). Stroke was confirmed by
high-income countries. Two-thirds of stroke survi- an expert panel based on clinical findings and MRI
vors in the UK will have some disability1 and a and subtyped as ‘cortical’ or ‘lacunar’ based on clin-
third will be dependent. Stroke is associated with ical stroke syndrome.10
© Author(s) (or their
employer(s)) 2019. Re-use impairments in mobility,2 gait and balance3 and
permitted under CC BY. poor dexterity,1 as well as cognitive impairment and Follow-up
Published by BMJ. dementia.2 4–6 These impairments lead to decreased All participants were invited for follow-up at 1 and
To cite: McHutchison CA, quality of life, low mood and increased mortality, 3 years’ post-index stroke. At 3 years, we contacted
Cvoro V, Makin S, et al. J dependency and disability.4 Risk factors for post- the general practitioner (GP) to ascertain if the
Neurol Neurosurg Psychiatry stroke physical and cognitive impairment overlap participant was alive before sending a brief ques-
2019;90:436–443. and include older age, lower premorbid intelligence tionnaire assessing new diagnoses since the 1-year
436 McHutchison CA, et al. J Neurol Neurosurg Psychiatry 2019;90:436–443. doi:10.1136/jnnp-2018-319134
follow-up. We invited participants to attend a face-to-face outcomes. Where appropriate, we controlled for known risk
assessment by a trained researcher. Where participants could not factors including demographic (eg, age, sex, further education
attend, we offered home visits or telephone interviews. Every and occupation), stroke (eg, stroke subtype and stroke severity),
effort was made to follow up all participants. Where participants vascular risk factors (eg, hypertension, diabetes, hyperlipi-
did not respond, we sought further information from the GP and daemia and AF) and lifestyle variables (eg, smoking and alcohol
hospital records, and sought cause of death from hospital records consumption). Some outcome variables were log transformed to
and death certificates for participants who were deceased. avoid non-normal data and back transformed for reporting.
We used multinomial logistic regression to examine risk factors
for disability (mRS). We grouped participants into no disability
Assessments (mRS=0), no disability but symptoms present (mRS=1), slight
The initial follow-up questionnaire collected information on disability (mRS=2), moderate to severe disability (mRS=3–5)
vascular events (eg, stroke, transient ischaemic attack (TIA) and deceased (mRS=6). Based on the most complete available
and myocardial infarction (MI)), new diagnoses of vascular risk data, we included age at index stroke, sex, stroke type, index
factors and lifestyle factors (eg, smoking and alcohol use) since stroke severity, recurrent stroke, vascular risk factors and self-re-
1 year of follow-up. ported subjective cognitive difficulties at 1 year (yes/no) as
We collected sociodemographic information including socio- predictors.
economic status in adulthood (eg, occupation, living situation)
and childhood (eg, address, size of house and number of people
living in their home at age 11), and education (secondary school Results
or less/further education following secondary school). At baseline, 264 patients with clinically confirmed minor isch-
We assessed recovery from stroke using the mRS (6=deceased), aemic stroke were recruited.6 At 3 years post-stroke, all living
Clinical Dementia Rating Scale (CDR),11 Stroke Impact Scale participants were followed up and 202/264 (77%) provided
(SIS)12 and European Quality of Life (EQ-5D-5L) scale.13 When data either in person (157, 78%) or by post or phone (45, 22%;
SIS Emotion Domain responses were inconsistent (eg, feel figure 1). Those who participated at 3 years (n=202) were more
sad=‘none of the time’ and feel like life is worth living=‘none of likely to have self-reported subjective cognitive difficulties at 1
the time’) and the participant could not be contacted for confir- year than those without follow-up. There were no significant
mation, responses were removed (n=10). differences in demographic or index stroke characteristics.
Participants who were not seen for in-person assessment (due Of the 62 participants without follow-up data, 25 (40%) were
to illness or no longer living in the area) were invited to complete not contactable, 15 (24%) declined and 22 (3%) were deceased.
