Acute Diffusion-Weighted Imaging Lesion Patterns Predict Progressive Small Subcortical Infarct in the Perforator Territory of the Middle Cerebral Artery

Small subcortical ischemic infarction and other DWI lesions establish predictive model for MES

Objective

The relationship between small subcortical ischemic infarction remains poorly characterized. Therefore, the present study aimed to investigate the association between artery-to-artery embolization and small subcortical infarctions.

Methods

This retrospective observational cross-sectional study enrolling 230 patients with acute middle cerebral artery (MCA) stroke classified into the microembolic signals-positive (MES+) and MES-negative (MES-) groups. The diffusion weighted imaging (DWI) infarction patterns in the MCA were divided into the territorial, border zone (BZ), cortical, and subcortical infarcts. We set the standard of small subcortical infarction (SCI) into two levels: < 10 mm diameter and <5 mm diameter. Relevant DWI parameters were used to build a nomogram for MES+, using free statistics.

Results

MES occurred in 38 of the 230 cases, yielding a positivity rate of 16.5%. BZ, SCI <10 mm, cortical ischemia (CI), stenosis, white blood cell count, and gender were compared between the MES+ and MES- groups. Multivariate analysis revealed that BZ, SCI < 10 mm, and CI were independently associated with MES. Based on DWI parameters, a nomogram model was built for MES+. The area under the curve of the model was 0.826 (95%CI 0.764 to 0.889). In internal cross-validation, the slope of the calibration curve was 1.000, indicating that the model accurately predicted unsuccessful treatment outcomes.

Conclusion

Small subcortical infarctions are associated with MES. In the present study, we built a predictive nomogram model for MES+ based on small subcortical infarctions and other DWI parameters. This model demonstrated good performance in clinical practice.

Clinical and Prognostic Characteristics of Acute BAD-Related Stroke: A Multicenter MRI-Based Prospective Study

BACKGROUND

Branch atheromatous disease (BAD)-related stroke has emerged as a meaningful subtype of ischemic stroke yet remained understudied. We aimed to investigate the demographic, clinical, therapeutic, and prognostic characteristics of BAD-related stroke.

METHODS

The BAD-study was a nationwide, multicenter, prospective, observational cohort study in 20 Chinese hospitals from June 2021 to June 2023, enrolling patients aged 18 to 80 years with BAD-related stroke within 72 hours of onset. Eligible single subcortical infarct in the territory of lenticulostriate artery and paramedian pontine artery was included. Clinical, laboratory, and treatment data were collected at baseline. The primary outcome was a proportion of good outcomes (modified Rankin Scale score, 0-2) at 90 days. Main secondary outcomes included early neurological deterioration (END), cerebrovascular event, major bleeding, and excellent outcome (modified Rankin Scale score, 0-1) during 90-day follow-up.

RESULTS

We finally enrolled 476 patients, with a median age of 60 (interquartile range, 53-68) years, and 70.2% were male. The median National Institutes of Health Stroke Scale score was 3 (interquartile range, 2-6) at enrollment. Involvement of the lenticulostriate artery was more common than the paramedian pontine artery (60.7% versus 39.3%). END occurred in 14.7% of patients, with a median time from onset of 38 (interquartile range, 22-62) hours. The rates of good and excellent outcomes were 86.5% and 72%, respectively. Its 90-day stroke recurrence rate was 1.9%. Acute-phase therapy (from onset to 7 days of enrollment) showed heterogeneity and was not associated with prognosis. Multivariable logistic regression analysis identified the National Institutes of Health Stroke Scale score ≥4 at admission and END as negative predictors and extracranial artery stenosis as a positive predictor of good outcomes. Age ≥60 years, National Institutes of Health Stroke Scale score ≥4 at admission, and END were negative predictors of excellent outcomes.

CONCLUSIONS

With distinct demographic, clinical, and prognostic characteristics, along with a high incidence of END and a low risk of stroke recurrence, BAD-related stroke could be categorized as a separate disease entity. Moreover, its acute-phase treatment strategies were undetermined, awaiting further high-quality studies.

