Letter to the Editor Stroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 3 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited.
Response to Letter Regarding Article, “Serial Montreal Cognitive Assessments Demonstrate Reversible Cognitive Impairment in Patients With Acute Transient Ischemic Attack and Minor Stroke”
We thank Dr Regal for his interest and comments regarding our article.1 It is important to consider delirium in the differential diagnosis of stroke and to recognize that delirium can occur in the acute phase of ischemic stroke.2 We do agree that delirium and transient ischemic attack/minor stroke patients both exhibit rapid early neurological improvement. As pointed out by Dr Regal, these conditions are distinct from dementia and minimal cognitive impairment. Unlike the patients included in Dr Regal’s study, however, our patients demonstrated no signs of fluctuating attention or level of consciousness suggestive of delirium. In fact, we excluded patients with dementia as well as any acute medical condition associated with delirium. We, therefore, think that the rapidly reversible single-domain and multiple-domain impairment we observed was more likely related to the effects of focal cerebral ischemia itself, as has been described in the nonminor stroke population.3 The rate of change of cognitive domain change analysis by Dr Regal elegantly demonstrates the rapid improvement in overall cognition in our patients. In our patients, the attention domain was relatively stable between baseline and day 90. Instead, the majority of the improvement in overall cognitive function seems to be related to better recall at day 7.1 We agree that prestroke test scores would have been useful to quantify cognitive decline and improvement later, although this certainly is a more difficult study. In addition to differences in the attention domain, grouping transient ischemic attack/minor stroke and Central Coast Australia Delirium Intervention Study (CADIS)4 patients may be problematic, because the latter likely have multiple causes. Finally, the median (interquartile range) in-hospital stay for our study patients was 2 (5) days, which is considerably shorter than that previously reported for elderly delirious patients where the
mean was 9 to 32 days.5 Regardless, we do agree that patients with transient ischemic attack/minor stroke should be assessed for transient cognitive changes using the same approach and tools currently being used by Dr Regal in the CADIS study.
Disclosures None.
Leka Sivakumar, MSc Mahesh Kate, MD, DM Laura Gioia, MD Richard Camicioli, MD Kenneth Butcher, MD, PhD Division of Neurology, Department of Medicine University of Alberta Edmonton, Alberta, Canada 1. Sivakumar L, Kate M, Jeerakathil T, Camicioli R, Buck B, Butcher K. Serial Montreal Cognitive Assessments demonstrate reversible cognitive impairment in patients with acute transient ischemic attack and minor stroke. Stroke. 2014;45:1709–1715. 2. Oldenbeuving AW, de Kort PL, Jansen BP, Algra A, Kappelle LJ, Roks G. Delirium in the acute phase after stroke: incidence, risk factors, and outcome. Neurology. 2011;76:993–999. 3. Srikanth VK, Thrift AG, Saling MM, Anderson JF, Dewey HM, Macdonell RA, et al; Community-Based Prospective Study of Nonaphasic English-Speaking Survivors. Increased risk of cognitive impairment 3 months after mild to moderate first-ever stroke: a Community-Based Prospective Study of Nonaphasic English-Speaking Survivors. Stroke. 2003;34:1136–1143. 4. Regal P. Confusion Assessment Method (CAM) indicators when CAM positivity in 647 individuals has good outcome. J Am Geriatr Soc. 2013;61:173. 5. Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing. 2006;35:350–364.
