Recurrent lacunar infarction following a previous lacunar stroke: a clinical study of 122 patients

Pure motor stroke as the most frequent lacunar syndrome: A clinical update

Pure motor stroke (PMS), also known as pure motor hemiparesis, is the most common of any lacunar form (between one half and two thirds of cases, depending on the series). In an acute stroke registry, 733 patients presented a lacunar infarct and PMS accounted for 12.7% (n = 342) of all first-ever stroke patients and for 48% of all lacunar syndromes. The posterior limb of the internal capsule, corona radiata, and pons are the most frequent brain topographies. Infarcts in the mesencephalus or medullary pyramid have been exceptionally reported. This present update is focused on the clinical evidence and mechanisms underlying the relationship between PMS and different stroke etiologies.

Relevance of stroke subtype in vascular risk prediction

OBJECTIVE

To ascertain the risk of a new vascular event (NVE) occurring after ischemic stroke and evaluate differences in risk based on stroke subtype.

METHODS

This was a prospective observational study of consecutive patients with nonfatal stroke recruited at a single tertiary stroke center with follow-up ranging from 2 to 5 years (average, 31 ± 15.9 months). An NVE (vascular death, nonfatal stroke or myocardial infarction, and hospitalization for other atherothrombotic events) was defined according to criteria used in a previously developed large multicenter register of atherothrombotic patients (Reduction of Atherothrombosis for Continued Health Registry [REACH]). We analyzed age, sex, and atherosclerotic burden (AB) based on a number of vascular risk factors, affected vascular areas, and stroke subtype according to Stop Stroke Study Trial of Org 10172 in acute stroke treatment (SSS-TOAST) criteria in cardioaortic, large artery atherosclerosis (LAA), unclassified (more than one causal mechanism), small-artery disease (SAD), and undetermined (without cause) stroke categories.

RESULTS

The final cohort consisted of 748 patients. An NVE occurred in 162 patients (21.7%), equivalent to a rate of 0.084 events per patient/year. Multivariate analysis revealed that higher NVE risk was associated with AB and 3 stroke subtypes, namely cardioaortic (hazard ratio [HR] = 2.58; 95% confidence interval [CI] 1.27-5.22), LAA (HR = 4.17; 95% CI 2.03-8.56), and unclassified (HR = 5.70; 95% CI 2.49-13.08). Patients with SAD or stroke of undetermined cause had lower NVE risk.

CONCLUSIONS

Patients who survive stroke are at increased risk for NVEs. The risk for NVE varies according to stroke subtype.

[Relapsing non-traumatic intracerebral hemorrhage: study of 28 patients]

BACKGROUND AND OBJECTIVE

To characterize the clinical factors and prognosis and identify determinants of hemorrhage recurrence (HCR) in patients with acute non-traumatic intracerebral hemorrhage.

PATIENTS AND METHOD

Stroke patterns were studied in 28 consecutive recurrent non-traumatic intracerebral hemorrhage patients admitted to the Department of Neurology of the Sagrat Cor Hospital of Barcelona for a 19 year period. Demographic, risk factors, clinical, neuroimaging and outcome variables were analyzed and compared with patients with first-ever non-traumatic intracerebral hemorrhage (n=380) to identify predictors of hemorrhage recurrence. Significant variables were entered into a multivariate logistic regression analysis.

RESULTS

HCR accounted for 6.8% of all patients with acute consecutive non-traumatic intracerebral hemorrhages. The HCR were mostly lobar (67.9%). Other topographies include: thalamus (10.7%), capsule-ganglionar (7.1%), intraventricular (3.6%) and multiple topographies (10.7%). Although the HCR have poor prognosis, it is not worse compared to the first-ever intracerebral hemorrhages, both at the high hospital mortality (17.9 vs. 28.2%) as the low frequency of absence of limitation at discharge (3.6 vs. 6.1%). The clinical profile significantly associated with HCR was: valvular heart disease (odds ratio [OR] 5.32; 95% confidence interval [95% CI] 1.45-19.47), lobar topography (OR 3.53, 95% IC 1.53-8.13), and the presence of nausea and vomiting (OR 2.43, 95% IC 1.06-5.52).

CONCLUSIONS

HCR constitute less than one tenth of non-traumatic intracerebral hemorrhages and are most commonly located in the brain lobes. Although the prognosis is serious, this is no worse during the acute phase, than of the first-ever non-traumatic intracerebral hemorrhages. Clinical profiles were different in recurrent non-traumatic intracerebral hemorrhage patients when compared to first-ever non-traumatic intracerebral hemorrhage patients.

