Stroke is the third leading cause of death in the developed world and is the leading neurological cause of disability with a massive impact on personal life and society. Large artery atherosclerosis is one of the main causes of ischaemic stroke. However, in several aspects of this condition there is still a significant amount of uncertainty about its prevalence, appropriate investigation and possible treatment. Reliable data on epidemiology are therefore necessary to provide clinicians and researchers with crucial information to guide diagnostic and therapeutic management as well as further research. With this thesis I aimed to provide useful information about the prevalence of large artery disease in certain groups of patients, and to contribute to investigation- and managementstrategies using data from a large population based study, the Oxford Vascular Study (OXVASC). OXVASC is a prospective, population-based incidence study of vascular disease in Oxfordshire, UK, which started in 2002 and is ongoing. The study population comprises all 91,106 individuals registered with nine general practices and uses multiple methods of case ascertainment to identify all patients with vascular events. Firstly, I have shown that the prevalence of ≥50% vertebral or basilar artery stenosis in posterior circulation TIA or minor stroke is more than twice as high as the prevalence of ≥50% carotid stenosis in patients with carotid territory events, and is associated with a very high early risk of stroke of 22% and TIA of 46%. Furthermore, severe vertebral and/or basilar artery stenosis is associated with multiple TIAs at first presentation. Secondly, I have shown that early risk of stroke was higher after posterior circulation TIA, with a 1-year risk of 16%, than after carotid territory TIA, with a 1-year risk of 9%. In addition, I was able to show for the first time, that the ABCD2 score was predictive of early stroke not only in patients with carotid circulation TIA but also in patients with vertebrobasilar TIA. Thirdly, in a pilot feasibility study about arterial spin labelling magnetic resonance imaging in patients with large artery disease in the vertebrobasilar circulation I have shown that patients with severe large artery disease have significantly impaired occipital brain perfusion. My results suggest that this new technique might be a useful tool to identify suitable patients for interventional treatment of vertebrobasilar large artery disease. Fourthly, I was able to show that the risk of ipsilateral stroke and TIA in patients with an asymptomatic carotid stenosis is very low with contemporary best medical treatment alone, suggesting that routine carotid endarterectomy for asymptomatic carotid stenosis might not longer be feasible. Finally, I have clarified that lower rates of intervention for moderate to severe symptomatic carotid stenosis in women than in men can be explained by sex-differences in the populationbased incidence of carotid large artery disease and not due to under-investigation or reluctance amongst women to undergo investigation or treatment.

<strong>Background:</strong> Stroke is a leading cause of disability and premature death in China and blood pressure is widely considered to be a major cause. Despite this, substantial uncertainty remains about the shape and strength of the association between blood pressure and stroke pathological types in China. <strong>Methods:</strong> Information from the China Kadoorie Biobank study (a prospective cohort study of 0.5 million men and women in China recruited during 2004-8) was used to relate usual blood pressure to risk of stroke, by stroke pathological type (cerebral infarction [ischaemic stroke], intracerebral haemorrhage and subarachnoid haemorrhage). Prospective analyses excluded participants with a history of vascular disease recorded at baseline; involved correction for regression dilution bias; used incident stroke events for which the diagnosis involved a head CT or MRI scan; and, assessed for confounding and effect modification by major vascular risk factors. These prospective analyses were informed by a set of prior analyses, including: a description of baseline associations between blood pressure and other vascular risk factors, to identify potential confounders; analyses of resurvey blood pressure data from ~20_000 participants, to assess regression dilution bias; and analyses of stroke follow-up data, involving an adjudication ‘sub-study’ performed specifically as part of this thesis, to evaluate the diagnostic accuracy of incident stroke events (~1000 events were adjudicated). <strong>Results:</strong> During 2.1 million person-years at risk, there were 5783 incident stroke events. At ages 40-79 years, the proportional difference in risk of both cerebral infarction and intracerebral haemorrhage associated with a given absolute difference in usual blood pressure was constant throughout the range of blood pressures examined (SBP 120-170 mm Hg, DBP 70-100 mm Hg). Overall, the strength of association was approximately 1.5-times greater for intracerebral haemorrhage than for the other stroke pathological types: 10 mm Hg higher usual SBP was associated with 82% (95% CI: 76%-89%) higher risk of intracerebral haemorrhage, 47% (44%- 50%) higher risk of cerebral infarction and 52% (35%-71%) higher risk of subarachnoid haemorrhage (the overall mean age at event for each stroke pathological type was ~60 years). For both cerebral infarction and intracerebral haemorrhage, there was strong evidence of major effect modification by age and to a lesser extent by a number of other vascular risk factors. The associations by age were around a third as extreme at age 70-79 years than at 40-49 years. The annual absolute differences in risk associated with a given absolute increase in usual blood pressure, however, were greater at older age. <strong>Conclusions:</strong> In Chinese adults, usual blood pressure was strongly and positively related to risk of all stroke pathological types. The strength of association was greater for intracerebral haemorrhage than other stroke pathological types. For both cerebral infarction and intracerebral haemorrhage, there was evidence of major effect modification by age. The overall effect of blood pressure on stroke risk was much greater than estimated by previous prospective studies in China, particularly for intracerebral haemorrhage.

