Background
Methods
Study design
Study subjects
Procedure
Demographic and clinical characteristics
Classification of ischemic stroke; etiology, and neuroimaging
Cognitive assessment
Functional assessment battery
Domain | Assessment |
---|---|
Stroke severity | National Institute of Health Stroke Scale (NIHSS) |
Activities of daily living | Korean modified Barthel Index (K-MBI) |
Functional Independence Measure (FIM) | |
Cognition function | Korean Mini-Mental State Examination (K-MMSE) |
Motor function | Fugl-Meyer Assessment (FMA) |
Modified Ashworth scale (mRS) | |
Mobility function | Functional Ambulatory Category (FAC) |
Mood | Geriatric depression scale-short form (GDS) |
Quality of life | Euro Quality of Life-5D |
Statistical analysis
Results
Age | Group | n (%) | Cognitive Change | 3 months after onset | 12 months after onset | |
---|---|---|---|---|---|---|
n (%) | K-MMSE (mean ± SD) | K-MMSE (mean ± SD) | ||||
Total Subjects (n = 2,625) | Normal Cognition | 1,735 (66.1) | Stable | 1,430 (82.4) | 28.09 ± 2.66 | 28.14 ± 2.75 |
Converter | 93 (5.4) | 23.67 ± 3.60 | 27.41 ± 3.19 | |||
Reverter | 212 (12.2) | 26.81 ± 3.53 | 22.00 ± 4.80 | |||
Declined Cognition | 890 (33.9) | Stable | 472 (53.0) | 16.14 ± 9.81 | 16.42 ± 10.09 | |
Converter | 321 (36.1) | 17.87 ± 9.81 | 24.11 ± 5.69 | |||
Reverter | 97 (10.9) | 16.34 ± 7.27 | 11.03 ± 7.46 | |||
Older age (n = 1,431) | Normal Cognition | 835 (58.4) | Stable | 612 (73.3) | 26.86 ± 3.41 | 26.88 ± 3.50 |
Converter | 79 (9.5) | 23.18 ± 3.69 | 27.01 ± 3.30 | |||
Reverter | 144 (17.2) | 25.85 ± 3.82 | 20.66 ± 4.90 | |||
Declined Cognition | 596 (41.6) | Stable | 336 (56.4) | 14.46 ± 9.71 | 14.68 ± 9.95 | |
Converter | 183 (30.7) | 15.95 ± 7.64 | 22.46 ± 5.78 | |||
Reverter | 77 (12.9) | 16.08 ± 7.09 | 10.52 ± 7.21 |
Parameters | Normal Cognition (n = 1,735) | Declined Cognition (n = 890) | ||||||
---|---|---|---|---|---|---|---|---|
Stable (n = 1,430) | Converter (n = 93) | Reverter (n = 212) |
P value | Stable (n = 472) | Converter (n = 321) | Reverter (n = 97) |
P value | |
1) Baseline medical record assessments | ||||||||
Male, n (%) | 991 (69.3) | 46 (49.5) | 107 (50.5) | .000
**
| 248 (52.5) | 185 (57.6) | 52 (53.6) | .362 |
Age, (mean ± SD) | 61.52 ± 12.53
a
| 69.44 ± 11.16
b
| 73.75 ± 8.85
c
| .000
**
| 70.32 ± 11.07
a
| 66.34 ± 11.54
b
| 72.32 ± 9.45
ab
| .000
**
|