the SIS, EQ-5D-5L and sociodemographic questionnaire by post Causes of death included cancer (n=13), recurrent stroke (n=3),
or phone (figure 1 indicates subjective/self-reported and objec- MI (n=2), heart failure, pulmonary fibrosis, sepsis and unknown
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tive/in-person measures). (all n=1). As such, outcomes were available for 224 (202 with
For those seen in person, we assessed current cognition using follow-up data and 22 deceased)/264 (85%) participants, with
the Montreal Cognitive Assessment (MoCA),14 Addenbrooke’s mean age at index stroke=67, and 126 (56%) men. Of these,
Cognitive Examination–Revised (ACE-R)15 and Mini-Mental 29/223 (13%) experienced a further vascular event including
State Examination (MMSE)16 and premorbid IQ using the 21 (9%) with recurrent stroke or TIA and 8 (4%) with MI. A
National Adult Reading Test (NART), which provided a stan- new diagnosis of hypertension, hyperlipidaemia, diabetes and/
dardised estimate of peak cognitive performance in early adult- or AF was reported by 67 (30%) participants since the 1-year
hood.17 Where possible, an informant provided information follow-up (table 1, online supplementary table 1).
on prestroke changes in cognition using the Informant Ques-
tionnaire of Cognitive Decline in the Elderly.18 We assessed
depression using Beck’s Depression Inventory (BDI).19 When Cognition
participants did not provide a response to question 21 (Loss of We assessed cognitive functioning in 153/157 (97%) participants
interest in sex) citing it was not applicable (eg, partner deceased), seen for in-person assessment. Reasons for no cognitive assess-
a score of 0 was assigned (n=12). ment included visual impairment, English as a second language,
We measured physical functioning using the Timed Get Up declined and not completed (all n=1).
and Go (TUG),20 where participants rise from a chair, walk 3 Scores on the MoCA (n=153) ranged from 10 to 30/30
metres and back returning to a seated position, and the Nine (M=25.15, SD 4.03) with impairment (MoCA <26) in 71
Hole Peg Test (9HPT)21 where participants remove nine small (46%) participants. Scores on the MMSE (n=153) ranged
pegs one at a time before replacing them. Both tasks are timed. from 16 to 30/30 (M=27.96, SD 2.48) with impairment in 28
(18.3%) participants. Scores on the ACE-R (n=151) ranged
from 54 to 100/100 (M=88.32, SD 8.92) with severe impair-
Statistical analysis ment (ACE-R ≤82) in 31 (21%), mild impairment (ACE-R=83–
We analysed cognitive and physical functioning as contin- 88) in 35 (23%) and normal cognition in 85 (56%) participants
uous variables. Where applicable, we categorised scores based (figure 2). Those with impairment showed significantly poorer
on established cut-offs. MoCA scores ≥26 were considered performance across all subscales compared with those with no
normal.14 ACE-R scores were grouped into severe (≤82), mild impairment on the ACE-R and MoCA (table 2).
(83-88) and no cognitive impairment (≥89).15 Several cut-offs Scores on the CDR (n=157) ranged from 0 to 1/3. Question-
exist for the MMSE. We considered scores ≥27 as normal.22 able (CDR=0.5) and mild (CDR=1) symptoms of dementia
We used Mann-Whitney U test (U) to compare groups based on were reported in 75 (48%) and 8 (5%) participants, respectively
levels of cognitive impairment on subscales of the ACE-R and (figure 2). No symptoms of dementia (CDR=0) were reported
MoCA to determine whether any specific deficit was driving this. in the remaining 74 (47%).
We used linear regression to examine predictors of cognitive Age (β=−0.306, 95% CI −0.181 to −0.042), male sex
and physical functioning and the relationship between these (β=−0.191, 95% CI −2.966 to −0.164), premorbid IQ
McHutchison CA, et al. J Neurol Neurosurg Psychiatry 2019;90:436–443. doi:10.1136/jnnp-2018-319134 437
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Figure 1 Flow diagram for data collection in the MSS2 3-year follow-up. *Number with self-reported modified Rankin Scale. †Scores of 6 are based
on those deceased at 3-year follow-up. ‡Self-reported/subjective measure. §In-person/objective measure. ACE-R, Addenbrooke’s Cognitive Examination–
Revised; EQ-5D-5L, European Quality of Life scale; FU, follow-up; MMSE, Mini-Mental State Examination; MoCA, Montreal Cognitive Assessment; MSS2,
Mild Stroke Study 2; NART, National Adult Reading Test; 9HPT, Nine Hole Peg Test; SIS, Stroke Impact Scale; TUG, Timed Get Up and Go.
