Lacunar Infarction Patients Research Articles

Variable Lengths of Stay among Ischemic Stroke Subtypes in Chinese General Teaching Hospitals

BackgroundLength of stay (LOS) is one of the most important quantitative indexes that measures health service utilization within a hospital. Many studies have examined the association of three major stroke categories with LOS. Our aim is to investigate the differences of LOS among ischemic stroke subtypes, results from which are helpful to healthcare providers and government agencies to improve health care delivery efficiency.Methodology/Principal FindingsUsing the Beijing Municipal Health Bureau’s hospitalization summary reports, we performed a retrospective study among first-ever in-hospital patients with ischemic stroke (ICD-10 I63) in three general teaching hospitals in Beijing, China, from 2006 to 2010 with generalized linear model. In our study, 5,559 patients (female, 36.0%; age, 64.4±12.9 years) were included. The estimated mean LOS of ischemic stroke was 17.4±1.8 days. After adjusting for confounders, LOS of lacunar infarction (14.7 days; p<0.001) and LOS of small cerebral infarction (17.0 days; p = 0.393) were shorter than that of single cerebral infarction (17.9 days, p<0.001). LOS of multi-infarct (19.0 days; p = 0.028), brainstem infarction (19.3 days; p = 0.045), basal ganglia infarction (18.5 days; p = 0.452) and other subtypes of ischemic stroke (18.9 days; p = 0.327) were longer than that of single cerebral infarction.ConclusionsLOS of ischemic stroke patient differes across single cerebral infarction, lacunar infarction, multi-infarct and brainstem infarction patients. The ascending order of LOS was lacunar infarction, small cerebral infarction, single cerebral infarction, basal ganglia infarction, other subtypes of ischemic stroke, multi-infarct and brainstem infarction.

Branch Atheromatous Plaque: A Major Cause of Lacunar Infarction (High-Resolution MRI Study)

Background: Lacunar infarctions account for up to 25% of all ischemic strokes and, thus, constitute a numerically important subgroup. It is important that the two pathogeneses of lacunar infarction, that is, small-vessel occlusion and branch atheromatous disease, be differentiated because prognoses and treatment strategies differ. The authors evaluated the presence of branch atheromatous plaque in parent arteries that supply lacunar infarcts by high-resolution magnetic resonance imaging (HR-MRI). Methods: HR-MRI was performed in 15 patients with (1) a clinical presentation consistent with classical lacunar syndromes; (2) an acute lacunar infarction by diffusion-weighted imaging, measuring ≤20 mm in maximal diameter; (3) a magnetic resonance angiography showing a normal middle cerebral artery or basilar artery supplying the ischemic lesion, and (4) no other obvious etiology for small-vessel distribution ischemic stroke. Results: The median time of vessel wall imaging after index events was 4 days (range, 2–15 days). Six of the 15 patients had a lacunar infarction in the middle cerebral artery territory, and 9 had a lesion in the basilar artery territory. HR-MRI detected underlying atheromatous plaques in 9 patients (60%) with a lacunar infarction. In these 9 patients, asymptomatic intracranial atherosclerotic stenosis was more frequent compared to patients without branch atheromatous plaque (55.6 vs. 16.7%). In pontine infarctions, ischemic lesions that extended to the pial base of the pons were more frequent in patients with branch atheromatous plaques (83.3 vs. 33.3%), and all the ischemic lesions and atheromatous plaques were on the same side (right, n = 2; left, n = 4). All plaques responsible for acute symptomatic lacunar infarction were enhanced in contrast-enhanced T1-weighted HR-MR images. Conclusions: HR-MRI results enabled underlying symptomatic branch atheromatous disease to be detected in lacunar infarction patients. The experience gained during this study indicates that HR-MRI better delineates intracranial arterial lesions, suggesting that its use will lead to a further understanding of the mechanisms involved in stroke.

