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While women have greater incidence of dementia, men have higher prevalence of vascular risk factors. This study examined sex differences in risk of screening positive for cognitive impairment after stroke. Ischemic stroke/TIA patients (N = 5969) participated in this prospective, multi-centered study, which screened for cognitive impairment using a validated brief screen. Men showed a higher risk of screening positive for cognitive impairment after adjusting for age, education, stroke severity, and vascular risk factors, suggesting that other factors may be contributing to increased risk among men (OR = 1.34, CI 95% [1.16, 1.55], p < 0.001). The effect of sex on cognitive impairment after stroke warrants further attention.

Background: Depletion of blood-derived progenitor cells, including so called “early endothelial progenitor cells”, has been observed in individuals with early stage Alzheimer’s disease relative to matched older control subjects. These findings could implicate the loss of angiogenic support from hematopoietic progenitors or endothelial progenitors in cognitive dysfunction. Objective: To investigate links between progenitor cell proliferation and mild levels of cognitive dysfunction. Methods: We conducted in vitro studies of blood-derived progenitor cells using blood samples from sixty-five older adults who were free of stroke or dementia. Peripheral blood mononuclear cells from venous blood samples were cultured in CFU-Hill media and the number of colony forming units were counted after 5 days in vitro. Neuropsychological testing was administered to all participants. Results: Fewer colony forming units were observed in samples from older adults with a Clinical Dementia Rating global score of 0.5 versus 0. Older adults whose samples developed fewer colony forming units exhibited worse performance on neuropsychological measures of memory, executive functioning, and language ability. Conclusion: These data suggest blood progenitors may represent a vascular resilience marker related to cognitive dysfunction in older adults.

BackgroundThe DOC screen was developed to identify Depression, Obstructive sleep apnea, and Cognitive impairment (“DOC” comorbidities) after stroke. Each component has its own score, but additional information may be gained from the time to complete the screen. Cognitive screening completion time is rarely used as an outcome measure. We assessed the added value of using DOC screen completion time as a predictor of impairment on detailed cognitive assessments.MethodsConsecutive English-speaking new referrals to the stroke prevention clinic were consented to participate in detailed neuropsychological testing (n=437). DOC screen scores and times were compared to cognitive test scores using multiple linear regression and receiver operating characteristic (ROC) analysis. All linear regression analyses controlled for age, sex, years of education, and functional outcome as assessed by the modified Rankin score.ResultsAverage completion time for the DOC screen was 3.8 ± 1.3 minutes. After accounting for age, sex and cognitive screen score, completion time was a significant independent predictor, of speed of processing (p = .002, 95% CI: -0.016 to -0.004), verbal fluency (p < .001, CI: -0.012 to -0.006) and executive (p = .004, CI: -0.006 to -0.001), but not memory, function. Completion time above 5.5 minutes (332.5 seconds) was associated with a high likelihood of impairment on gold standard executive (likelihood ratios 3.9-5.2) and speed of processing (likelihood ratio = 5.2) tasks.ConclusionsDOC screen completion time is easy to collect in routine care and is independently associated with speed of processing, language and executive dysfunctions after stroke. People who take more than 5.5 minutes to complete the DOC screen are likely to have deficits in executive functioning and speed of processing. These domains can be challenging to screen for in stroke survivors, and this measure provides a simple, clinically feasible method to screen for these under-appreciated concerns.Clinical Trials Registration Identifier:NCT02363114Clinical Trials URL:https://clinicaltrials.gov/ct2/show/NCT02363114

Neurovascular imaging for patients with high-risk transient ischemic attack (TIA) or minor stroke in the emergency department (ED) with computed tomography angiography (CTA) of the head and neck is the guideline-recommended standard of care, but it is underutilized in routine practice. We conducted a quality initiative to improve adherence to guidelines. Between January 2017 and March 2019, we implemented a decision support tool integrated into the electronic ordering system to guide ED physicians to order a CTA on patients with high-risk TIA or minor stroke defined as ongoing neurological deficits in the ED or resolved motor or speech deficits in the preceding 48 h. Data were collected retrospectively pre-intervention and prospectively post-intervention. We used an interrupted time-series analysis for the before–after comparison of the use of CTA among patients who met criteria (main process measure) and those who did not meet criteria (balancing measure). Among 861 patients with TIA or minor stroke, the proportion of patients with high-risk events imaged with a CTA in the ED increased from 12.0% pre-intervention to 77.0% post-intervention and this shift was sustained over 11 months. CTA use in those without high-risk events increased to a lesser extent (15.3% versus 42.9%). The interrupted time-series analysis showed a step change immediately post-intervention where the increase in CTA use in patients with high-risk events was 51.7% higher than its use in those without high-risk events (p