Variants in 3p24.3 predicts the risk of early neurological deterioration in large artery atherosclerotic stroke

The rate of early neurological deterioration (END) differs in different subtypes of ischaemic stroke. Previous studies showed PLCL2 gene is a novel susceptibility locus for the occurrence of atherosclerosis and thrombotic events. The objective of this research is to examine the efficacy that PLCL2 may have on the risk of END in large artery atherosclerotic (LAA) stroke. Tagged single nucleotide polymorphisms (SNPs) were identified by a strategy of fine-mapping. The genotyping of the selected SNPs was performed by SNPscan. The impact of PLCL2 on indicating the susceptibility of END in LAA patients was evaluated by binary logistic regression. The SNP-SNP interactions of PLCL2 for END was assessed by generalized multifactor dimensionality reduction (GMDR). A total of 1527 LAA stroke patients were recruited, 582 patients (38 %) experienced END. Compared to participants without END, participants experienced END were much older (P = 0.018), more likely to suffer pre-existing diabetes mellitus (P = 0.036), higher frequent in active tobacco users (P = 0.022) and had much higher median NIHSS on admission (P < 0.001). Rs4685423 was identified to be a predictor to the risk of END: the frequency of END in AA genotype patients is lower than that in AC or CC genotype patients (multivariate-adjusted, OR 0.63; 95 % CI 0.49-0.80; P < 0.001). The SNP-SNP interactions analysis indicates rs4685423 has the greatest impacton the risk of END for LAA patients. The time from admission diagnosis to END onset in AA genotype patients is much later than that in CA or CC genotype patients (log-rank, P = 0.005). In summary, the PLCL2 rs4685423 SNP is probably associated with the END risk in LAA stroke patients.

Lesion Indexes Predict Early Neurologic Deterioration in Lenticulostriate Single Small Subcortical Infarction

BACKGROUND AND PURPOSE

Early neurologic deterioration (END) often occurs during hospitalization in single small subcortical infarction (SSSI). The objective was to identify imaging predictors of END.

MATERIALS AND METHODS

SSSIs in the lenticulostriate artery within 72 hours of stroke onset from January 2015 to June 2021 were consecutively enrolled. The posteriority and laterality indexes were assessed on the second section from the top of the corona radiata section showing the lateral ventricle on DWI. A multivariate logistic analysis was used to explore the predictors of END.

RESULTS

A total of 402 patients were included in this study, among whom 93 (23.1%) experienced END. The optimal cutoff points of the posteriority and laterality indexes for predicting END were given by a receiver operating characteristic curve. A multivariate logistic analysis showed that the posteriority index of ≥0.669 (OR: 2.53; 95% CI: 1.41-4.56; P = .002) and the laterality index of ≥0.950 (OR: 2.03; 95% CI: 1.03-4.00; P = .042) were independently associated with the risk of END. Accordingly, the SSSIs were further divided into 4 types: anterior lateral type (AL-type), anterior medial type (AM-type), posterior lateral type (PL-type), and posterior medial type (PM-type). After the multivariate analysis, in comparison with the AL-type, the AM-type (OR: 3.26; 95% CI: 1.10-9.65), PL-type (OR: 4.68; 95% CI: 1.41-15.56), and PM-type (OR: 6.77; 95% CI: 2.53-18.04) carried significantly elevated risks of END. The PM-type was associated with the highest risk of END.

CONCLUSIONS

The PM-type was found to be associated with the highest risk of END.

European stroke organisation (ESO) guideline on cerebral small vessel disease, part 2, lacunar ischaemic stroke

A quarter of ischaemic strokes are lacunar subtype, typically neurologically mild, usually resulting from intrinsic cerebral small vessel pathology, with risk factor profiles and outcome rates differing from other stroke subtypes. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations to assist with clinical decisions about management of lacunar ischaemic stroke to prevent adverse clinical outcomes. The guideline was developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We addressed acute treatment (including progressive lacunar stroke) and secondary prevention in lacunar ischaemic stroke, and prioritised the interventions of thrombolysis, antiplatelet drugs, blood pressure lowering, lipid lowering, lifestyle, and other interventions and their potential effects on the clinical outcomes recurrent stroke, dependency, major adverse cardiovascular events, death, cognitive decline, mobility, gait, or mood disorders. We systematically reviewed the literature, assessed the evidence and where feasible formulated evidence-based recommendations, and expert concensus statements. We found little direct evidence, mostly of low quality. We recommend that patients with suspected acute lacunar ischaemic stroke receive intravenous alteplase, antiplatelet drugs and avoid blood pressure lowering according to current acute ischaemic stroke guidelines. For secondary prevention, we recommend single antiplatelet treatment long-term, blood pressure control, and lipid lowering according to current guidelines. We recommend smoking cessation, regular exercise, other healthy lifestyle modifications, and avoid obesity for general health benefits. We cannot make any recommendation concerning progressive stroke or other drugs. Large randomised controlled trials with clinically important endpoints, including cognitive endpoints, are a priority for lacunar ischaemic stroke.

