Progressive stroke, lacunae, and systemic blood pressure.

Abstract

To the Editor: We read with great interest the article by Steinke and Ley and the editorial by Caplan in the June issue of Stroke .1 Among 941 patients with stroke, Steinke and Ley identified 92 patients with prevalent motor deficit; motor performances further deteriorated in 22 of these patients, and a prevalence of deep (lacunar) lesions was found on these latter patients. The conclusion, which gives the title to the article, is that lacunar stroke is the major cause of progressive motor deficits. Some observations could be made. The strict inclusion criteria of Steinke and Ley allowed selection of only a minimal number of the screened patients. Such a situation is highly “at risk” for selection biases; for example, the exclusion of patients with “minor motor or predominantly other deficits” may rule out the whole population of patients with embolic occlusion of small pial branches of the middle cerebral artery, or may overestimate relatively rare conditions such as basal ganglia infarctions as a major consequence of an embolic occlusion of the main trunk of the middle cerebral artery, with an efficient leptomeningeal collateral circulation. Moreover, the European Stroke Scale baseline is different between groups: the 22 patients with progressive courses had more limited neurological deficits and less frequent consciousness impairment, due to smaller infarctions as demonstrated on neuroimaging studies. In this setting, …