BACKGROUND Elevated blood pressure (BP) variability is predictive of increased risk for stroke, cerebrovascular disease, and other vascular brain injuries, independent of traditionally studied average BP levels. However, no studies to date have evaluated whether BP variability is related to diminished cerebrovascular reactivity, which may represent an early marker of cerebrovascular dysfunction presaging vascular brain injury. METHODS The present study investigated BP variability and cerebrovascular reactivity in a sample of 41 community-dwelling older adults (mean age 69.6 [SD 8.7] years) without a history of dementia or stroke. Short-term BP variability was determined from BP measurements collected continuously during a 5-minute resting period followed by cerebrovascular reactivity during 5-minute hypocapnia and hypercapnia challenge induced by visually guided breathing conditions. Cerebrovascular reactivity was quantified as percent change in cerebral perfusion by pseudo-continuous arterial spin labeling (pCASL)-MRI per unit change in end-tidal CO2. RESULTS Elevated systolic BP variability was related to lower whole brain cerebrovascular reactivity during hypocapnia (ß = −0.43 [95% CI −0.73, −0.12]; P = 0.008; adjusted R2 =.11) and hypercapnia (ß = −0.42 [95% CI −0.77, −0.06]; P = 0.02; adjusted R2 = 0.19). CONCLUSIONS Findings add to prior work linking BP variability and cerebrovascular disease burden and suggest BP variability may also be related to prodromal markers of cerebrovascular dysfunction and disease, with potential therapeutic implications.

Background/Objective: Structural brain magnetic resonance imaging (MRI) is not mandatory in Alzheimer's disease (AD) research or clinical guidelines. We aimed to explore the use of structural brain MRI in AD/mild cognitive impairment (MCI) trials over the past 10 years and determine the frequency with which inclusion of standardized structural MRI acquisitions detects comorbid vascular and non-vascular pathologies. Methods: We systematically searched ClinicalTrials.gov for AD clinical trials to determine their neuroimaging criteria and then used data from an AD/MCI cohort who underwent standardized MRI protocols, to determine type and incidence of clinically relevant comorbid pathologies. Results: Of 210 AD clinical trials, 105 (50%) included structural brain imaging in their eligibility criteria. Only 58 (27.6%) required MRI. 16,479 of 53,755 (30.7%) AD participants were in trials requiring MRI. In the observational AD/MCI cohort, 141 patients met clinical criteria; 22 (15.6%) had relevant MRI findings, of which 15 (10.6%) were exclusionary for the study. Discussion: In AD clinical trials over the last 10 years, over two-thirds of participants could have been enrolled without brain MRI and half without even a brain CT. In a study sample, relevant comorbid pathology was found in 15% of participants, despite careful screening. Standardized structural MRI should be incorporated into NIA-AA diagnostic guidelines (when available) and research frameworks routinely to reduce diagnostic heterogeneity.

Background and Purpose— Depression and anxiety are common after stroke/transient ischemic attack (TIA). These conditions are associated with poor functional outcome and worse quality of life. However, few studies have explored predictors of poststroke risk of generalized anxiety, especially in patients without comorbid depressive symptoms. We aimed to explore predictors of high risk of generalized anxiety after stroke/TIA. Methods— Consecutive stroke and TIA referrals to the Sunnybrook Stroke Prevention Clinic over a 2-year period (April 2012–April 2014) who spoke English, were not severely aphasic, and who consented to complete neuropsychological testing were included in this analysis. Generalized anxiety and depressive symptoms were assessed using the Generalized Anxiety Disorder 7-item scale and Center for Epidemiological Studies Depression Scale, respectively. Results— Two hundred and fifty-eight patients completed the Generalized Anxiety Disorder 7-item scale, of whom 56 (22%) were at high risk for generalized anxiety (scores ≥10). Younger age (odds ratio=0.96; 95% CI, 0.93–0.99; P =0.004) and greater depressive symptoms (odds ratio=1.20; 95% CI, 1.14–1.26; P ≤0.001) were significant predictors of being at high risk for generalized anxiety after stroke/TIA. Younger patients (≤50 years) were significantly more likely to be at high risk for both depression and generalized anxiety than older patients (30% versus 12%, χ 2 [1, N=258]=10.98, P =0.001). Our model explained 56% of the variance in risk of generalized anxiety after stroke. In patients without severe depressive symptoms (n=193, 75%), age and severity of depressive symptoms remained the only factors associated with risk of generalized anxiety. Conclusions— Anxiety is common after stroke/TIA and is highly correlated with poststroke depressive symptoms and age, even among those without severe depressive symptoms. Given the greater frequency of both generalized anxiety and depressive symptoms in young survivors, routine screening for depression and further evaluation of anxiety after stroke/TIA is warranted.