Predictive factors for early neurological deterioration after intravenous thrombolysis of single subcortical infarction in the territory of the middle cerebral artery

INTRODUCTION

Patients with a single subcortical infarction (SSI) in the territory of the middle cerebral artery (MCA) often experience early neurological deterioration (END) despite receiving intravenous thrombolytic therapy (IVT). In this study, predictors of END were investigated in patients with SSI in the MCA after IVT.

METHODS

Patients with SSI in the MCA territory who had received IVT between June 2020 and 2022 were included. END was defined as an increase in the total National Institutes of Health Stroke Scale (NIHSS) score by ≥2 or in the motor NIHSS score by ≥1 within the first 72 h of admission. Patients with proximal (pSSI) and distal SSI (dSSI) were analyzed to determine SSI type-specific predictors for END.

RESULTS

We evaluated 174 patients with SSI in the MCA territory who underwent IVT. Multivariable logistic regression analysis showed that pSSI (odds ratio [OR] = 0.242; 95% confidence interval [CI], 0.104-0.564; p = .001), lower high-density lipoprotein cholesterol (HDL-C) (OR = 0.150; 95% CI, 0.033-0.682; p = .014), higher blood glucose (OR = 0.858; 95% CI, 0.752-0.979; p = .023), and higher red blood cells count (OR = 1.966; 95% CI, 1.154-3.349; p = .013) were risk factors for END. In patients with pSSI, HDL-C and blood glucose were associated with END. No variable related to END was found in the dSSI group.

CONCLUSIONS

The proportion of END in patients with SSI in the MCA territory after IVT was not low; therefore, pSSI, HDL-C, blood glucose, and red blood cells should be monitored closely. The frequency and predictors of SSI in the MCA territory differed between pSSI and dSSI.

The impact of asymptomatic intracranial atherosclerotic stenosis on the clinical outcomes of patients with single subcortical infarction

Background

The presence of parental arterial disease (PAD) is correlated with the outcomes of patients with a single subcortical infarction (SSI). Due to the relatively low incidence of PAD, the predictors of outcomes seem to be limited for SSI patients without PAD. This study aims to investigate the association between asymptomatic intracranial atherosclerotic stenosis (aIAS) and outcomes in patients with SSI and in the subgroup without PAD.

Methods

Patients with SSI were consecutively enrolled. aIAS referred to a stenosis of ≥50% in intracranial arteries irrelevant to SSI by using magnetic resonance angiography. A poor outcome refers to a modified Ranking Scale >2 points at discharge.

Results

In total, 298 participants were enrolled. The presence of aIAS could predict a poor outcome for all SSI patients [adjusted relative risk (aRR) = 2.14, 95% confidence interval (CI) = 1.17-3.93, p = 0.014] and in the subgroup without PAD (aRR = 3.12, 95% CI = 1.47-6.62, p = 0.003), but not in the subgroup with PAD. Compared with participants with neither aIAS nor PAD, the risk of a poor outcome increased approximately 2-fold in those with aIAS only (aRR = 2.95, 95% CI = 1.55-5.60, p = 0.001) and in those with concomitant aIAS and PAD (aRR = 3.10, 95% CI = 1.62-5.95, p = 0.001).

Conclusion

The presence of aIAS is a predictor of a poor outcome in SSI patients, especially in those without PAD.