Stroke is the second most common cause of death worldwide and the commonest cause of dependency, creates a huge societal burden and is responsible for billions of pounds in health and social care costs. About 30% of strokes occur in individuals with a previous transient ischaemic attack (TIA) or minor stroke. Effective prevention would minimise the consequences. However, the diagnosis of TIA is difficult, particularly by non-experts. About 50% of patients with a suspected TIA or minor stroke have atypical TIAs or a non-vascular diagnosis (TIA/minor stroke mimics). Although there is some evidence that non-specific Transient Neurological Attacks (TNAs) have an increased risk of acute vascular events, the evidence is still both thin and controversial. The aim of my thesis has been to evaluate the burden of TIA/minor stroke mimics, TNAs and all acute cerebrovascular events among all referrals from the general population to a TIA clinic; to determine the reliability of clinical diagnosis of TIA and non-specific TNA; to improve the classification of non-specific TNAs; and to predict the risk of stroke and other major vascular events after a non-specific TNA and TNA syndromes. I have collected and analysed data from a population-based study, the Oxford Vascular Study (OXVASC). OXVASC is an ongoing prospective, population-based incidence study of all vascular diseases in all territories in Oxfordshire, UK, which started in 2002. The study population comprises approximately 92,728 individuals registered with nine GP practices and uses multiple overlapping methods of "hot" and "cold" pursuit to identify patients with acute vascular events. The research described in this thesis has several clinically relevant findings which can contribute to improving the diagnosis and treatment of patients with suspected TIAs. First, I highlighted that TIA/minor stroke mimics (mimics) were responsible for one quarter of all suspected TIAs, had similar short- and long-term risk of acute cardiac events as did TIAs, and that the majority (70%) of mimics were complex neurological conditions. Second, I showed that TIA/minor ischaemic strokes are each more common than major ischaemic strokes and that TIA/minor ischaemic stroke patients together had two-thirds of all recurrent strokes and two-thirds of all myocardial infarctions and sudden cardiac deaths. Moreover, the 10 years' cumulative risk of stroke in patients with TIA, minor stroke and major stroke was very high and the risk of death among all cerebrovascular events was greater than 50%. Third, I found that the crude incidence rate of TNAs per 1000 people in OXVASC was slightly higher than the crude incidence rate of TIAs (0.73 versus 0.67) and increased with age. In addition, I reported that among TNA syndromes, transient isolated vertigo, unilateral sensory symptoms, migraine-aura like events and transient confusion had high incidence rates, whereas transient total paralysis and transient speech arrest had low incidence rates. Fourth, I showed that about one-third of TIAs seen in the first 10 years of OXVASC did not fulfil the classical criteria (NINDS-negative TIA) and had the same short- and long-term risk of stroke as NINDS-positive TIAs. Fifth, although the 90 days stroke risk after a TNA was lower than after a NINDS-positive TIA, in the post 90 days up to 10 years period the risk of recurrent stroke was not significantly different between the two groups. Sixth, the risks of stroke were higher than expected in the background population in all TNA categories (focal-TNA, non-focal TNA and focal plus non-focal TNA) and all TNA syndromes (isolated brainstem syndrome, migraine-like syndrome, isolated sensory syndromes, isolated visual disturbance, isolated speech disturbance, transient confusion and transient unresponsiveness) except transient amnesia. Moreover, non-focal TNAs and focal plus non-focal TNAs had a six times higher risk of stroke than expected and a similar risk to NINDS-positive TIAs. Finally, transient confusion and transient unresponsiveness had a relative risk of stroke nine times higher than expected and twice the risk of NINDS-positive TIAs.