Education, n (%) | ||||||||
Uneducated | 114 (8.0) | 25 (26.9) | 44 (20.8) | .000
**
| 35 (7.4) | 11 (3.4) | 13 (13.4) | .000
**
|
0–3 years | 46 (3.2) | 10 (10.8) | 12 (5.7) | 40 (8.5) | 26 (8.1) | 11 (11.3) | ||
4–6 years | 189 (13.2) | 25 (26.9) | 52 (24.5) | 117 (24.8) | 73 (22.7) | 27 (27.8) | ||
7–9 years | 222 (15.5) | 17 (18.3) | 45 (21.2) | 113 (23.9) | 70 (21.8) | 21 (21.6) | ||
10–12 years | 468 (32.7) | 8 (8.6) | 36 (17.0) | 135 (28.6) | 93 (29.0) | 19 (19.6) | ||
13 years– | 391 (27.3) | 8 (8.6) | 23 (10.8) | 32 (6.8) | 48 (15.0) | 6 (6.2) | ||
BMI (kg/m2), (mean ± SD) | 24.10 ± 3.28
a
| 23.59 ± 3.61
ab
| 23.49 ± 3.33
b
| .023
*
| 23.35 ± 3.08 | 23.47 ± 3.30 | 22.62 ± 3.27 | .071 |
Risk factors of stroke, n (%) | ||||||||
Hypertension | 779 (54.5) | 63 (67.7) | 118 (88.7) | .030
*
| 275 (58.3) | 178 (55.5) | 68 (70.1) | .037
*
|
Diabetes Mellitus | 206 (14.4) | 15 (16.1) | 24 (11.3) | .412 | 70 (14.8) | 44 (13.7) | 22 (22.7) | .091 |
Coronary heart disease | 98 (6.9) | 9 (9.7) | 15 (7.1) | .587 | 40 (8.5) | 20 (6.2) | 5 (5.2) | .339 |
Atrial fibrillation | 118 (8.3) | 14 (15.1) | 27 (12.7) | .014
*
| 68 (14.4) | 37 (11.5) | 11 (11.3) | .433 |
Hyperlipidemia | 246 (17.2) | 12 (12.9) | 39 (18.4) | .493 | 54 (11.4) | 42 (13.1) | 15 (15.5) | .505 |
Obesity | 190 (13.3) | 14 (15.1) | 23 (10.8) | .522 | 49 (10.4) | 40 (12.5) | 4 (4.1) | .063 |
Family history | 135 (9.4) | 5 (5.4) | 20 (9.4) | .420 | 48 (10.2) | 26 (8.1) | 7 (7.2) | .483 |
Smoking, n (%) | ||||||||
Current smokers | 462 (32.3) | 17 (18.3) | 44 (20.8) | .000
**
| 127 (26.9) | 87 (27.1) | 29 (29.9) | .859 |
Former smokers | 202 (14.1) | 10 (10.8) | 19 (9.0) | 55 (11.7) | 39 (12.1) | 8 (8.2) | ||
Never smokers | 766 (53.6) | 66 (71.0) | 149 (70.3) | 290 (61.4) | 195 (60.7) | 60 (61.9) | ||
Alcohol consumption, n (%) | ||||||||
None | 793 (55.5) | 62 (66.7) | 144 (67.9) | .002
**
| 327 (69.3) | 202 (63.0) | 67 (69.1) | .253 |
Moderate | 452 (31.6) | 23 (24.7) | 42 (19.8) | 97 (20.6) | 72 (22.4) | 21 (21.6) | ||
Heavy | 185 (12.9) | 8 (8.6) | 26 (12.3) | 48 (10.2) | 47 (14.6) | 9 (9.3) | ||
2) Stroke characteristics | ||||||||
Ischemic type (TOAST) | ||||||||
Large–artery atherosclerosis | 641 (44.8) | 58 (62.4) | 101 (47.6) | .062 | 229 (48.5) | 173 (53.9) | 56 (57.7) | .572 |
Small-artery occlusion | 373 (26.1) | 14 (15.1) | 53 (25.0) | 85 (18.0) | 57 (17.8) | 15 (15.5) | ||
