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Effect of Formal Education on Vascular Cognitive Impairment after Stroke: A Meta-analysis and Study in Young-Stroke Patients

  • Roy P.C. Kessels (a1) (a2) (a3), Willem Sake Eikelboom (a1), Pauline Schaapsmeerders (a4), Noortje A.M. Maaijwee (a4), Renate M. Arntz (a4), Ewoud J. van Dijk (a1) (a4) and Frank-Erik de Leeuw (a1) (a4)...


Objectives: The extent of vascular cognitive impairment (VCI) after stroke varies greatly across individuals, even when the same amount of brain damage is present. Education level is a potentially protective factor explaining these differences, but results on its effects on VCI are inconclusive. Methods: First, we performed a meta-analysis on formal education and VCI, identifying 21 studies (N=7770). Second, we examined the effect of formal education on VCI in young-stroke patients who were cognitively assessed on average 11.0 (SD=8.2) years post-stroke (the FUTURE study cohort). The total sample consisted of 277 young-stroke patients with a mean age at follow-up 50.9 (SD=10.3). Age and education-adjusted expected scores were computed using 146 matched stroke-free controls. Results: The meta-analysis showed an overall effect size (z') of 0.25 (95% confidence interval [0.18–0.31]), indicating that formal education level had a small to medium effect on VCI. Analyses of the FUTURE data showed that the effect of education on post-stroke executive dysfunction was mediated by age (β age −0.015; p<.05). Below-average performance in the attention domain was more frequent for low-education patients (χ2(2)=9.8; p<.05). Conclusions: While education level was found to be related to post-stroke VCI in previous research, the effects were small. Further analysis in a large stroke cohort showed that these education effects were fully mediated by age, even in relatively young stroke patients. Education level in and of itself does not appear to be a valid indicator of cognitive reserve. Multi-indicator methods may be more valid, but have not been studied in relation to VCI. (JINS, 2017, 23, 223–238)


Corresponding author

Correspondence and reprint requests to: R.P.C. Kessels, Radboud University, Donders Institute for Brain, Cognition and Behaviour, Montessorilaan 3, 6525 HR Nijmegen, The Netherlands. E-mail:


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Studies labeled with * were included in the meta-analysis.
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