Lacunar Stroke Patients Research Articles

Rescue therapy of early neurological deterioration in lacunar stroke

BackgroundEarly neurological deterioration (END) occurs in many patients with acute ischemic stroke due to a variety of causes. Although pharmacologically induced hypertension (PIH) and anticoagulants have been investigated in several clinical trials for the treatment of END, the efficacy and safety of these treatments remain unclear. Here, we investigated whether PIH or anticoagulation is better as a rescue therapy for the progression of END in patients with lacunar stroke.MethodsThis study included patients with lacunar stroke who received rescue therapy with END within 3 days of symptom onset between April 2014 and August 2021. In the PIH group, phenylephrine was administered intravenously for 24 h and slowly tapered when symptoms improved or after 5 days of PIH. In the anticoagulation group, argatroban was administered continuously intravenously for 2 days and twice daily for next 5 days. We compared END recovery, defined as improvement in NIHSS from baseline, excellent outcomes (0 or 1 mRS at 3 months), and safety profile.ResultsAmong the 4818 patients with the lacunar stroke, END occurred in 147 patients. Seventy-nine patients with END received PIH (46.9%) and 68 patients (46.3%) received anticoagulation therapy. There was no significant difference in age (P = 0.82) and sex (P = 0.87) between the two groups. Compared to the anticoagulation group, the PIH group had a higher incidence of END recovery (77.2% vs. 51.5%, P < 0.01) and excellent outcomes (34.2% vs. 16.2%, P = 0.04). PIH was associated with END (HR 2.49; 95% CI 1.06–5.81, P = 0.04). PIH remained associated with END recovery (adjusted HR 3.91; 95% CI 1.19–12.90, P = 0.02). Safety outcomes, like hemorrhagic conversion and mortality, were not significantly different between the two groups.ConclusionsAs a rescue therapy for the progression of END in lacunar stroke patients, PIH with phenylephrine was more effective with similar safety compared to anticoagulation with argatroban.

Exercise transiently increases the density of incipient blood clots in antiplatelet-treated lacunar stroke patients

IntroductionOlder individuals and, in particular, individuals at risk of recurrent stroke, may be susceptible to thrombosis when participating in exercise, however, this aspect has not been well investigated.MethodsClot microstructure and conventional markers of thrombotic risk were determined in twenty lacunar stroke patients and fifteen healthy age-matched controls before, immediately after and 1 h after a bout of moderate intensity cycling exercise. Data were analyzed using a linear mixed model approach.ResultsAt rest, clot microstructure (1.69 ± 0.07 vs. 1.64 ± 0.05, corresponding to a difference of ~ 50% in normalized clot mass; p = 0.009) and thrombocyte count (73%; p < 0.0001) were higher, and activated partial thromboplastin time was lower (18%; p = 0.0001) in stroke patients compared to age-matched controls. Acute exercise increased thrombogenic markers similarly in the two groups: incipient clot microstructure (1.69 ± 0.07 vs. 1.74 ± 0.05; p = 0.0004 and 1.64 ± 0.05 vs. 1.71 ± 0.04; p < 0.0001, for stroke and controls respectively), plasma fibrinogen (12%; p < 0.0001 and 18%; p < 0.0001, for stroke and controls respectively) and the combined coagulation factors II, VII and X (p = 0.0001 and p < 0.0001, for stroke and controls respectively).ConclusionThe results show that exercise transiently increases the risk of blood clot formation in both stroke patients and controls, however, due to the higher baseline thrombogenicity in stroke patients, the post exercise risk of forming blood clots may be higher in this group.Trial registrationRegistered at ClinicalTrials.gov (NCT03635177).

Abstract TMP67: Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy May Affect Large Cerebral Arteries

Introduction: CADASIL is the most common monogenic small-vessel disease (SVD) form. Large and small brain arteries are intimately related, but it is unclear whether people with CADASIL have changes in their large arteries as a result. We hypothesized that CADASIL patients have affected large arteries compared to controls. Methods: We conducted a comparative analysis by matching 37 CADASIL patients with 104 lacunar stroke patients from the NYP/ Columbia University Medical Center Stroke Registry Study matched by age +/-3 and sex. We measured the basilar and intracranial carotid artery diameters in both groups in T2 MRI images. We rated cervical artery tortuosity as 0 for no tortuosity, 1 for 45-90°, and 2 for &gt;90°. We ran generalized linear models to compare cases and controls, adjusting for demographics and clinical variables. Results: Patients with CADASIL were less likely Hispanic\Latino (10.8% vs. 51.9%, p=&lt;0.001), hypertensive (27% vs. 73.1%, p=&lt;0.001), current smokers (5.4%vs. 22.1%, p=0.024), but more likely to have a prior stroke (56.8% vs. 24%, p=&lt;0.001) than controls—Table 1. In the adjusted model, patients with CADASIL had larger basilar artery diameters (p=0.007) and a statistical trend for greater cervical carotid artery tortuosity—Table 2. Conclusions: Although traditionally considered an example of pure SVD, patients with CADASIL have a higher prevalence of cervical tortuosity and intracranial artery dilatation. Whether changes in large arteries result from small artery disease or part of the NOTCH3 mutation phenotype is uncertain. Further investigation is needed to determine if large artery involvement influences the clinical manifestations of CADASIL.