Cardioembolism | 156 (10.9) | 6 (6.5) | 24 (11.3) | 74 (15.7) | 39 (12.1) | 9 (9.3) | ||
Other determined | 115 (8.0) | 4 (4.3) | 12 (5.7) | 29 (6.1) | 14 (4.4) | 5 (5.2) | ||
Undetermined ischemic stroke | 145 (10.1) | 11 (11.8) | 22 (10.4) | 55 (11.7) | 38 (11.8) | 12 (12.4) | ||
Ischemic location | ||||||||
Rt. hemisphere | 680 (47.6) | 46 (49.5) | 99 (46.7) | .580 | 178 (37.7) | 117 (36.4) | 41 (42.3) | .698 |
Lt. hemisphere | 648 (45.3) | 37 (39.8) | 94 (44.3) | 262 (55.5) | 185 (57.6) | 48 (49.5) | ||
Both hemisphere | 102 (7.1) | 10 (10.8) | 19 (9.0) | 178 (37.7) | 19 (5.9) | 8 (8.2) | ||
Affected level | ||||||||
Cortical level | 440 (30.8) | 37 (39.8) | 70 (33.0) | .007
**
| 191 (40.5) | 139 (43.3) | 41 (42.3) | .878 |
Subcortical level | 454 (31.7) | 22 (23.7) | 49 (23.1) | 115 (24.4) | 83 (25.9) | 25 (25.8) | ||
Brainstem level | 330 (23.1) | 13 (14.0) | 58 (27.4) | 63 (13.3) | 41 (12.8) | 14 (14.4) | ||
Multiple level | 206 (14.4) | 21 (22.6) | 35 (16.5) | 103 (21.8) | 58 (18.1) | 17 (17.5) | ||
3) Treatment characteristics | ||||||||
IV thrombolysis | 104 (7.3) | 7 (7.5) | 13 (6.1) | .826 | 43 (9.1) | 29 (9.0) | 15 (15.5) | .136 |
IA thrombolysis | 21 (1.5) | 3 (3.2) | 4 (1.9) | .404 | 23 (4.9) | 9 (2.8) | 2 (2.1) | .208 |
IV heparin | 121 (8.5) | 5 (5.4) | 17 (8.0) | .573 | 33 (7.0) | 18 (5.6) | 10 (10.3) | .271 |
Antiplatelet agent | 1,140 (79.7) | 77 (82.8) | 166 (78.3) | .668 | 333 (70.6) | 240 (74.8) | 65 (67.0) | .241 |
Rehabilitation Therapy | 386 (27.0) | 29 (31.2) | 59 (27.8) | .669 | 187 (60.4) | 116 (36.1) | 43 (44.3) | .311 |
Cognitive Therapy | 56 (3.9) | 4 (4.3) | 9 (4.2) | .961 | 28 (5.9) | 33 (10.3) | 11 (11.3) | .041
*
|
4) Functional assessments | ||||||||
Cognitive function (K-MMSE) | ||||||||
3 months from onset | 28.09 ± 2.66
a
| 23.67 ± 3.60
b
| 26.81 ± 3.53
c
| .000
**
| 16.14 ± 9.81
a
| 17.87 ± 7.81
b
| 16.34 ± 7.27
ab
| .024
*
|
12 months from onset | 28.14 ± 2.75
a
| 27.41 ± 3.19
a
| 22.00 ± 4.80
b
| .000
**
| 16.42 ± 10.09
a
| 24.11 ± 5.69
b
| 11.03 ± 7.46
c
| .000
**
|
Variation (from 3 months to 12 months) | 0.05 ± 1.07
a
| 3.41 ± 1.23
b
| −4.81 ± 2.91
c
| .000
**
| 0.29 ± 1.09
a
| 6.25 ± 4.19
b
| −5.31 ± 2.81
c
| .000
**
|
Stroke Severity, ADL, Motor, Gait, Depression, QoL (3 months from onset) | ||||||||
NIHSS | 0.77 ± 1.85
a
| 1.11 ± 2.03
ab
| 1.12 ± 2.02
b
| .015
*
| 5.09 ± 6.86
a