Relationship of blood glucose, blood lipids, blood uric acid and fibrinogen level, and prognosis of acute lacunar cerebral infarction patients

Objective To investigate the relationship of blood glucose,blood lipids,serum uric acid,fibrinogen level and prognosis of patients with acute lacunar cerebral infarction.Methods Clirical data of 127 cases with acute lacunar cerebral infarction were retrospectively analyed.Patients with normal blood glucose,blood lipid,uric acid and fibrinogen level were enrolled into A group of 64 cases,63 cases with abnormal levels were selected as group B,an average of 2 years of follow-up,observing the two groups of neurologic,re-infarction incidence and prevalence of vascular dementia were obsenved in two groups.Results After 4 weeks of treatment,A group of neural function defect score(9.6 ±7.3) was significantly lower than group B( 14.3 ±7.4) (t =3.8696,P ＜0.05) ;95.4％ total effective rate in A group was significantly higher than B group of 82.0％ ( x2 =5.8623,P ＜ 0.05 ).After an average follow-up of 2 years,A group of recurrent cerebral infarction rate( 18.8％ ),vascular dementia rates(7.8％ ),were significantly lower than group B(28.6％),17.5％(11/63)(x2 =6.5421,5.9623,P＜0.05).Conclusion A number of abnormal serum biochemical indexes had a significant impact on short and long-term prognosis of acute lacunar cerebral infarction. Key words: Cerebral infarction; Apolipoproteins; Blood glucose; Uric acid; Fibrinogen

Abstract 2724: Comparison Of Hypertensive And Non-hypertensive Lacunar Infarcts

Background: Hypertension and arteriolosclerosis in perforating arteries are the most common hypothetical pathogenesis in lacunar infarcts so far. Few studies on non-hypertensives have been inconsistent, partly because of unavoidable misclassification of lacunar infarcts. Using a DWI MRI-based stroke classification algorithm, we aimed to compare the clinical and laboratory characteristics of patients with lacunar infarction by the presence of hypertension. Methods: A consecutive series of patients, who were hospitalized due to acute ischemic stroke to 9 centers that were participating in the ‘Clinical Research Center for Stroke’ program funded by the Korean government, were registered prospectively between April 2008 and March 2010. Lacunar infarct was defined as a single DWI lesion less than 2cm in perforator territories without relevant artery steno-occlusion or cardiac embolic sources. Correlates of nonhypertensive lacunar infarction were obtained by multiple logistic regression analysis. Results: Among 6696 stroke patients, 1340 (20.0%) showed lacunar infarcts. Lacunar infarct patients without hypertension showed less frequent diabetes mellitus, hyperlipidemia, previous stroke history, ischemic heart disease, prior use of antiplatelets, and prior use of statin than hypertensive patients with lacunar infarct. Body mass index, plasma glucose, and serum creatinine level were also lower, while smoking and HDL level were higher in non-hypertensive patients. Initial NIHSS score and the frequency of early neurological deterioration (NIHSS score increase 1 point or higher on discharge than initial) and good outcome (3month mRS ≤ 1) were not different in two groups. After multivariable analysis, age (odds ratio 0.987, 95% CI 0.977 to 0.998), diabetes (OR 0.665, 95% CI 0.487 to 0.907), stroke history (OR 0.512, 95% CI 0.358 to 0.733), and BMI (OR 0.899, 95% CI 0.862 to 0.938) seemed to be independent factors associated with lacunar infarct in nonhypertensives compared to lacunar infarction in hypertensives. Conclusion: This study shows that non-hypertensives with lacunar stroke seem to be younger, and have less frequent diabetes and stroke history, and lower BMI than hypertensives with lacunar stroke. Stroke severity and outcome were not different in lacunar infarct patients with or without hypertension.

Chronic kidney disease, 24-h blood pressure and small vessel diseases are independently associated with cognitive impairment in lacunar infarct patients

