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Background:There is increasing interest in the concept of frailty in stroke, including both physical frailty and imaging-evidence of brain frailty. We aimed to establish the prevalence of brain frailty in stroke survivors as well as the concurrent and predictive validity of various frailty measures against long-term cognitive outcomes.Methods:We included consecutively admitted stroke or transient ischaemic attack (TIA) survivors from participating stroke centres. Baseline CT scans were used to generate an overall brain frailty score for each participant. We measured frailty via the Rockwood frailty index, and a Fried frailty screening tool. Presence of major or minor neurocognitive disorder at 18-months following stroke or TIA was established via a multicomponent assessment. Prevalence of brain frailty was established based upon observed percentages within groups defined by frailty status (robust, pre-frail, frail). We assessed the concurrent validity of brain frailty and frailty scales via Spearman’s rank correlation. We conducted multivariable logistic regression analyses, controlling for age, sex, baseline education and stroke severity, to evaluate association between each frailty measure and 18-month cognitive impairment.Results:Three-hundred-forty-one stroke survivors participated. Three-quarters of people who were frail had moderate-severe brain frailty and prevalence increased according to frailty status. Brain frailty was weakly correlated with Rockwood frailty (Rho: 0.336; p Conclusions:There appears to be value in the assessment of both physical and brain frailty in patients with ischaemic stroke and TIA. Both are associated with adverse cognitive outcomes and physical frailty remains important when assessing cognitive outcomes.

Supplemental material, sj-docx-1-eso-10.1177_23969873231186480 for Physical and brain frailty in ischaemic stroke or TIA: Shared occurrence and outcomes. A cohort study by Martin Taylor-Rowan, Melanie Hafdi, Bogna Drozdowska, Emma Elliott, Joanna Wardlaw and Terence J Quinn in European Stroke Journal

Objectives:\ud Various informant-based questionnaires are used in clinical practice to screen for pre-stroke cognitive problems. However, there is no guidance on which tool should be preferred. We compared the validity of the two most commonly used informant-based tools.\ud \ud Methods:\ud We recruited consecutively admitted stroke patients. Patients' informants completed the Informant Questionnaire for Cognitive Decline in the Elderly Short Form (IQCODE-SF, 16-item) and Ascertain Dementia 8 (AD8). We assessed construct validity (accuracy) against a semi-structured clinical interview for dementia or mild cognitive impairment (MCI), describing test accuracy metrics and comparing area under ROC curves (AUROC). We described criterion validity by evaluating associations between test scores and neuroimaging markers of dementia and overall ‘brain frailty’. Finally, we described prognostic validity comparing ROC curves for 18-month clinical outcomes of dementia, death, stroke, and disability.\ud \ud Results:\ud One-hundred-thirty-seven patient-informant dyads were recruited. At usual clinical cut-points, the IQCODE-SF had comparable sensitivity to the AD8 (both = 92%) for pre-stroke dementia, but superior specificity (IQCODE-SF: 82% vs. AD8: 58%). Youden index suggested that the optimal AD8 threshold for diagnosis of dementia is ≥4. The IQCODE-SF demonstrated stronger associations with markers of generalised and medial-temporal lobe atrophy, neurovascular disease, and overall brain frailty. IQCODE-SF also demonstrated greater accuracy for predicting future dementia (IQCODE-SF AUROC = 0.903, 95% CI = 0.798–1.00; AD8 AUROC = 0.821, 95% CI = 0.664–0.977).\ud \ud Conclusions:\ud Both IQCODE-SF and AD8 are valid measures of pre-stroke dementia. Higher cut points for AD8 may improve performance in the acute stroke setting. Based on consistent superiority across a range of validity analyses, IQCODE-SF may be preferable to AD8 for pre-stroke dementia screening.

Stroke is the second leading cause of death and the third leading cause of disability worldwide and its burden is increasing rapidly in low-income and middle-income countries, many of which are unable to face the challenges it imposes. In this Health Policy paper on primary stroke prevention, we provide an overview of the current situation regarding primary prevention services, estimate the cost of stroke and stroke prevention, and identify deficiencies in existing guidelines and gaps in primary prevention. We also offer a set of pragmatic solutions for implementation of primary stroke prevention, with an emphasis on the role of governments and population-wide strategies, including task-shifting and sharing and health system re-engineering. Implementation of primary stroke prevention involves patients, health professionals, funders, policy makers, implementation partners, and the entire population along the life course.

