Evolution of acute lacunar lesions in terms of size and shape: a PICASSO sub-study

Association of total cerebral small vessel disease burden with the cavitation of recent small subcortical infarcts

BACKGROUND

Recent small subcortical infarcts (RSSIs) could evolve into cavitation (lacunes) or non-cavitation (white matter hyperintensities or disappearance) during the chronic period, but the factors involved remain unclear.

PURPOSE

To explore the association between total cerebral small vessel disease (CSVD) burden and lesion cavitation.

MATERIAL AND METHODS

We retrospectively selected 202 inpatients with an isolated RSSI who underwent baseline and follow-up magnetic resonance imaging (median interval = 16.6 months; interquartile range [IQR]=8.2-30.1). Inpatients were divided into cavitation and non-cavitation groups depending on whether a fluid-filled cavity formed. Data including demographic, clinical, and radiological features were collected and analyzed. To determine total CSVD burden, four imaging markers, including lacunes, microbleeds, white matter hyperintensities, and enlarged perivascular spaces, were rated and summed as a final practical score between 0 and 4.

RESULTS

Overall, 137 (67.8%) patients progressed to cavitation and 65 (32.2%) to non-cavitation. Binary multivariable regression analysis showed that the baseline total CSVD burden (P = 0.005) and infarct diameter (P = 0.002) were independent risk factors for cavitation. A severe total burden (scores of 3-4) at baseline was independently related to cavitation (P = 0.001). Moreover, the total CSVD burden score varied from 2 (IQR=1-3) at baseline to 3 (IQR=2-4) at follow-up. The extent of the increase in total burden was correlated with cavitation (r = 0.201; P = 0.004).

CONCLUSION

Total CSVD burden, both the baseline value and extent of increase, was positively associated with cavitation. RSSIs with severe total CSVD burden at baseline have a greater potential to become cavitated.

Factors Associated With the Occurrence and Evolution of Recent Small Subcortical Infarcts (RSSIs) in Different Locations

Recent small subcortical infarcts (RSSIs) can occur in different brain regions. Distinct etiologies might be involved for RSSIs in different locations and could further affect RSSI cavitation and functional outcomes. In this study, we aim to analyze the baseline clinical and imaging characteristics associated with the occurrence and cavitation of RSSIs in different locations. We retrospectively include patients who presented with RSSIs from a database for cerebral small vessel disease. Detailed information, including demographic, clinical, laboratory, and radiological data, were collected. We identify baseline RSSIs on diffusion-weighted images and divide them into brainstem, subcortical white matter, and basal ganglia region groups. Cavitation is evaluated on follow-up T2 fluid-attenuated inversion recovery (FLAIR) images. Statistical analysis is performed to determine factors associated with the occurrence and cavitation of RSSIs in different locations. We find that patients with brainstem RSSIs have a higher proportion of diabetes (64.1%) compared to patients with subcortical white matter (27.3%, P < 0.001) and basal ganglia region RSSIs (35.2%, P = 0.006) and have higher levels of HbA1c (7.20%) compared to patients with subcortical white matter (6.10%, P = 0.001) and basal ganglia region RSSIs (6.20%, P = 0.003). In addition, patients with brainstem RSSIs have higher NIHSS scores than patients with subcortical white matter RSSIs (2 vs 0, P = 0.001). Patients with subcortical white matter RSSIs have higher a white matter hyperintensity (WMH) burden compared to patients with basal ganglia region RSSIs (21.64 cm³ vs 11.10 cm³, P = 0.004). Follow-up analysis demonstrates that basal ganglia region RSSIs are less likely to cavitate than subcortical white matter RSSIs (61.4% vs 83.6%, P = 0.010), and contacting with WMH is associated with the cavitation of subcortical white matter RSSIs (OR: 101.760, P = 0.003). Our study demonstrates that RSSIs in different locations are associated with different clinical and imaging characteristics. Furthermore, cavitation of RSSIs might be affected by local lesion features and the surrounding environment rather than general demographic and clinical factors.

Cavitation of symptomatic acute single small subcortical infarctions

BACKGROUND AND PURPOSE

To investigate cavitation of symptomatic acute single small subcortical infarctions (SSSI).

METHODS

Acute SSSI were diagnosed with magnetic resonance (MR) diffusion-weighted imaging (DWI) combined with apparent diffusion coefficient (ADC) sequence on follow-up MR imaging. Cavitation of the acute SSSI was comprehensively viewed on FLAIR, T2-, and T1-weighted sequences.

RESULTS

We enrolled 123 patients with acute SSSI. The follow-up median interval was 303 (125-390) days. The lesions of SSSI evolved into cavitation in 93 patients (75.6%), evolved into WMHs in nine patients (7.3%), and were no visible in 21 patients (17.1%). Cavitation was independently associated with larger infarct diameter on baseline DWI [odds ratio (OR), 1.250, 95% CI (1.078-1.451), P = 0.003], higher score of baseline old lacunar infarct [OR 3.44, 95% CI (1.49-7.91), P = 0.004], and lower rate of dyslipidemia [OR 0.30, 95% CI (0.10-0.76), P = 0.013].

CONCLUSION

Cavitation occurred more in the setting of small vessel diseased brain and less in the SSSI of possible atherosclerotic etiology. This suggested that the etiology of infarct was associated with cavitation after acute SSSI.

Post-stroke cognitive impairment as an independent predictor of ischemic stroke recurrence: PICASSO sub-study

INTRODUCTION

To devise appropriate preventive strategies after stroke, knowledge of the association between post-stroke cognitive impairment (PSCI) and prognosis of stroke patients is important. We investigated the association between PSCI and the vascular outcomes in patients with ischemic stroke with best medical care considering their risk factors and adherence to medications.

METHODS

Of the 1534 ischemic stroke patients who randomly assigned to aspirin or cilostazol treatment with best medical therapy by the PICASSO (PreventIon of CArdiovascular events in iSchemic Stroke patients with high risk of cerebral hemOrrhage) trial, 1240 with baseline mini-mental state examination (MMSE) scores were analysed retrospectively. The patients were classified into three groups based on MMSE scores. Recurrence of ischemic stroke, stroke of any type and composite of major vascular events were compared among them.

RESULTS

Of the 1240 patients, 376 had MMSE scores of 28-30 (highest tertile), 419 had scores of 24-27 (middle tertile) and 445 had scores of 0-23 (lowest tertile). The average time from stroke onset to MMSE examination was 31.8 days. By trend analysis, lower tertile of MMSE score was significantly associated with recurrent ischemic stroke (p = 0.0017), stroke of any type (p = 0.0053) and composite vascular outcome (p = 0.0122). After adjustment for covariates, PSCI was independently associated with risk of recurrent ischemic stroke (HR 2.40, 95% confidence interval 1.12-5.14).

CONCLUSIONS

Cognitive impairment was associated with recurrence of ischemic stroke in high risk patients during adequate medical therapy including antiplatelet therapy. However, the other vascular events were not.