The "island sign" on diffusion-weighted imaging predicts early neurological deterioration in penetrating artery territory infarctions: a retrospective study

BACKGROUND

Early neurological deterioration (END) sometimes occurs in patients with penetrating artery territory infarction (PATI) and leads to poor prognosis. In this study, we analyzed clinical and neuroimaging characteristics of PATI, and focused on the infarct patterns on diffusion-weighted imaging (DWI). We tried to investigate whether the "island sign" pattern is associated with END.

METHODS

We enrolled consecutive patients admitted with acute PATI within 48 h after onset from May 2020 to July 2022. They were divided into with and without the "island sign" pattern on DWI. According to infarct location, all the patients were classified into two groups: the territories of the lenticulostriate arteries (LSA) and paramedian pontine arteries (PPA). The patients in each group were further divided into two groups according to whether they developed END or not. Through analyzing the clinical and neuroimaging characteristics of the patients, we tried to identify the factors that might associated with the "island sign" pattern and the potential predictors of END within the LSA and PPA groups.

RESULTS

Out of the 113 patients enrolled in this study, END was found in 17 patients (27.9%) in the LSA group and 20 patients (38.5%) in the PPA group. The "island sign" was found in 26 (23%) patients. In the multivariate analysis, the independent predictors of END in the LSA group were the "island sign" (OR 4.88 95% CI 1.03-23.2 P = 0.045) and high initial National Institute of Health Stroke Scale (NIHSS) (OR 1.79 95% CI 1.08-2.98 P = 0.024) and in the PPA group was the presence of lesions extending to the ventral pontine surface (OR 7.53 95% CI 1.75-32.37 P = 0.007).

CONCLUSIONS

The predictive factors for END were different in the LSA and PPA groups. The "island sign" was particularly associated with END in the LSA group.

Infarct growth velocity predicts early neurological outcomes in single subcortical infarction

In single subcortical infarction (SSI), changes in lesion size are a major determinant of early neurological deterioration. We evaluated the association between END and infarct growth velocity (IGV) in patients with SSI. We included consecutive patients with SSI who underwent MRI within 24 h of symptom onset between 2010 and 2020. END was defined as an increase of ≥ 2 in the total National Institutes of Health Stroke Scale (NIHSS) score or ≥ 1 in the motor NIHSS score. IGV was calculated using the following formula: IGV (mL/h) = diffusion-weighted imaging volume (mL)/time to MRI (h). A total of 604 patients with SSI were evaluated. Multivariable logistic regression analysis showed that IGV remained significant after adjusting for confounders (aOR = 1.34, 95% CI 1.12-1.61). In a subgroup analysis based on the type of SSI, only patients with distal SSI showed an association between IGV and END (aOR = 1.64, 95% CI 1.24-2.16). In patients with proximal SSI, IGV did not show any statistical association with END. In conclusion, IGV was positively associated with END in patients with SSI. IGV should be interpreted differently in clinical settings depending on the location of the SSI lesion.

Clinical factors associated with functional outcomes in patients with single subcortical infarction with neurological deterioration

Objective

Factors that predict poor outcomes in patients with single subcortical infarction (SSI) may differ from those that predict poor outcomes in the SSI subgroup with neurological deterioration (ND). This study aimed to investigate the effect of ND on functional outcomes in patients with SSI and the clinical factors that predict poor outcomes in patients with SSI with ND (SSI-ND) and in all patients with SSI.

Methods

Patients with SSI were consecutively enrolled in this study. ND was defined as an increase of ≥2 points in the National Institutes of Health Stroke Scale (NIHSS) total score, an increase of ≥1 point in the NIHSS subscore of consciousness or motor function, or any new neurological deficit.