Quantitative Analysis of Multimodal MRI Markers and Clinical Risk Factors for Cerebral Small Vessel Disease Based on Deep Learning.

Cerebral small vessel disease lacks specific clinical manifestations, and extraction of valuable features from multimodal images is expected to improve its diagnostic accuracy. In this study, we used deep learning techniques to segment cerebral small vessel disease imaging markers in multimodal magnetic resonance images and analyze them with clinical risk factors. We recruited 211 lacunar stroke patients and 83 control patients. The patients' cerebral small vessel disease markers were automatically segmented using a V-shaped bottleneck network, and the number and volume were calculated after manual correction. The segmentation results of the V-shaped bottleneck network for white matter hyperintensity and recent small subcortical infarction were in high agreement with the ground truth (DSC>0.90). In small lesion segmentation, cerebral microbleed (average recall=0.778; average precision=0.758) and perivascular spaces (average recall=0.953; average precision=0.923) were superior to lacunar infarct (average recall=0.339; average precision=0.432) in recall and precision. Binary logistic regression analysis showed that age, systolic blood pressure, and total cerebral small vessel disease load score were independent risk factors for lacunar stroke (P<0.05). Ordered logistic regression analysis showed age was positively correlated with cerebral small vessel disease load score and total cholesterol was negatively correlated with cerebral small vessel disease score (P<0.05). Lacunar stroke patients exhibited higher cerebral small vessel disease imaging markers, and age, systolic blood pressure, and total cerebral small vessel disease score were independent risk factors for lacunar stroke patients. V-shaped bottleneck network segmentation network based on multimodal deep learning can segment and quantify various cerebral small vessel disease lesions to some extent.

Differences in characteristics between patients from Egypt and Germany presenting with lacunar stroke

Despite the enormous health burden of lacunar stroke, data from low- and middle-income countries on lacunar stroke characteristics and its comparison with that of high-income countries are scarce. Thus, we aimed to investigate and compare the variable characteristics and vascular status in patients from Egypt and Germany suffering lacunar stroke. Two cohorts of lacunar stroke patients from Ain Shams University Hospital, Egypt and Goethe University Hospital Frankfurt, Germany were retrospectively collected between January 2019 and December 2020 and analyzed for demographics, risk factors, mode of presentation, neuroimaging features, treatment protocols and outcomes. MRI showed a different distribution pattern of lacunar strokes between cohorts, detecting posterior circulation lacunar infarctions preponderantly in patients from Egypt and anterior circulation lacunar infarctions preponderantly in patients from Germany. Complementary MR/CT angiography revealed a significantly higher proportion of intracranial and combined intracranial and extracranial arterial stenosis in patients from Egypt than in patients from Germany, suggesting differences in pathological processes. Younger age, higher NIHSS on admission, and posterior circulation lacunar infarction were predictors of Egyptian origin, whereas hypertension was a predictor of German origin. Our results support the idea of clinical and neuroimaging phenotype variations in lacunar stroke, including different sources of lacunar stroke in patients of different populations and geographical regions. This implies that guidelines for management of lacunar stroke might be tailored to these differences accordingly.

