Serial Montreal Cognitive Assessments Demonstrate
Reversible Cognitive Impairment in Patients With Acute
Transient Ischemic Attack and Minor Stroke
Leka Sivakumar, MSc; Mahesh Kate, MD, DM; Thomas Jeerakathil, MD, MSc;
Richard Camicioli, MD; Brian Buck, MD, MSc; Ken Butcher, MD, PhD
Downloaded from http://stroke.ahajournals.org/ by guest on July 31, 2017
Background and Purpose—Cognitive changes after ischemic stroke are often overlooked, particularly acutely and in patients
with mild or transient deficits. We assessed patients with transient ischemic attack (TIA)/minor stroke with serial cognitive
screening tests. We tested the hypothesis that mild acute deficits are transient and improve after TIA/minor stroke.
Methods—Patients with acute TIA/minor ischemic stroke, without a history of cognitive impairment, presenting with a
National Institute of Health Stroke Scale score ≤3 were assessed <72 hours of onset. Patients were administered the M
­ iniMental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) at days 1, 7, 30, and 90. Cognitive
impairment was defined as MoCA <26 and MMSE ≤26.
Results—One hundred patients with a median (interquartile range) National Institute of Health Stroke Scale score of 1 (2)
and median age of 68 (20) years were included. Baseline median MoCA score (26 [4]) was lower than the MMSE (29 [2];
P<0.0001). Cognitive impairment was detected in 54 of 100 patients (54%) with MoCA and 16 of 100 (16%; P=0.001)
with MMSE. MoCA scores improved at day 7 (27 [5]), day 30 (28 [2]), and day 90 (28 [2]; P<0.0001). Resolution of
cognitive deficits was because of resolution of recall deficits.
Conclusions—Acute temporary cognitive impairment after TIA/minor stroke is common. The MoCA is sensitive to these
changes, but the MMSE is not. Routine cognitive assessment after TIA/minor stroke may be warranted and relevant to
return to activities even when other neurological deficits are not evident. (Stroke. 2014;45:1709-1715.)
Key Words: ischemic attack, transient ◼ mild cognitive impairment
L
ong-term cognitive impairment is a well-known consequence of ischemic stroke.1–3 Approximately two thirds
of patients develop cognitive impairment within 3 months
of stroke.4 A history of transient ischemic attacks (TIAs)
and minor strokes is also associated with vascular cognitive
impairment.5 Cognitive changes are often overlooked or not
assessed in the acute setting. Although detailed neuropsychological testing is ideal, it is time-consuming and impractical in
the large TIA/minor stroke population.
Screening tests for cognitive impairment include the
­Mini-Mental State Examination (MMSE) and the Montreal
Cognitive Assessment (MoCA). The MMSE, originally
designed to screen for dementia of the Alzheimer type, is
currently widely used to assess for poststroke cognitive
impairment.6 Previous studies have indicated that MMSE
has reduced sensitivity for mild cognitive deficits and those
associated with right-­hemisphere lesions.7–11 In contrast, the
MoCA was developed more recently to detect mild cognitive impairment with higher sensitivity. This assessment has
demonstrated high test–retest reliability, good internal consistency, and a particular strength in detecting executive function, a subtest not assessed by MMSE.12 Although previous
studies have compared these assessments in acute ischemic
stroke, acute changes in specific cognitive domains after TIA/
minor stroke have not been characterized.
In this prospective observational study, we tested the hypothesis that the MoCA is more sensitive than MMSE to acute cognitive changes after TIA/minor stroke. Using serial assessments, we
also assessed the temporal pattern of overall and d­ omain-specific
cognitive changes within 90 days of TIA/minor stroke.
Methods
Patients
Patients with acute TIA/minor ischemic stroke with a National Institute
of Health Stroke Scale (NIHSS) score ≤3 at admission and aged ≥18
years were recruited within 72 hours of symptom onset. Patients were
recruited from the Emergency Department at the University of Alberta
hospital between July 2008 and April 2013. Exclusion criteria included
stroke mimics (ie, seizures, migraine) and acute infections or other acute
medical conditions that might be associated with delirium, severe aphasia (>1 on NIHSS item 9), or a prior history of dementia. Preexisting
dementia was ruled out with a functional assessment at baseline and
a corroborative history from ≥1 relative/neighbor. Subjects who were
unable to complete baseline neuropsychological testing were excluded.