Although the relationships between chronic kidney disease (CKD) and cognitive impairment (CI) have been highlighted, the etiology of CI in CKD remains uncertain. Subjects comprised 224 consecutive patients with symptomatic lacunar infarction who underwent magnetic resonance imaging and ambulatory blood pressure monitoring (ABPM). Diurnal blood pressure (BP) patterns were categorized into three groups: dippers, non-dippers and risers. Lacunar infarcts (LIs), including both symptomatic and silent and diffuse white matter lesions (WMLs), were graded into three grades according to their degree. The results of kidney function were evaluated using estimated glomerular filtration rate (eGFR), categorized into three groups: stage 1, >60; stage 2, 30-60; and stage 3, <30 ml min(-1) per 1.73 m(2). There were 44 patients with CI. Confluent WMLs, including WML 2 and WML 3, were found in 36 patients (81.8%), and multiple lacunae including LI 2 and LI 3 were found in 30 patients (68.1%) with CI. Age >75 years (odds ratio (OR), 5.5; P<0.05), male sex (OR, 2.8; P<0.05), non-dippers (OR, 6.3; P<0.05) and risers (OR, 5.6; P<0.05), eGFR 30-60 ml min(-1) per 1.73 m(2) (OR, 2.9; P<0.05) and eGFR <30 ml min(-1) per 1.73 m(2) (OR, 23.8; P<0.01), WML grade 2 (OR, 5.1; P<0.01) and WML grade 3 (OR, 45.2; P<0.001) and LI grade 2 (OR, 3.2; P<0.05) and LI grade 3 (OR, 6.4; P<0.05) were independently associated with CI. Age >75 years (OR, 4.1; P<0.05), eGFR 30-60 ml min(-1) per 1.73 m(2) (OR, 3.7; P<0.05) and eGFR <30 ml min(-1) per 1.73 m(2) (OR, 8.7; P<0.05) were independently associated with WML grade 3. Extensive small vessel diseases, CKD and non-dipping status were independently associated with CI. CKD appears to mainly contribute to vascular CI, whereas possibilities of overlapping with other mechanisms such as degenerative CI cannot be excluded. Strict night time BP control and renoprotective treatment may be warranted to prevent CI.

Induced-hypertension in progressing lacunar infarction

Although an early neurological deterioration after lacunar infarction is not rare, its therapeutic options are still undetermined. We investigated the effect of induced-hypertension in lacunar infarction with motor progression. We reviewed 82 lacunar infarction patients who experienced motor progression [≥ 1-point increase of NIH stroke scale (NIHSS) during hospitalization]. Induced-hypertension using phenylephrine was applied to 52 patients and the others received conventional treatment. Target blood pressure (BP) was defined as a 20% increase of initial systolic BP and motor stabilization time as a period from motor progression to motor stabilization. Good outcome was designated as a modified Rankin disability scale 0-2 at discharge in phenylephrine group. Phenylephrine group (vs. conventional group) had a lower NIHSS motor score after each treatment (p=0.022), a shorter motor stabilization time (p<0.001) and hospitalization period (p=0.047), although there were not significantly different from baseline clinical and laboratory findings (ie. age, sex, risk factors for stroke, initial BPs, and NIHSS motor score) in two groups. In multiple regression analysis, a history of hypertension (odds ratio, OR 7.11, 95% CI 1.43-35.31, p=0.016), achievement of target BP (OR 8.13, 95% CI 1.49-44.45, p=0.016) and motor stabilization time (OR 0.51 per 1-day increase, 95% CI 0.29-0.87, p=0.015) were independent predictors for good outcome in the phenyephrine group. Side effects of phenylephrine treatment were transient chest tightness (n=3) and dysuria (n=2). The present study suggests that phenylephrine induced-hypertension can result in early motor restoration without serious side effects in progressing lacunar infarction.

Ischemic stroke related to intracranial branch atheromatous disease and comparison with large and small artery diseases

BackgroundThe mechanism of ischemic stroke in intracranial branch atheromatous disease (BAD) is different from large artery atherothrombotic disease (LAD) or lacunar infarction (LACI). The concept of BAD is underused in clinical practice and research. MethodsPatients admitted over 24-months with ischemic stroke caused by atherosclerotic disease were reviewed retrospectively and classified according to radiological±clinical criteria into LAD, BAD and LACI. The BAD cases were further divided into 5 BAD syndromes. Clinical characteristics, vascular risk factors, results of vascular workup and outcome among these subgroups were compared. Results123 cases of LAD (17% of all stroke patients or 33% of all studied patients), 147 BAD (20% or 40%) and 102 LACI (14% or 27%) presented during the study period. Compared to LAD, BAD patients had milder neurological deficits, were less often diabetic and carotid stenosis was less common, while stenosis of the intracranial arteries was more frequent in BAD as compared with LACI patients. Outcome in BAD patients was intermediate between LAD and LACI. Comparisons among the BAD syndromes indicated they were homogenous conditions. ConclusionsBAD is the most prevalent ischemic stroke subtype in our cohort. The homogeneity among the BAD syndromes suggests they might represent a distinctive stroke entity.