Neurovascular imaging for patients with high-risk transient ischemic attack (TIA) or minor stroke in the emergency department (ED) with computed tomography angiography (CTA) of the head and neck is the guideline-recommended standard of care, but it is underutilized in routine practice. We conducted a quality initiative to improve adherence to guidelines.Between January 2017 and March 2019, we implemented a decision support tool integrated into the electronic ordering system to guide ED physicians to order a CTA on patients with high-risk TIA or minor stroke defined as ongoing neurological deficits in the ED or resolved motor or speech deficits in the preceding 48 h. Data were collected retrospectively pre-intervention and prospectively post-intervention. We used an interrupted time-series analysis for the before-after comparison of the use of CTA among patients who met criteria (main process measure) and those who did not meet criteria (balancing measure).Among 861 patients with TIA or minor stroke, the proportion of patients with high-risk events imaged with a CTA in the ED increased from 12.0% pre-intervention to 77.0% post-intervention and this shift was sustained over 11 months. CTA use in those without high-risk events increased to a lesser extent (15.3% versus 42.9%). The interrupted time-series analysis showed a step change immediately post-intervention where the increase in CTA use in patients with high-risk events was 51.7% higher than its use in those without high-risk events (p 0.001). Compared to pre-intervention, the median ED length of stay increased by 2 h and neurology consultation in the ED was more frequent (5.8% versus 19.5%) post-intervention.We provide a detailed framework that improved adherence to acute imaging guidelines for patients with TIA or minor stroke and anticipate that our approach could improve acute imaging for such patients in most EDs.RéSUMé: CONTEXTE: L'imagerie neurovasculaire pour les patients présentant un risque élevé d'accident ischémique transitoire (AIT) ou d'accident vasculaire cérébral mineur aux services d'urgence, avec une angiographie par tomodensitométrie (CTA) de la tête et du cou, est la norme de soins recommandée par les directives, mais elle est sous-utilisée dans la pratique courante. Nous avons mené une initiative de qualité pour améliorer le respect des lignes directrices. MéTHODES: Entre janvier 2017 et mars 2019, nous avons mis en place un outil d'aide à la décision intégré au système de commande électronique pour guider les médecins du service d'urgence à prescrire un CTA sur des patients atteints d'un AIT à haut risque ou d'un AVC mineur défini comme des déficits neurologiques en cours au service des urgences ou une résolution de la motricité ou des troubles de la parole dans les 48 heures précédentes. Les données ont été recueillies rétrospectivement avant l'intervention et prospectivement après l'intervention. Nous avons utilisé une analyse de séries chronologiques interrompues pour la comparaison avant-après de l'utilisation du CTA chez les patients qui répondaient aux critères (mesure principale du processus) et ceux qui ne répondaient pas aux critères (mesure d'équilibrage). RéSULTATS: Parmi les 861 patients atteints d'un AIT ou d'un AVC mineur, la proportion de patients présentant des événements à haut risque imagés avec un CTA au service d'urgence est passé de 12,0 % avant l'intervention à 77,0 % après l'intervention et ce changement s'est maintenu pendant 11 mois. L'utilisation de CTA chez les personnes sans événements à haut risque a augmenté dans une moindre mesure (15,3 % contre 42,9 %). L'analyse des séries chronologiques interrompues a montré un changement d'étape immédiatement après l'intervention où l'augmentation de l'utilisation du CTA chez les patients présentant des événements à haut risque était 51,7 % plus élevée que son utilisation chez ceux sans événements à haut risque (p0,001). Par rapport à la pré-intervention, la durée médiane du séjour au SU a augmenté de deux heures et les consultations de neurologie au SU étaient plus fréquentes (5,8 % contre 19,5 %) après l'intervention. CONCLUSION: Nous fournissons un cadre détaillé qui a amélioré le respect des lignes directrices en matière d'imagerie aiguë pour les patients souffrant d'AIT ou d'AVC mineur et nous prévoyons que notre approche pourrait améliorer l'imagerie aiguë pour ces patients dans la plupart des urgences.