Informed consent was obtained from all patients before enrollment. This
Received January 6, 2014; final revision received March 21, 2014; accepted March 26, 2014.
From the Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Alberta, Canada.
Correspondence to Ken Butcher, MD, PhD, Division of Neurology, 2E3 WMC Health Sciences Centre, University of Alberta, 8440 112th St, Edmonton,
Alberta T6G 2B7, Canada. E-mail [email protected]
© 2014 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.114.004726
1709
1710 Stroke June 2014
was an observational study, and secondary stroke prevention measures
were implemented in accordance with current practice guidelines.13
Clinical Assessment
Downloaded from http://stroke.ahajournals.org/ by guest on July 31, 2017
All patients underwent a clinical evaluation at days 1, 7, 30, and 90.
Stroke syndromes were classified using the Oxfordshire Community
Stroke Project system.14 Etiological classification was completed
using the Trial of Org 10172 in Acute Stroke Treatment (TOAST)
criteria, by day 90.15 At each visit, the MMSE and the MoCA were administered by the physician or trained study team member. Identical
versions of the MoCA were administered at all time points. Each
MMSE version differed with respect to words used in recall and the
orientation of shapes to be copied. The order of testing at each visit
was fixed with the MMSE administered first, followed by the MoCA.
Patients with <12 years of education were assigned 1 additional point
on their MoCA score.12 Patients with an MMSE ≤26 or MoCA score
<26 were considered cognitively impaired.7
Neurological function was assessed with the NIHSS score at each
time point. Functional outcome was assessed with the modified
Rankin Scale (mRS) at days 7, 30, and 90. All raters were certified
in NIHSS and mRS administration.16,17 Mood was assessed with the
Geriatric Depression Scale18 at days 7, 30, and 90.
Statistical Analysis
Data were analyzed using Statistical Package for Social Sciences version 20.0.0 (SPSS Inc, 2007). Changes in MoCA and MMSE scores
between days 1 and 90 were tested using Freidman test followed
by post hoc analysis with Wilcoxon signed-rank tests. For both the
MMSE and the MoCA, performance within each cognitive domain
was calculated as a percentage score (median score/maximum possible score) to allow for relative comparisons between domains and
assessments. A linear regression model was used to assess the relationship between baseline domain impairments and cognitive function after 30 days. Spearman correlation was calculated to assess
the relationship between both NIHSS and mRS scores and cognitive
function. A P value of <0.05 was considered significant.
Results
Patient Characteristics
A total of 118 patients with TIA/minor stroke were enrolled in
the study and 18 patients were excluded. The most common
reason for exclusion was the presence of known preexisting dementia. The remaining 100 patients (68% men) had a
median (interquartile range) NIHSS score of 1 (2) on admission and median population age of 63 (20) years. Of these
patients, 19% had a prior history of stroke/TIA. The distribution of stroke syndromes (Oxfordshire Community Stroke
Project)14 was partial anterior circulation (57%), lacunar
(34%), and posterior circulation (9%). Stroke pathogenesis
using TOAST criteria were undetermined (37%), large artery
atherosclerosis (25%), cardioembolic (21%), small vessel disease (13%), and other determined causes (4%).15
MoCA Versus MMSE
Median (interquartile range) MoCA and MMSE scores at
baseline were 26 (4) and 29 (2), respectively (P<0.0001). The
MoCA indicated cognitive impairment in 54 of 100 patients
(54%) at baseline. At the same time, the MMSE detected
impairment in only 16 of 100 (16%; P=0.001). Thus, 38% of
patients with cognitive impairment present at baseline went
undetected by MMSE (Figure 1).
Temporal Pattern of Cognitive Changes
Median MoCA scores progressively increased after the onset
of symptoms. At days 7, 30, and 90, MoCA scores were 27
(5), 28 (3), and 28 (3), respectively. Median MMSE scores
at the same time points remained stable at 29 (2). Wilcoxon
­signed-rank test indicated a significant improvement in MoCA
scores between baseline and day 90 (P<0.0001), whereas
MMSE scores remained the same after 90 days (P=0.591).