Tang, Suk Yan Amy. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2001. / Includes bibliographical references (leaves [207]-[227]). / Abstracts in English and Chinese. / ACKNOWLEDGEMENTS / ABSTRACTS / TABLE OF CONTENTS / "LIST OF APPENDIX, TABLES & FIGURES" / Chapter CHAPTER ONE --- INTRODUCTION --- p.1 / Chapter 1.1 --- Cerebrovascular disease --- p.1 / Chapter 1.1.1 --- Ischemic Stroke --- p.1 / Chapter 1.1.2 --- Hemorrhagic Stroke --- p.2 / Chapter 1.2 --- Laboratory diagnosis --- p.3 / Chapter 1.2.1 --- Transcranial Doppler ultrasonography --- p.4 / Chapter 1.2.1.1 --- Normal Brain --- p.4 / Chapter 1.2.1.2 --- Intracranial Large Artery Stenosis --- p.5 / Chapter 1.3 --- Asymptomatic Intracranial Stenosis --- p.6 / Chapter CHAPTER TWO --- LITERATURE REVIEW --- p.7 / Chapter 2.1 --- Global Stroke Facts --- p.7 / Chapter 2.2 --- Stroke Studies --- p.7 / Chapter 2.2.1 --- Risk profile of stroke --- p.7 / Chapter 2.2.2 --- Stroke epidemiological study --- p.8 / Chapter 2.2.2.1 --- Incidence --- p.8 / Chapter 2.2.2.2 --- Mortality --- p.10 / Chapter 2.2.2.3 --- Increased stroke rates with increased age --- p.12 / Chapter 2.2.2.4 --- Associated disease in stroke subjects --- p.12 / Chapter 2.2.3 --- Stroke risk factors --- p.13 / Chapter 2.3 --- Stroke Impact --- p.14 / Chapter 2.3.1 --- Stroke patients --- p.14 / Chapter 2.3.2 --- Medical burden --- p.15 / Chapter 2.3.3 --- Socioeconomic burden --- p.16 / Chapter 2.4 --- Stroke Prevention --- p.17 / Chapter 2.5 --- Stroke Facts in Hong Kong --- p.19 / Chapter 2.6 --- Stroke Facts in China --- p.21 / Chapter 2.7 --- Asymptomatic Intracranial Stenosis in Asian Subjects --- p.22 / Chapter 2.7.1 --- Asymptomatic individuals --- p.22 / Chapter 2.7.2 --- Intracranial occlusive disease --- p.23 / Chapter 2.8 --- Transcranial Doppler Sonography --- p.25 / Chapter CHAPTER THREE --- AIM & OBJECTIVES OF THE RESEARCH --- p.30 / Chapter 3.1 --- Aim of the research --- p.30 / Chapter 3.2 --- Objectives of this research --- p.30 / Chapter CHAPTER FOUR --- "CLINIC-BASED CROSS-SECTIONAL SCREENING IN AN URBAN CITY 226}0ؤ HONG KONG, THE PEOPLE'S REPUBLIC OF CHINA" --- p.31 / Chapter 4.1 --- Background & Purpose --- p.31 / Chapter 4.2 --- Methods --- p.34 / Chapter 4.2.1 --- Defining the population --- p.34 / Chapter 4.2.2 --- Procedures --- p.36 / Chapter 4.2.2.1 --- Standardized TCD Report Form --- p.39 / Chapter 4.2.2.2 --- Transcranial Doppler Screening --- p.39 / Chapter 4.2.2.3 --- Data collected --- p.40 / Chapter 4.2.3 --- Defining the Risk Factors --- p.43 / Chapter 4.3 --- Statistical Analyses --- p.45 / Chapter 4.3.1 --- Research Design --- p.46 / Chapter 4.3.2 --- Descriptive Summary --- p.46 / Chapter 4.3.2.1 --- Cross-tabulated between Gender --- p.46 / Chapter 4.3.2.2 --- Cross-tabulated between Normal & Abnormal MCA status --- p.47 / Chapter 4.3.3 --- Measures for Association --- p.48 / Chapter 4.3.3.1 --- Univariate analysis --- p.48 / Chapter 4.3.3.2 --- Multivariate analysis --- p.48 / Chapter 4.3.4 --- Modeling the Risks --- p.50 / Chapter 4.3.5 --- nfluence of the number of associated risk factors on the MCA status --- p.50 / Chapter 4.4 --- Result --- p.51 / Chapter 4.4.1 --- Baseline characteristics of all screened subjects by Gender --- p.51 / Chapter 4.4.1.1 --- Age by Gender --- p.53 / Chapter 4.4.1.2 --- "Medical History of HT, DM, Hyperlipidemia, IHD, Retinopathy and Albuminuria by Gender" --- p.55 / Chapter 4.4.1.3 --- Social habit in Smoking by Gender --- p.56 / Chapter 4.4.1.4 --- Body Mass Index and Waist-to-Hip Ratio by Gender --- p.57 / Chapter 4.4.2 --- Diseased Middle Cerebral Artery --- p.61 / Chapter 4.4.3 --- Characteristics between subjects with Normal TCD result and Abnormal TCD result in the MCA status --- p.62 / Chapter 4.4.3.1 --- Age --- p.64 / Chapter 4.4.3.2 --- Gender --- p.67 / Chapter 4.4.3.3 --- "Medical History of HT, DM, Hyperlipidemia, IHD, Retinopathy