| 3.12 ± 4.62
b
| 5.25 ± 4.63
a
| .000
**
|
mRS | 0.99 ± 1.02
a
| 1.44 ± 1.28
b
| 1.43 ± 1.20
b
| .000
**
| 2.57 ± 1.68
a
| 2.17 ± 1.52
b
| 3.15 ± 1.29
c
| .000
**
|
FIM | 120.00 ± 12.73
a
| 114.16 ± 17.39
b
| 113.93 ± 18.05
b
| .000
**
| 88.70 ± 38.13
a
| 100.18 ± 30.85
b
| 82.80 ± 30.61
a
| .000
**
|
K-MBI | 95.44 ± 11.90
a
| 90.03 ± 16.88
b
| 89.88 ± 17.34
b
| .000
**
| 69.11 ± 36.99
a
| 79.71 ± 28.65
b
| 63.41 ± 30.94
a
| .000
**
|
FMA | 94.11 ± 15.80 | 91.19 ± 18.70 | 89.88 ± 17.34 | .119 | 72.75 ± 35.71
a
| 81.68 ± 30.77
b
| 63.65 ± 35.07
c
| .000
**
|
FAC | 4.66 ± 0.87
a
| 6.59 ± 4.07
b
| 6.74 ± 4.40
b
| .000
**
| 3.10 ± 2.03
a
| 3.65 ± 1.77
b
| 2.66 ± 1.83
a
| .000
**
|
GDS | 4.95 ± 3.79
a
| 6.59 ± 4.07
b
| 6.74 ± 4.40
b
| .000
**
| 7.25 ± 4.11
a
| 7.30 ± 4.32
a
| 9.31 ± 3.92
b
| .006
**
|
EQ-5D | 0.78 ± 0.28
a
| 0.69 ± 0.33
b
| 0.65 ± 0.36
b
| .000
**
| 0.44 ± 0.41
a
| 0.53 ± 0.40
b
| 0.31 ± 0.37
c
| .000
**
|
Parameters | Normal Cognition (n = 835) | Declined Cognition (n = 596) | ||||||
---|---|---|---|---|---|---|---|---|
Stable (n = 612) | Converter (n = 79) | Reverter (n = 144) |
P value | Stable (n = 336) | Converter (n = 183) | Reverter (n = 77) |
P value | |
1) Baseline medical record assessments | ||||||||
Male, n (%) | 375 (61.3) | 37 (46.8) | 66 (45.8) | .000
**
| 163 (48.5) | 91 (49.7) | 38 (49.4) | .963 |
Age, (mean ± SD) | 73.15 ± 5.86
a
| 75.24 ± 6.84
b
| 76.53 ± 6.21
b
| .000
**
| 76.06 ± 6.15 | 74.78 ± 5.55 | 75.95 ± 6.09 | .059 |
Education, n (%) | ||||||||
Uneducated | 98 (16.0) | 24 (30.4) | 41 (28.5) | .000
**
| 33 (9.8) | 10 (5.5) | 12 (15.6) | .307 |
0–3 years | 34 (5.6) | 9 (11.4) | 10 (6.9) | 36 (10.7) | 20 (10.9) | 9 (11.7) | ||
4–6 years | 132 (21.6) | 22 (27.8) | 43 (29.9) | 106 (31.5) | 61 (33.3) | 23 (29.9) | ||
7 - 9 years | 103 (16.8) | 12 (15.2) | 25 (17.4) | 74 (22.0) | 35 (19.1) | 17 (22.1) | ||
10 - 12 years | 142 (23.2) | 4 (5.1) | 15 (10.4) | 71 (21.1) | 41 (22.4) | 13 (16.9) | ||
13 years - | 103 (16.8) | 8 (10.1) | 10 (6.9) | 16 (4.8) | 16 (8.7) | 3 (3.9) | ||
BMI (kg/m2), (mean ± SD) | 23.72 ± 3.20 | 23.59 ± 3.61 | 23.11 ± 3.43 | .115 | 23.00 ± 2.96 | 23.24 ± 3.15 | 22.26 ± 3.23 | .066 |
Risk factors of stroke, n (%) | ||||||||
Hypertension | 414 (67.6) | 54 (68.4) | 91 (63.2) | .570 | 212 (63.1) | 116 (63.4) | 55 (71.4) | .371 |
Diabetes Mellitus | 102 (16.7) | 12 (15.2) | 15 (10.4) | .175 | 55 (16.4) | 28 (15.3) | 17 (22.1) | .392 |