Cognitive Domains
Assessment subtests were used to analyze performance in specific cognitive domains. The MoCA was divided into 7 cognitive
domains, which included orientation, attention, recall, naming,
visuospatial, language, and abstract reasoning. The MMSE was
divided into 6 cognitive subtests assessing orientation, attention,
Figure 1. Scatter plot of Mini-Mental State
Examination (MMSE) vs Montreal Cognitive
Assessment (MoCA) scores for all patients at
baseline. The horizontal dashed line shows the
cutoff for MMSE at ≤26 and the vertical dashed
line shows the cutoff for MoCA at <26. Black
data points indicate those patients who scored
>27 on the MMSE but <26 on the MoCA.
Sivakumar et al Serial MoCA Testing After TIA and Minor Stroke 1711
recall, language, registration, and constructional praxis. Mean
(SD) raw scores and percentage scores for each subtest are summarized in Table 1.
Baseline MoCA assessments indicated that the performance
of patients with TIA/minor stroke was poorest in language and
recall domains (Figure 2). Although language subtest scores
remained stable over 90 days, recall and abstract reasoning
subtest scores improved by day 7 and remained stable until
day 90. When assessed with MMSE, cognitive performance
was poorest in the constructional praxis and recall domains
at baseline. Recall performance worsened at day 7 and then
gradually improved at days 30 and 90 (Figure 2). Deficits in
the other 5 cognitive domains were stable between baseline
and day 90.
Four cognitive domains were directly comparable between
the MoCA and MMSE: attention, language, recall, and orientation. The greatest difference between the 2 assessments at
baseline was in recall (27.5%; P=0.014) and language (28.3%;
P<0.0001) domains (Figure 3). At baseline, the performance
in recall was only 53.3% of the maximum possible score when
assessed with MoCA. In contrast, recall performance was
80.8% when assessed with MMSE. Performance in language
Table 1. MoCA and MMSE Subtest Scores
Mean Raw Scores (SD) and Mean Percentage Scores
Subtest Details
Day 1
Percentage
Score
Day 7
Percentage
Score
Day 30
Percentage
Score
Day 90
Percentage
Score
Visuoexecutive/5
Trail B test, cube copy,
clock drawing
3.9 (1.4)
76.9
4.1 (1.2)
82.6
4.2 (1.0)
83.9
4.3 (1.0)
85.8
Naming/3
Confrontation naming
(lion, hippo, camel)
2.8 (0.6)
91.5
2.9 (0.4)
96.1
2.9 (0.3)
96.6
2.9 (0.4)
96.5
Attention/6
Forward (5 digits),
backward (3 digits)
Tapping the letter A in
letter list
Serial 7 subtractions
5.2 (1.3)
87.4
5.3 (1.0)
88.6
5.4 (1.1)
90.7
5.6 (0.9)
92.7
Language/3
Repetition of 2 complex
sentences
≥11 words beginning
with f in 1 min
2.0 (1.0)
66.7
2.1 (0.9)
69.4
2.1 (0.9)
68.2
2.3 (0.8)
75.8
Abstraction/2
Similarities, for
example, train and
bicycle=transport
1.6 (0.7)
78.1
1.8 (0.5)
89.5
1.8 (0.5)
90.3
1.9 (0.5)
93.2
MoCA subtest/max score
Downloaded from http://stroke.ahajournals.org/ by guest on July 31, 2017
Recall/5
Recall a list of 5 words
2.7 (1.7)
53.3
3.6 (1.5)
72.8
3.6 (1.6)
72.3
3.7 (1.5)
74.5
Orientation/6
Date, month, year, day,
place, city
5.8 (0.6)
96.3
5.8 (0.6)
96.1
5.8 (0.6)
97.2
5.8 (0.7)
96.2
24.7 (4.1)
82.3
26.0 (4.3)
86.7
26.8 (3.4)
89.3
27.0 (3.4)
90.0
9.7 (0.6)
96.8
9.5 (0.9)
95.4
9.5 (0.9)
94.9
9.6 (1.1)
95.6
Total/30
MMSE subtest/max score
Orientation/10