(NART; β=0.344, 95% CI 0.063 to 0.260), MoCA scores at (BDI=30–63) in 6 (34%) participants. The remaining 95 (61%)
1 year (β=0.368, 95% CI 0.188 to 0.639) and hypertension scored within the normal range. Higher BDI scores were asso-
(β=0.328, 95% CI 0.864 to 5.571) predicted MoCA scores ciated with male sex (β=0.705, p<0.05) and recurrent stroke
at 3 years. Age (B=0.980, p<0.001), ACE-R scores at 1 year (β=1.659, p<0.01). No other demographic, stroke or lifestyle
(B=1.054, p<0.001) and premorbid IQ (NART; B=1.023, variables significantly contributed.
p<0.05) predicted ACE-R scores at 3 years. Sex, further educa-
tion, adult SES, vascular risk factors and lifestyle factors did not Physical outcomes
significantly contribute (table 3). Physical functioning was assessed in 153/157 (97%) participants
seen for in-person assessment. Four did not complete the 9HPT
Depression (poor vision (n=2), ran out of time and did not consent (both
Depression scores (BDI; n=156) ranged from 0 to 49/63 n=1)) and 12 did not complete the TUG (mobility difficulties
(M=9.81, SD 9.12) with mild depression (BDI=10–18) in (n=6), did not consent or declined (n=4), ran out of time and
35 (22%), moderate (BDI=19–29) in 61 (39%) and severe other (both n=1)).
p<0.05, respectively) and left hand performance (β=1.012,
Table 1 Descriptive statistics at 3-year follow-up
p<0.001 and β=1.214, p<0.05, respectively). Slower TUG
Variable N Descriptive times were associated with age (β=1.009, p<0.01) and stroke
Demographics severity (β=1.064, p<0.01; table 4).
Age at index stroke 224 67.13±11.49
Sex: male n (%) 224 126 (56.25) Physical, cognitive and functional outcomes
Further education: yes n (%) 159 65 (29.15) When controlling for age, higher ACE-R scores were associated
Adult SES n (%) 157 with faster TUG (β=−0.279, p<0.05) and 9HPT times (right
High 49 (31.21) hand: β=−0.257, p<0.05; left hand: β=−0.302, p=0.05).
Middle 49 (31.21) Lower ACE-R scores were associated with increased risk of
Low 59 (37.58) moderate to severe disability (mRS=3–5; OR 0.88, 95% CI 0.80
Premorbid IQ 153 112.2±8.44 to 0.97) when controlling for age and premorbid IQ.
Stroke characteristics
Stroke type n (%) 224 Disability and recovery after stroke
Cortical 131 (58.48) Disability was measured using self-reported (n=217, including
Lacunar 93 (41.52) those who were deceased) and interviewer-reported mRS
NIHSS worst 224 2.34 (1.32) (n=156). Moderate to severe disability (mRS=3–5) was reported
3-year outcomes in 26/217 (12%) and 19/156 (12%) participants in self-reported
Further vascular event: yes n (%)*† 224
and in-person assessment, respectively (table 1).
Stroke or TIA 21 (9.37)
Moderate to severe disability (mRS=3–5) was associated with
age (OR 1.06, 95% CI 1.01 to 1.12), stroke severity (OR 2.29,
MI 8 (3.57)
95% CI 1.48 to 3.36), recurrent stroke (OR 5.25, 95% CI 1.63
Disability: mRS† n (%) 217
to 20.48) and self-reported cognitive difficulties at 1 year (OR
No symptoms 54 (24.88)
6.53, 95% CI 2.11 to 20.22). Death (mRS=6) was associated
No significant disability 69 (31.80)
with age (OR 1.10, 95% CI 1.05 to 1.18). Sex, stroke type and
Slight disability 46 (21.20) vascular risk factors were not associated with disability. Self-re-
Moderate disability 14 (6.45) ported cognitive difficulties at 1 year were also associated with
Moderate/severe disability 9 (4.15) increased risk of symptoms without disability (mRS=1; OR
Severe disability 3 (1.38) 3.00, 95% CI 1.31 to 6.82) and slight disability (mRS=2; OR
Dead 22 (10.14) 5.10, 95% CI 2.05 to 12.68).
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Cognition‡
ACE-R 151 88.32±8.92 In-person versus indirect assessments
MoCA 153 25.15±4.03 We used the SIS (n=166) and EQ-5D-5L (n=163) to measure
MMSE 153 27.96±2.48 self-reported post-stroke recovery with higher scores indicating
BDI‡ 156 9.81±9.12 better functioning. Overall, self-reported functioning was good
Physical functioning‡ with median scores of 1/5 across the EQ-5D-5L domains and
TUG 145 11.91±4.61 average scores on the SIS domains ranging from 82.27/100
9HPT-right 153 28.18±11.68 (Strength Domain) to 90.34/100 (Communication Domain;
9HPT-left 153 31.05±15.42 online supplementary table 1).