Promoter variant of angiopoietin-2 and plasma angiopoietin-2 are associated with risk of stroke recurrence in lacunar infarct patients

Angiopoietin-2 has been reported to regulate the inflammation process, which is associated with recurrence of stroke. The purpose of this study was to test the hypothesis that plasma levels of angiopoietin-2 and variants of angiopoietin-2 will confer risk of stroke recurrence. The association of plasma angiopoietin-2 (determined by using ELISA) and the variants in angiopoietin-2 promoter with stroke recurrence was tested in 1735 patients with stroke of three subtypes, lacunar infarct (n=475), atherothrombotic (n=794) and hemorrhage (n=466), for a period of following-up 4.5years (mean), the association was evaluated by using Kaplan–Meier analysis and the Cox regression models. We found that angiopoietin-2 levels were associated with risk of stroke recurrence in lacunar infarct patients. Taking the lowest quartile as reference, the adjusted hazard ratio (HR) and 95% confidence intervals (CI) for stroke recurrence was 1.48 (0.74–2.95) for the second quartile, 2.56 (1.35–4.86) for the third and 2.15 (1.11–4.17) for the fourth. Allele T of rs3739391 in angiopoietin-2 promoter was associated with elevated angiopoietin-2 levels and increased risk of stroke recurrence in patients with lacunar infarct with HR 1.67 (1.06–2.63) relative to the allele C, but neither in those with atherothrombotic nor in those with hemorrhagic stroke. Our results indicate that both angiopoietin-2 and allele T of rs3739391 might be the risk marker for stroke recurrence in the patients with lacunar infarction. These findings may help to improve future prevention or therapy strategies for stroke. Even some conventional risk factors have been identified responsible for stroke recurrence, but these factors could not fully explain all the recurrent stroke events. Our study opens a new page for the first time that angiopoietin/tie2 pathway has a potential role in lacunar stroke recurrence. Since several strategies are available for blocking or neutralizing plasma angiopoietin-2, especially eicosapentaenoic acid rich in sea food. Our finding obviously has its clinical implication if it was proved by large, prospective clinical studies.

Proportion, Risk Factors and Outcome of Lacunar Infarction: A Hospital-Based Study in a Chinese Population

Background: There is scant information on the proportion, risk factors and outcome of lacunar infarction in China. Methods: Prospective registry data entered within 1 month after a first-ever stroke between March 2002 and March 2007 were used from 4 Chinese hospitals. Data regarding stroke risk factors and baseline characteristics were examined in a long-term follow-up. Case fatality, death and dependency, and stroke recurrence were assessed at 30, 90, 180 days and 1 year. Predictive factors for death at 1 year in patients with lacunar infarction were tested by logistic regression analysis. We constructed Kaplan-Meier survival curves and compared groups with lacunar infarction and nonlacunar infarction by means of log rank tests for significant difference. Results: A total of 3,905 patients with first-ever cerebral infarction were included, of whom 1,650 (42.3%) had a lacunar infarction and 2,255 (57.7%) a nonlacunar infarction. Case fatality was lower in patients with lacunar infarction at all 4 time points (5.3, 6.4, 7.8 and 17.4%, respectively), as compared to patients with nonlacunar infarction (9.5, 14.3, 16.5 and 20.1%, respectively). Age, diabetes, smoking and NIHSS score at admission were the independent predictors for 1-year case fatality in patients with lacunar infarction. Death and dependency rates were also lower in patients with lacunar infarction than in those with nonlacunar infarction. Recurrent stroke was an important cause of death for lacunar infarction patients. Conclusions: The proportion of lacunar infarction in China is much higher than that in Western countries. The long-term prognosis of lacunar infarction is not benign.