Orientation to place
and time
Registration/3
Repeat ball, car, man
3.0 (0.1)
99.7
3.0 (0.1)
99.6
3.0 (0.1)
99.6
3.0 (0.2)
99.0
Attention/5
Serial 7 subtractions
World backward
4.5 (1.1)
87.8
4.7 (0.9)
89.9
4.7 (0.9)
88.2
4.7 (0.8)
91.3
Recall/3
Language/8
Praxis/1
Total/30
Recall ball, car, man
2.4 (0.8)
80.8
2.1 (1.0)
69.3
2.1 (1.0)
75.7
2.4 (0.9)
80.4
Confrontation naming
(pen, watch)
Repeat no ifs, ands,
or buts
Perform 3-step
command
Obey written instruction
(close your eyes)
Write a complete
sentence
7.6 (0.8)
95.0
7.7 (0.8)
95.6
7.7 (0.8)
96.3
7.7 (0.6)
96.7
Copy intersecting
pentagons
0.8 (0.4)
79.4
0.8 (0.4)
80.9
0.8 (0.4)
78.7
0.8 (0.4)
75.0
28.5 (2.4)
95.0
28.1 (2.0)
93.7
28.5 (2.0)
95.0
28.7 (1.8)
95.7
Mean percentage scores calculated as a percentage of maximum possible score. MMSE indicates Mini-Mental State Examination; MoCA, Montreal Cognitive
Assessment; and SD, standard deviation.
1712 Stroke June 2014
(day 7, 69.4%; day 30, 68.2%; and day 90, 75.8%; P=0.088),
but more severe than indicated by MMSE. Impairments
detected by MoCA in recall, however, improved substantially
from baseline to day 7 (19.5% increase; P<0.0001), matching
MMSE scores at day 7 and onward (Figure 3).
Resolution of Cognitive Deficits
Downloaded from http://stroke.ahajournals.org/ by guest on July 31, 2017
Figure 2. Mean of Montreal Cognitive Assessment (MoCA; top)
and Mini-Mental State Examination (MMSE; bottom) subtest
scores shown as a percentage of the maximum subtest score for
all patients at baseline, days 7, 30, and 90.
was 66.7% with MoCA and 95.0% with MMSE (P=0.001;
Figure 3). During the following 90 days, language impairments detected by MoCA remained stable at all time points
Patients with baseline impairment (n=54; MoCA<26) were
then divided into 2 groups based on the improvement/worsening of cognitive function by day 30. Patients, in whom MoCA
scores improved by ≥2 points by day 30, were defined as
reverters (n=35; 65%). Those with persisting or worse deficits
by day 30 were defined as nonreverters (n=19; 35%). Reverters
improved from a baseline median (interquartile range) MoCA
of 23 (7) to 27 (5) at day 30. MoCA scores in nonreverters
worsened from 23 (5) to 22 (7) after 30 days.
A comparison of demographic characteristics showed that
median (interquartile range) age was lower in reverters (68
[19] years) than nonreverters (79 [12] years; Tables 2 and 3).
Baseline neurological deficits as assessed by NIHSS were also
more common in nonreverters (14/19; 74%) than in reverters (20/35; 57%; Tables 2 and 3). Spearman correlation indicated that NIHSS scores were significantly correlated with
MoCA scores at baseline (ρ=−0.517; P=0.023) and day 30
(ρ=−0.514; P=0.041) in nonreverters.
Reverters demonstrated significant improvements in all 7
subtests, with performance in the recall domain showing the
greatest improvement (34% increase; P<0.0001). In nonreverters, 6 of 7 subtests remained the same after 30 days,
whereas performance in the language domain worsened significantly (18% decrease; P=0.045; Tables 2 and 3).
Figure 3. Mean (SD) of Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) subtest scores shown as a percentage of the maximum subtest score for all patients in attention, language recall, and orientation domains at baseline, days 7, 30, and 90.
