Factors associated with occurrence of large vessel and lacunar cerebral infarctions

Homogeneity of large and small vessel disease over time: Arguments from a study on recurrent stroke in 998 patients with first cerebral infarct

BACKGROUND

Data on subtype and location of recurrent stroke after a first cerebral infarct may be relevant for prognosis and for understanding progression of the vascular disease underlying stroke subtypes over time. Therefore, we studied 30-day case fatality, stroke subtype, and stroke location in first and recurrent stroke, accounting for stroke subtype.

METHODS

We conducted a cross-sectional follow-up of 998 patients with first cerebral infarct registered in a hospital-based stroke registry.

RESULTS

After a follow-up of 691 +/- 521 (SD) days, there were 138 (13.8%) first recurrent strokes, 84 (61%) of which had computed tomography. Recurrent stroke was of the same subtype as the first stroke in 27 (57%) of 339 lacunar, 38 (83%) of 435 atherothrombotic, and 33 (94%) of 224 cardioembolic cerebral infarcts. The annual stroke recurrence rate was about 7% for the whole group. Logistic regression analysis showed lacunar first stroke and hypertension as independent predictors for recurrent lacunar stroke, and atherothrombotic first stroke type for recurrent atherothrombotic stroke. Stroke recurrences that were of the same type as the first stroke occurred in the same brain area as the first stroke in 70% of lacunar and 79% of atherothrombotic cases. This was more frequent when compared with nonsimilar recurrence types: odds ratio (OR) 4.38, 95% confidence interval (CI) 1.09-15.79; and OR 5.63, 95% CI 1.38-22.92, respectively. Only 33% of cardioembolic recurrent strokes occurred in the same area. The 30-day case fatality in index and recurrent stroke was, respectively, 2% and 14% (OR 7.90, 95% CI 2.78-22.48) for lacunar, 10% and 26% (OR 3.27, 95% CI 1.62-6.60) for atherothrombotic, and 23% and 31% (OR 1.47, 95% CI 0.55-3.93) for cardioembolic index infarcts.

CONCLUSIONS

The annual stroke recurrence rate after a first brain infarcts is about 7%. Early case fatality after recurrent stroke is higher than after first stroke, with marked differences between stroke subtypes. Progression of small and large vessel disease, and the brain area of their location, are rather homogeneous over time.

Differentiation of acute cortical and subcortical ischemic stroke by risk factors and clinical examination findings

BACKGROUND

Differentiation between acute cortical and subcortical ischemic stroke may be problematic when cortical stroke presents without obvious cortical deficits such as aphasia, neglect or hemianopia. This study explores stroke risk factors and clinical variables that may assist in this differentiation.

METHODS

Records of consecutive patients with acute ischemic stroke, examined within 72 h of symptom onset, were reviewed. Stroke type was verified by clinical course and follow-up imaging. Stroke risk factors and acute examination findings were compared by odds ratios and positive predictive values for cortical and subcortical stroke.

RESULTS

For 355 patients studied, 237 had cortical stroke and 118 had subcortical stroke. Odds ratios for cortical stroke were highest for atrial fibrillation by EKG (OR = 4.77, CI = 2.08-10.94), recent hospitalization (OR = 4.51, CI = 2.39-8.53) and nonalert mental status (OR = 4.50, CI = 2.29-8.87). Possible cardioembolic condition, ischemic heart disease and peripheral vascular disease were also significant, but hypertension, age and diabetes mellitus were not significantly different for the stroke subtypes. Cortical deficits were absent in 19.4% of cortical stroke patients on initial examination. Predictive models were generated based on the presence or absence of cortical deficits and the interaction of significant risk factors with degree of motor deficit.

CONCLUSIONS

There are clinical features that, in addition to initial examination, may help differentiate cortical from subcortical ischemic stroke. These features may be relevant to both diagnostic and therapeutic approaches to acute stroke.