Introduction: Cerebral small vessel disease (SVD) resulting from pathological changes in cerebral microvessels is a common precursor of stroke and dementia. Progressive and insidious damage to the cerebral microvasculature may trigger angiogenic processes to promote vessel repair. However, few previous studies have explored the angiogenic response to SVD. In a cohort of older adults with early evidence of SVD, we aimed to examine circulating levels of vascular endothelial growth factor D (VEGF-D)—a secreted glycoprotein with high angiogenic and lymphangiogenic potential—which has previously been linked to heart failure, atrial fibrillation, and ischemic stroke. Methods: Sixty independently living older adults (mean age = 69.7 years; SD = 7.5; age range 55-90 years; 38.3% male) free of dementia or clinical stroke were recruited from the community and underwent venipuncture and brain MRI. Plasma was assayed for proangiogenic factors (VEGF-A, VEGF-C, VEGF-D, Tie-2, Flt-1). MRI changes thought to represent microvascular pathologies (white matter hyperintensities, microbleeds and lacunes) were evaluated and total SVD load was determined using a previously validated score. Multiple linear regression examined the relationship between circulating proangiogenic proteins levels and total SVD load. Results: Moderate/severe white matter hyperintensity burden was identified by Fazekas scale in 40.0% of participants, small lacunes were identified in 13.3% and microbleeds in 6.7%. Simple linear regression revealed a positive relationship between circulating VEGF-D and total SVD score (p = .019), which remained significant in multiple regression controlling for age, sex and Framingham stroke score (p = .017). VEGF-D was significantly positively correlated with VEGF-C (r = .37), Flt-1 (r = .31) and Tie-2 (r = .42). Conclusions: These findings suggest that elevated levels of circulating VEGF-D correspond with greater damage to the cerebral microvasculature in older adults with no history of clinical stroke or dementia. Additional studies are warranted to determine whether activation of systemic proangiogenic growth factors represents an early attempt to rescue the vascular endothelium and repair damage in cerebral SVD.

The Notch signaling pathway is an evolutionarily conserved cell signaling system known to be involved in vascular development and function. Recent evidence suggests that dysfunctional Notch signaling could play a critical role in the pathophysiology of neurodegenerative diseases. We reviewed current literature on the role of Notch signaling pathway, and specifically Notch receptor genes and proteins, in aging, cerebrovascular disease and Alzheimer's disease. We hypothesize that Notch signaling may represent a key point of overlap between age-related vascular and Alzheimer's pathophysiology contributing to their comorbidity and combined influence on cognitive decline and dementia. Numerous findings from studies of genetics, neuropathology and cell culture models all suggest a link between altered Notch signaling and Alzheimer's pathophysiology. Age-related changes in Notch signaling may also trigger neurovascular dysfunction, contributing to the development of neurodegenerative diseases; however, additional studies are warranted. Future research directly exploring the influence of aberrant Notch signaling in the development of Alzheimer's disease is needed to better understand this mechanism.

Background:Improvements in management of transient ischemic attack (TIA) have decreased stroke and mortality post-TIA. Studies examining trends over time on a provincial level are limited. We analyzed whether efforts to improve management have decreased the rate of stroke and mortality after TIA from 2003 to 2015 across an entire province.Methods:Using administrative data from the Canadian Institute for Health Information’s (CIHI) databases from 2003 to 2015, we identified a cohort of patients with a diagnosis of TIA upon discharge from the emergency department (ED). We examined stroke rates at Day 1, 2, 7, 30, 90, 180, and 365 post-TIA and 1-year mortality rates and compared trends over time between 2003 and 2015.Results:From 2003 to 2015 in Ontario, there were 61,710 patients with an ED diagnosis of TIA. Linear regressions of stroke after the index TIA showed a significant decline between 2003 and 2015, decreasing by 25% at Day 180 and 32% at 1 year (p < 0.01). The 1-year stroke rate decreased from 6.0% in 2003 to 3.4% in 2015. Early (within 48 h) stroke after TIA continued to represent approximately half of the 1-year event rates. The 1-year mortality rate after ED discharge following a TIA decreased from 1.3% in 2003 to 0.3% in 2015 (p < 0.001).Interpretation:At a province-wide level, 1-year rates of stroke and mortality after TIA have declined significantly between 2003 and 2015, suggesting that efforts to improve management may have contributed toward the decline in long-term risk of stroke and mortality. Continued efforts are needed to further reduce the immediate risk of stroke following a TIA.