Abstract 5499: Promoter Variant of Angiopoietin-2 and Plasma Angiopoietin-2 Are Associated With Risk of Stroke Recurrence in Patient With Lacunar Infarction

Background- Risk factors for stroke recurrence are still not fully defined. Angiopoietin-2 is a very important mediator in the vessel development and repair. We hypothesized that altered expression of angiopoietin-2 will confer risk of stroke recurrence. Methods - The association of plasma angiopoietin-2 (determined by using ELISA) and the variants in angiopoietin-2 promoter with stroke recurrence was tested in 1735 patients with stroke of three subtypes, lacunar infarct (n=475), atherothrombotic (n=794) and hemorrhage (n=466), for a period of following-up 4.5 years (mean), the association was evaluated by using Kaplan-Meier analysis and the Cox regression models. Results -We found that angiopoietin-2 levels were associated with risk of stroke recurrence in lacunar infarct patients. Taking the lowest quartile as reference, the adjusted hazard ratio (HR) and 95% confidence intervals (CI) for stroke recurrence was 1.47 (0.75–2.88) for the second quartile, 2.44 (1.31–4.56) for the third and 2.00 (1.05–3.85) for the fourth. Allele T of rs3739391 in angiopoietin-2 promoter was associated with elevated angiopoietin-2 levels and increased risk of stroke recurrence in patients with lacunar infarct with HR 1.72 (1.09–2.72) relative to the allele C, but neither in those with atherothrombotic nor in those with hemorrhagic stroke. Conclusion- Our results indicate that both angiopoietin-2 and allele T of rs3739391 might be the risk marker for stroke recurrence in the patients with lacunar infarction. These findings may help to improve future prevention or therapy strategies for stroke.

Association of PRKCH gene with lacunar infarction in a local Chinese Han population

Recent evidence indicated that the PRKCH gene was a susceptibility gene for lacunar infarction in a Japanese population. The aim of the present study was to explore the association of the gene with lacunar infarction in a population of Chinese Han ancestry. A total of 280 consecutive lacunar infarction patients and 306 unrelated population-based controls that had been matched for age and sex were examined using a case–control design. Two single nucleotide polymorphisms (SNPs) of PRKCH gene (rs3783799 and rs2230500) were genotyped with ligase detection reaction (LDR) and multiplex polymerase chain reaction (PCR). Linkage disequilibrium (LD) and haplotype analysis were also investigated between these two groups. Overall alleles and genotype frequencies were similar between cases and controls. No significant association was detected with the gene polymorphisms mentioned above and lacunar infarction; no significant difference was found with haplotype analysis between these two groups. None of the two SNPs showed significant association with lacunar infarction in the whole subjects before and after adjustment for conventional stroke risk factors (hypertension, diabetes mellitus, and hypercholesterolemia). The frequencies of PRKCH differed largely from those in the Japanese population. The present study suggests that variants in the PRKCH gene are not the risk factors for lacunar infarction in individuals from a small population of Chinese Han ancestry. Population differences in alleles and haplotype frequencies as well as LD structure may contribute to the observed differences between populations.

Normal Magnetic Resonance Perfusion-Weighted Imaging in Lacunar Infarcts Predicts a Low Risk of Early Deterioration

Background: Current clinical tools to identify lacunar infarct patients at risk of deterioration are inadequate, and imaging techniques to predict fluctuation and deterioration would be of value. We sought to determine the occurrence of MRI perfusion-weighted imaging (PWI) abnormalities in lacunes, and whether they help predict clinical and radiological outcome. Methods: Patients with lacunar stroke or TIA were selected from a prospective MR imaging study. MRI was performed within 24 h of the event and follow-up imaging completed at 30 or 90 days. Baseline perfusion maps were qualitatively assessed and infarct volumes measured. Early clinical deterioration (NIHSS worsening of ≥3 points within 72 h of event) and 90-day modified Rankin Scale score (mRS) were recorded. Results: Twenty-two patients were included. Fifteen (68.2%) had abnormal PWI at the site of the diffusion-weighted imaging lesion. Patients with abnormal PWI were more likely to have stroke than TIA as their index event (RR 2.2, 95% CI 0.9–5.2, p = 0.02). Early clinical deterioration occurred in 4 patients (18.2%), all of whom had abnormal PWI. PWI lesions were not associated with a higher 90-day NIHSS or mRS score, nor did they predict infarct volume growth. Conclusions: MR-PWI abnormalities are seen in two thirds of lacunar infarcts, and are associated with stroke rather than TIA. Normal PWI identifies patients at low risk of early clinical deterioration.