Descriptive statistics are either ±mean and SD or n (%). Higher ACE-R scores (β=0.41, bootstrapped (2000 repli-
*Since 1-year follow-up and including those with further vascular events as cause cations) 95% CI 0.33 to 1.32) were associated with better SIS
of death. Memory domain scores when controlling for age and premorbid
†Subjective/self-reported. IQ. Faster TUG performance was associated with better SIS
‡Objective/in-person assessment. Mobility domain scores (β=−0.63, 95% CI −2.87 to −1.86)
ACE-R, Addenbrooke's Cognitive Examination - Revised; BDI, Beck's Depression
and faster right and left 9HPT performance was associated
Inventory; 9HPT, Nine Hole Peg Test; MI, Myocardial Infarction; MMSE, Mini Mental
State Examination; MoCA, Montreal Cognitive Assessment; NIHSS, National with better SIS Hand Function domain scores (β=−0.40, boot-
Institutes of Health Stroke Scale; SES, Socioeconomic status; TIA, Transient strapped (2000 replications) 95% CI −1.06 to −0.46 and
Ischaemic Attack; TUG, Timed Get Up and Go; mRS, Modified Rankin Scale. β=−0.48, bootstrapped (2000 replications) 95% CI −0.91
to −0.46, respectively) when controlling for age. Lower SIS
Emotion domain scores were associated with higher BDI scores
Scores on the TUG (n=145) ranged from 3 to 39 s (M=12, (β=−0.77, 95% CI −1.80 to −1.37).
SD 5). Scores on the 9HPT (n=153) ranged from 14 to 110 s
(mean=28, SD 12) and 16–149 s (M=31, SD 15) for right and Discussion
left hand, respectively. Based on normative data for patients with This prospective, long-term study of outcomes at 3 years post-
acute stroke 6 months post-stroke,23 four (3%) participants were minor ischaemic stroke, at an average age of 67, identified
impaired on their right and seven (5%) on their left hand. Poorer impairments in cognitive functioning in almost half (47%) of
TUG performance was associated with slower right-handed the 153/202 patients available for the assessment, with around a
(β=0.086, p<0.05) and left-handed 9HPT times (β=0.201, third being impaired in physical functioning, 13% having mRS
p<0.05) when controlling for age, stroke severity and recurrent score indicating dependency and 29/224 (13%) having a further
stroke. TIA/minor stroke or MI between 1 and 3 years of follow-up.
When controlling for demographic, stroke characteristics, Cognitive dysfunction affected all subdomains of the ACE-R,
vascular factors and lifestyle variables, age and recurrent stroke was consistent across all measures of current cognition, and
predicted slower 9HPT right (β=1.011, p<0.001 and β=1.30, was associated with higher levels of physical dysfunction and
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Figure 2 Frequency of cognitive impairment by measure. ACE-R, Addenbrooke’s Cognitive Examination–Revised; CDR, Clinical Dementia Rating Scale;
MMSE, Mini-Mental State Examination; MoCA, Montreal Cognitive Assessment.
disability. Lower premorbid IQ, poorer cognition at 1 year and particularly in cognition, even in a relatively young population
older age predicted cognitive dysfunction, while index stroke with potentially >20 years’ life expectancy.
severity and recurrent stroke predicted physical dysfunction.
Data on the long-term outcomes post-minor ischaemic stroke
are sparse since most studies report outcomes at 3 to 6 months Cognition
and include more severe strokes. We show that important long- Our findings using the ACE-R support previous research in
term negative consequences are common after minor stroke, (mostly) patients with acute stroke with a range of stroke sever-
ities at 1–5 years of follow-up (n=55)24 25 and reflect the global
nature of this dysfunction found using full neuropsychological
Table 2 Differences between those with versus without cognitive testing.26 Fluctuations in cognition shortly following stroke are
impairment by subscales common,26 but long-term improvements, particularly at 1 year,
have been shown.26 27 As follow-up past 1 year is uncommon, it
U† r
is not clear whether these improvements are temporary. Some
ACE-R evidence suggests that the risk of cognitive impairment increases
Attention and orientation 4164* −0.49 for up to 5 years at a rate of 3% per year.5 However, these find-
Memory 5218.5* −0.74 ings are not specific to patients with minor stroke. Pre-stroke
Fluency 5049.5* −0.69 cognitive decline is associated with post-stroke cognitive
Language 4493.5* −0.54 decline.5 28 However, pre-stroke cognitive decline differs from
Visuospatial 4159* −0.44 premorbid IQ, the latter representing an individual’s peak cogni-
MoCA tive ability in early adulthood prior to any neurological damage
Orientation 2232* −0.32 or ageing effects. Premorbid or childhood IQ correlates strongly
Language 598.5* −0.70 with adulthood intelligence,29 risk of cognitive impairment and
Executive 1295* −0.51 dementia, particularly vascular dementia.30 Our findings show
Language 1456* −0.49 that lower premorbid IQ, but not necessarily pre-stroke cogni-
Visuospatial 1615* −0.43
tive decline, is associated with higher risk of poorer cognition
post-stroke.