Background:Delayed presentation to the emergency department influences acute stroke care and can result in worse outcomes. Despite public health messaging, many young adults consider stroke as a disease of older people. We determined the differences in ambulance utilization and delays to hospital presentation between women and men as well as younger (18–44 years) versus older (≥45 years) patients with stroke.Methods:We conducted a population-based retrospective study using national administrative health data from the Canadian Institute of Health Information databases and examined data between 2003 and 2016 to compare ambulance utilization and time to hospital presentation across sex and age.Results:Young adults account for 3.9% of 463,310 stroke/transient ischemic attack/hemorrhage admissions. They have a higher proportion of hemorrhage (37% vs. 15%) and fewer ischemic events (50% vs. 68%) compared with older patients. Younger patients are less likely to arrive by ambulance (62% vs. 66%, p < 0.001), with younger women least likely to use ambulance services (61%) and older women most likely (68%). Median stroke onset to hospital arrival times were 7 h for older patients and younger men, but 9 h in younger women. There has been no improvement among young women in ambulance utilization since 2003, whereas ambulance use increased in all other groups.Conclusions:Younger adults, especially younger women, are less likely to use ambulance services, take longer to get to hospital, and have not improved in utilization of emergency services for stroke over 13 years. Targeted public health messaging is required to ensure younger adults seek emergency stroke care.

Depression and cognitive complaints are common after stroke; these issues have been studied in older populations, but not in the young. Two hundred and seventy four eligible stroke and TIA patients consented to participate and complete the Center for Epidemiologic Studies Depression Scale, and National Institute of Neurological Disorders and Stroke - Canadian Stroke Network 30-min neuropsychological battery; 57 (21%) were ≤ 50 years of age. Younger patients reported greater symptoms of depression and less executive dysfunction than older patients. This study highlights age differences in post-stroke depression symptoms and cognitive impairment, and emphasizes the need for screening across ages.

Background The incidence of stroke in young adults is increasing. While many young survivors are able to achieve a good physical recovery, subtle dysfunction in other domains, such as cognition, often persists, and could affect return to work. However, reported estimates of return to work and factors affecting vocational outcome post-stroke vary greatly. Aims The aims of this systematic review were to determine the frequency of return to work at different time points after stroke and identify predictors of return to work. Summary of review Two electronic databases (Medline and Embase) were systematically searched for articles according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 6473 records were screened, 68 were assessed for eligibility, and 29 met all inclusion criteria (working-age adults with stroke, return to work evaluated as an outcome, follow-up duration reported, and publication within the past 20 years). Return to work increased with time, with median frequency increasing from 41% between 0 and 6 months, 53% at 1 year, 56% at 1.5 years to 66% between 2 and 4 years post-stroke. Greater independence in activities of daily living, fewer neurological deficits, and better cognitive ability were the most common predictors of return to work. Conclusion This review highlights the need to examine return to work in relation to time from stroke and assess cognition in working age and young stroke survivors. The full range of factors affecting return to work has not yet been explored and further evaluations of return to work interventions are warranted.

Objectives: To assess the efficacy of repetitive transcranial magnetic stimulation for post-stroke non-fluent aphasia through a review of current literature.Methods: Three electronic databases (Medline, Embase & Scopus) were searched for articles. Relevant studies were further evaluated and studies that met inclusion criteria were reviewed.Results: The literature search yielded 4713 studies. Thirty-five articles were further evaluated to be included. Thirteen met all inclusion criteria and were chosen for review. The studies provide moderate to strong evidence that rTMS may be an effective treatment for non-fluent stroke aphasia.Conclusion: There are some strong studies evaluating the efficacy of rTMS in non-fluent stroke patients but further research is required to fully establish the usefulness of this treatment. Future directions and limitations are presented.