Omega‐3 Index as a risk factor of ischemic and haemorrhagic stroke: a pilot case‐control study

Previous studies suggested that fish consumption and blood level of omega‐3 fatty acids negatively correlated with ischemic stroke, but the relation to the risk of haemorrhagic stroke remains unclear. This study was investigated the effect of Omega‐3 Index (EPA + DHA in red blood cell, RBC) on hemorrhagic and ischemic stroke.Hemorrhagic (n=24) and ischemic stroke (n=31) cases, and controls (n=20) were included in the present study. Omega‐3 Index (8.36 ± 0.58 vs. 10.66 ± 0.68 %), total n‐3 fatty acids (15.30 ± 0.57 vs. 12.61 ± 0.78 %), and C22:6n3 (DHA; 8.93 ± 0.55 vs. 7.09 ± 0.38 %) in RBC were significantly higher in control than ischemic and haemorrhagic stroke patients. Omega‐3 Index and total n‐3 fatty acids, and DHA were significantly increased the risk for haemorrhagic stroke, but not for ischemic stroke. However, among the ischemic stroke subgroups, lacunar infarction patients had the significantly lower level of Omega‐3 Index and EPA, suggesting that low level of omga‐3 fatty acids might be a provocating factor on lacunar infarction. There was no significant difference in intake of nutrients and foods between control and patients, except low intake of brown rice, seaweed soup, bean sprouts soup, and bean paste pot stew in stroke patients. In conclusion, n‐3 fatty acids may have beneficial effect on haemorrhagic stroke and lacunar infarction, a subgroup of ischemic stroke.

Dynamic cerebral autoregulation and cerebrovascular reactivity: a comparative study in lacunar infarct patients

The major purpose of this study was to simultaneously evaluate dCA before and shortly after cerebral vasodilatation evoked by infusion of acetazolamide (ACZ). It was questioned if and to what degree dCA was changed after ACZ infusion. Using 15 mg kg−1 ACZ infusion cerebrovascular reactivity (CVR) was assessed in 29 first ever lacunar stroke patients (19 M/10 F). During the CVR-test, the electrocardiogram, non-invasive finger arterial blood pressure (ABP) and middle cerebral artery blood flow velocity (CBFV) were recorded. DCA based on spontaneous blood pressure variations was evaluated in 24 subjects by linear transfer function analysis. Squared coherence, gain and phase angle in the frequency range of autoregulation (0.04–0.16 Hz) were compared before and after ACZ infusion. After ACZ infusion, median phase angle decreased significantly (p < 0.005 Wilcoxon) to 0.77 rad compared to a pre-test baseline value of 1.05 rad, indicating less efficient dCA due to ACZ. However, post-test phase values are still mostly within the normal range. Poor and statistically non-significant correlations were found between CVR and absolute dCA phase angle. It can be concluded that CVR testing with body weight adjusted infusion of ACZ lowers dCA performance but by no means exhausts dCA, suggesting that in this way maximal CVR is not determined. Characterizing dCA based on transfer function analysis of ABP to CBFV needs no provocation and adverse patient effects are minimal. The poor correlation between CVR and dCA phase angle supports an interpretation that CVR and dCA study different mechanisms of cerebrovascular control.

Higher severity of frontal periventricular white matter and basal ganglia hyperintensities in first-ever lacunar stroke with multiple silent lacunes

We investigated whether patients with a lacunar infarct (LI) syndrome exhibiting unique LI or multiple LI on magnetic resonance imaging (MRI) examinations differed in terms of topography and severity of white matter hyperintensities (WMH) ratings. Forty consecutive patients with a first-ever acute LI, who presented a lacunar syndrome according to Miller-Fisher's classification were recruited and were classified into a group presenting isolated LI on MRI (n = 17) or multiple LI (n = 23). Despite equivalent demographic, clinical and cognitive characteristics, patients with multiple LI had increased ratings of WMH in frontal, occipital and subcortical regions. No significant correlations could be evidenced between the number of LI and WMH ratings. Present findings provide support to previous hypothesis considering single and multiple LI MRI presentations of lacunar infarct patients as distinct entities.

