WSO October 2023 – Issue 1 - 909

Wei et al.
909
Introduction
Globally, stroke is the second-leading cause of death.1 The
estimated global cost of stoke is over US$700 billion annually.2
With the aging population, the health and economic
burden caused by stroke is highly likely to continue to
increase. A great proportion of the burden is due directly to
the complications of stroke, such as dysphagia, aphasia,
dyskinesias, and cognitive impairment.3-6
Post-stroke cognitive impairment (PSCI) is one of the
common complications of stroke. Previous research indicates
that the incidence of PSCI varies from two-thirds to
three-quarters.7-9 PSCI damages multiple cognitive
domains, particularly in attention and executive ability,10,11
which not only affects stroke survivors' daily lives severely12
but also places a heavy burden on nursing staff and medical
institutions.13 As people attach great importance to disease
and health, cognitive and psychological hazards are receiving
more and more attention. Hence, the early recognition
and diagnosis of PSCI have important implications for the
functional recovery of stroke survivors.
Currently, many international stroke clinical guidelines
and best practice statements recommend that cognitive
screening tools should be routinely used to assess cognitive
impairments in stroke survivors, followed by comprehensive
assessment if needed.14,15 The Montreal Cognitive
Assessment (MoCA) is a brief screening tool for PSCI16
although it was originally designed to detect mild cognitive
impairment and dementia.17 The MoCA gives a test score
for holistic cognitive function with the assessment of numerous
cognitive fields, including memory, language, attention,
orientation, and executive function. In clinical practice, an
important prerequisite for using the MoCA scale to screen
for cognitive impairment is to determine in advance the
optimal cutoff value for screening a specific population.
However, there are different views on the use of the optimal
cutoff value of MoCA in stroke survivors. Munthe-Kaas
et al.18 found that the original MoCA cutoff of 26 had reasonable
validity for screening PSCI, while Feng et al.19 indicated
that the optimal cutoff value of MoCA was 22, and
Potocnik et al.20 discovered that the optimal cutoff was 25
on MoCA. Therefore, a valid cutoff value with satisfactory
detection accuracy in stroke populations needed to be identified
to guide clinical practice effectively.
A previous review on this topic compared the accuracy
of MoCA for detecting PSCI at the cutoffs of <22/30 and
<26/30.21 However, being able to contrast the accuracy of
different cutoffs to determine the optimal cutoff may be
more reliable. There has been an acceleration of research in
the area following this review, indicating that the clinical
importance of screening for PSCI has gained attention.
More recently, a systematic review and meta-analysis found
the optimal cutoff of MoCA is 19/20 for detecting PSCI
within 1 month.22 However, the result has to be interpreted
cautiously because only three studies were included in this
analysis. And another issue is that this research only examined
the optimal cutoff within 1 month after stroke, rather
than exploring other settings adequately. As the volume of
research in this area has increased, further research is
urgently needed to determine the optimal cutoff of MoCA.
Therefore, the aim of our study was to conduct a systematic
literature and meta-analysis to quantitatively evaluate
and identify the optimal MoCA cutoff in the detection of
PSCI. This study will provide a basis for clinicians and
other health care providers to select the optimal MoCA cutoff
in stroke settings.
Methods
Protocol and registration
This systematic review and meta-analysis were performed
in reference to the Preferred Reporting Items for Systematic
Reviews and Meta-Analysis of Diagnostic Test Accuracy
Studies.23 Protocol details for this review were registered
with PROSPERO (ID: CRD42022333961).
Eligibility criteria
Studies that met the following criteria were considered eligible:
(1) used a cohort, cross-sectional, or case-control
study design; (2) recruited patients with stroke or transient
ischemic attack (TIA); (3) used the MoCA as a screening
tool; (4) used the neuropsychological assessment as the reference
standard; (5) reported true positive (TP), false positive
(FP), true negative (TN), false negative (FN), sensitivity
(SEN), and specificity (SPE) to derive diagnostic accuracy
or provided sufficient details to calculate these numbers;
and (6) written in English. The exclusion criteria were as
follows: (1) studies with incomplete data, (2) the full text
was unavailable, (3) abstracts presented at congresses or
review articles, and (4) duplicate studies.
Search strategy
We searched PubMed, CINAHL, Embase, the Cochrane
Library, and Web of Science databases. The initial search
was performed from inception to April 30, 2022, followed
by an updated search from May 2022 to March 23, 2023.
Searches were conducted using the following combination
of MeSH headings and free-text terms: " stroke " (e.g., apoplexy,
cerebral infarction, cerebral hemorrhage, etc.), " cognitive
impairment " (e.g., cognitive dysfunction, cognitive
decline, cognitive defect, etc.), and " Montreal Cognitive
Assessment " (e.g., MoCA). The detailed search strategies
for all databases can be found in the Supplementary
Material. In addition, we scanned the references of the
selected studies for relevant articles.
International Journal of Stroke, 18(8)
WSO October 2023 – Issue 1

Table of Contents for the Digital Edition of WSO October 2023 – Issue 1