Objective The aim of this systematic review and meta-analysis was to determine the effect of antidepressant discontinuation on the risk of relapse of depression during pregnancy. Data sources MEDLINE, EMBASE, CINAHL, and PsycInfo were searched from the inception of each database through March 2019 using keywords such as antidepressants, pregnancy, preconception, discontinuation, stop, recurrence, reintroduction, and relapse. Study selection Original studies that involved pregnant women who discontinued antidepressants during preconception (ie, 3 months prior to pregnancy) or pregnancy and examined the relapse of depression during pregnancy (ie, the reemergence of depression or reintroduction of medication) and published in English were included. A total of 2,172 records were identified, and the full texts of 37 articles were reviewed. Eight studies met the inclusion criteria, 6 of which fulfilled the quality criteria, with 4 studies providing data for the meta-analysis. Data extraction Data were extracted using a data extraction form developed for the purpose of this study. The Cochrane Collaboration Review Manager software version 5.3 was used to conduct the meta-analysis. Results Pooled data did not show higher risk of relapse of depression during pregnancy for women who discontinued antidepressants than for those who continued antidepressants (risk ratio [RR] = 1.74; 95% CI, 0.97 to 3.10; P = .06). In the subanalysis based on the severity and recurrence of depression in the study populations, the risk of relapse was significantly higher for populations suggestive of severe or recurrent depression (RR = 2.30; 95% CI, 1.58 to 3.35) but not for populations suggestive of mild or moderate depression severity (RR = 1.59; 95% CI, 0.83 to 3.04). Conclusions Women with severe or recurrent depression should be informed about the increased risk of relapse following antidepressant discontinuation, and those who discontinue antidepressants should be monitored for relapse.

Background: Depression and anxiety are common post-stroke conditions associated with poor functional outcome and worse quality of life. However, few studies have explored post-stroke generalized anxiety disorder (GAD), especially in patients without comorbid depression. Hypothesis/Aim: We aimed to explore the frequency and the predictors of GAD after stroke/TIA. Our secondary aim was to identify the frequency and predictors of GAD in patients without comorbid depression. Methods: Consecutive stroke and TIA referrals to the Sunnybrook Stroke Prevention Clinic over a two-year period (April 2012 to April 2014) who spoke English, were not severely aphasic, and who consented to complete neuropsychological testing were included in this analysis. Anxiety and depression were assessed using the Generalized Anxiety Disorder 7-item (GAD-7) scale and Center for Epidemiologic Studies Depression Scale (CES-D), respectively. Scores ≥ 10 on the GAD-7 signified moderate to severe anxiety and ≥16 on CESD indicated moderate to high risk of depression. Clinical depression was assessed using the Structured Clinical Interview for the DSM-IV-Depression Module. Results: 258 patients completed the GAD-7 scale, of which 56 (22%) had scores ≥ 10. Lower age (p = .004) and greater depressive symptoms (p ≤ .001) were significant predictors of post-stroke GAD, while sex, modified Rankin score, and education did not predict anxiety. Younger patients (≤ 50 years) were significantly more likely to have comorbid depression and anxiety than older patients (30% vs. 12%, p = .001). Our model explained 56% of the variance in GAD after stroke. Anxiety was present in 12% of patients without comorbid clinical depression. In patients without clinical depression (n = 207, 80%), age and symptoms of depression remained the only significant predictors of GAD. Conclusion: Anxiety is common after stroke/TIA and is highly correlated with post-stroke depressive symptoms and age, even among those without clinical depression. Given the greater frequency of both anxiety and depression in young survivors, routine screening for depression and further evaluation of anxiety after stroke is warranted. Interventions to improve these conditions could improve quality of life and outcomes following stroke

