Predictors of neurologic deterioration in patients with small-vessel occlusion and infarcts in the territory of perforating arteries

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

BACKGROUND AND AIMS

Small 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 METHODS

Single 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.

RESULTS

Of 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.

CONCLUSION

Progressive 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.

Prediction of Symptoms on Admission with Early Neurological Deterioration in Single Small Subcortical Infarct

BACKGROUND

Early neurological deterioration (END) often occurs during hospitalization in single small subcortical infarct (SSSI). While, symptoms on admission were rarely reported about its performance on predicting the risk of END.

OBJECTIVES

The objective of this study is to explore the relationship between symptoms on admission and END in SSSI.

METHODS

Patients with SSSI in the lenticulostriate artery (LSA) territory presenting within 72 hours of stroke onset were screened prospectively. Clinical characteristics, including symptoms on admission, laboratory tests and imaging findings, were collected. Based on the body regions involved including spherical face (SF), upper limb (UL) or lower limb (LL), symptoms on admission were classified into single spherical face (sSF) and any involvement of limbs (AL). END was defined as ≥2 points increase in total National Institutes of Health Stroke Scale (NIHSS) score or ≥ 1 point increase in motor score within 72 hours after admission. Multivariate logistic regression was used to analyze factors associated with END.

RESULTS

Out of 5,832 ischemic stroke patients in the database, 394 patients were finally enrolled in analysis. 65 patients (16.5%) developed END. Multivariable logistic regression revealed that symptoms with LL (OR 2.337, 95% CI 1.041-5.246), UL (OR 2.936, 95% CI 1.349-6.390) were both associated with END, while the involvement of SF (OR 0.447, 95% CI 0.249-0.804) showed the opposite result. Further analysis found that symptoms with AL (OR 3.958, 95% CI 1.355-11.565) showed a higher risk of END compared to sSF after adjustment.

CONCLUSION

Our results discovered that symptoms with AL carried a higher risk of END than those involving sSF in SSSI.

Outcomes and risk factors of perforating and non-perforating middle cerebral artery infarctions after intravenous thrombolysis

The clinical symptoms of perforating arteries differ, and responses to intravenous thrombolytic therapy are heterogeneous. Here, we investigated the effect of intravenous thrombolytic therapy and the related factors influencing acute perforating and non-perforating middle cerebral artery infarctions. We analyzed 320 patients with acute middle cerebral artery infarction who received alteplase thrombolysis within 4.5 h of onset at two stroke centers from January 2016 to December 2019. Outcome measures included rates of a favorable functional outcome (modified Rankin Scale scores of 0-2), distribution of modified Rankin Scale scores, intracranial hemorrhage, and symptomatic cerebral hemorrhage at 14 days, with comparisons between perforating artery and non-perforating artery cerebral infarction groups. In the perforating vessel disease group, 12 cases (17.4%) of intracranial hemorrhage occurred, with symptomatic cerebral hemorrhage in three cases (4.3%); there were no significant differences between the perforating and non-perforating vessel disease groups (all P > 0.05). In the perforating vessel disease group, the only significant prognostic factor was the National Institutes of Health Stroke Scale score before thrombolysis (Exp(B) = 1.365; 95% confidence interval [CI] 1.124-1.659; P = 0.002), and the only significant risk factor for hemorrhagic transformation was previous perforator disease (Exp(B) = 0.078; P = 0.038). Regardless of whether an acute infarction is perforating or non-perforating, intravenous thrombolytic therapy can yield a favorable outcome. Therefore, intravenous thrombolysis should be actively administered to treat perforating artery infarctions with a high risk of disability.

Cilostazol Addition to Aspirin could not Reduce the Neurological Deterioration in TOAST Subtypes: ADS Post-Hoc Analysis

BACKGROUND

Our previous trial acute dual study (ADS) reported that dual antiplatelet therapy (DAPT) using cilostazol and aspirin did not reduce the rate of short-term neurological worsening in non-cardioembolic stroke patients. Present post-hoc analysis investigated whether the impact of combined cilostazol and aspirin differed among stroke subtypes and factors associated with neurological deterioration and/or stroke recurrence.

METHODS

Using the ADS registry, the rate of neurological deterioration, defined as clinical worsening and/or recurrent stroke, including transient ischemic attack was calculated. Stroke subtypes included large-artery atherosclerosis (LAA), small vessel occlusion (SVO), other determined etiology (Others), and undetermined etiology of stroke (Undetermined).