and Albuminuria" --- p.67 / Chapter 4.4.3.4 --- Social habit in cigarette smoking --- p.68 / Chapter 4.4.3.5 --- Body Mass Index and Waist-to-Hip Ratio --- p.71 / Chapter 4.4.3.6 --- "Other Measurements - on Blood Pressure, Fasting Plasma Glucose, HbAlc, Lipid profiles and Fibrinogen" --- p.79 / Chapter 4.4.4 --- Unadjusted Odds Ratio --- p.84 / Chapter 4.4.4.1 --- By contingency table method --- p.84 / Chapter 4.4.4.2 --- By logistic regression model --- p.86 / Chapter 4.4.5 --- Adjusted Odds Ratio --- p.92 / Chapter 4.4.5.1 --- Entering all explanatory variables: --- p.92 / Chapter 4.4.5.2 --- Using Forward and Backward Stepwise methods with the probability for entry of 0.05 and probability for removal of 0.10: --- p.95 / Chapter 4.4.5.3 --- Applying the Model-Building Strategy: --- p.100 / Chapter 4.4.6 --- Comparing the final fitted multiple logistic regression models made by the three approaches ： --- p.103 / Chapter 4.4.7 --- Probability and Odds derived from the logistic regression model --- p.110 / Chapter 4.4.8 --- Relationship between the diseased MCA and the number of significant risk indicators that the subjects associated with..… --- p.112 / Chapter 4.4.8.1 --- Logistic regression analysis on number of risk indicators associated with the MCA status --- p.115 / Chapter 4.5 --- Discussion --- p.118 / Chapter 4.5.1 --- Research Design --- p.118 / Chapter 4.5.1.1 --- Advantage --- p.118 / Chapter 4.5.1.2 --- Disadvantage --- p.118 / Chapter 4.5.2 --- Sampling --- p.119 / Chapter 4.5.3 --- Data collected and Outcome variable classified --- p.119 / Chapter 4.5.3.1 --- Medical Record - Patients Characteristics --- p.119 / Chapter 4.5.3.2 --- Transcranial Doppler - Middle Cerebral Artery status --- p.120 / Chapter 4.5.4 --- Statistical Analyses --- p.121 / Chapter 4.5.4.1 --- Odds Ratio --- p.121 / Chapter 4.5.4.2 --- Logistic Regression Model --- p.122 / Chapter 4.5.4.3 --- Sources of Error --- p.123 / Chapter 4.5.5 --- Result --- p.125 / Chapter 4.5.5.1 --- Prevalence --- p.125 / Chapter 4.5.5.2 --- Risk indicators --- p.126 / Chapter CHAPTER FIVE --- "POPULATION-BASED CROSS-SECTIONAL SURVEY IN A RURAL VILLAGE OF HENAN, PEOPLE'S REPUBLIC OF CHINA" --- p.134 / Chapter 5.1 --- Background & Purpose --- p.134 / Chapter 5.2 --- Methods --- p.135 / Chapter 5.2.1 --- Defining the Population --- p.135 / Chapter 5.2.2 --- Procedures --- p.135 / Chapter 5.2.2.1 --- Standardized Screening Form --- p.136 / Chapter 5.2.2.2 --- Transcranial Doppler Examination --- p.137 / Chapter 5.2.3 --- Defining the Risk Factors --- p.137 / Chapter 5.3 --- Statistical Analyses --- p.140 / Chapter 5.3.1 --- Research Design --- p.141 / Chapter 5.3.2 --- Descriptive Summary --- p.141 / Chapter 5.3.2.1 --- Cross-tabulated between Gender --- p.141 / Chapter 5.3.2.2 --- Cross-tabulated between With & Without intracranial large artery stenosis --- p.142 / Chapter 5.3.3 --- Measures for Association --- p.143 / Chapter 5.3.3.1 --- Univariate analysis --- p.143 / Chapter 5.3.3.2 --- Multivariate analysis --- p.143 / Chapter 5.3.4 --- Modeling the Risks --- p.144 / Chapter 5.3.5 --- Influence of the number of associated risk factors on the prevalence of intracranial large artery stenosis --- p.144 / Chapter 5.4 --- Result --- p.145 / Chapter 5.4.1 --- Baseline characteristics of all examined villagers by Gender --- p.145 / Chapter 5.4.1.1 --- Age by Gender --- p.147 / Chapter 5.4.1.2 --- "Medical History of HT, DM and Heart disease by Gender" --- p.149 / Chapter 5.4.1.3 --- Social habit in Cigarette smoking and Alcoholic drinking by Gender --- p.149 / Chapter 5.4.1.4 --- "Family History of HT, DM, Stroke and Heart disease by Gender" --- p.149 / Chapter 5.4.1.5 --- Body Mass Index and Waist-to-Hip Ratio by Gender --- p.150 / Chapter 5.4.2 --- Distribution of the Diseased intracranial artery --- p.154 / Chapter 5.4.3 --- Characteristics between subjects with and without