*p<0.001.
†Mann-Whitney U Test. The association between childhood/premorbid IQ and educa-
ACE-R, Addenbrooke’s Cognitive Examination–Revised; MoCA, Montreal Cognitive tion has been widely discussed and many use education as a proxy
Assessment. for IQ given its close relationship.31 However, the relationship
for patients 6 months post-stroke showed that impairments in
Table 3 Predictors of poor cognitive performance at 3-year follow-up
dexterity were uncommon in the MSS2.23 These findings were
MoCA ACE-R supported by generally high SIS Hand Function scores. We were
β SE β SE unable to identify any studies which examined dexterity, gait
Demographics and walking speed in patients with minor stroke after more than
Age at onset −0.306* 0.035 0.98† 0.006 6 months, so it is possible that hand functioning continues to
Sex (male) −0.191‡ 0.704 0.963 0.118
improve; the association between poorer 9HPT and recurrent
Further education (no) 0.071 0.758 0.834 0.133
stroke in the MSS2 supports the suggestion that hand func-
tioning is sensitive to the impact of stroke.
Premorbid IQ 0.344* 0.049 1.023‡ 0.010
MoCA/ACE-R 1 year 0.368† 0.113 1.054† 0.011
Adult SES
Strengths and limitations
Middle −0.140 0.851 1.006 0.147
We followed up 224/264 participants (85%) at 3 years post-
Low −0.105 0.922 1.019 0.161 stroke. Most were seen in-person, but where this was not
Stroke characteristics possible, questionnaire follow-up was conducted by phone
Stroke subtype (lacunar) −0.054 0.677 1.065 0.120 or post to maximise response rate. We found no differences
Stroke severity—worst (NIHSS) 0.018 0.238 0.968 0.042 between those with and without follow-up. Our follow-up was
Recurrent stroke (yes) −0.122 0.762 0.912 0.134 comprehensive, assessing physical and cognitive functioning,
Vascular factors subjectively and objectively, and causes of death. This allowed
Diabetes 0.056 0.856 1.028 0.146 us to determine the rates of difficulties experienced in daily life
Hypertension 0.328* 1.183 1.166 0.200 as well as the difficulties that would be seen by clinicians. The
Hyperlipidaemia 0.098 0.814 0.967 0.140 large sample allowed us to adjust for potential confounders and
Atrial fibrillation 0.110 0.779 1.020 0.137 test for independent risk factors relevant to clinical practice and
Lifestyle factors patients.
Smoker We used cognitive screening tools sensitive to detecting
Previous −0.004 1.122 1.118 0.198
impairment in patients with stroke24 and assessed premorbid
IQ. Cognitive screening tools are quick and easy to administer
Current −1.645 0.735 1.074 0.125
but may lack sensitivity to impairments in other areas of cogni-
Alcohol (yes) 0.196 1.108 0.999 0.185
tion (eg, processing speed and areas of executive functioning).
Overall model fit (R2adjusted) 0.490 0.597
Detailed neuropsychological testing would be needed to deter-
Multivariate analysis controlling for all variables included in the table.
mine the full effects of minor stroke; however, this would
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*p<0.01.
†p<0.001. increase assessment time, participant burden, fatigue and risk of
‡p<0.05. missing data.
ACE-R, Addenbrooke’s Cognitive Examination–Revised; MoCA, Montreal Cognitive We defined minor ischaemic stroke using an NIHSS score <8;
Assessment; NIHSS, National Institutes of Health Stroke Scale; SES, socioeconomic however, many definitions exist.36 An NIHSS score ≤3 has been
status. associated with favourable short-term and long-term outcomes
and has been suggested as a reliable definition.36 In our sample,
202/264 (77%) met this criteria at baseline (158/202, 78% at
between these variables is complex and few studies have exam- 3 years’ follow-up). Participants with follow-up and cognitive
ined their independent association with health outcomes, partic- and physical assessment did not differ on the initial NIHSS
ularly with stroke. We show that premorbid IQ (as measured compared with those without. We controlled for stroke severity
by NART) associated with post-stroke cognition, independent of in our analyses; therefore, it is unlikely that our findings are
the education. At the 1-year follow-up, both NART and years of influenced by those with more severe strokes.
education were significant independent predictors32 suggesting Individuals unable to undergo MRI at baseline were excluded,
that these variables should be treated separately. However, our which may have introduced bias in our sample. However, this
education variable may lack statistical power; therefore, further is likely to be minimal as we include patients with minor stroke
research is needed to determine the independent association of only and contraindications to MRI were not related to index
these variables with stroke risk and outcomes. stroke characteristics.