Pure sensory syndromes and post-stroke pain secondary to bilateral thalamic lacunar infarcts: a case report

Introduction

Patients often complain about sensory symptoms that appear to the doctor as harmless, and reassurances are often given. Sensory strokes may easily be ignored.

Case presentation

A 48-year-old Caucasian woman with insulin-dependent diabetes and hyperlipidemia experienced symptoms that progressed within hours to a complete left-sided hemisensory syndrome. This was caused by a lacunar infarct in the ventral posterior tier nuclei of the right thalamus. A few days later she gradually developed an almost identical, but incomplete hemisensory syndrome on the opposite side caused by a corresponding lacune in the left thalamus. Severe persistent and paroxysmal pain on both sides of the body became disabling.

Conclusion

Small strokes only affecting the somatosensory system should not be underestimated. Neuropathic pain may result. Probably unique in the present case is the demonstration of bilateral thalamic pain secondary to two almost identical thalamic infarcts. Small vessel disease (microatheroma or lipohyalinosis) was the most likely cause of the lacunes. One can only speculate if there was an occlusion in two separate thalamic perforators, or in a single dominant artery supplying the bilateral thalami.

Small vessel cerebrovascular disease: the past, present, and future

Brain infarction due to small vessel cerebrovascular disease (SVCD)-also known as small vessel infarct (SVI) or "lacunar" stroke-accounts for 20% to 25% of all ischemic strokes. Historically, SVIs have been associated with a favorable short-term prognosis. However, studies over the years have demonstrated that SVCD/SVI is perhaps a more complex and less benign phenomenon than generally presumed. The currently employed diagnostic and therapeutic strategies are based upon historical and contemporary perceptions of SVCD/SVI. What is discovered in the future will unmask the true countenance of SVCD/SVI and help furnish more accurate prognostication schemes and effective treatments for this condition. This paper is an overview of SVCD/SVI with respect to the discoveries of the past, what is known now, and what will the ongoing investigations evince in the future.

Arterial hypertension, cerebrovascular diseases and dementia

Arterial hypertension (AH) is the most relevant risk factor for acute cerebrovascular disease in general. However, the prevalence of AH is not the same for the different stroke subtypes and is particularly high in lacunar infarcts and atherothrombotic stroke, low in infarcts of unusual cause and undetermined origin, and intermediate in cardioembolic stroke. This risk factor has also been related to vascular dementia and Alzheimer’s disease and their pathological manifestations (senile plaques, neurofibrillary tangles, hippocampal atrophy). The mechanisms linking AH to Alzheimer’s disease remain to be elucidated but some recent studies showed that white matter lesions seen on cerebral magnetic resonance imaging appear to be a good marker of this association. Hypertension-associated pathological changes in the brain and its vasculature include vascular remodelling and impaired cerebral autoregulation like hypoperfusion, ischemia and hypoxia, which may initiate the pathological process of Alzheimer’s disease and the expression of dementia. Therefore, prompt diagnosis and adequate control of hypertension and different vascular risk factors are the rational basis for a more effective strategy in the secondary prevention of cerebrovascular disease and dementia.

[Recurrent ischemic stroke. Study of 605 patients]

BACKGROUND AND OBJECTIVES

To characterize the clinical factors and prognosis and identify determinants of ischemic stroke recurrence in acute stroke.

PATIENTS AND METHODS

Recurrent stroke patterns were studied in 605 consecutive patients admitted with a second or further ischemic stroke to the Department of Neurology of the Sagrat Cor Hospital of Barcelona over a 17 year period. Demographic, risk factors, clinical, neuroimaging and outcome variables were analyzed and compared with patients with first-ever cerebral infarction (n=2.099) to identify predictors of ischemic recurrent stroke. Significant variables were entered into a multivariate logistic regression analysis.

RESULTS

Ischemic recurrent strokes accounted for 22.4% of all acute consecutive ischemic strokes. Frequency of ischemic stroke recurrence were significantly different among ischemic stroke subtypes: 26.2% in atherothrombotic, 24.4% in cardioembolic, 21.8% in lacunar stroke, 15.8% in infarcts of unusual etiology and 12% infarctions of uncertain etiology. The overall in-hospital mortality and symptom free at discharge in recurrent vs. non-recurrent stroke patients rate was 16.2 vs. 12% (p=0.005) and 17.8 vs. 27.3% (p=0.0001) respectively. Previous intracerebral hemorrhage (OR=3.07; 95% CI, 1.51-6.25), intermittent claudication (OR=1.39; 95% CI, 1.01-1.90), arterial hypertension (OR=1.32; 95% CI, 1.09-1.59), diabetes mellitus (OR=1.26; 95% CI, 1.02-1.56), age (OR=1.02; 95% CI, 1.01-1.03), female gender (OR=0.63; 95% CI, 0.52-0.77), headache (OR=0.62; 95% CI, 0.44-0.87) and bulbar topography (OR=0.21; 95% CI, 0.05-0.89) were independent clinical variables related to ischemic stroke recurrence.