intracranial large artery stenosis --- p.155 / Chapter 5.4.3.1 --- Age --- p.157 / Chapter 5.4.3.2 --- Gender --- p.158 / Chapter 5.4.3.3 --- "Medical History of HT, DM and Heart disease" --- p.158 / Chapter 5.4.3.4 --- Social habit in cigarette smoking and alcohol drinking --- p.158 / Chapter 5.4.3.5 --- "Family History of HT, DM, Stroke and Heart Disease" --- p.159 / Chapter 5.4.3.6 --- Body Mass Index and Waist-to-Hip Ratio --- p.160 / Chapter 5.4.3.7 --- Other Measurements - on BP and Urine Glucose --- p.163 / Chapter 5.4.4 --- Unadjusted Odds Ratio --- p.165 / Chapter 5.4.4.1 --- By contingency table method --- p.165 / Chapter 5.4.4.2 --- By logistic regression model --- p.166 / Chapter 5.4.5 --- Adjusted Odds Ratio --- p.172 / Chapter 5.4.5.1 --- Entering all explanatory variables: --- p.172 / Chapter 5.4.5.2 --- Using the Stepwise methods available with the probability for entry is 0.05 and 0.10 for removal: --- p.175 / Chapter 5.4.5.3 --- Applying the Model-Building Strategy: --- p.180 / Chapter 5.4.6 --- Comparing the final multiple logistic regression models by the three approaches： --- p.182 / Chapter 5.4.7 --- Probability and Odds derived from the logistic regression model --- p.189 / Chapter 5.4.8 --- Relationship between the transcranial Doppler result on Intracranial large artery and the number of significant risk indicators that the subjects associated with --- p.190 / Chapter 5.4.8.1 --- Logistic Regression Model --- p.192 / Chapter 5.5 --- Discussion --- p.196 / Chapter 5.5.1 --- Research Design --- p.196 / Chapter 5.5.1.1 --- Advantage --- p.196 / Chapter 5.5.1.2 --- Disadvantage --- p.196 / Chapter 5.5.2 --- Sampling --- p.197 / Chapter 5.5.3 --- Data collected and the Outcome variable classified --- p.197 / Chapter 5.5.3.1 --- Self-Reported - Subjects Characteristics --- p.197 / Chapter 5.5.3.2 --- Transcranial Doppler - Intracranial Large Artery status --- p.198 / Chapter 5.5.4 --- Statistical Methods --- p.199 / Chapter 5.5.4.1 --- Odds Ratio --- p.199 / Chapter 5.5.4.2 --- Logistic Regression --- p.199 / Chapter 5.5.4.3 --- Sources of Error --- p.199 / Chapter 5.5.5 --- Result --- p.200 / Chapter 5.5.5.1 --- Prevalence --- p.200 / Chapter 5.5.5.2 --- Risk Indicators --- p.201 / Chapter CHAPTER SIX --- CONCLUSION --- p.204 / Chapter 6.1 --- The Clinic-based study of diseased middle cerebral artery among asymptomatic hong kong chinese --- p.204 / Chapter 6.2 --- The Population-base study of intracranial large artery stenosis among mid-aged & above chinese in rural china --- p.205 / REFERENCES / APPENDIX / Appendix I Neuroimaging - Transcranial Doppler Ultrasonography / Appendix II Statistical Methods / "Appendix III (a) Standardized TCD report form used in PWH, Hong Kong (b) Standardized Screening Form used In Yuzhou, China" / Appendix IV The ICD 9th Revision - Disease of the Circulatory System / "Appendix V Prospective Hospital-Based study in Asia, AASAP (a) Standardized Data Collection From used in AASAP" / Appendix VI Contributed in published papers

Introdução: O AVC (acidente vascular cerebral) é uma das mais importantes causas de alterações neuropsicológicas. Uma avaliação cognitiva inicial realizada por telefone implicaria em um diagnóstico mais precoce de prejuízo cognitivo e demência, reduzindo custos e tempo. Objetivo: Examinar as propriedades psicométricas da versão brasileira da Entrevista Telefônica para Avaliação do Estado Cognitivo - Modificada (TICS-M) em pacientes pós-AVC. Métodos: Previamente à validação da TICS-M em indivíduos acometidos por AVC, foi realizada tradução para o Português do Brasil e adaptação transcultural da versão original da TICS-M em uma amostra de 30 sujeitos não clínicos. Após esta fase, um subgrupo de 61 pacientes com AVC, participantes do Estudo da Mortalidade e Morbidade do AVC (EMMA) que ocorre no Hospital Universitário da Universidade de São Paulo, foram convidados a participar