Post-stroke cognitive impairment remains highly prevalent and disabling despite state-of-the-art stroke treatment.

BACKGROUND: State-of-the-art stroke treatment significantly reduces lesion size and stroke severity, but it remains unclear whether these therapeutic advances have diminished the burden of post-stroke cognitive impairment (PSCI).

AIMS: In a cohort of patients receiving modern state-of-the-art stroke care including endovascular therapy, we assessed the frequency of PSCI and the pattern of domain-specific cognitive deficits, identified risk factors for PSCI, and determined the impact of acute PSCI on stroke outcome.

METHODS: In this prospective monocentric cohort study, we examined patients with first-ever anterior circulation ischemic stroke without pre-stroke cognitive decline, using a comprehensive neuropsychological assessment ≤ 10 days after symptom onset. Normative data were stratified by demographic variables. We defined PSCI as at least moderate (< 1.5 SD) deficits in ≥ 2 cognitive domains. Multivariable regression analysis was applied to define risk factors for PSCI.

RESULTS: We analyzed 329 non-aphasic patients admitted from December, 2020 to July, 2023 (67.2±14.4 years old, 41.3% female, 13.1±2.7 years of education). Though most patients had mild stroke (median NIHSS 24h=1.00 [0.00; 3.00]; 87.5% with NIHSS ≥ 5), 69.3% of them presented with PSCI 2.7±2.0 days post-stroke. The most severely and often affected cognitive domains were verbal learning, episodic memory, executive functions, selective attention, and constructive abilities (39.1%-51.2% of patients), whereas spatial neglect was less frequent (18.5%). The risk of PSCI was reduced with more years of education (odds ratio [OR] 0.47, 95% CI: 0.23-0.99) and right hemispheric lesions (OR 0.47, 95% CI: 0.26-0.84), and increased with stroke severity (NIHSS 24h, OR 4.19, 95% CI: 2.72-6.45), presence of hyperlipidemia (OR 1.93, 95% CI: 1.01-3.68), but was not influenced by age. After adjusting for stroke severity and depressive symptoms, acute PSCI was associated with poor functional outcome (modified Rankin Scale > 2, F =13.695, p <0.001) and worse global cognition (MoCA-score, F =20.069, p <0.001) at 3 months post-stroke.

CONCLUSIONS: Despite modern stroke therapy and many strokes having mild severity, PSCI in the acute stroke phase remains frequent and associated with worse outcome. The most prevalent were learning and memory deficits. Cognitive reserve operationalized as years of education independently protects post-stroke cognition.