Progressive lacunar strokes behave differently from stable ones even at one year—An observational study

Background and aimsSmall fraction of lacunar stroke patients have an early fluctuating course, described as progressive lacunar syndrome [PLS].We studied the predictors and short term outcome of progressive lacunar strokes in comparison with those with an early stable course. Materials and methodsSingle centre retrospective study where patients with lacunar strokes from 2016 to 2020 were included in the study. Progression was defined as increase in stroke severity [NIHSS] by ≥2 points from baseline without imaging evidence of new infarcts or haemorrhagic transformation. We compared the clinical variables, risk factors, imaging, treatment received and 1 year outcome of subjects with PLS with those with a stable course, with modified Rankin score 0–2 taken as good outcome. ResultsOf the 216 patients with a mean age 63.17 years, progressive course was noted in 56 subjects [26 %].Majority of the fluctuations occurred within 24 h of onset of symptoms. Though stroke severity at admission was comparable between the 2 groups, discharge and 1 year outcome was poorer in those with an early progressive course. We found that presentation as pure motor syndrome, hypertriglyceridemia and thrombolytic therapy were predictors of poor outcome in progressive lacunar strokes, while age, risk factors, infarct location or leukoaraiosis failed to show an association. Thalamic infarcts and atypical lacunar syndromes were associated with a stable course. ConclusionProgressive course is seen in a quarter of lacunar strokes and they have poorer outcome at 1 year. Our finding of thrombolysis being associated with worse outcome in PLS patients, should alert physicians regarding need for more definitive therapies for this condition.

Regional white matter hyperintensity volume predicts persistent cognitive impairment in acute lacunar infarct patients.

White matter hyperintensity (WMH) is often described in acute lacunar stroke (ALS) patients. However, the specific relationship between regional WMH volume and persistent cognitive impairment remains unclear. We enrolled patients with ALS who were hospitalized at the First Affiliated Hospital of Soochow University between January 2020 and November 2022. All patients were assessed for global cognitive function using the Montreal Cognitive Assessment (MoCA) scale at 14 ± 2 days and 6 months after the onset of ALS. Manifestations of chronic cerebral small vessel disease (CSVD) were assessed via MRI scan. The distributions of regional WMH were segmented, and their relationship with cognitive impairment was evaluated. A total of 129 patients were enrolled. Baseline frontal WMH volume (OR = 1.18, P = 0.04) was an independent risk factor for long-term cognitive impairment after ALS. Furthermore, the presence of WMH at the genu of the corpus callosum (GCC) at baseline (OR = 3.1, P = 0.033) was strongly associated with persistent cognitive decline. Multivariable logistic regression analysis showed that depression (OR = 6.252, P = 0.029), NIHSS score (OR = 1.24, P = 0.011), and albumin at admission (OR = 0.841, P = 0.032) were also important determinants of long-term cognitive impairment after ALS. Our study found that WMH, especially frontal WMH volume and the presence of WMH at the GCC at baseline, independently contributed to long-term cognitive decline in ALS patients. This study provides new evidence of the clinical relationship between regional WMH volume and cognitive impairment in ALS patients.

CLINICAL CHARACTERISTICS OF LACUNAR ISCHEMIC STROKE PATIENTS

Background: Stroke is the leading causes of death and disability in the world. Ischemic stroke covered 85% of stroke types. Based on the subtypes of ischemic stroke, lacunar ischemic stroke encompassed 20% of them. Knowing the characteristics help physicians to diagnose patients clinically and offer management to treat risk factors. Objective: This study aimed to know the characteristics of lacunar ischemic stroke based on patients risk factors, ischemic location on CT-scan, clinical syndrome, and NIHSS score. Methods: Using retrospective analytical study with cross sectional approach, medical record data from 2019-2022 were collected from RSUP DR. Hasan Sadikin Bandung. Results: From 60 patients, 35% (21) are 55-64 years old. Both sexes are equally distributed. 50 patients (83.3%) have multiple risk factors. Out of 60 patients, 57 (95%) have hypertension, 8 (13.3%) have diabetes mellitus, 44 (73.3%) have dyslipidemia, 6 (10%) have hyperuricemia, and 14 (23.3%) smoke. On admission, out of 60 patients, 34 (56.7%) have mild stroke, 23 (38.3%) have moderate stroke, 2 (3.3%) have moderate to severe stroke, and 1 (1.7%) has severe stroke. 44 (73.3%) out of 60 patients have pure motor hemiparesis. 41 (68.3%) out of 60 patients have basal ganglia ischemic. Conclusion: Lacunar ischemic stroke patients were equally distributed in sex with peak incidence occur between 55-64 years old. Most patients have multiple risk factors, basal ganglia lesion, pure motor hemiparesis, and history of hypertension, dyslipidemia, and smoking. On admission, most patients have mild stroke, followed by moderate stroke.