Sivakumar et al Serial MoCA Testing After TIA and Minor Stroke 1713
Table 2. Demographic and Clinical Characteristics of
Reverters and Nonreverters
Reverters (n=35)
Nonreverters (n=19)
Demographic characteristics
Age, y
68 (19)
79 (12)
Sex (men)
17 (49%)
13 (68%)
NIHSS=0
15 (43%)
5 (26%)
NIHSS=1
7 (20%)
5 (26%)
NIHSS=2
7 (20%)
3 (16%)
NIHSS=3
6 (17%)
6 (32%)
Median NIHSS
1 (2)
1 (3)
Day-7 GDS
5 (7)
5 (8)
Day-30 GDS
5 (11)
7 (6)
Day-90 GDS
4 (10)
2 (9)
Baseline pre-mRS
0 (0)
0 (1)
Day-30 mRS
2 (1)
2 (3)
Day-90 mRS
0 (2)
2 (3)
Baseline neurological function
Affective symptoms, median (IQR)
Downloaded from http://stroke.ahajournals.org/ by guest on July 31, 2017
Functional outcome, median (IQR)
GDS indicates Geriatric Depression Scale; IQR, interquartile range; mRS,
modified Rankin Scale; NIHSS, National Institute of Health Stroke Scale; and
Pre-mRS, premorbid modified Rankin Scale.
Affective Symptoms and Cognition
The median mood (Geriatric Depression Scale) score at day 7
was 5 (7). Most patients had scores in the normal range (0–9),
but 22% had scores of 10 to 19, consistent with a mild affective disturbance.
Table 3. Baseline and Day 30 MoCA Subtest Scores of
Reverters and Nonreverters
Reverters,
Mean (SD)
Reverters,
Percentage
Score
Nonreverters,
Mean (SD)
Nonreverters,
Percentage
Score
Baseline MoCA subtests
Visuospatial
3.3 (1.5)
66.1
3.1 (1.5)
61.1
Naming
2.5 (0.8)
82.8
2.6 (0.8)
87.0
Attention
4.6 (1.7)
72.3
4.7 (1.6)
78.7
Language
1.6 (0.9)
53.5
1.6 (1.1)
53.7
Abstraction
1.2 (0.8)
62.1
1.3 (0.8)
63.9
Recall
1.9 (1.8)
38.8
2.1 (1.7)
43.3
5.6 (0.7)
93.9
5.6 (0.8)
92.6
Orientation
Total
21.0 (4.4)
21.1 (4.9)
Day-30 MoCA subtests
Visuospatial
4.2 (1.0)
83.1
3.4 (1.4)
67.5
Naming
2.9 (0.3)
96.9
2.6 (0.5)
85.4
Attention
5.3 (1.1)
88.5
4.5 (1.6)
75.0
Language
2.3 (0.7)
67.7
1.1 (0.7)
35.4
Abstraction
1.8 (0.5)
89.1
1.5 (0.7)
75.0
Recall
3.6 (1.2)
72.5
1.6 (1.8)
32.5
Orientation
5.9 (0.3)
99.0
5.3 (1.1)
87.5
Total
25.8 (3.2)
20.1 (4.7)
MoCA indicates Montreal Cognitive Assessment; and SD, standard deviation.
Scores were similar in reverters (5 [7]) and nonreverters (5
[8]; P=0.93) at day 7, remained in the normal range at day
30 (reverters, 5 [11]; nonreverters, 7 [6]) and decreased by
day 90 in both groups (reverters, 4 [10]; nonreverters 2 [9];
Tables 2 and 3). Spearman correlation indicated that MoCA
scores were correlated with Geriatric Depression Scale scores
(ρ=−0.316; P=0.003).
Functional Outcome and Cognition
The premorbid mRS at baseline was not significantly different
between reverters (0 [0]) and nonreverters (0 [1]; P=0.122).
Median mRS scores at day 30 were similar in reverters (2 [1])
and nonreverters (2 [3]). However, by day 90, these impairments resolved in reverters (0 [2]) and remained unchanged in
nonreverters (2 [3]).