RESULTS

Data of 1022 patients were analyzed. Deterioration was seen in 104 (10%) patients, and the rates were not markedly different between patients treated with DAPT vs. aspirin in any stroke subtypes: LAA, 19% vs. 11%, (p=0.192); SVO, 10% vs. 10% (p=1.000); Others, 6% vs. 6% (p=1.000); Undetermined, 11% vs. 8% (p=0.590). Diabetes mellitus was the independent factor associated with deterioration (odds ratio 4.360, 95% confidence interval 1.139-16.691, p=0.032) in the LAA group. Age (1.030 [1.004-1.057], p=0.026), systolic blood pressure (1.012 [1.003-1.022], p=0.010), and infarct size (2.550 [1.488-4.371], p=0.001) were associated with deterioration in SVO group, and intracranial stenosis/occlusion was associated with it in the Undetermined group (3.744 [1.138-12.318], p=0.030).

CONCLUSIONS

Combined cilostazol and aspirin did not reduce the rate of short-term neurological deterioration in any clinical stroke subtype. The characteristics of patients whose condition deteriorates in the acute period may differ based on the stroke subtypes.

Clinical and radiological factors associated with unfavorable outcome after intravenous thrombolysis in patients with mild ischemic stroke

BACKGROUND

A significant proportion of patients with mild ischemic stroke become disabled despite receiving intravenous thrombolytic therapy. The purpose of this study was to assess the clinical and radiological factors associated with unfavorable outcomes in patients with minor ischemic stroke that received intravenous recombinant tissue plasminogen activator (rt-PA) therapy.

METHODS

We identified anterior circulation stroke patients with initial National Institutes of Health Stroke Scale (NIHSS) scores ≤5 who received intravenous thrombolysis within 4.5 h of stroke onset and had pretreatment magnetic resonance (MR)/MR angiography using our prospective stroke database. We analyzed baseline characteristics, infarction patterns on diffusion-weighted imaging (DWI), and steno-occlusive lesions on MR angiography. Unfavorable outcome was defined as a modified Rankin Scale (mRS) score ≥ 2 at 90 days. Logistic regression was used to determine independent predictors of unfavorable outcomes.

RESULTS

Among 121 patients (85 men; mean age, 63.4 ± 11.3 years) included in this study, 46 (38%) had unfavorable outcomes at 90 days and DWI lesion patterns showing infarction in the deep middle cerebral artery (MCA) territory involving the perforating artery area was observed in 47 (38.8%) patients. On multivariable analysis, unfavorable outcomes at 90 days were associated with diabetes [odds ratio (OR), 3.41; 95% confidence interval (CI), 1.06-10.9; P = 0.039), NIHSS score on admission (OR, 2.11; 95% CI, 1.35-3.30; P = 0.001), and infarction in the deep MCA territory on DWI (OR, 4.19; 95% CI, 1.63-10.8; P = 0.003). Lesions in the deep MCA territory was independently associated with early neurological deterioration (P = 0.032). The patients without deep MCA territory infarction had a higher prevalence of cardiac embolism (P = 0.009).

CONCLUSIONS

Higher NIHSS scores, diabetes, and deep MCA territory infarction may be useful for predicting unfavorable outcomes in patients with minor stroke treated with intravenous rt-PA therapy.

Predictors of clinical outcome in patients with acute perforating artery infarction

BACKGROUND AND PURPOSE

We aimed to determine the predictive factors for super-acute perforating artery infarctions (PAI) involving lenticulostriate arteries infarctions (LSAI), anterior pontine arteries infarctions (APAI) and thalamic arteries infarctions (TAI). Whether intravenous thrombolysis (iv-tPA) therapy would influence the clinical outcome was also studied.

METHODS

We analyzed 84 consecutive patients within 12h of stroke symptom onset from January 2008 to June 2015. All patients had an imaging-proven acute infarction in the perforating territory of LSA (n=53), TA (n=21) and APA (n=10). Favorable clinical outcome was defined as modified Rankin Scale ≤1 at 90days. Patients were divided into groups according to clinical outcome, lesion location and thrombolysis therapy. Baseline demographic data, past medical history, National Institutes of Health Stroke Scale (NIHSS) score and infarction volume were compared between groups.

RESULTS

Eighty-four patients were recruited (median age: 61y; 67.9% male). All patients with TAI (n=21), 34/53 (64.2%) patients with LSAI and 4/10 (40%) patients with APAI achieved favorable clinical outcome (mRS≤1). Ninety-day clinical outcome was associated with age, previous stroke, baseline NIHSS, infarct location, infarct volume. Intravenous thrombolysis improved 24h NIHSS, but was not significantly associated with favorable outcome at 90days. In multivariate analysis, only previous stroke/TIA (OR 0.09, 95%CI 0.01-0.68, p=0.020) and infarct volume (OR 0.64, 95%CI 0.43-0.96, p=0.032) were independently associated with the outcome of acute PAI at 90days.

CONCLUSIONS

Previous stroke/TIA, infarct location and infarct volume were independently associated with the short-term clinical outcome of acute PAI.