Coronary heart disease | 60 (9.8) | 8 (10.1) | 11 (7.6) | .711 | 27 (8.0) | 16 (8.7) | 5 (6.5) | .831 |
Atrial fibrillation | 78 (12.7) | 11 (13.9) | 22 (15.3) | .712 | 59 (17.6) | 27 (14.8) | 10 (13.0) | .515 |
Hyperlipidemia | 110 (18.0) | 11 (13.9) | 31 (21.5) | .357 | 39 (11.6) | 19 (10.4) | 12 (15.6) | .489 |
Obesity | 79 (12.9) | 12 (15.2) | 11 (7.6) | .154 | 29 (8.6) | 20 (10.9) | 3 (3.9) | .185 |
Family history | 52 (8.5) | 4 (5.1) | 11 (7.6) | .562 | 30 (8.9) | 12 (6.6) | 6 (7.8) | .635 |
Smoking, n (%) | ||||||||
Current smokers | 105 (17.2) | 11 (13.9) | 23 (16.0) | .050 | 67 (19.9) | 27 (14.8) | 19 (24.7) | .285 |
Former smokers | 107 (17.4) | 10 (12.7) | 12 (8.3) | 39 (11.6) | 28 (15.3) | 8 (10.4) | ||
Never smokers | 400 (65.4) | 58 (73.4) | 109 (75.7) | 230 (68.5) | 128 (69.9) | 50 (64.9) | ||
Alcohol consumption, n (%) | ||||||||
None | 414 (67.6) | 54 (68.4) | 108 (75.0) | .322 | 249 (74.1) | 133 (72.7) | 56 (72.7) | .367 |
Moderate | 141 (23.0) | 20 (25.3) | 23 (16.0) | 63 (18.8) | 28 (15.3) | 15 (19.5) | ||
Heavy | 57 (9.3) | 5 (6.3) | 13 (9.0) | 24 (7.1) | 22 (12.0) | 6 (7.8) | ||
2) Stroke characteristics | ||||||||
Ischemic type (TOAST) | ||||||||
Large-artery atherosclerosis | 278 (45.4) | 51 (64.6) | 67 (46.5) | .052 | 167 (49.7) | 94 (51.4) | 46 (59.7) | .662 |
Small-artery occlusion | 155 (25.3) | 11 (13.9) | 39 (27.1) | 60 (17.9) | 34 (18.6) | 12 (15.6) | ||
Cardioembolism | 89 (14.5) | 5 (6.3) | 17 (11.8) | 59 (17.6) | 28 (15.3) | 7 (9.1) | ||
Other determined | 36 (5.9) | 4 (5.1) | 5 (3.5) | 15 (4.5) | 5 (2.7) | 4 (5.2) | ||
Undetermined ischemic stroke | 54 (8.8) | 8 (10.1) | 16 (11.1) | 35 (10.4) | 22 (12.0) | 8 (10.4) | ||
Ischemic location | ||||||||
Rt. hemisphere | 309 (50.5) | 39 (49.4) | 64 (44.4) | .394 | 135 (40.2) | 68 (37.2) | 33 (42.9) | .667 |
Lt. hemisphere | 247 (40.4) | 31 (39.2) | 70 (48.6) | 178 (53.0) | 106 (57.9) | 38 (49.4) | ||
Both hemisphere | 56 (9.2) | 9 (11.4) | 10 (6.9) | 23 (6.8) | 9 (4.9) | 6 (7.8) | ||
Affected level | ||||||||
Cortical level | 203 (33.2) | 32 (40.5) | 49 (34.0) | .047
*
| 143 (42.6) | 75 (41.0) | 32 (41.6) | .729 |
Subcortical level | 193 (31.5) | 20 (25.3) | 30 (20.8) | 83 (24.7) | 53 (29.0) | 21 (27.3) | ||
Brainstem level | 125 (20.4) | 11 (13.9) | 40 (27.8) | 42 (12.5) | 20 (10.9) | 13 (16.9) | ||