Silent cerebral microbleeds on susceptibility-weighted imaging of patients with ischemic stroke and leukoaraiosis

Objective: Cerebral microbleeds (CMBs) are an increasingly recognized in patients with cerebrovascular disease who undergo the new MRI techniques. Susceptibility-weighted MRI is sensitive to detect silent microbleeds which are associated with microangiopathy from atherosclerosis, amyloid angiopathy or asymptomatic elderly individuals. CMBs are intracerebral old hemosiderin deposits in the perivascular space, and the clinical significance of such 'microbleeds' remains controversy. We investigated the incidence of microbleeds among different ischemic stroke subtypes and the severity of leukoaraiosis.Methods: In this study, we collected 137 patients (73.5 ± 9.1 years old, 84 men and 53 women) who were divided into five groups: atherothrombotic infarction (34 patients), cardioembolic infarction (24 patients), lacunar infarction (35 patients), other determined or undetermined infarction (21 patients) and control (23 patients), in which 52 had primary stroke and 62 had recurrent stroke. Microbleeds were counted and leukoaraiosis was graded using susceptibility-weighted, T1-, T2- and FLAIR MRI with a 3.0 T system.Results: Microbleeds were high in lacunar infarction (25.7%) and atherothrombotic infarction patients (20.6%). Microbleeds were low in patients with cardioembolic infarction (4.2%). Both microbleeds (≥grade 2) and leukoaraiosis in severity (≥grade 2) were higher in the recurrent stroke group (14.5 and 48.4%) than those in the primary stroke group (3.8 and 7.7%). Leukoaraiosis (r=0.803, p<0.05) and recurrent stroke (r=0.708, p<0.05) were significantly associated with microbleeds.Conclusions: Asymptomatic CMBs are observed with a markedly higher frequency in recurrent stroke, and are closely associated with the severity of leukoaraiosis.

Statins and Cerebral Vasomotor Reactivity

See related article, pages 2540-2545. Animal models have shown that cholesterol-lowering therapy with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (commonly called statins) may augment absolute cerebral blood flow (CBF) by enhancing nitric oxide synthase (eNOS).1 Statins upregulate type III endothelial eNOS in thrombocytes, decrease platelet activation, and protect from cerebral ischemia in normocholesterolemic mice.2 Statins may also provide additional beneficial effects by upregulating endogenous tissue plasminogen activator and enhancing clot lysis in a mouse model of embolic focal ischemia.3 Statins given 24 hours after experimental ischemia can enhance CBF, angiogenesis, neurogenesis and sinaptogenesis.4 How can these findings be applied in the clinical setting? A meta-analysis of published clinical trials showed that low-density lipoprotein–lowering with statins may decrease the risk of stroke in diabetic or hypertensive patients with normal low-density lipoprotein cholesterol at baseline, and in patients with coronary artery disease, with respectively 48%, 27% and 25% reduction in stroke incidence.5 Does any relationship exist among statins and cerebral vasomotor reactivity? Functional transcranial Doppler (TCD) ultrasonography permits the assessment of cognitively induced CBF velocity changes6 and the evaluation of cerebral vasomotor reactivity.7 TCD can be used to reliably evaluate age-related changes in the physiological response of the human cerebral circulation. A diminished nitric oxide–mediated cerebral vasomotor response may exist in aging subjects and in patients with vascular risk factors.8 Because there are no reliable markers for the functional status of the cerebral small vessels in elderly patients at risk of stroke, TCD studies may be useful. Although some parameters …

Comparing risks of death and recurrent vascular events between lacunar and non-lacunar infarction