da validação da TICS-M, seis meses após o evento agudo. A TICS-M foi aplicada em três momentos: avaliação inicial (entrevista presencial), uma e duas semanas após a primeira avaliação. Na avaliação inicial, além da TICS-M, questionários adicionais foram aplicados para avaliar a cognição: MoCA (Montreal Cognitive Assessment), MEEM (Mini Exame do Estado Mental); e para a depressão, HDRS (Hamilton Depression Rating Scale). Todos os questionários foram aplicados por duas entrevistadoras treinadas para o estudo. A confiabilidade intra-observador da TICS-M foi testada através dos coeficientes de Pearson, Intraclasse e alfa de Cronbach. As características internas do TICS-M também foram avaliadas através de uma análise exploratória utilizando o método Análise de Componentes Principais. A validade discriminatória do instrumento para rastreamento de demência pós-AVC foi avaliada em comparação a MEEM pela análise da área sob a curva (AUC) determinada pela curva ROC. Foram calculadas sensibilidade e especificidade para o ponto de corte ideal para rastrear demência. Resultados: De maneira geral, a TICS-M traduzida para o português apresentou um bom entendimento dos itens na mostra de indivíduos não clínicos. Foi observada uma frequência de 23% sugestiva de demência pós-AVC. O nível de escolaridade esteve positivamente associado ao estado demencial rastreado pelo MEEM. O estado depressivo assim como outras características de base não se associou à demência sugerida pelo MEEM. A confiabilidade teste-reteste intra-observador revelou taxas quase totais nos três momentos avaliados (Pearson Coeficiente > 0,85, Coeficientes de Correlação Intraclasse > 0,85 e Coeficiente alfa de Cronbach: 0,96). A análise fatorial determinou três domínios: memória de trabalho e atenção; memória recente e de evocação e orientação. A área sob a curva (AUC) determinada para a TICS-M em comparação com MEEM foi de 0,89 (intervalo de confiança 95%: 0,80-0,98). O ponto de corte sugerido para TICS-M foi de 14 pontos (escala de 0-39 pontos) para rastrear demência com sensibilidade de 91,5% e especificidade de 71,4%. Resultados semelhantes foram observadas com o MoCA. Conclusão: A versão brasileira da TICS-M sugere ser um instrumento de pesquisa útil e confiável para rastrear demência em pacientes pós-AVC / Introduction: Stroke is one most important cause of neuropsychological disorders. An initial cognitive assessment performed by telephone resulting in an early diagnosis of cognitive impairment and dementia, reducing costs and time. Objective: To examine the psychometric properties of the Brazilian version of the Modified Telephone Interview for Cognitive Status Assessment (TICS-M) for assessment of dementia in post-stroke patients. Methods: Prior to validation of TICS-M in post-stroke patients, translation was performed for the Brazilian-Portuguese and cross-cultural adaptation of the original version of TICS-M in a non-clinical sample of 30 subjects. After this phase, 61 stroke patients enrolled in the Stroke Mortality and Morbidity Study (The EMMA study) that occurs at the University Hospital of the University of São Paulo, were invited to participate in this sub-study to validate the TICS-M six months after the acute event. The TICS-M was applied in three moments: first evaluation (personal interview), one and two weeks after of the first evaluation. At the first evaluation, beyond the TICS-M, additional questionnaires were applied to assess cognition: MoCA (Montreal Cognitive Assessment), MMSE (Mini-Mental Status Examination), and for depression, HDRS (Hamilton Depression Rating Scale). All questionnaires were administered by two trained interviewers for the study. Reliability of the TICS-M was tested by intra-observer rates using Pearson, Intraclass and Cronbach´s alpha coefficients. The internal characteristics of TICS-M were also evaluated by an exploratory analysis using