Discussion
This is the first longitudinal assessment of domain-specific
cognitive impairment in patients with TIA/minor stroke,
including the acute phase of the illness. The MoCA was more
sensitive to language deficits, which were consistently present
during the first 90 days. Memory deficits detected with MoCA
at baseline improved over time. Cognitive function in patients
with persisting impairment was correlated significantly with
baseline neurological deficits and functional outcome.
Five studies have assessed the sensitivity of neuropsychological assessments to overall and domain-specific cognitive
impairments after TIA/minor stroke.7–10,19 These studies have
primarily been cross-sectional, rather than longitudinal and
none assessed cognitive function after acute TIA. No previous study has used serial assessment to examine the temporal
profile of domain-specific cognitive impairments after TIA/
minor stroke.
Studies of the MoCA in cerebrovascular patients are consistent with our results. Pendlebury et al7 assessed 413 patients
with TIA/stroke at 6-month or 5-year follow-ups using a
cutoff score <26 to indicate impairment in both MoCA and
MMSE. According to MoCA, 291 (70%) patients were cognitively impaired, of whom 162 (56%) had normal MMSE
scores. MMSE detected impairments in only 30% of all
patients. A study by Dong et al9 assessed 100 patients at a
mean of 4.2±2.4 days post stroke. The MoCA detected deficits
in 59% of patients, whereas only 43% were impaired according to MMSE. In another study, 91 patients were administered
the MMSE and MoCA ≥1 year after TIA/stroke.8 The MoCA
identified mild cognitive impairment with good sensitivity and
specificity, whereas MMSE scores were consistently skewed
toward higher values. The MMSE may be able to identify deficits in patients with more severe strokes.
Three cross-sectional studies have assessed d­ omain-specific
changes in cognitive function after TIA and stroke.7,9,19
Pendlebury et al19 assessed patients with TIA (n=156) or
stroke (n=207) at ≥6 months after symptom onset. TIA subjects performed better than patients with stroke on 1 MMSE
subtest versus 6 MoCA subtests (visuoexecutive tasks, attention, verbal fluency, abstraction, recall, and orientation). In
patients with TIA, MoCA detected subtle deficits in recall
and verbal fluency domains, which were less impaired when
assessed with MMSE. In another study from the same group,
1714 Stroke June 2014
Downloaded from http://stroke.ahajournals.org/ by guest on July 31, 2017
413 patients with TIA/stroke were assessed 6 months or 5
years post event.7 The MoCA demonstrated deficits in executive function, attention, recall, and repetition, which were not
detected by the MMSE. Finally, Dong et al9 compared the
ability of MoCA and MMSE domain subtest scores to classify cognitive patterns in 100 patients with ischemic stroke or
TIA within 14 days. Based on baseline cognitive screening
scores, patients were divided into 3 groups: acute vascular
cognitive impairment no dementia moderate (screened positive for both MoCA and MMSE), acute vascular cognitive
impairment no dementia mild (positive for either test), and
no cognitive impairment (negative for both tests). The MMSE
subtest scores did not differentiate between these groups,
whereas MoCA subtest scores in the visuospatial/executive
function, attention, and recall domains did.
Previous studies indicate that the MoCA is more difficult
than MMSE, which likely improves sensitivity for mild cognitive deficits in certain domains.7,9,12 This is particularly relevant in the TIA/minor stroke population, where cognitive
changes are subtle. To test for attention, MMSE uses only the
serial 7’s task, but the MoCA includes 2 additional tests (digit
span and vigilance). The MoCA memory questions are more
challenging, with more words, fewer learning trials, and a longer delay before recall. The MoCA also uses more tasks to
assess executive function, language, and visuospatial processing thoroughly. It is likely that these differences contributed to
the MoCA’s higher overall sensitivity to acute impairment, as
well as domain-specific changes in memory and language in
our patients. The MMSE has also been associated consistently
with a ceiling effect,7,8,19 which is the most plausible explanation for the stable MMSE scores across 90 days in our study.
