First-ever Lacunar Infarction Research Articles

Long-term Prognosis of First-Ever Lacunar Strokes

Information concerning the long-term prognosis of lacunar strokes is still limited and has shown different results. The aim of this study was to investigate the long-term prognosis of first-ever lacunar strokes and the possible role of clinical prognostic factors and different pathogenic mechanisms. Between March 1990 and November 1993, a cohort of consecutive patients presenting with first-ever lacunar infarcts was prospectively evaluated after stroke onset at day 0 to 3 and/or day 7, every 3 months up to 1 year, and every 6 months thereafter. All patients were studied according to a protocol that included demographic and clinical data, neurological examination, Toronto Stroke Scale, Barthel Index, Rankin Scale, CT scan, routine laboratory workup, electrocardiogram, carotid duplex scanning, and echocardiogram. More recently, patients have also been evaluated with transcranial Doppler ultrasonography. Recurrent strokes, myocardial infarction, and death were registered through direct observation, chart review, or interviews with the attending physician or family members. One hundred forty-five patients-94 (65%) with pure hemiparesis, 33 (23%) with sensorimotor stroke, 11 (8%) with ataxic hemiparesis, 5 (3%) with pure sensory stroke, and 2(1%) with dysarthria-clumsy hand syndrome-were followed for a median period of 39 months. During follow-up ther were 17 deaths (3 vascular), 30 recurrent strokes (1 fatal), and 4 myocardial infarctions. Five-year survival rate free of recurrent stroke was 63% (95% confidence interval [CI], 52% to 73%), while 5-year survival rate was 86% (95% CI, 78% to 91%). Cox proportional hazards analysis showed that age (p=.02) was the only significant predictor of survival free of recurrent stroke. Age (P<.001) and the degree of neurological dysfunction and functional disability at 7 days after the index stroke measured by the Toronto Stroke Scale (P=.05) and a Barthel Index score <40 (P=.04) were the only significant predictors of death. The 5-year probability rate of stroke-free recurrence was 72% (95% CI, 60% to 81%). Sixty-three percent of the first recurrent strokes were lacunar infarcts. When clinical, laboratory, and CT data as well as possible etiopathogenic mechanisms of lacunar strokes were considered, Cox proportional hazards analysis could not identify any predictor of stroke recurrence. Our study confirms that lacunar infarcts are associated with low stroke recurrence and mortality rates. In our series, the majority of first recurrent strokes were also lacunar infarcts. Age, degree of neurological dysfunction, and functional disability at day 7 after the index stroke were significant predictors of death.

Prognosis for Survival, Handicap and Recurrence of Stroke in Lacunar and Superficial Infarction

In a prospective study, we compared the prognosis for survival, handicap, and recurrence of stroke in 103 patients with a first-ever lacunar infarct, presumably due to small-vessel obstruction, with that in 94 patients who had a first-ever superficial infarct associated with large-vessel disease. Patients with lacunar infarction had better survival, as shown by Kaplan-Meier analysis, and less disability than patients with superficial infarction, whereas the difference in risk of recurrent infarction was not statistically significant. Six of the 7 (86%) recipient infarcts in the lacunar infarction group were lacunar again, supporting the hypothesis that lacunar infarcts are usually caused by a local small-vessel obstruction.

Lacunar infarcts. Pathogenesis and validity of the clinical syndromes.

In this study, we investigated the lacunar hypothesis to answer three questions: 1) Is the lacunar syndrome valid for diagnosing lacunar infarction? 2) What is the frequency of potential cardiac versus carotid sources of embolism in patients with lacunar versus cortical infarct? 3) What is the frequency of vascular risk factors in these two groups of patients? The study was performed in a well-defined prospective series of 103 patients with a first-ever lacunar infarct and 144 other patients with a first-ever infarct involving the cortex. Sensitivity and specificity of the lacunar syndromes in diagnosing lacunar infarction were 95% and 93%, respectively. Positive and negative predictive values of diagnosing lacunar infarction in patients with lacunar syndromes were 90% and 97%, respectively. Risk factor analysis showed no differences for either group of cerebral infarction. A cardiac source of embolism was significantly less frequent in patients with lacunar infarction (odds ratio = 0.32, 95% confidence interval = 0.17-0.61, p less than 0.001). Significant carotid stenosis (diameter reduction greater than or equal to 50%) was also less frequent in patients with lacunar infarction (odds ratio = 0.35, 95% confidence interval = 0.16-0.76, p less than 0.001). These findings show that the lacunar syndrome is an excellent clinical test for diagnosing lacunar infarction and that cardiac and carotid embolism are unlikely causes of lacunar infarction, supporting the hypothesis that lacunar infarcts are usually caused by small vessel disease.