CONCLUSIONS

About one in every four patients with ischemic stroke had an ischemic stroke recurrence. In-hospital mortality is 16.2% and clinical profiles were different in ischemic stroke recurrence when compared to first-ever ischemic stroke patients.

Is investigating for carotid artery disease warranted in non-cortical lacunar infarction?

Carotid intervention in severe carotid stenosis after an anterior circulation ischemic event reduces the risk of further infarcts if the surgery is performed soon after the incident event. At present, there is no recommendation to differentiate among subtypes of anterior circulation infarcts or transient ischemic events. However, evidence is mounting that demonstrates a difference in pathophysiology of lacunar and nonlacunar (large artery) infarcts. The natural history of lacunar strokes is different from large artery infarcts for recurrence and mortality. Stroke is a heterogenous disease and consideration needs to be directed to manage different stroke subtypes differently. Lacunar infarcts mostly do not arise from large artery atheromatous disease or by cardioembolic phenomena, and there is a negative predictive value for severe carotid stenosis in lacunar strokes. Thus, current evidence suggests that lacunar strokes may not warrant investigation for carotid stenosis.

Clinicoradiological features of recurrent ischemic stroke: healthcare for poststroke patients

OBJECTIVE

Little is known about recurrent risk profile of brain infarct (BI) in Japan. The study aimed to clarify clinicoradiological features of recurrent BI patients.

METHODS

374 consecutive BI patients (231 men and 143 women) were admitted to our department between 2007 and 2008. Recurrent BI was defined as a prior history of BI. Cardiovascular disease (CVD) risk profile, stroke mechanism subtypes and Bamford subtypes were compared between the first BI and the recurrent BI group. CVD risk factors, stroke subtypes of the first BI and preventative medication were analyzed in recurrent BI patients.

RESULTS

Recurrent BI existed in 72 patients (40 men and 32 women). Age of the recurrent BI group was significantly older than the first BI group (P < 0.01). In comparison to the first BI group, the recurrent BI group had a high frequency of hypertension (P < 0.01) and CVD comorbidity (P < 0.05). Recurrent rates were increased significantly in cardioembolic patients as compared to the first BI patients (P < 0.05). Bamford BI subtypes did not differ between both groups. Mean recurrent interval (SD) was 3.1 (2.3) years. Approximately half the patients experienced recurrent BI less than 2 years after the first BI. Antiplatelet agents were used in 33 patients and warfarin was used in 12 patients as preventative medication. The remaining 27 patients had no prevention therapy by self-cessation. Nine warfarin users were controlled poorly. There were no significant correlations between the first and recurrent Bamford subtypes in recurrent BI patients.

CONCLUSIONS

The present study indicated that the recurrent frequency of BI was 19.3%. Causative profile of recurrent BI suggested elderly age (≥65 years), hypertension, prior history of CVD, cardioembolism, 2 years poststroke, insufficient treatment of warfarin and self-cessation of preventative medication. Thus, physicians should pay more attention to these aspects for prophylaxis of recurrent BI in poststroke patients.

Pretreatment with statins improves early outcome in patients with first-ever ischaemic stroke: a pleiotropic effect of statins or a beneficial effect of hypercholesterolemia?

Background

Data from different studies suggest a favourable association between pretreatment with statins or hypercholesterolemia and outcome after ischaemic stroke. We examined whether there were differences in in-hospital mortality according to the presence or absence of statin therapy in a large population of first-ever ischaemic stroke patients and assessed the influence of statins upon early death and spontaneous neurological recovery.

Methods

In 2,082 consecutive patients with first-ever ischaemic stroke collected from a prospective hospital-based stroke registry during a period of 19 years (1986-2004), statin use or hypercholesterolemia before stroke was documented in 381 patients. On the other hand, favourable outcome defined as grades 0-2 in the modified Rankin scale was recorded in 382 patients.

Results

Early outcome was better in the presence of statin therapy or hypercholesterolemia (cholesterol levels were not measured) with significant differences between the groups with and without pretreatment with statins in in-hospital mortality (6% vs 13.3%, P = 0.001) and symptom-free (22% vs 17.5%, P = 0.025) and severe functional limitation (6.6% vs 11.5%, P = 0.002) at hospital discharge, as well as lower rates of infectious respiratory complications during hospitalization. In the logistic regression model, statin therapy was the only variable inversely associated with in-hospital death (odds ratio 0.57) and directly associated with favourable outcome (odds ratio 1.32).

