Comprehensive cognitive neurological assessment in stroke Background Cerebrovascular disease and neuropsychiatric dis- orders are the leading causes of disability world- wide (1, 2). Cognitive impairment is present in the majority of patients with stroke (3–5), transient ischemia attack (6) and even in patients without stroke who have cerebrovascular risk factors (7). Cognitive syndromes were undervalued in the stroke assessment literature, yet may be important to measure and monitor neurological outcome, management and assessment of current and emerg- ing therapies (8–20). Behavioral neurology and neuropsychiatry are replete with numerous and intriguing syndromes that occur in association with stroke. The rich diversity of some of these syndromes hint at the complexity of the underlying neural networks and at the same time remind us that simple mental status or rating scales are resoundingly inadequate for documenting these sequelae. Furthermore, neuropsychological proce- dures do not capture the majority of behavioral neurological syndromes in either a syndromic or metric fashion, nor is this form of evaluation practical in the acute and subacute stroke phases. A growing body of literature identified frontal network syndromes reflecting discreet lesions outside the anatomical boundary of the frontal lobe, such as subcortical gray matter (21, 22), subcortical white matter (23–25) and with isolated lesions of the brainstem and cerebellum (25–27). Localization of a lesion may be less important than Acta Neurol Scand 2009: 119: 162–171 DOI: 10.1111/j.1600-0404.2008.01101.x Copyright Ó 2008 The Authors Journal compilation Ó 2008 Blackwell Munksgaard ACTA NEUROLOGICA SCANDINAVICA Hoffmann M, Schmitt F, Bromley E. Comprehensive cognitive neurological assessment in stroke. Acta Neurol Scand 2009: 119: 162–171. Ó 2008 The Authors Journal compilation Ó 2008 Blackwell Munksgaard. Background – Cognitive syndromes (CS) after stroke may be important to measure and monitor for management and emerging therapies. Aim – To incorporate known behavioral neurological and neuropsychiatric syndromes into a bedside cognitive assessment in patients with stroke. Methods – A validated cognitive examination (comprehensive cognitive neurological test in stroke, Coconuts) was administered during the first month of stroke presentation and analyzed according to five large-scale networks for cognition and correlated with neuropsychological tests. Validity testing of the test was performed for overall sensitivity, specificity, positive predictive value and negative predictive value to stroke in comparison with MRI diagnosis of stroke as well as discriminant validity, construct validity and inter-rater reliability. Results – Overall the sensitivity of the Coconuts scale was 91% and specificity 35%, PPV 88% and NPV 41% vs stroke lesions using MRI. Cognitive syndrome frequencies: frontal network syndrome frequency was 908 ⁄ 1796 (51%), left hemisphere network syndrome frequency was 646 ⁄ 1796 (36%), right hemisphere network included 275 ⁄ 1796 (15.3%), occipitotemporal network for complex visual processing 107 ⁄ 1796 (6%), the hippocampal limbic network for amnesias and emotional disorders 397 ⁄ 1796 (22%) and miscellaneous network syndromes 481 ⁄ 1796 (27%). Conclusion – The Coconuts is a valid and practical test of a comprehensive array of known behavioral neurological and neuropsychiatric syndromes in patients with stroke. M. Hoffmann 1 , F. Schmitt 2 , E. Bromley 3 1 Division of Cognitive Vascular Neurology, University of South Florida, Tampa, FL, USA; 2 Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY, USA; 3 Biostat Solutions Incorporated, Mt Airy, MD, USA Key words: cognitive syndromes; stroke Michael Hoffmann MD, Division of Cognitive Vascular Neurology, University of South Florida, 12901 Bruce B. DownÕs Blvd, Tampa, FL 33612, USA Tel.: +1 813 9742794 Fax: +1 813 9743160 e-mail: mhoffman@hsc.usf.edu Statistical analyses were performed by Ena Bromley, PhD. Accepted for presentation at the Fifth International Congress on Vascular Dementia in Budapest, Hungary, 8–11 November 2007 and presented in part at the American Neurological Association meeting in Chicago October 2006 and International Stroke Conference in Cape Town South Africa October 2006. Accepted for publication July 25, 2008 162