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We investigated the impact of regionally imposed social and healthcare restrictions due to coronavirus disease 2019 (COVID-19) to the time metrics in the management of acute ischemic stroke patients admitted at the regional stroke referral site for Central South Ontario, Canada.
We compared relevant time metrics between patients with acute ischemic stroke receiving intravenous tissue plasminogen activator (tPA) and/or endovascular thrombectomy (EVT) before and after the declared restrictions and state of emergency imposed in our region (March 17, 2020).
We identified a significant increase in the median door-to-CT times for patients receiving intravenous tPA (19 min, interquartile range (IQR): 14–27 min vs. 13 min, IQR: 9–17 min, p = 0.008) and/or EVT (20 min, IQR: 15–33 min vs. 11 min, IQR: 5–20 min, p = 0.035) after the start of social and healthcare restrictions in our region compared to the previous 12 months. For patients receiving intravenous tPA treatment, we also found a significant increase (p = 0.005) in the median door-to-needle time (61 min, IQR: 46–72 min vs. 37 min, IQR: 30–50 min). No delays in the time from symptom onset to hospital presentation were uncovered for patients receiving tPA and/or endovascular reperfusion treatments in the first 1.5 months after the establishment of regional and institutional restrictions due to the COVID-19 pandemic.
We detected an increase in our institutional time to treatment metrics for acute ischemic stroke patients receiving tPA and/or endovascular reperfusion therapies, related to delays from hospital presentation to the acquisition of cranial CT imaging for both tPA- and EVT-treated patients, and an added delay to treatment with tPA.
Vascular cognitive impairment (VCI) post-stroke is frequent but may go undetected, which highlights the need to better screen cognitive functioning following a stroke.
We examined the clinical utility of the Montreal Cognitive Assessment (MoCA) in detecting cognitive impairment against a gold-standard neuropsychological battery.
We assessed cognitive status with a comprehensive battery of neuropsychological tests in 161 individuals who were at least 3-months post-stroke. We used receiver operating characteristic (ROC) curves to identify two cut points for the MoCA to maximize sensitivity and specificity at a minimum 90% threshold. We examined the utility of the Symbol Digit Modalities Test, a processing speed measure, to determine whether this additional metric would improve classification relative to the MoCA total score alone.
Using two cut points, 27% of participants scored ≤ 23 and were classified as high probability of cognitive impairment (sensitivity 92%), and 24% of participants scored ≥ 28 and were classified as low probability of cognitive impairment (specificity 91%). The remaining 48% of participants scored from 24 to 27 and were classified as indeterminate probability of cognitive impairment. The addition of a processing speed measure improved classification for the indeterminate group by correctly identifying 65% of these individuals, for an overall classification accuracy of 79%.
The utility of the MoCA in detecting cognitive impairment post-stroke is improved when using a three-category approach. The addition of a processing speed measure provides a practical and efficient method to increase confidence in the determined outcome while minimally extending the screening routine for VCI.
Screening for cognitive impairment is recommended in patients with cerebrovascular disease. We sought to establish the incidence of cognitive impairment using the Montreal Cognitive Assessment (MoCA) in a cohort of consecutive patients attending our stroke prevention clinic (SPC), and to determine whether a subset of the MoCA could be derived for use in this busy clinical setting.
The MoCA was administered to 102 patients. Incidence of cognitive impairment was compared to presenting complaint and final diagnosis. extent of cerebral white matter changes (WMC) was rated using the Age Related White Matter Changes (ARWMC) scale in 80 patients who underwent neuroimaging. A subset of the three most predictive test elements of the MoCA was derived using regression analysis.
63.7% of patients scored <26/30 on the MoCA, in keeping with cognitive impairment. This was unrelated to the final diagnosis or extent of WMC, although a trend for lower MoCA scores was observed in older patients. A mini-MoCA subscore combining the clock drawing test, five-word delayed recall, and abstraction was highly correlated with the final MoCA score (R=0.901). A score of <7/10 using this 10-point mini-MoCA identified cognitive impairment as defined by the MoCA with a sensitivity of 98.5%, and a specificity of 77.6%.
Two-thirds of SPC patients demonstrated evidence for cognitive impairment, irrespective of their final diagnosis or the presence of WMC. A mini-MoCA comprised of the clock drawing test, five-word delayed recall, and abstraction represents a potential alternative to the full MoCA in this population.
Sporadic Creutzfeldt-Jakob disease (CJD) is a fatal, transmissible spongiform encephalopathy characterized by rapidly progressive dementia, myoclonus, ataxia and akinetic mutism. The underlying mechanism is believed to be a conformational change of a native prion protein which characteristically fails to provoke an immune response. Commensurate with the latter, cerebrospinal fluid (CSF) classically exhibits a non-inflammatory profile.
We report two patients with pathologically-proven sporadic CJD presenting with a significant CSF pleocytosis.
Although uncommon, the presence of an inflammatory CSF profile should not exclude the diagnosis of sporadic CJD.
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