Differences in prognosis of lacunar and non-lacunar infarction patients might support distinct arterial pathological processes underlying these two subtypes of ischaemic stroke. We performed a systematic review in which we identified cohort studies with ischaemic stroke subtype-specific follow-up data on death, recurrent stroke and/or myocardial infarction (MI). We calculated risks of death and recurrent stroke at 1 month, 1-12 months and 1-5 years, as well as risks of MI and cardiac death. We compared non-lacunar with lacunar infarction, using study-specific and summary odds ratios. We also compared the pattern of recurrent stroke subtypes after lacunar and non-lacunar infarction. One month odds of death and of recurrent stroke were significantly greater following non-lacunar than lacunar infarction, but the difference decreased thereafter (1 month mortality: OR 3.81, 95% CI 2.77-5.23; 1-12 month mortality: OR 2.32, 95% CI 1.74-3.08; 1-5 year mortality: OR 1.77, 95% CI 1.28-2.45; 1 month stroke recurrence: OR 2.11, 95% CI 1.20-3.69; 1-12 month stroke recurrence: OR 1.24, 95% CI 0.85-1.83; 1-5 year stroke recurrence: OR 1.61, 95% CI 0.96-2.70). Recurrent strokes were more likely to be lacunar if the index event was lacunar. Few studies reported on the risk of MI, but we found no significant difference in risk of cardiac death in non-lacunar versus lacunar infarction. Thus, although early mortality and stroke recurrence risks are higher among non-lacunar than lacunar infarct patients, the risks appear not to differ in the longer term and the risks of cardiac outcomes are similar, although data are limited. There is some evidence that recurrent ischaemic stroke subtypes breed true. These results provide limited support for a distinct arterial pathology underlying lacunar infarction.

Cognitive Dysfunction After Acute Lacunar Infarct

Vascular dementia and vascular cognitive impairment have attracted more attention recently due to their association with increased risk of death and institutionalization. The purpose of the present study was to detect and identify the characteristics of cognitive impairments during the early stage of lacunar stroke. The subjects consisted of 23 consecutive first-ever acute lacunar infarction patients who were admitted to the Department of Neurology, Kaohsiung Municipal Hsiao-Kang Hospital, Taiwan, from November 2001 to October 2002. The National Institutes of Health Stroke Scale and Cognitive Abilities Screening Instrument (CASI) were used to evaluate stroke severity and cognitive function, and assessments were performed by a neurologist and psychologist, within 10 days of stroke onset. Of the 23 patients, 21 (91.3%) had CASI scores below their respective cutoff values and all patients had cognitive impairment in at least one cognitive domain in CASI. There were no significant correlations between CASI abnormality (below the cutoff value) and patient age, education, or the interval from stroke onset. Recent memory impairment was the most often impaired cognitive domain on CASI (19 patients, 82.6%). There were significant correlations between recent memory and "attention or concentration"(correlation coefficient, 0.52; p < 0.05), and "abstraction and judgment" (correlation coefficient, 0.44; p < 0.05). The correlations between recent memory and other domains were not significant. It was concluded that cognitive impairment after acute lacunar infarct is quite common and recent memory is the most often impaired cognitive domain. This may have been caused by the location of the specific lesion as well as by the impairment in "attention or concentration" or "abstraction and judgment".

Dotlike Hemosiderin Spots Are Associated With Past Hemorrhagic Strokes in Patients With Lacunar Infarcts

Background and Purpose. Dotlike hemosiderin spots ongradient-echo T2*-weighted magnetic resonance imaging of the brain have been histologically diagnosed as old microbleeds associated with small vessel disease (SVD). The authors hypothesize that the presence of many dotHSs may be correlated with the fragility of small vessels and the recurrence of SVD, including lacunar infarction and deep intracerebral hemorrhage (ICH). Methods. To investigate how dotHSs are related to past history of SVD, the number of subcortical or deep dotHSs was investigated in 146 patients with lacunar infarctions (95men, 51 women, age 38 to 90 [66.6 ± 9.4] years). They were divided into 2 subgroups according to history of deep ICHs or lacunar infarctions. The odds ratio (OR) for past history was estimated from logistic regression analyses with the number of subcortical or deep dotHSs as well as other factors. Results. Of 146 patients with lacunar infarctions, 11 had past symptomatic ICHs and 19 had past symptomatic lacunar infarctions. An elevated rate of history of ICH was found for lacunar infarction patients with many deep dotHSs (≥3; OR, 9.1; 95% confidence interval, 1.6–51, P= .015). However, history of lacunar infarction was not significantly associated with the number of subcortical or deep dotHSs. Conclusions. Our findings suggest that many deep dotHSs on T2*-weighted magnetic resonance imaging may be correlated with deep ICH—lacunar infarction type of SVD recurrence but not lacunar infarction—lacunar infarction type.