Although previous research has shown significant associations
between stroke severity and cognition,5 we do not find these
associations to be significant in our cohort. This is likely due to Implications
the small range in stroke severities included in this study. Physical dysfunction is frequently the focus in post-stroke clin-
ical practice as difficulties are more obvious as stroke severity
Physical functioning increases. We show that those with minor stroke, hence less
Physical functioning varied greatly, particularly on the 9HPT. obvious physical dysfunction, experience high levels of disability
Although no published norms for patients with stroke on the and difficulties in ADL. Furthermore, identification of those
TUG exist, several studies including patients with stroke of a with physical dysfunction, via risk factors such as stroke severity
similar age used a cut-off of 12 s.33 Based on this, 46 (32%) and recurrent stroke, may help identify those with cognitive
participants in the MSS2 would be classified as impaired. impairment, even when the impairment is mild.
Furthermore, 37% of participants reported some degree of Importantly, cognitive dysfunction, though common, could
disability (mRS ≥2) indicating loss of independence and difficul- easily go unnoticed without objective assessment. Even when
ties in activities of daily living (ADL). mild, cognitive dysfunction can have a substantial impact on the
Although hand dysfunction is common in patients with patient’s independence and ability to monitor and control other
stroke,34 35 comparison of 9HPT scores with normative data risk factors (eg, take antihypertensive medications, maintain a
Table 4 Predictors of poor physical functioning and higher depression scores at 3-year follow-up
TUG 9HPT—right hand 9HPT—left hand BDI
β SE β SE β SE β SE
Demographics
Age at onset 1.009* 0.003 1.011† 0.002 1.012† 0.003 1.009 0.008
Sex (male) 1.024 0.059 1.079 0.049 1.108 0.052 0.705‡ 0.153
Further education (no) 0.970 0.066 0.968 0.053 0.985 0.058 0.998 0.168
Adult SES
Middle 1.072 0.074 1.028 0.061 1.014 0.065 0.994 0.191
Low 1.049 0.075 1.059 0.062 0.968 0.066 1.228 0.192
Stroke characteristics
Stroke subtype (lacunar) 1.052 0.061 1.062 0.051 1.039 0.054 0.866 0.156
Stroke severity—worst (NIHSS) 1.064* 0.023 1.023 0.018 1.011 0.019 1.068 0.055
Recurrent stroke (yes) 1.023 0.067 1.130‡ 0.055 1.214‡ 0.058 1.659* 0.169
Vascular factors
Diabetes 1.103 0.076 0.917 0.063 1.049 0.067 0.945 0.195
Hypertension 0.924 0.101 1.003 0.086 0.871 0.091 0.865 0.267
Hyperlipidaemia 0.924 0.073 0.941 0.059 0.882‡ 0.063 0.966 0.183
Atrial fibrillation 1.002 0.071 1.005 0.059 1.009 0.063 0.981 0.182
Lifestyle factors
Smoker
Previous 1.030 0.089 1.013 0.074 1.056 0.080 1.358 0.234
Current 0.973 0.067 1.048 0.056 1.044 0.060 1.336 0.174
Alcohol (yes) 0.959 0.086 0.922 0.069 0.891 0.075 0.620 0.213
Overall model fit (R2adjusted) 0.044 0.148 0.195 0.140
Multivariate analysis controlling for all variables included in the table.
*p<0.01,
†p<0.001.
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‡p<0.05.
BDI, Beck's Depression Inventory; 9HPT, Nine Hole Peg Test; NIHSS, National Institutes of Health Stroke Scale; SES, socioeconomic status; TUG, Timed Get Up and Go.
healthy diet) and thus maintain brain health.37 These findings Heart, Stroke Scotland, grants from the Sackler Foundation, European Union Horizon
highlight the multidimensional effects of stroke and the possible 2020 grant No 666881, ’SVDs@target’, Fondation Leducq, UK Medical Research
Council, Stroke Association, Alzheimer’s Society and British Heart Foundation.
benefits of considering premorbid IQ when determining risk of
post-stroke cognitive dysfunction. Patient consent Obtained.