Principal Component Analysis. The discrimination validity of the instrument to assess dementia was evaluated by comparison to the MMSE analysis of the area under the curve (AUC) determined by the ROC curve. Sensitivity and specificity for the ideal cutoff to assess dementia were calculated. Results: In general, the TICS-M translated into Portuguese version showed a good understanding of the items in non-clinical individuals. A frequency of 23% suggestive of post-stroke dementia was observed. The level of education was positively associated with dementia status assessed by MMSE. The depressive status, as well as, other baseline characteristics was not associated with dementia suggested by MMSE. Test-retest reliability intra-observer revealed almost total rates in the three evaluation moments (Pearson coefficient > 0.85, Intraclass Correlation Coefficient > 0.85 and Cronbach\'s alpha coefficient: 0.96). The factorial analysis determined three domains: working memory and attention, recent and recall memory and orientation. The area under the curve (AUC) determined by TICS-M compared to MMSE was 0.89 (95% confidence interval: 0.80-0.98). The cutoff suggested for TICS-M was equal or greater than 14 points (range 0-39 points) to assess dementia (91.5% sensitivity, 71.4 % specificity). Similar results were observed with the MoCA. Conclusion: The Brazilian version of TICSM suggests being a useful and reliable research instrument to evaluate dementia in poststroke patients in epidemiological studies

Introdução: O AVC (acidente vascular cerebral) é uma das mais importantes causas de alterações neuropsicológicas. Uma avaliação cognitiva inicial realizada por telefone implicaria em um diagnóstico mais precoce de prejuízo cognitivo e demência, reduzindo custos e tempo. Objetivo: Examinar as propriedades psicométricas da versão brasileira da Entrevista Telefônica para Avaliação do Estado Cognitivo - Modificada (TICS-M) em pacientes pós-AVC. Métodos: Previamente à validação da TICS-M em indivíduos acometidos por AVC, foi realizada tradução para o Português do Brasil e adaptação transcultural da versão original da TICS-M em uma amostra de 30 sujeitos não clínicos. Após esta fase, um subgrupo de 61 pacientes com AVC, participantes do Estudo da Mortalidade e Morbidade do AVC (EMMA) que ocorre no Hospital Universitário da Universidade de São Paulo, foram convidados a participar da validação da TICS-M, seis meses após o evento agudo. A TICS-M foi aplicada em três momentos: avaliação inicial (entrevista presencial), uma e duas semanas após a primeira avaliação. Na avaliação inicial, além da TICS-M, questionários adicionais foram aplicados para avaliar a cognição: MoCA (Montreal Cognitive Assessment), MEEM (Mini Exame do Estado Mental); e para a depressão, HDRS (Hamilton Depression Rating Scale). Todos os questionários foram aplicados por duas entrevistadoras treinadas para o estudo. A confiabilidade intra-observador da TICS-M foi testada através dos coeficientes de Pearson, Intraclasse e alfa de Cronbach. As características internas do TICS-M também foram avaliadas através de uma análise exploratória utilizando o método Análise de Componentes Principais. A validade discriminatória do instrumento para rastreamento de demência pós-AVC foi avaliada em comparação a MEEM pela análise da área sob a curva (AUC) determinada pela curva ROC. Foram calculadas sensibilidade e especificidade para o ponto de corte ideal para rastrear demência. Resultados: De maneira geral, a TICS-M traduzida para o português apresentou um bom entendimento dos itens na mostra de indivíduos não clínicos. Foi observada uma frequência de 23% sugestiva de demência pós-AVC. O nível de escolaridade esteve positivamente associado ao estado demencial rastreado pelo MEEM. O estado depressivo assim como outras características de base não se associou à demência sugerida pelo MEEM. A confiabilidade