Stroke is the second leading cause of death and the third leading cause of disability worldwide and its burden is increasing rapidly in low-income and middle-income countries, many of which are unable to face the challenges it imposes. In this Health Policy paper on primary stroke prevention, we provide an overview of the current situation regarding primary prevention services, estimate the cost of stroke and stroke prevention, and identify deficiencies in existing guidelines and gaps in primary prevention. We also offer a set of pragmatic solutions for implementation of primary stroke prevention, with an emphasis on the role of governments and population-wide strategies, including task-shifting and sharing and health system re-engineering. Implementation of primary stroke prevention involves patients, health professionals, funders, policy makers, implementation partners, and the entire population along the life course.

Supplemental Material, sj-pdf-3-eso-10.1177_23969873211042192 for European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment by Terence J Quinn, Edo Richard, Yvonne Teuschl, Thomas Gattringer, Melanie Hafdi, John T O’Brien, Niamh Merriman, Celine Gillebert, Hanne Huyglier, Ana Verdelho, Reinhold Schmidt, Emma Ghaziani, Hysse Forchammer, Sarah T Pendlebury, Rose Bruffaerts, Milija Mijajlovic, Bogna A Drozdowska, Emily Ball and Hugh S Markus in European Stroke Journal

Supplemental Material, sj-pdf-1-eso-10.1177_23969873211042192 for European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment by Terence J Quinn, Edo Richard, Yvonne Teuschl, Thomas Gattringer, Melanie Hafdi, John T O’Brien, Niamh Merriman, Celine Gillebert, Hanne Huyglier, Ana Verdelho, Reinhold Schmidt, Emma Ghaziani, Hysse Forchammer, Sarah T Pendlebury, Rose Bruffaerts, Milija Mijajlovic, Bogna A Drozdowska, Emily Ball and Hugh S Markus in European Stroke Journal

Supplemental Material, sj-pdf-2-eso-10.1177_23969873211042192 for European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment by Terence J Quinn, Edo Richard, Yvonne Teuschl, Thomas Gattringer, Melanie Hafdi, John T O’Brien, Niamh Merriman, Celine Gillebert, Hanne Huyglier, Ana Verdelho, Reinhold Schmidt, Emma Ghaziani, Hysse Forchammer, Sarah T Pendlebury, Rose Bruffaerts, Milija Mijajlovic, Bogna A Drozdowska, Emily Ball and Hugh S Markus in European Stroke Journal

Supplemental Material, sj-pdf-4-eso-10.1177_23969873211042192 for European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment by Terence J Quinn, Edo Richard, Yvonne Teuschl, Thomas Gattringer, Melanie Hafdi, John T O’Brien, Niamh Merriman, Celine Gillebert, Hanne Huyglier, Ana Verdelho, Reinhold Schmidt, Emma Ghaziani, Hysse Forchammer, Sarah T Pendlebury, Rose Bruffaerts, Milija Mijajlovic, Bogna A Drozdowska, Emily Ball and Hugh S Markus in European Stroke Journal

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

The optimal management of post-stroke cognitive impairment remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making around prevention, diagnosis, treatment and prognosis. These guidelines were developed according to ESO standard operating procedure and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and, where possible, meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. There was limited randomised controlled trial evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Interventions to improve lifestyle and treat vascular risk factors may have many health benefits but a beneficial effect on cognition is not proven. We found no evidence around routine cognitive screening following stroke but recognise the importance of targeted cognitive assessment. We described the accuracy of various cognitive screening tests but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognitive syndromes (cognitive impairment, dementia and delirium). The association between post-stroke cognitive impairment and most acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on acute MRI brain may help predict cognitive outcomes. These guidelines have highlighted fundamental areas where robust evidence is lacking. Further, definitive randomised controlled trials are needed, and we suggest priority areas for future research. ispartof: European Stroke Journal vol:6 issue:3 pages:1-177 ispartof: location:England status: Published online