This ceiling effect also applied to the 5 MMSE domains (orientation, registration, attention, language, and praxis), which
remained unchanged between baseline and day 90. The exception was the memory domain, which transiently worsened at
day 7, improving by day 30. We do not feel that this represents
a true cognitive change in our patients, as the MoCA recall
scores improved. It is theoretically possible that fatigue led
to worsening of performance on the MMSE, but we would
expect the MoCA scores to worsen as well, unless we hypothesize a floor effect on the latter test. This is speculative, however, and this more likely represents a type I error.
Reverter status in patients with TIA/minor stroke may be
explained by the presence of baseline neurological deficits.
The greater severity of baseline neurological deficits observed
in nonreverters may have played a role in suppressing certain
cognitive domains, affecting improvement over time. It would
be useful to use MRI to compare the extent of tissue injury
between reverters and nonreverters. Reversion of cognitive
impairment may be related to the localization of acute lesions,
affecting strategic regions of cognition more so in nonreverters than in reverters.
Many of our patients had mild affective changes, which
were correlated with the presence of acute cognitive changes.
They did not, however, predict resolution of cognitive deficits
over time. Nonetheless, an assessment of mood should also be
considered in patients with most TIA/minor stroke.
This study has several limitations. We used identical versions of the MoCA test at each time point because alternate
forms were not available at the time of study inception. It is
possible that patients may have learned aspects of a task, contributing to the development of a learning curve. Modifying
details of certain tasks such as recall words and repetition
sentences would help minimize learning effects. In addition,
although patients with preexisting dementia were excluded,
it is possible that some patients with stroke with mild cognitive impairment without dementia (vascular cognitive impairment no dementia) may have gone undetected and therefore
influenced results. Cognitive assessment timing (time of day/
beginning versus end of the visit) and fatigue may have also
resulted in decreased capacity to sustain an effort, increasing
the likelihood of error. Finally, language barriers may have
hindered the patient’s ability to thoroughly understand certain
tasks, contributing to increased error.
Conclusions
An MoCA is the preferred cognitive screening test in patients
with TIA/minor stroke. Given the frequency of cognitive
changes seen in this population, it could be considered a standard assessment tool. The transient cognitive changes seen
in some patients suggest that studies of long-term cognitive
changes after stroke/TIA should include a baseline assessment at day 90 or later, after acute changes have stabilized.
Persisting cognitive deficits are relevant, as they are correlated with functional outcome. These findings are relevant to
patients with TIA/minor stroke disposition and advice with
respect to vocation, driving, and activities of daily living.
Sources of Funding
Dr Butcher holds a Canada Research Chair in Cerebrovascular
Disease, a Heart and Stroke Foundation of Alberta Professorship
in Stroke Medicine, and a New Investigator Award from Alberta
Innovates Health Solutions.
Disclosures
None.
References
1. Pasi M, Poggesi A, Salvadori E, Pantoni L. Post-stroke dementia and
cognitive impairment. Front Neurol Neurosci. 2012;30:65–69.
2. Pendlebury ST. Stroke-related dementia: rates, risk factors and implications for future research. Maturitas. 2009;64:165–171.
3. Shim H. Vascular cognitive impairment and post-stroke cognitive deficits. Curr Neurol Neurosci Rep. 2014;14:418.
4. Blackburn DJ, Bafadhel L, Randall M, Harkness KA. Cognitive screening in the acute stroke setting. Age Ageing. 2013;42:113–116.
5. Moran GM, Fletcher B, Calvert M, Feltham MG, Sackley C, Marshall
T. A systematic review investigating fatigue, psychological and cognitive
impairment following TIA and minor stroke: protocol paper. Syst Rev.
2013;2:72.
6. Folstein MF, Robins LN, Helzer JE. The Mini-Mental State Examination.
Arch Gen Psychiatry. 1983;40:812.
7.Pendlebury ST, Cuthbertson FC, Welch SJ, Mehta Z, Rothwell PM.
Underestimation of cognitive impairment by Mini-Mental State Examination
versus the Montreal Cognitive Assessment in patients with transient ischemic
attack and stroke: a population-based study. Stroke. 2010;41:1290–1293.