Outcome of Lacunar vs Non-lacunar Infarcts in a Prospective Stroke Database (P14-5.029)

<h3>Objective:</h3> To prospectively compare recovery outcomes, presentation with NIH stroke scale and modified ranking scale (MRS) in the study population with follow up at discharge. <h3>Background:</h3> Earlier studies suggested lacunar stroke has a better prognosis compared to other strokes, but recent studies show prognosis of lacunar stroke is simiar or worse when compared to large strokes. <h3>Design/Methods:</h3> We prospectively collected demographic information, admission NIH stroke scale, and modified ranking scale with serial measurements during hospitalized course in single tertiary care hospital in six-month period(n=74). We also collected information on discharge disposition between lacunar and non-lacunar stroke groups. Two groups adjusted for sex and race. Independent t-test is used for comparing continuous variables and chi-square test for comparing categorical variables. <h3>Results:</h3> There were 30 lacunar stroke patients and 44 non-lacunar stroke patients with mean age of 60 years for lacunar stroke patients and 70 for non-lacunar stroke patients. Mean admission NIH stroke scale was 11 in the non-lacunar group with MRS of 0.4 compared to 6 (p= 0.009) and 1(p=0.006), respectively in the lacunar group. Discharge NIH and MRS values were 7 and 2.3 respectively for the non-lacunar group compared to 4(p=0.03) and 2.2(p=0.88) for the lacunar group. ΔNIH (admit-discharge) is 4 and 2 for non-lacunar and lacunar group, respectively. ΔMRS (admit-discharge) is −1.9 and −1.3 for non-lacunar and lacunar group, respectively. Discharge to home was 46.7% &amp; 37% (p=0.03) in non-lacunar group and lacunar group, respectively. Discharge to Skilled nursing facility was 13.3% and 18.5%(p=0.03) in non-lacunar group and lacunar group, respectively. <h3>Conclusions:</h3> Despite the relatively small volume of infarct associated with lacunar stroke compared to typically large infarcts seen with non-lacunar stroke, we found that the outcome was similar if not worse in terms of recovery for lacunar type stroke based upon prospective information collected in our six-month database extending from May 2021 to November <b>Disclosure:</b> Dr. Buchhanolla has nothing to disclose. Dr. PANDEY has nothing to disclose. Dr. Bir has nothing to disclose. Dr. Javalkar has nothing to disclose. Dr. Kelley has nothing to disclose.

The Correlation of Glial Fibrillary Acid Protein Level to Cognitive Function Outcome in Acute Lacunar Ischemic Stroke Patient

ABSTRACT :&#x0D; Introduction : Glial fibrillary acidic protein (GFAP) is a filamentous protein found in central nervous system astrocytes. Increased serum GFAP levels are caused by the process of astrogliosis after ischemic stroke and are associated with multisynaptic disorders so that they are at risk of causing cognitive disorders.&#x0D; Objective: To analyze the correlation between GFAP levels and cognitive function output in acute lacunar ischemic stroke patients.&#x0D; Research Methods : Analytical observational with prospective cohort approach. The subjects of this study were Acute lacunar ischemic stroke patients with mild to moderate NIHSS scores. Serum GFAP levels were taken at the onset of 48-72 hours of stroke. Cognitive function was measured using the Indonesian version of MoCA (MoCA Ina) test on the seventh and thirtieth day. Bivariate and multivariate analyzes were performed to assess the correlation between GFAP levels, cognitive functions and the confounding factors.&#x0D; Results: There was a significant correlation between GFAP levels and the MoCA Ina scores on the seventh day (r= -0.32, p=0.044), the thirtieth day (r= -0.398, p=0.011), and improvement in MoCA Ina scores (r= -0.342, p = 0.031). There was a significant correlation between GFAP levels on the executive domain on the seventh day (p= 0.01) and thirtieth day (p= 0.005), visuospatial on seventh day (p= 0.004) and thirtieth day (p= 0.016), language on the thirtieth day (p = 0.005), and memory on thirtieth day (p= 0.001). There was no significant correlation between GFAP levels and improvements in attentional, memory, language, visuospatial, and executive domains.&#x0D; Conclusion: There was a significant correlation between GFAP levels and MoCA Ina scores on the seventh, thirtieth day and the improvement of MoCA Ina scores. There was a significant correlation between GFAP levels with the executive, visuospatial, language, and memory domains.&#x0D; Keywords: cognitive, GFAP, lacunar ischemic stroke, MoCA Ina