Results

A total of 255 patients were enrolled, and nine (3.53%) were lost to a follow-up. ND [adjusted relative risk (aRR) = 1.37, 95% confidence interval (CI) = 1.22-1.55, p < 0.001], female sex (aRR = 1.13, 95% CI = 1.03-1.24, p = 0.12), initial NIHSS (aRR = 1.08, 95% CI = 1.07-1.10, p < 0.001), and parental arterial disease (PAD) (aRR = 1.16, 95% CI = 1.07-1.26, p = 0.038) were associated with a poor 90-day outcome (the modified Rankin scale (mRS) > 2 points) in patients with SSI. In the SSI-ND subgroup, PAD (aRR = 2.15, 95% CI = 1.20-3.86, p = 0.01), glycosylated hemoglobin (aRR = 1.17, 95% CI = 1.01-1.35, p = 0.035), and severe NIHSS (aRR = 1.15, 95% CI = 1.06-1.25, p = 0.001) were predictive of a poor outcome, and PAD (aRR = 1.87, 95% CI = 1.19-2.95, p = 0.007) was correlated with higher/worsened NIHSS [> 2 points (median)]. For predicting poor outcomes in patients with SSI-ND with PAD, a more severe NIHSS (aRR = 1.09, 95% CI = 1.02-1.17, p = 0.01) was the only determinant, with a cutoff of 4.5 points, a sensitivity of 94.0%, and a specificity of 83.3%.

Conclusions

ND is an independent predictor of poor outcomes in patients with SSI, and poor outcome determinants in the SSI-ND subgroup and in all patients with SSI are not identical. For patients with SSI-ND, PAD could aggravate ND and was therefore an essential predictor of poor outcomes.

Different Predictive Factors for Early Neurological Deterioration Based on the Location of Single Subcortical Infarction: Early Prognosis in Single Subcortical Infarction

BACKGROUND AND PURPOSE

Patients with single subcortical infarctions (SSIs) have relatively a favorable prognosis, but they often experience early neurological deterioration (END). In this study, we compared the predictors for END in patients with SSI according to the location of the lesion.

METHODS

We included consecutive patients with SSIs within 72 hours of symptom onset presenting between 2010 and 2016. END was defined as an increase of ≥2 in the total National Institutes of Health Stroke Scale (NIHSS) score or ≥1 in the motor NIHSS score within the first 72 hours of admission. Along with the analysis of all patients with SSI, we also analyzed the predictors for END in proximal/distal SSI patients and anterior/posterior circulation SSI patients.

RESULTS

A total of 438 patients with SSI were evaluated. In multivariable analysis, initial NIHSS score (adjusted odds ratio, 1.36 [95% CI, 1.15-1.60]), pulsatility index (adjusted odds ratio, 1.25 [95% CI, 1.03-1.52]), parent artery disease (adjusted odds ratio, 2.14 [95% CI, 1.06-4.33]), and neutrophil-to-lymphocyte ratio (adjusted odds ratio, 1.24 [95% CI, 1.04-1.49]) were positively associated with END. In patients with proximal SSI, initial NIHSS score, pulsatility index, parent artery disease, and neutrophil-to-lymphocyte ratio showed positive associations with END. Meanwhile, no variable related to END was found in the distal SSI group. When we compared the predictors for END based on the involved vascular territory, higher initial NIHSS score and neutrophil-to-lymphocyte ratio were significantly associated with END in patients with anterior circulation SSIs. On the contrary, higher pulsatility index values and the presence of parent artery disease were independent predictors for END in patients with SSIs in the posterior circulation.

CONCLUSIONS

Initial NIHSS score, pulsatility index, parent artery disease, and neutrophil-to-lymphocyte ratio are associated with END in patients with SSIs. The frequency and predictors for END differ depending on the location of the SSI.

Lacunar stroke: mechanisms and therapeutic implications

Lacunar stroke is a marker of cerebral small vessel disease and accounts for up to 25% of ischaemic stroke. In this narrative review, we provide an overview of potential lacunar stroke mechanisms and discuss therapeutic implications based on the underlying mechanism. For this paper, we reviewed the literature from important studies (randomised trials, exploratory comparative studies and case series) on lacunar stroke patients with a focus on more recent studies highlighting mechanisms and stroke prevention strategies in patients with lacunar stroke. These studies suggest that lacunar stroke is a heterogeneous disease with various mechanisms, including most commonly lipohyalinosis and less commonly atheromatous disease and cardioembolism, highlighting the importance of a careful review of brain and neurovascular imaging, a cardiac and systemic evaluation. A better understanding of pathomechanisms of neurological deterioration may lead to investigating the utility of novel treatment strategies and optimisation of short-term antithrombotic treatment strategies to reduce the risk of neurological deterioration and prevent long-term disability in patients with lacunar stroke.