Conclusions

Use of statins or hypercholesterolemia before first-ever ischaemic stroke was associated with better early outcome with a reduced mortality during hospitalization and neurological disability at hospital discharge. However, statin therapy may increase the risk of intracerebral haemorrhage, particularly in the setting of thrombolysis.

Stroke prognosis in diabetes mellitus: new insights but questions remain

Diabetes is not only an independent risk factor for lacunar infarction, especially in patients with multiple lacunar infarcts, but the presence of diabetes is also associated with worse functional recovery in these patients.

Lacunar stroke

Lacunar infarcts or small subcortical infarcts result from occlusion of a single penetrating artery and account for one quarter of cerebral infarctions. Patients with a lacunar infarct usually present with a classical lacunar syndrome (pure motor hemiparesis, pure sensory syndrome, sensorimotor stroke, ataxic hemiparesis or dysarthria-clumsy hand) and, less frequently, an atypical lacunar syndrome. Hypertension and diabetes mellitus are major risk factors for lacunar stroke. Lacunar infarcts show a paradoxical clinical course with a favorable prognosis in the short term, characterized by a low early mortality and reduced functional disability on hospital discharge, but with an increased risk of death, stroke recurrence and dementia in the mid- and long term. Asymptomatic progression of small-vessel disease is a typical feature of the lacunar infarcts. For this reason, lacunar infarction should be regarded as a potentially severe condition rather than a relatively benign disorder and, therefore, lacunar stroke patients require adequate and rigorous management and follow-up. Antiplatelet drugs, careful blood pressure control, the use of statins and modification of lifestyle risk factors are key elements in secondary prevention after lacunar stroke.

The Relationship Between Baseline Blood Pressure and Computed Tomography Findings in Acute Stroke

Background and Purpose— High blood pressure (BP) is present in ≈80% of patients with acute ischemic stroke and is independently associated with poor outcome. There are few data examining the relationship between admission BP and acute CT findings.

Methods— TAIST was a randomized controlled trial assessing 10 days of treatment with tinzaparin versus aspirin in 1489 patients with acute ischemic stroke (<48 hr) with admission BP of ≤220/120 mmHg. CT brain scans were performed before randomization and after 10 days. The relationships between baseline BP and adjudicated CT findings were assessed. Odds ratios per 10 mmHg change in BP were calculated.

Results— Higher systolic BP (SBP) was associated with abnormal CT scans because of independent associations with chronic changes of leukoariosis (OR, 1.12; 95% CI, 1.05–1.17) and old infarction (OR, 1.12; 95% CI, 1.06–1.17) at baseline, and signs of visible infarction at day 10 (OR, 1.06; 95% CI, 1.00–1.13). A lower SBP was associated with signs of acute infarction (OR, 0.94; 95% CI, 0.89–0.99). Hemorrhagic transformation, dense middle cerebral artery sign, mass effect, and cerebral edema at day 10 were not independently associated with baseline BP.

Conclusion— Although high baseline BP is independently associated with a poor outcome after stroke, this was not shown to be through an association with increased hemorrhagic transformation, cerebral edema, or mass effect; trial design may be suboptimal to detect this. Higher SBP is associated with visible infarction on day 10 scans. The influence of changing BP in acute stroke on CT findings is still to be ascertained.

On the etiology of incident brain lacunes: longitudinal observations from the LADIS study

BACKGROUND AND PURPOSE

We investigated regional differences in MRI characteristics and risk factor profiles of incident lacunes over a 3-year period.

METHODS

Baseline and 3-year follow-up MRI were collected within the LADIS study (n=358). Incident lacunes were characterized with respect to brain region, their appearance within pre-existent white matter hyperintensities (WMH), surrounding WMH size, and risk factors.

RESULTS

106 incident lacunes were observed in 62 patients (58 subcortical white matter [WM], 35 basal ganglia, and 13 infratentorial). Incident subcortical WM lacunes occurred more often within preexisting WMH (P=0.01) and were mostly accompanied by new and expanded WMH (P<0.001), compared to incident basal ganglia and infratentorial lacunes. Risk factors for incident subcortical WM lacunes were history of hypertension and stroke, whereas atrial fibrillation predicted incident basal ganglia/infratentorial lacunes.

CONCLUSIONS

Differences in relation to WMH and risk factor profiles may suggest that incident lacunes in the subcortical WM have a different pathogenesis than those in the basal ganglia and infratentorial region.