8. Pendlebury ST, Mariz J, Bull L, Mehta Z, Rothwell PM. MoCA, ­ACE-R,
and MMSE versus the National Institute of Neurological Disorders
and Stroke-Canadian Stroke Network Vascular Cognitive Impairment
Harmonization Standards Neuropsychological Battery after TIA and
stroke. Stroke. 2012;43:464–469.
9. Dong Y, Sharma VK, Chan BP, Venketasubramanian N, Teoh HL, Seet
RC, et al. The Montreal Cognitive Assessment (MoCA) is superior to the
Sivakumar et al Serial MoCA Testing After TIA and Minor Stroke 1715
Mini-Mental State Examination (MMSE) for the detection of vascular
cognitive impairment after acute stroke. J Neurol Sci. 2010;299:15–18.
10. Godefroy O, Fickl A, Roussel M, Auribault C, Bugnicourt JM, Lamy C,
et al. Is the Montreal Cognitive Assessment superior to the Mini-Mental
State Examination to detect poststroke cognitive impairment? A study
with neuropsychological evaluation. Stroke. 2011;42:1712–1716.
11. Nys GM, van Zandvoort MJ, de Kort PL, Jansen BP, Kappelle LJ, de
Haan EH. Restrictions of the Mini-Mental State Examination in acute
stroke. Arch Clin Neuropsychol. 2005;20:623–629.
12. Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead
V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: a
brief screening tool for mild cognitive impairment. J Am Geriatr Soc.
2005;53:695–699.
13. Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie K, et al.
Guidelines for prevention of stroke in patients with ischemic stroke or
transient ischemic attack: a statement for healthcare professionals from
the American Heart Association/American Stroke Association Council
on Stroke: co-sponsored by the Council on Cardiovascular Radiology
and Intervention: the American Academy of Neurology affirms the value
of this guideline. Circulation. 2006;113:e409–449.
14. Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. Classification
and natural history of clinically identifiable subtypes of cerebral infarction. Lancet. 1991;337:1521–1526.
15. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon
DL, et al. Classification of subtype of acute ischemic stroke. Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in
Acute Stroke Treatment. Stroke. 1993;24:35–41.
16.NIH Stroke Scale-English Program. TrainingCampus Network.
­­h ttp://nihss-english.trainingcampus.net/uas/modules/trees/windex.
aspx?resx=123. 1999. Accessed September 10, 2011.
17.Modified Rankin Scale-English Program. TrainingCampus Network.
­http://rankin-english.trainingcampus.net/uas/modules/trees/windex.
aspx. 1999. Accessed September 10, 2011.
18. Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, et al.
Development and validation of a geriatric depression screening scale: a
preliminary report. J Psychiatr Res. 1982;17:37–49.
19. Pendlebury ST, Markwick A, de Jager CA, Zamboni G, Wilcock GK,
Rothwell PM. Differences in cognitive profile between TIA, stroke and
elderly memory research subjects: a comparison of the MMSE and
MoCA. Cerebrovasc Dis. 2012;34:48–54.
Downloaded from http://stroke.ahajournals.org/ by guest on July 31, 2017
Serial Montreal Cognitive Assessments Demonstrate Reversible Cognitive Impairment in
Patients With Acute Transient Ischemic Attack and Minor Stroke
Leka Sivakumar, Mahesh Kate, Thomas Jeerakathil, Richard Camicioli, Brian Buck and Ken
Butcher
Downloaded from http://stroke.ahajournals.org/ by guest on July 31, 2017
Stroke. 2014;45:1709-1715; originally published online April 22, 2014;
doi: 10.1161/STROKEAHA.114.004726
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2014 American Heart Association, Inc. All rights reserved.
Print ISSN: 0039-2499. Online ISSN: 1524-4628
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://stroke.ahajournals.org/content/45/6/1709
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published
in Stroke can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office.
Once the online version of the published article for which permission is being requested is located, click
Request Permissions in the middle column of the Web page under Services. Further information about this
process is available in the Permissions and Rights Question and Answer document.
Reprints: Information about reprints can be found online at:
http://www.lww.com/reprints
Subscriptions: Information about subscribing to Stroke is online at:
http://stroke.ahajournals.org//subscriptions/