Ethics approval This study was approved by the Lothian Research Ethics
Summary committee (ref: 09/S1101/54) according to the principles of the Declaration of
Helsinki.
Studies examining the long-term cognitive and physical outcomes
following minor ischaemic stroke are sparse. Our findings show Provenance and peer review Not commissioned; externally peer reviewed.
long-term cognitive and physical dysfunction is common and Open access This is an open access article distributed in accordance with the
that cognition may further negatively impact on their physical Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits
others to copy, redistribute, remix, transform and build upon this work for any
function and on their ADL. More research is required to iden- purpose, provided the original work is properly cited, a link to the licence is given,
tify the changes in functioning over the course of recovery post- and indication of whether changes were made. See: http://creativecommons.org/
minor stroke to help better understand their trajectories. licenses/by/4.0/.
Contributors CAM collected patient data at 3 years, analysed the data and drafted
the manuscript. VC was involved in the 3-year follow-up data collection, analysis References
and reviewed the manuscript. SM performed the original patient recruitment and 1 Adamson J, Beswick A, Ebrahim S. Is stroke the most common cause of disability? J
assessment and 1-year follow-up and reviewed the manuscript. FMC advised on Stroke Cerebrovasc Dis 2004;13:171–7.
the statistical analysis and interpretation of the data and reviewed the manuscript. 2 Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review.
KS managed the study data, assisted with the 1-year and 3-year follow-up data Lancet Neurol 2009;8:741–54.
collection and reviewed the manuscript. JMW conceived the project, obtained 3 Baezner H, Blahak C, Poggesi A, et al. Association of gait and balance disorders with
funding, managed the project, advised on analysis and interpretation of the data, age-related white matter changes: the LADIS study. Neurology 2008;70:935–42.
and reviewed and edited the manuscript. JMW is the guarantor of the project. 4 Patel MD, Coshall C, Rudd AG, et al. Cognitive impairment after stroke: clinical
Funding Chest, Heart Stroke Scotland, Ref No: Res14/A157; NHS Research determinants and its associations with long-term stroke outcomes. J Am Geriatr Soc
Scotland; The Wellcome Trust (WT088134/Z/09/A); the Row Fogo Charitable Trust; 2002;50:700–6.
the European Union Horizon 2020, PHC-03-15, project No 666881, ’SVDs@ 5 Pendlebury ST, Rothwell PM. Prevalence, incidence, and factors associated with
target’; the Fondation Leducq Transatlantic Network of Excellence for the Study pre-stroke and post-stroke dementia: a systematic review and meta-analysis. Lancet
of Perivascular Spaces in Small Vessel Disease, Ref No: 16 CVD 05; the Medical Neurol 2009;8:1006–18.
Research Council through the UK Dementia Research Institute; the Scottish Funding 6 Makin SD, Doubal FN, Dennis MS, et al. Clinically confirmed stroke with negative
Council through the Scottish Imaging Network, A Platform for Scientific Excellence diffusion-weighted imaging magnetic resonance imaging: longitudinal study of clinical
(SINAPSE) Initiative (http://www.sinapse.ac.u k). outcomes, stroke recurrence, and systematic review. Stroke 2015;46:3142–8.
7 Withall A, Brodaty H, Altendorf A, et al. Who does well after a stroke? The Sydney
Competing interests VC reports grants from NHS Research Scotland and Chest,
stroke study. Aging Ment Health 2009;13:693–8.
Heart, Stroke Scotland, which funded the study. JMW reports grants from Chest,

8 Hendricks HT, van Limbeek J, Geurts AC, et al. Motor recovery after stroke: a 24 Pendlebury ST, Mariz J, Bull L, et al. MoCA, ACE-R, and MMSE versus the
systematic review of the literature. Arch Phys Med Rehabil 2002;83:1629–37. National Institute of Neurological Disorders and Stroke-Canadian Stroke
9 Makin SD, Turpin S, Dennis MS, et al. Cognitive impairment after lacunar stroke: Network Vascular Cognitive Impairment Harmonization Standards
systematic review and meta-analysis of incidence, prevalence and comparison with Neuropsychological Battery after TIA and stroke. Stroke
other stroke subtypes. J Neurol Neurosurg Psychiatry 2013;84:893–900. 2012;43:464–9.