(Stroke. 2014;45:e194.) © 2014 American Heart Association, Inc. Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.114.006360
Downloaded from http://stroke.ahajournals.org/ at e194 Charité - Universitaetsmedizin Berlin on June 24, 2015
Response to Letter Regarding Article, ''Serial Montreal Cognitive Assessments Demonstrate Reversible Cognitive Impairment in Patients With Acute Transient Ischemic Attack and Minor Stroke'' Leka Sivakumar, Mahesh Kate, Laura Gioia, Richard Camicioli and Kenneth Butcher Stroke. 2014;45:e194; originally published online August 5, 2014; doi: 10.1161/STROKEAHA.114.006360 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/45/9/e194
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/
Downloaded from http://stroke.ahajournals.org/ at Charité - Universitaetsmedizin Berlin on June 24, 2015
Response to Letter Regarding Article, “Serial Montreal Cognitive Assessments Demonstrate Reversible Cognitive Impairment in Patients With Acute Transient Ischemic Attack and Minor Stroke”
We thank Dr Regal for his interest and comments regarding our article.1 It is important to consider delirium in the differential diagnosis of stroke and to recognize that delirium can occur in the acute phase of ischemic stroke.2 We do agree that delirium and transient ischemic attack/minor stroke patients both exhibit rapid early neurological improvement. As pointed out by Dr Regal, these conditions are distinct from dementia and minimal cognitive impairment. Unlike the patients included in Dr Regal’s study, however, our patients demonstrated no signs of fluctuating attention or level of consciousness suggestive of delirium. In fact, we excluded patients with dementia as well as any acute medical condition associated with delirium. We, therefore, think that the rapidly reversible single-domain and multiple-domain impairment we observed was more likely related to the effects of focal cerebral ischemia itself, as has been described in the nonminor stroke population.3 The rate of change of cognitive domain change analysis by Dr Regal elegantly demonstrates the rapid improvement in overall cognition in our patients. In our patients, the attention domain was relatively stable between baseline and day 90. Instead, the majority of the improvement in overall cognitive function seems to be related to better recall at day 7.1 We agree that prestroke test scores would have been useful to quantify cognitive decline and improvement later, although this certainly is a more difficult study. In addition to differences in the attention domain, grouping transient ischemic attack/minor stroke and Central Coast Australia Delirium Intervention Study (CADIS)4 patients may be problematic, because the latter likely have multiple causes. Finally, the median (interquartile range) in-hospital stay for our study patients was 2 (5) days, which is considerably shorter than that previously reported for elderly delirious patients where the
mean was 9 to 32 days.5 Regardless, we do agree that patients with transient ischemic attack/minor stroke should be assessed for transient cognitive changes using the same approach and tools currently being used by Dr Regal in the CADIS study.
Disclosures None.
Leka Sivakumar, MSc Mahesh Kate, MD, DM Laura Gioia, MD Richard Camicioli, MD Kenneth Butcher, MD, PhD Division of Neurology, Department of Medicine University of Alberta Edmonton, Alberta, Canada 1. Sivakumar L, Kate M, Jeerakathil T, Camicioli R, Buck B, Butcher K. Serial Montreal Cognitive Assessments demonstrate reversible cognitive impairment in patients with acute transient ischemic attack and minor stroke. Stroke. 2014;45:1709–1715. 2. Oldenbeuving AW, de Kort PL, Jansen BP, Algra A, Kappelle LJ, Roks G. Delirium in the acute phase after stroke: incidence, risk factors, and outcome. Neurology. 2011;76:993–999. 3. Srikanth VK, Thrift AG, Saling MM, Anderson JF, Dewey HM, Macdonell RA, et al; Community-Based Prospective Study of Nonaphasic English-Speaking Survivors. Increased risk of cognitive impairment 3 months after mild to moderate first-ever stroke: a Community-Based Prospective Study of Nonaphasic English-Speaking Survivors. Stroke. 2003;34:1136–1143. 4. Regal P. Confusion Assessment Method (CAM) indicators when CAM positivity in 647 individuals has good outcome. J Am Geriatr Soc. 2013;61:173. 5. Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing. 2006;35:350–364.
(Stroke. 2014;45:e194.) © 2014 American Heart Association, Inc. Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.114.006360
Downloaded from http://stroke.ahajournals.org/ at e194 Charité - Universitaetsmedizin Berlin on June 24, 2015
Response to Letter Regarding Article, ''Serial Montreal Cognitive Assessments Demonstrate Reversible Cognitive Impairment in Patients With Acute Transient Ischemic Attack and Minor Stroke'' Leka Sivakumar, Mahesh Kate, Laura Gioia, Richard Camicioli and Kenneth Butcher Stroke. 2014;45:e194; originally published online August 5, 2014; doi: 10.1161/STROKEAHA.114.006360 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/45/9/e194
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/
Downloaded from http://stroke.ahajournals.org/ at Charité - Universitaetsmedizin Berlin on June 24, 2015