S-03-1: BRAIN IMAGING FOR THE MANAGEMENT OF HYPERTENSION

Small vessels in the brain is susceptible especially for the effect of hypertension. Therefore, longstanding hypertension may induce cerebral small vessel disease (CSVD) which is designated as hypertensive CSVD. The patients with hypertensive CSVD may exhibit various types of lesions including lacunar infarction, white matter lesion, cerebral hemorrhage and microbleeds in brain magnetic resonance (MR) imaging. White matter lesions (WMLs) are one of the most representative lesions which are closely related to hypertension and aging. They are classified into periventricular hyperintensity (PVH) and deep white matter hyperintensity (DWMH), and the former is more closely involved in cognitive decline than the latter. In the SPRINT MIND trial which examined the significance of intensive blood pressure control, WML volume increased by 0.28 cm3 for 4years in the intensive treatment group whereas by 0.92 cm3 in the standard treatment group, indicating 70% suppression of WML expansion. We quantitatively assessed WML volume in patients with vascular dementia and Alzheimer disease, and as expected, both PVH DWMH were significantly larger in vascular dementia than in Alzheimer disease. The mechanisms for CMBs are not fully understood but may be secondary to blood-brain barrier damages from long-standing hypertension, or alternatively, amyloid deposition in the tissue. In our previous study, we investigated degree of SVD changes using hypertensive arteriopathy SVD (HA SVD) and cerebral amyloid angiopathy SVD (CAA SVD) scores. With the analysis of SVD scores in 53 subjects with CMBs admixed with lobar and deep distributions, mixed CMBs were mainly caused by HA. These neuroimaging markers are crucial for management of hypertension. Small subcortical stroke (SPS3) trial which enrolled patients with symptomatic lacunar infarctions, were divided into two groups: those with a systolic blood pressure target between 130 and 149 mm Hg and those with less than 130 mm Hg. There was no significant difference in the frequency of all strokes, the rate of intracerebral hemorrhage was significantly lower in the group with intensive blood pressure control. This SPS3 trial revealed that a systolic blood pressure target of less than 130 mm Hg is beneficial in reducing risk in lacunar stroke patients. Thus, we overview brain imaging markers in hypertensive patients and their significance for the management of SVD.

Risk factors related to early neurological deterioration in lacunar stroke and its influence on functional outcome.

To identify risk factors for early neurological deterioration (END) in acute lacunar stroke patients and its influence on functional outcome. Consecutive acute lacunar stroke patients defined by magnetic resonance imaging (MRI) between January 2018 and June 2020 were included in the study. END was defined as any persisting increase in National Institutes of Health Stroke Scale (NIHSS) score of ⩾ 2 points post admission, and favorable outcome was defined as a modified Rankin Scale (mRS) of 0-2 at discharge. Univariable and multivariable logistic regression were performed to identify risk factors related to END, as well as the influence of END on functional outcome. Among a total of 638 lacunar stroke patients (420 males (65.8%), median age 66 years (interquartile range (IQR): 56-74)), 108 (16.9%) developed END, and 94.4% (102/108) of the END occurred within 72 h post admission. Admission NIHSS score (adjusted odds ratio (aOR) 1.132, 95% confidence interval (CI) 1.046-1.225, p = 0.002), female (aOR 2.752, 95% CI 1.277-5.933, p = 0.010), admission systolic blood pressure (SBP) (160-179 mm Hg) (aOR 9.395, 95% CI 4.310-20.479, p < 0.001) and admission SBP (⩾180 mm Hg) (aOR 16.030, 95% CI 5.991-42.891, p < 0.001) were significantly associated with END. Delay time from onset to admission (aOR 0.995, 95% CI 0.990-1.000, p = 0.031), SBP dropping (⩾20 mm Hg) within 3 days or when END occurred (aOR 0.037, 95% CI 0.016-0.086, p < 0.001) and thalamic lacunar infarction (aOR 0.098, 95% CI 0.012-0.827, p = 0.033) were inversely associated with END. END (aOR 12.374, 95% CI 6.881-22.254, p < 0.001) and higher admission NIHSS score (aOR 1.488, 95% CI 1.359-1.629, p < 0.001) predicted unfavorable outcome at discharge. END in lacunar stroke patients is common and is associated with unfavorable outcome. Admission high SBP is a potentially modifiable risk factor for prevention of END, but this needs further investigation.