Multiple level | 91 (14.9) | 16 (20.3) | 25 (17.4) | 68 (20.2) | 35 (19.1) | 11 (14.3) | ||
3) Treatment characteristics | ||||||||
IV thrombolysis | 40 (6.5) | 5 (6.3) | 9 (6.3) | .991 | 27 (8.0) | 16 (8.7) | 7 (9.1) | .935 |
IA thrombolysis | 9 (1.5) | 2 (2.5) | 3 (2.1) | .722 | 20 (6.0) | 4 (2.2) | 1 (1.3) | .049
*
|
IV heparin | 52 (8.5) | 5 (6.3) | 9 (6.3) | .575 | 29 (8.6) | 10 (5.5) | 8 (10.4) | .301 |
Antiplatelet agent | 485 (79.2) | 65 (82.3) | 115 (79.9) | .818 | 239 (71.1) | 131 (71.6) | 53 (68.8) | .901 |
Rehabilitation Therapy | 157 (25.7) | 25 (31.6) | 43 (29.9) | .363 | 133 (39.6) | 54 (29.5) | 36 (46.8) | .015
*
|
Cognitive Therapy | 26 (4.2) | 4 (5.1) | 5 (3.5) | .844 | 19 (5.7) | 11 (6.0) | 10 (13.0) | .061 |
4) Neuropsychological assessments | ||||||||
Cognitive function (K-MMSE) | ||||||||
3 months from onset | 26.86 ± 3.41
a
| 23.18 ± 3.69
b
| 25.85 ± 3.82
c
| .000
**
| 14.46 ± 9.71 | 15.95 ± 7.64 | 16.08 ± 7.09 | .112 |
12 months from onset | 26.88 ± 3.50
a
| 27.01 ± 3.30
a
| 20.66 ± 4.90
b
| .000
**
| 14.68 ± 9.95
a
| 22.46 ± 5.78
b
| 10.52 ± 7.21
c
| .000
**
|
Variation (from 3 months to 12 months) | 0.03 ± 1.17
a
| 3.84 ± 1.31
b
| −5.19 ± 3.05
c
| .000
**
| 0.21 ± 1.10
a
| 6.51 ± 4.03
b
| −5.56 ± 2.99
c
| .000
**
|
Stroke Severity, ADL, Motor, Gait, Depression, QoL (3 months from onset) | ||||||||
NIHSS | 0.78 ± 1.98
a
| 1.15 ± 2.06
a
| 1.32 ± 2.15
b
| .009
**
| 5.75 ± 7.43
a
| 3.17 ± 4.69
b
| 5.08 ± 4.68
b
| .000
**
|
mRS | 1.12 ± 1.12
a
| 1.51 ± 1.32
b
| 1.63 ± 1.25
b
| .000
**
| 2.79 ± 1.68
a
| 2.37 ± 1.54
b
| 3.26 ± 1.29
a
| .000
**
|
FIM | 117.40 ± 15.58
a
| 113.08 ± 18.30
ab
| 111.16 ± 19.83
b
| .000
**
| 83.68 ± 39.78
a
| 95.74 ± 32.33
b
| 81.34 ± 31.60
a
| .001
**
|
K-MBI | 93.31 ± 16.11
a
| 89.09 ± 17.82
ab
| 87.34 ± 19.10
b
| .000
**
| 64.13 ± 38.83
a
| 75.71 ± 30.51
b
| 61.61 ± 32.50
a
| .001
**
|
FMA (affected side) | 93.92 ± 16.11 | 90.53 ± 19.31 | 91.44 ± 17.83 | .094 | 70.49 ± 36.80
a
| 81.45 ± 30.54
b
| 65.90 ± 35.97
a
| .000
**
|
FAC | 4.51 ± 1.05
a
| 4.15 ± 1.40
b
| 4.00 ± 1.35
b
| .000
**
| 2.83 ± 2.10
a
| 3.45 ± 1.79
b
| 2.70 ± 1.87
a
| .001
**
|
GDS | 5.40 ± 3.79
a
| 6.83 ± 4.19
b
| 7.41 ± 4.35
b
| .000
**
| 7.63 ± 4.09
a
| 8.03 ± 4.27
ab
| 9.65 ± 4.04
b
| .022
*
|
EQ-5D | 0.76 ± 0.29
a
| 0.67 ± 0.34
b
| 0.63 ± 0.36
b
| .000
**
| 0.39 ± 0.41
a
| 0.49 ± 0.40
b
| 0.31 ± 0.37
a
| .003
**
|