teste-reteste intra-observador revelou taxas quase totais nos três momentos avaliados (Pearson Coeficiente > 0,85, Coeficientes de Correlação Intraclasse > 0,85 e Coeficiente alfa de Cronbach: 0,96). A análise fatorial determinou três domínios: memória de trabalho e atenção; memória recente e de evocação e orientação. A área sob a curva (AUC) determinada para a TICS-M em comparação com MEEM foi de 0,89 (intervalo de confiança 95%: 0,80-0,98). O ponto de corte sugerido para TICS-M foi de 14 pontos (escala de 0-39 pontos) para rastrear demência com sensibilidade de 91,5% e especificidade de 71,4%. Resultados semelhantes foram observadas com o MoCA. Conclusão: A versão brasileira da TICS-M sugere ser um instrumento de pesquisa útil e confiável para rastrear demência em pacientes pós-AVC / Introduction: Stroke is one most important cause of neuropsychological disorders. An initial cognitive assessment performed by telephone resulting in an early diagnosis of cognitive impairment and dementia, reducing costs and time. Objective: To examine the psychometric properties of the Brazilian version of the Modified Telephone Interview for Cognitive Status Assessment (TICS-M) for assessment of dementia in post-stroke patients. Methods: Prior to validation of TICS-M in post-stroke patients, translation was performed for the Brazilian-Portuguese and cross-cultural adaptation of the original version of TICS-M in a non-clinical sample of 30 subjects. After this phase, 61 stroke patients enrolled in the Stroke Mortality and Morbidity Study (The EMMA study) that occurs at the University Hospital of the University of São Paulo, were invited to participate in this sub-study to validate the TICS-M six months after the acute event. The TICS-M was applied in three moments: first evaluation (personal interview), one and two weeks after of the first evaluation. At the first evaluation, beyond the TICS-M, additional questionnaires were applied to assess cognition: MoCA (Montreal Cognitive Assessment), MMSE (Mini-Mental Status Examination), and for depression, HDRS (Hamilton Depression Rating Scale). All questionnaires were administered by two trained interviewers for the study. Reliability of the TICS-M was tested by intra-observer rates using Pearson, Intraclass and Cronbach´s alpha coefficients. The internal characteristics of TICS-M were also evaluated by an exploratory analysis using Principal Component Analysis. The discrimination validity of the instrument to assess dementia was evaluated by comparison to the MMSE analysis of the area under the curve (AUC) determined by the ROC curve. Sensitivity and specificity for the ideal cutoff to assess dementia were calculated. Results: In general, the TICS-M translated into Portuguese version showed a good understanding of the items in non-clinical individuals. A frequency of 23% suggestive of post-stroke dementia was observed. The level of education was positively associated with dementia status assessed by MMSE. The depressive status, as well as, other baseline characteristics was not associated with dementia suggested by MMSE. Test-retest reliability intra-observer revealed almost total rates in the three evaluation moments (Pearson coefficient > 0.85, Intraclass Correlation Coefficient > 0.85 and Cronbach\'s alpha coefficient: 0.96). The factorial analysis determined three domains: working memory and attention, recent and recall memory and orientation. The area under the curve (AUC) determined by TICS-M compared to MMSE was 0.89 (95% confidence interval: 0.80-0.98). The cutoff suggested for TICS-M was equal or greater than 14 points (range 0-39 points) to assess dementia (91.5% sensitivity, 71.4 % specificity). Similar results were observed with the MoCA. Conclusion: The Brazilian version of TICSM suggests being a useful and reliable research instrument to evaluate dementia in poststroke patients in epidemiological studies