Transcranial Doppler assessment of patients with cerebral small vessel disease

BackgroundCerebral small vessel disease (SVD) is associated with acute events such as lacunar and hemorrhagic strokes, or chronic events such as cognitive deficit in the form of subcortical dementia, mood deficit in the form of late onset depression, sphincteric affection, and gait apraxia. Under conditions of moderate blood flow deficit, the inability of sclerotic vessels to dilate due to impairment of the cerebral autoregulation, renders the periventricular white matter seriously ischemic. Therefore, it is important to detect the implications of cerebral large artery disease on the severity of SVD, and the ability of transcranial duplex (TCD) to evaluate it in people at risk.MethodsFifty lacunar stroke patients were recruited, and evaluated using MRI brain to assess SVD score, carotid duplex and TCD to assess extracranial and intracranial stenoses, respectively.ResultsBoth intracranial and extracranial stenoses showed significant relation to the severity of cerebral SVD. Moreover, there were significant relation between intracranial stenosis and presence of lacuna and EPVS.ConclusionCerebral large artery disease contributes to the pathogenesis and severity of cerebral SVD. Therefore, TCD may be a useful tool for the prediction of occurrence of cerebral SVD in high-risk individuals, especially hypertensives.

Heterogeneity of White Matter Hyperintensity and Cognitive Impairment in Patients with Acute Lacunar Stroke.

The severity of white matter hyperintensity (WMH) in patients with acute lacunar stroke (ALS) may be not completely parallel to cognitive impairment. Controversies persist about the effects of WMH on cognitive dysfunction. It is vital to explore whether the association may be affected by certain factors and whether a subsequent subgroup analysis is necessary. The aim of this study was to evaluate the relationship between WMH and cognitive impairment in acute lacunar stroke patients and the possible causal factors. We continuously enrolled patients with ALS who were hospitalized at the First Affiliated Hospital of Soochow University between October 2017 and June 2022. The cognitive function of all patients was assessed by using the Montreal Cognitive Assessment (MoCA) scale 14 ± 2 days after the onset of AIS, and the results were adjusted to the education level. The MoCA scale was reevaluated at the 6-month (day 182 ± 7) follow-up by outpatient visit or video. Demographic and clinical data were collected. The manifestations of chronic cerebral small-vessel disease (CSVD), including the total Fazekas score and total CSVD burden score, were assessed with an MRI scan. A mismatch refers to an inconsistency between the severity of WMH and cognitive dysfunction. A Type 1 mismatch refers to cognitive impairment with mild WMH (total Fazekas score = 0-1), and a Type 2 mismatch refers to severe WMH (total Fazekas score = 5-6) in patients with normal cognitive function. Among 213 enrolled ALS patients, 66 patients (31.0%) had cognitive dysfunction, and 40 patients (18.8%) had mismatches. Twenty-seven cases (12.7%) were Type 1 mismatched, and seventeen cases (8.0%) were Type 2 mismatched. Age, gender, fibrinogen and cerebral infarction history were independent risk factors for cognitive impairment in ALS patients. Imaging features, including moderate to severe WMH, deep WMH and the total CSVD burden score, were also independently associated with cognitive impairment. The patients in the mismatched group were older, had more severe deep WMH and had a higher occurrence of depression (p &lt; 0.05). The NIHSS score, depression and microbleeds were significantly different between the Type 1 mismatched group and the matched group (p = 0.018, p = 0.012 and p = 0.047). Patients in the Type 2 mismatched group were male (p = 0.04), had a lower level of fibrinogen (p = 0.005), a lower incidence of CMBs (p = 0.003), a lower total CSVD burden score (p = 0.017), more severe paraventricular WMH (p = 0.035) and milder deep WMH (p = 0.026). Our study examined a homogeneous study cohort of recruited patients with symptomatic ALS. We found heterogeneity between WMH and cognitive function in ALS patients. Despite a similar WMH severity, some baseline clinical features and other conventional CSVD imaging characteristics may account for this heterogeneity phenomenon. Our findings provide data for the early diagnosis and prevention of cognitive impairment in ALS patients and suggest that the severity of WMH is not completely parallel to cognitive impairment. The white matter microstructural injury and remote WMH effects may account for the mismatch phenomenon. More attention should be paid to understanding the underlying mechanisms and finding new imaging markers.

