Recognizing, managing, and preventing cognitive sequelae after stroke. A narrative review

Post-stroke cognitive impairment (PSCI) affects up to one-third of stroke survivors and is a major contributor to long-term disability and reduced quality of life. Its heterogeneous phenotype reflects the interplay of acute cerebrovascular injury with chronic vascular pathology, inflammation, blood-brain barrier dysfunction, and, in many patients, coexisting neurodegeneration. Clinical manifestations vary according to lesion location and most commonly involve executive and attentional deficits, with variable impairment of memory, language, visuospatial function, and neuropsychiatric domains. Cognitive trajectories range from partial early recovery to persistent or progressive decline. Diagnosis remains challenging because covert cerebrovascular disease and overlapping neurodegenerative processes may mimic or amplify deficits. A stepwise diagnostic strategy combining focused cognitive screening, neuropsychological assessment when indicated, and neuroimaging is therefore recommended. In many acute stroke settings, CT continues to serve as the routine first-line modality, whereas MRI allows more detailed characterization where available. Emerging adjuncts include fluid biomarkers of neuroaxonal injury, inflammation, and vascular brain injury, as well as digital and telephone-based tools that may support longitudinal monitoring in selected populations. Treatment options remain limited. Non-pharmacological interventions, including cognitive rehabilitation, physical activity, and multimodal neurorehabilitation, are central to current management, although PSCI-specific high-quality evidence is scarce. Prevention is essential and should focus on vascular risk-factor control, lifestyle modification, cognitive reserve, and social engagement. This narrative review synthesizes current evidence on the mechanisms, presentation, diagnosis, and management of PSCI and highlights priorities for harmonized care pathways and the routine integration of cognitive health into stroke care.