10 Bamford J, Sandercock P, Dennis M, et al. Classification and natural history of clinically 25 Rothwell PM, Coull AJ, Giles MF, et al. Change in stroke incidence, mortality, case-
identifiable subtypes of cerebral infarction. Lancet 1991;337:1521–6. fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford
11 Hughes CP, Berg L, Danziger WL, et al. A new clinical scale for the staging of Vascular Study). Lancet 2004;363:1925–33.
dementia. Br J Psychiatry 1982;140:566–72. 26 Gottesman RF, Hillis AE. Predictors and assessment of cognitive dysfunction resulting
12 Duncan PW, Wallace D, Lai SM, et al. The stroke impact scale version 2.0. Evaluation from ischaemic stroke. Lancet Neurol 2010;9:895–905.
of reliability, validity, and sensitivity to change. Stroke 1999;30:2131–40. 27 Hofgren C, Björkdahl A, Esbjörnsson E, et al. Recovery after stroke: cognition, ADL
13 Herdman M, Gudex C, Lloyd A, et al. Development and preliminary testing of the new function and return to work. Acta Neurol Scand 2007;115:73–80.
five-level version of EQ-5D (EQ-5D-5L). Qual Life Res 2011;20:1727–36. 28 Mok VC, Wong A, Lam WW, et al. Cognitive impairment and functional outcome
14 Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, after stroke associated with small vessel disease. J Neurol Neurosurg Psychiatry
MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2004;75:560–6.
2005;53:695–9. 29 Deary IJ, Whiteman MC, Starr JM, et al. The impact of childhood intelligence on later
15 Mioshi E, Dawson K, Mitchell J, et al. The Addenbrooke’s Cognitive Examination life: following up the Scottish mental surveys of 1932 and 1947. J Pers Soc Psychol
Revised (ACE-R): a brief cognitive test battery for dementia screening. Int J Geriatr 2004;86:130–47.
Psychiatry 2006;21:1078–85. 30 McGurn B, Deary IJ, Starr JM. Childhood cognitive ability and risk of late-onset
16 Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method Alzheimer and vascular dementia. Neurology 2008;71:1051–6.
for grading the cognitive state of patients for the clinician. J Psychiatr Res 31 Deary IJ, Johnson W. Intelligence and education: causal perceptions drive analytic
1975;12:189–98. processes and therefore conclusions. Int J Epidemiol 2010;39:1362–9.
17 Nelson HE, Willison J. The National Adult Reading Test (NART). Windsor: NFER-Nelson, 32 Makin SDJ, Doubal FN, Shuler K, et al. The impact of early-life intelligence quotient on
1991. post stroke cognitive impairment. Eur Stroke J 2018;3:145–56.
18 Jorm AF. A short form of the Informant Questionnaire on Cognitive Decline in the 33 Bischoff HA, Stähelin HB, Monsch AU, et al. Identifying a cut-off point for normal
Elderly (IQCODE): development and cross-validation. Psychol Med 1994;24:9. mobility: a comparison of the timed ’up and go’ test in community-dwelling and
19 Beck AT. Depression: causes and treatment. Philadelphia: University of Pennsylvania institutionalised elderly women. Age Ageing 2003;32:315–20.
Press, 1972. 34 Lai SM, Studenski S, Duncan PW, et al. Persisting consequences of stroke measured by
20 Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility the Stroke Impact Scale. Stroke 2002;33:1840–4.
for frail elderly persons. J Am Geriatr Soc 1991;39:7–148. 35 Duncan PW, Bode RK, Min Lai S, et al. Rasch analysis of a new stroke-specific
21 Mathiowetz V, Weber K, Kashman N, et al. Adult norms for the nine hole peg test of outcome scale: the Stroke Impact Scale. Arch Phys Med Rehabil
finger dexterity. OTJR 1985;5:24–38. 2003;84:950–63.
22 Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive 36 Fischer U, Baumgartner A, Arnold M, et al. What is a minor stroke? Stroke
review. J Am Geriatr Soc 1992;40:922–35. 2010;41:661–6.
23 Beebe JA, Lang CE. Relationships and responsiveness of six upper extremity 37 Gorelick PB, Furie KL, Iadecola C, et al. Defining optimal brain health in adults:
function tests during the first six months of recovery after stroke. J Neurol Phys Ther a presidential advisory from the American Heart Association/American Stroke
2009;33:96–103. Association. Stroke 2017;48:e284–e303.
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442 McHutchison CA, et al. J Neurol Neurosurg Psychiatry 2019;90:436–443. doi:10.1136/jnnp-2018-319134

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