Triglyceride-glucose index is associated with early neurological deterioration in single subcortical infarction: Early prognosis in single subcortical infarctions

BACKGROUND

The research about the influence of triglyceride-glucose index on early prognosis in stroke is lacking.

AIMS

In this study, we evaluated the association between triglyceride-glucose index and early neurological deterioration in patients with single subcortical infarctions.

METHODS

Consecutive patients with single subcortical infarctions within 72 h of symptom onset between 2011 and 2015. Early neurological deterioration was defined as an increase of ≥2 in the total NIHSS score or ≥1 in the motor NIHSS score. The triglyceride-glucose index was calculated using the log scale of fasting triglyceride (mg/dL) × fasting glucose (mg/dL)/2.

RESULTS

A total of 305 patients with single subcortical infarctions were evaluated. In multivariable analysis, the triglyceride-glucose index (adjusted odds ratio [aOR] = 2.94, 95% confidence interval [CI] = 1.58-5.45) and age (aOR = 1.05, 95% CI = 1.01-1.09) were associated with early neurological deterioration. In subgroup analysis according to the type of single subcortical infarctions, only patients with proximal single subcortical infarctions showed a significant association between the triglyceride-glucose index and early neurological deterioration (aOR = 2.92, 95% CI = 1.35-6.29). On the other hand, there was no statistical significance in patients with distal single subcortical infarctions. Patients with untreated diabetes also showed the close association between the triglyceride-glucose index and early neurological deterioration (aOR = 3.94, 95% CI = 1.47-10.52).

CONCLUSIONS

The triglyceride-glucose index was associated with early neurological deterioration in single subcortical infarctions. This association differed depending on the location of lesion and the presence of untreated diabetes.

Cerebral small vessel disease: neuroimaging markers and clinical implication

Cerebral small vessel disease (CSVD) is a broad category of cerebrovascular diseases which primarily affect the perforating arterioles, capillaries and venules with multiple distinct etiologies. In spite of distinctive pathogenesis, CSVD shares similar neuroimaging markers, including recent small subcortical infarct, lacune of presumed vascular origin, white matter hyperintensity of presumed vascular origin, perivascular space and cerebral microbleeds. The radiological features of neuroimaging markers are indicative for etiological analysis. Furthermore, in sporadic arteriosclerotic pathogenesis associated CSVD, the total CSVD burden is a significant predictor for stroke events, global cognitive impairment, psychiatric disorders and later life quality. This review aims to summarize the radiological characteristics as well as the clinical implication of CSVD markers and neuroimaging interpretation for CSVD symptomatology.

Pathogenic Heterogeneity of Distal Single Small Subcortical Lenticulostriate Infarctions Based on Lesion Size

BACKGROUND

Single small subcortical infarctions (SSSIs) in the lenticulostriate artery territory can be classified as proximal single small subcortical infarction (pSSSI) or distal single small subcortical infarction (dSSSI) lesions depending on the involvement of the lowest part of the basal ganglia. It was reported that pSSSI lesions have more characteristics of large artery atherosclerosis, whereas dSSSI lesions are more characteristic of small vessel disease. Because infarction of small vessels is more likely to be distal and may result in small lesions, we hypothesized that the clinical features of dSSSI lesions might be heterogeneous and classified based on lesion size.

METHODS

Lenticulostriate SSSI patients admitted within 72 hours of stroke onset were included from a prospectively registered hospital-based stroke database. We determined the location (lowest slice [LS] involved) and size (total number of slices [TNS] involved) of SSSIs on magnetic resonance imagings. Based on lesion location, SSSIs were divided into pSSSI (LS ≤ 2) and dSSSI (LS > 2); the latter were further subdivided into distal and small SSSI (ds-SSSI, TNS ≤ 2) or distal and large SSSI (dl-SSSI, TNS > 2). The clinical characteristics were compared between different groups.

RESULTS

A total of 204 patients were included out of 1158 patients registered in the database. We found that ds-SSSI was most often associated with severe white matter hyperintensities. However, patients with dl-SSSI most often had a higher rate of additional concurrent atherosclerotic disease as coronary heart disease, compared to patients with ds-SSSI.

CONCLUSIONS

The pathogenesis of dSSSI may be heterogeneous depending on lesion size.