Introduction: Stroke is a leading cause of mortality and morbidity. Important sex differences have been observed in stroke outcomes. Compared to men, women have poorer outcomes, but the reasons for this observation are unclear. Depression affects approximately one-third of patients post-stroke and is associated with poor outcomes. We aimed to determine any sex differences in the prevalence of symptoms of depression in stroke survivors. Methods: We identified a cohort of adult patients with stroke or TIA from the prospective, multi-centered Depression, Obstructive sleep apnea, and Cognitive impairment (DOC) study. All patients systematically completed a depression screening tool (Patient Health Questionnaire-2). A score of 4 or more out of 6 indicates that the patient is at high risk of depression. We used logistic regression with and without adjustment for age, event type (TIA or ischemic stroke), education level, vascular risk factors, cognitive symptoms, cancer, and disability to determine the association between sex and risk of depression. Results: We included 2,379 patients (mean age 68 years (SD = 14.8), 1310 men (55.1%). There were 222 (9.3%) patients at high risk for depression. Women were more likely to be at high risk (Odds Ratio OR 1.4, 95% CI [1.1, 1.9]) in univariable analysis. This association remained true after adjustment for covariates (OR 1.6, 95% CI [1.2, 2.1]). Conclusion: With systematic screening post-stroke, women are at higher risk for depression than men, even after controlling for baseline differences. Further research into whether our findings mediate the sex differences in outcomes post-stroke and the implications on treatment of depression post-stroke is needed.

Background: Management of transient ischemic attacks (TIA) in specialized stroke centres and prevention clinics have been shown to decrease stroke recurrence and mortality. The impact of these services on a population level are unknown. We aimed to analyze whether modern medical management of TIA has decreased the rate of stroke recurrence and mortality over time in Ontario. Methods: Administrative data from the Canadian Institute for Health Information’s Discharge Abstract Database (DAD) and National Ambulatory Care Reporting System (NACRS) database 2003-2015 were analyzed and rates of stroke recurrence and mortality were calculated. Results: From 2003 to 2015 in Ontario, there were an increasing number of discharges from emergency departments (ED) and a decreasing number of discharges from hospitals. Linear regressions of stroke recurrence at 24 hours, 48 hours, day 7, 30, 90, 180, and 1 year after a TIA showed significantly faster decline between 2003-2015 (p Interpretations: There is increasing outpatient management of TIAs in Ontario. The observed decline in stroke recurrence was greater than can be explained by referral bias alone, and the increasingly negative slopes of these lines from 24 hours to 1 year suggest a cumulative benefit of improved TIA management over time rather than just increased labelling of low-risk patients. On a population-level, stroke recurrence and mortality after TIA have declined from 2003 to 2015 with a province-wide system of organized stroke care. In contrast to other studies that have shown reduced stroke recurrence and mortality at specialized centres, this study demonstrates the impact of these programs at a population level.

Objective To determine whether a simple small vessel disease (SVD) score, which uses information available on rapid visual assessment of clinical MRI scans, predicts risk of cognitive decline and dementia, above that provided by simple clinical measures. Methods Three prospective longitudinal cohort studies (SCANS [St George's Cognition and Neuroimaging in Stroke], RUN DMC [Radboud University Nijmegen Diffusion Imaging and Magnetic Resonance Imaging Cohort], and the ASPS [Austrian Stroke Prevention Study]), which covered a range of SVD severity from mild and asymptomatic to severe and symptomatic, were included. In all studies, MRI was performed at baseline, cognitive tests repeated during follow-up, and progression to dementia recorded prospectively. Outcome measures were cognitive decline and onset of dementia during follow-up. We determined whether the SVD score predicted risk of cognitive decline and future dementia. We also determined whether using the score to select a group of patients with more severe disease would reduce sample sizes for clinical intervention trials. Results In a pooled analysis of all 3 cohorts, the score improved prediction of dementia (area under the curve [AUC], 0.85; 95% confidence interval [CI], 0.81–0.89) compared with that from clinical risk factors alone (AUC, 0.76; 95% CI, 0.71–0.81). Predictive performance was higher in patients with more severe SVD. Power calculations showed selecting patients with a higher score reduced sample sizes required for hypothetical clinical trials by 40%–66% depending on the outcome measure used. Conclusions A simple SVD score, easily obtainable from clinical MRI scans and therefore applicable in routine clinical practice, aided prediction of future dementia risk.