Increase in repulsive guidance molecule-a (RGMa) in lacunar and cortical stroke patients is related to the severity of the insult

Repulsive guidance molecule-a (RGMa) inhibits angiogenesis and increases inflammation. Animal models of cerebral ischemia have shown that an increased expression of RGMa leads to larger infarction and its inhibition attenuates effects of ischemia. We report on the relationship of RGMa to stroke types and severity. This is a prospective study in patients admitted to the stroke service in Qatar. We collected the clinical determinants, including NIHSS at admission, imaging and outcome at discharge and 90-days. RGMa levels were determined by measuring mRNA levels extracted from peripheral blood mononuclear cells (PBMCs) within 24 h of onset and at 5 days. There were 90 patients (lacunar: 64, cortical: 26) and 35 age-matched controls. RGMa mRNA levels were significantly higher in the stroke patients: day 1: 1.007 ± 0.13 versus 2.152 ± 0.19 [p < 0.001] and day-5: 3.939 ± 0.36 [p < 0.0001]) and significantly higher in patients with severe stroke (NIHSS ≥ 8) compared to milder symptoms (NIHSS < 8) at day 1 (NIHSS ≥ 8: 2.563 ± 0.36; NIHSS < 8: 1.947 ± 0.2) and day 5 (NIHSS ≥ 8: 5.25 ± 0.62; NIHSS < 8: 3.259 ± 0.419). Cortical stroke patients had marginally higher RGMa mRNA levels compared to lacunar stroke at day 1 (cortical stroke: 2.621 ± 0.46 vs lacunar stroke: 1.961 ± 0.19) and day 5 (cortical stroke: 4.295 ± 0.76 vs lacunar stroke: 3.774 ± 0.39). In conclusion, there is an increase in the level of RGMa mRNA in patients with acute stroke and seen in patients with lacunar and cortical stroke. The increase in RGMa mRNA levels is related to the severity of the stroke and increases over the initial 5 days. Further studies are required to determine the effects of the increase in RGMa on stroke recovery.

A Retrospective Study of Lacunar Stroke Cases in University Malaya Medical Centre (UMMC) According to Age and Gender

Worldwide, stroke was ranked as the second commonest cause of death and the third most common cause of disability-adjusted life-years. Lacunar stroke is one type of stroke. The aim of this study is to determine the dependability of gender differences in lacunar stroke epidemiology on patient age as the influence of gender on stroke risk and outcome changes across the lifespan. Thus, this study was to identify age, and gender differences among lacunar stroke patients at University Malaya Medical Centre (UMMC). This study was conducted retrospectively from January 2016 to December 2019 in UMMC. Patients were selected based on inclusion and exclusion criteria. The inclusion criteria include a clinical diagnosis of lacunar stroke, age categories of middle age (40 – 59 years old) and older age (60 years and above), as well as undergo CT examination. The exclusion criterion is other than lacunar stroke patients. Patient’s data on gender and age were retrieved from the database PACS of UMMC. The analyzation includes cross tabulation of categorical data and independent t-test. Among 94 cases, higher cases of lacunar stroke are found to occur in men (58.51%). Furthermore, both middle age (13.83%) and older age (44.68%) among male patient shows higher percentage of lacunar incidence compared to female patients. Moreover, old age patients (76.60%) for each gender shows higher percentage of lacunar incidence compared to middle-aged patients (23.30%). Meanwhile the independent t-test result demonstrated that the mean age of female patients (67.79) diagnosed with lacunar stroke is not statistically different from the mean age of male patients (68.47). The study indicated that lacunar stroke is most likely to occur in men either at age 40 or 60 and above. Higher cases were recorded in older category which is at age 60 and above for both genders.

Clinical Utility of the Transthoracic Echocardiogram for Isolated Lacunar Infarcts: A Single-Center Experience.

Stroke is a prominent and financially burdensome disease. Lacunar strokes are traditionally attributed to small vessel disease rather than cardioemboli, which typically occlude larger arteries. Thus, the benefit of screening for potential sources of cardioemboli in lacunar stroke patients is unclear. We evaluated the clinical utility of the transthoracic echocardiogram performed in patients with lacunar strokes. A single-center retrospective analysis of ischemic stroke patients from January 2013 through December 2017 was performed. Brain magnetic resonance imaging was used to select patients with a single lacunar infarct. Patients presenting with acute symptoms of cardiac disease or an abnormal electrocardiogram were excluded. Transthoracic echocardiogram results were reviewed, and their utility in decision-making was evaluated. Of the 442 patients at our institution diagnosed with ischemic stroke during the inclusion period, 89 met inclusion criteria. Transthoracic echocardiogram detected a patent foramen ovale in 5.6% of patients, mitral annular calcification in 9.0% of patients, and abnormal wall motion in 4.5% of patients. For all patients, there were no findings that prompted anticoagulation, antibiotic, or surgical intervention. The cost of an inpatient transthoracic echocardiogram is $4100, resulting in $364,900 in unnecessary health care spending. Transthoracic echocardiogram appears to have minimal therapeutic value in most patients with lacunar strokes. In stroke patients with no acute symptoms of cardiac disease and a normal electrocardiogram, it may be reasonable to forgo the transthoracic echocardiogram if the brain magnetic resonance imaging shows an isolated lacunar infarct.

