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Background <p>Post-stroke cognitive impairment (PSCI) is highly prevalent among ischemic stroke patients in China, a population who received less education compared to Western counterparts. Commonly used cognitive assessments often affected by educational levels. Drawing tests may mitigate educational bias, but the diagnostic accuracy of combined drawing tests remains understudied and unclear.</p> Methods <p>The diagnostic accuracy of the Cube Copying Test (CCT), Clock Drawing Test (CDT), and Pentagon Copying Test (PCT), and their various combinations was evaluated against the Montreal Cognitive Assessment (MoCA) as the reference standard. Ischemic stroke patients at a hospital in Chongqing, China, were enrolled between January 2022 and June 2025. Receiver operating characteristic (ROC) curves and the area under the curve (AUC) were used to assess diagnostic accuracy.</p> Results <p>Among 413 participants, 260 were in the acute phase (mean age was 64.3 years, and 47.7% had primary education) and 153 in the convalescent phase (mean age was 64.7 years, and 33.3% had primary education). PSCI was identified in 61.2% and 60.8% of acute and convalescent patients, respectively. Among individual tests, the CDT showed the highest AUC in both phases (acute: 0.83, 95% CI: 0.78, 0.88; convalescent: 0.78, 95% CI: 0.72, 0.86). For test combinations, the full battery (CCT + CDT+PCT) achieved the highest AUC in the acute phase (0.85, 95% CI: 0.80, 0.90), with a sensitivity of 80.5% (95% CI: 73.3%, 86.2%) and a specificity of 83.2% (95% CI: 74.1%, 90.0%); while the CCT + CDT combination performed the best in the convalescent phase (0.82, 95% CI: 0.75, 0.88), with a sensitivity of 78.5% (95% CI: 68.5%, 86.1%) and a specificity of 71.7% (95% CI: 58.4%, 82.2%). These two combinations exhibited AUC &gt; 0.8 across sex and age subgroups. In acute patients, the full battery showed better AUC in those with primary (0.88, 95% CI: 0.80, 0.97) and secondary education (0.84, 95% CI: 0.76, 0.92) compared to higher education (0.74, 95% CI: 0.57, 0.90). This educational gradient was less evident in convalescent patients (primary school: 0.72, 95% CI: 0.52, 0.93; secondary school: 0.83, 95% CI: 0.75, 0.92; ≥university: 0.65, 95% CI: 0.42, 0.88).</p> Conclusion <p>Combined drawing tests demonstrate good diagnostic accuracy for PSCI, with their de-linguistic design reducing educational bias, particularly in acute patients. The CCT + CDT+PCT combination is recommended for acute-phase PSCI screening, while CCT + CDT may suffice during convalescence. These findings suggest that combined drawing tests may offer practical tools for rapid PSCI screening in stroke patients with lower education.</p>

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Diagnostic accuracy of drawing tests and their combinations for post-stroke cognitive impairment in patients with lower education

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  • 发表日期：

    2026年5月25日

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  • Yanqin Wang,
  • Yongqi Wang,
  • Yayun Xiang,
  • Fang Fang,
  • Ning Yan,
  • Yaoyue Hu

摘要

Background

Post-stroke cognitive impairment (PSCI) is highly prevalent among ischemic stroke patients in China, a population who received less education compared to Western counterparts. Commonly used cognitive assessments often affected by educational levels. Drawing tests may mitigate educational bias, but the diagnostic accuracy of combined drawing tests remains understudied and unclear.

Methods

The diagnostic accuracy of the Cube Copying Test (CCT), Clock Drawing Test (CDT), and Pentagon Copying Test (PCT), and their various combinations was evaluated against the Montreal Cognitive Assessment (MoCA) as the reference standard. Ischemic stroke patients at a hospital in Chongqing, China, were enrolled between January 2022 and June 2025. Receiver operating characteristic (ROC) curves and the area under the curve (AUC) were used to assess diagnostic accuracy.

Results

Among 413 participants, 260 were in the acute phase (mean age was 64.3 years, and 47.7% had primary education) and 153 in the convalescent phase (mean age was 64.7 years, and 33.3% had primary education). PSCI was identified in 61.2% and 60.8% of acute and convalescent patients, respectively. Among individual tests, the CDT showed the highest AUC in both phases (acute: 0.83, 95% CI: 0.78, 0.88; convalescent: 0.78, 95% CI: 0.72, 0.86). For test combinations, the full battery (CCT + CDT+PCT) achieved the highest AUC in the acute phase (0.85, 95% CI: 0.80, 0.90), with a sensitivity of 80.5% (95% CI: 73.3%, 86.2%) and a specificity of 83.2% (95% CI: 74.1%, 90.0%); while the CCT + CDT combination performed the best in the convalescent phase (0.82, 95% CI: 0.75, 0.88), with a sensitivity of 78.5% (95% CI: 68.5%, 86.1%) and a specificity of 71.7% (95% CI: 58.4%, 82.2%). These two combinations exhibited AUC > 0.8 across sex and age subgroups. In acute patients, the full battery showed better AUC in those with primary (0.88, 95% CI: 0.80, 0.97) and secondary education (0.84, 95% CI: 0.76, 0.92) compared to higher education (0.74, 95% CI: 0.57, 0.90). This educational gradient was less evident in convalescent patients (primary school: 0.72, 95% CI: 0.52, 0.93; secondary school: 0.83, 95% CI: 0.75, 0.92; ≥university: 0.65, 95% CI: 0.42, 0.88).

Conclusion

Combined drawing tests demonstrate good diagnostic accuracy for PSCI, with their de-linguistic design reducing educational bias, particularly in acute patients. The CCT + CDT+PCT combination is recommended for acute-phase PSCI screening, while CCT + CDT may suffice during convalescence. These findings suggest that combined drawing tests may offer practical tools for rapid PSCI screening in stroke patients with lower education.