Background: Stroke can impact multiple levels of function and result in complex disability. Few studies have examined limitations across the range of functions from body function to social participation, or explored the impact of post-stroke comorbidities, such as depression, obstructive sleep apnea (OSA) and cognition, on function, especially in the long-term. We aimed to determine post-stroke predictors of multiple levels of functioning approximately 2 years after a stroke, and to specifically evaluate the impact of depressive symptoms, OSA and cognitive impairment on outcome. Hypothesis: We hypothesized that in addition to traditional predictors of outcome–age and stroke severity–depression, OSA and cognitive impairment will predict functional outcome in multiple domains. Methods: Baseline assessment of depression, apnea and cognitive impairment with 2-year follow-up assessment of functional outcome to evaluate each of the three levels of functioning as stated in the WHO International Classification of Functioning: Body Function (Montreal Cognitive Assessment), Activity (modified Rankin) and Participation (Reintegration to Normal Living Index). Results: A total of 162 patients were enrolled at approximately 2 years and 5 months post-stroke. Forty one percent had activity limitations, 58% were cognitively impaired and 68% had restrictions in participation. Long-term activity limitation was predicted by greater age (OR = 0.95), stroke severity (OR = 1.69) and cognitive impairment (OR = 1.28) at baseline. Body function impairment was predicted by greater age (OR = 0.96), and cognitive impairment (OR = 1.49). Participation restriction was predicted by cognitive impairment (OR = 1.26). Conclusion: Baseline cognition predicts long-term function in multiple domains and is a better predictor of long-term participation than age or baseline stroke severity. In view of the widespread impact of post-stroke cognitive impairment on every level of functioning, routine post-stroke cognitive screening and target interventions are warranted. Greater attention to functional domains beyond activity could further optimize recovery and enhance outcome after stroke.

Background and Purpose— Functional outcome after stroke is often only evaluated using the modified Rankin Scale, which primarily assesses activities of daily living. Stroke patients may experience difficulties with social reintegration and mental functions, feel isolated, and experience poor quality of life, even after physical recovery is complete. Functional assessments based solely on activity limitations may not be able to capture the full range of problems experienced by stroke survivors. Methods— Telephone interviews were conducted 2 to 3 years poststroke to assess outcome on multiple levels of functioning as stated in the WHO International Classification of Functioning: body function (Montreal Cognitive Assessment and Patient Health Questionnaire-2), activity (modified Rankin Scale), and participation (Reintegration to Normal Living Index). Results— Ninety-six (68%) patients had a favorable functional outcome (modified Rankin Scale Conclusions— More than half of stroke patients with excellent functional recovery measured by the modified Rankin Scale continue to have cognitive impairment and participation restrictions, and one third of patients continue to have depression 2 to 3 years later. Current definitions of good functional outcome used in the majority of stroke acute trials focus on activity limitations, but greater attention to multiple levels of recovery is required.

Introduction: Disability is often an assumed and accepted consequence of stroke. Post-stroke disability is frequently attributed to demographic risk factors such as age and stroke severity. These factors cannot explain all the variability in stroke outcomes. Other factors, such as post-stroke depression, sleep apnea and cognitive impairment can impact function, and yet their relationships to long-term outcomes are rarely assessed. The primary purpose of our research is to understand the role of these potentially modifiable factors in predicting long-term post-stroke functional outcomes. Hypothesis: Stroke patients who screen positive for depression, sleep apnea or cognitive impairment at baseline will have significantly worse long-term functional outcome. Methods: A follow up outcome assessment of stroke patients is being conducted by telephone 2-3 years after an initial baseline visit where their risk of depression, sleep apnea and cognitive impairment was assessed. Baseline predictors such as age and stroke severity are also abstracted from their baseline visit. Assessment measures were selected to evaluate numerous levels of human functioning and include the following: modified Rankin Scale, MoCA, Barthel Index, Frenchay Activites Index and Reintegration to Normal Living Index. The primary outcome is mRS Score, with a score ≥ 2 indicating poor outcome. Results: Seventy six patients have been enrolled in our study and projected enrolled of another 100 patients should be complete by December 2015. Based on preliminary data, our prognostic logistic regression model including only stroke severity and age is statistically significant, χ2(2)= 29.06, p < 0.001. This model explains 42.7% (Nagelkerke R2) of the variance in long-term outcomes and correctly classifies outcome in 78.9% of patients. Future analyses with the full sample size and addition of potentially modifiable factors will verify whether these factors increase the predictive value of our prognostic model. Conclusion: By identifying modifiable factors related to poor functional outcomes, this study may allow the development of novel interventions to alter the trajectory of this vulnerable population to help optimize long-term function after stroke.