The Relationship Between Renal Function and Imaging Markers and Total Burden of Cerebral Small Vessel Disease.

Previous studies demonstrating the association between renal functions and cerebral small vessel diseases have usually focused on white matter hyperintensity in the general population or lacunar stroke patients. This study aimed to investigate the effects of renal function on imaging markers of cerebral small vessel disease and etiologic subtypes of stroke in patients with acute ischemic stroke or transient ischemic attack. A total of 356 consecutive patients with acute ischemic stroke or transient ischemic attack who were admitted to the Stroke Unit and underwent brain magnetic resonance imaging were evaluated. Demographic data, vascular risk factors, stroke etiology, estimated glomerular filtration rate and severity of cerebral small vessel disease markers, and total cerebral small vessel disease burden were evaluated. There was a significant inverse correlation between estimated glomerular filtration rate and total number of lacunes, periventricular and deep subcortical Fazekas scores, grade of enlarged perivascular spaces in the centrum semiovale, lobar and total cerebral microbleeds, and total cerebral small vessel disease burden. Impaired renal function was an independent risk factor for the presence of lacunes, deep cerebral microbleeds, and increased total burden. Renal function impairment and periventricular white matter hyperintensities were significantly associated with the etiologic subgroup of small vessel occlusion. The results were still significant after the exclusion of patients below 50 years of age. Our results indicate that there is a relationship between renal function impairment and increased total burden, as well as acute ischemic stroke/transient ischemic attack due to small vessel occlusion.

Prevalence and Clinical Characteristics of Lacunar Stroke: A Hospital-Based Study.

Lacunar stroke (LS) is responsible for one-quarter of the overall number of ischemic strokes with long-term complications and carries health and economic issues for patients and health care systems. Therefore, we aimed to investigate lacunar versus non-lacunar strokes in a tertiary academic center. From February 2016 to July 2019, all patients admitted to the stroke unit were retrospectively reviewed. We included LS patients and compared them to other TOAST subtypes. Hemorrhagic stroke and conditions mimicking stroke were excluded. Regression analysis was done to determine LS predictors and outcomes. A 35.5% rate of LS among 989 ischemic stroke patients was found. Most patients (71.9%) were males. Lower National Institutes of Health Stroke Scale (NIHSS) scores at admission and negative history for cardiac diseases were predictors for LS in our population. At discharge, LS patients had low NIHSS scores and shorter hospitalization periods compared to non-LS patients. In conclusion, LS was prevalent among ischemic stroke patients in our cohort. Future studies are highly needed with long follow-up intervals to identify the stroke recurrence, complications, and outcomes.

Atrial fibrosis in embolic stroke of undetermined source: A multicenter study.

Left atrial (LA) cardiac disease is a suspected cause of embolic stroke of undetermined source (ESUS). We tested the hypothesis that LA fibrosis, quantified using late-gadolinium-enhancement magnetic resonance imaging (LGE-MRI), predicts recurrent stroke or atrial fibrillation (AF) in patients with ESUS. We compared atrial fibrosis in healthy controls and patients with lacunar stroke, ESUS, and known AF with or without prior stroke. We followed patients with ESUS prospectively for the primary outcome of recurrent ischemic stroke, incident AF, or both. We enrolled 203 patients from three centers: 103 patients without AF (35healthy controls, 15 with lacunar strokes, 53 with ESUS) and 100 patients with AF (50 with and 50 without prior stroke). Patients with ESUS had significantly higher atrial fibrosis (15.0±6.2%) compared to healthy controls (8.1±7.9%; <0.0001) and compared to lacunar stroke patients (10.8±8.4; p=0.02), but had comparable fibrosis to patients with AF with (17.9±11.4%) or without prior stroke (16.6±9.2%; p=NS for both). Over a mean follow-up of 19months, nine of 53 patients (16.9%) with ESUS experienced the combined primary outcome, which included six patients (11.3%) with recurrent ischemic stroke and five patients with incident AF (9.4%). Patients with ESUS with fibrosis ≥12% had a higher proportion of the combined outcome: 25.0% vs. 4.8%; p=0.039. Patients with ESUS demonstrate atrial fibrosis comparable to that seen in AF. Atrial fibrosis ≥12% was associated with recurrent stroke, incident AF or both. This subgroup of ESUS patients may benefit from anticoagulation for secondary prevention of ischemic stroke.