Irregularly shaped lacunar infarction: risk factors and clinical significance

Correlation of blood pressure levels at different time periods throughout the day with total CSVD burden and MRI imaging markers

Purpose

Hypertension is an important risk factor for atherosclerotic cerebral small vessel disease (CSVD). Higher blood pressure is associated with a higher CSVD burden and the presence of relevant magnetic resonance imaging (MRI) markers. However, the effect of blood pressure level on CSVD burden and imaging markers including white matter hyperintensity (WHM), lacune, enlarged perivascular spaces (EPVS), and cerebral microbleed (CMB) remains unknown. The purpose of this study was to investigate the correlation between blood pressure level and CSVD burden at different time periods throughout the day.

Methods

In total, 144 in-patients with CSVD (66.4 ± 9.8 years, 50% male) were enrolled and underwent brain MRI, and 24-h ambulatory blood pressure was assessed. Patients were categorized into five groups according to their MRI-evaluated total CSVD burden scores (0-4). Spearman's correlation analysis was performed to examine the correlation between blood pressure levels at different time periods and the total CSVD score or the markers of periventricular WMH, deep WMH, lacune, EPVS, and CMB.

Results

Of the 144 patients, 83.3% (120/144) harbored one or more CSVD markers of interest. The systolic blood pressure (SBP) of 24-h, daytime, nighttime, and morning differed significantly among the five groups. The SBP levels increased significantly with the total CSVD scores during 24 h (P = 0.018), daytime (P = 0.018), and nighttime (P = 0.035). Spearman's correlation analysis demonstrated that the SBP of 24 h, daytime, nighttime, and morning and the diastolic blood pressure (DBP) of 24 h and morning positively and significantly correlated with the total CSVD score (P < 0.05). A logistic regression analysis indicated that both morning SBP and DBP were independent risk factors for total CSVD burden (OR = 1.13, 95% CI: 1.02-1.23, P = 0.015; OR = 1.19, 95% CI: 1.06-1.33, P = 0.005). Spearman's correlation analysis indicated a significant positive correlation between morning SBP and higher deep WMH Fazekas score (r = 0.296, P < 0.001), EPVS grade in the basal ganglia (r = 0.247, P = 0.003), and the presence of lacune (r = 0.173, P = 0.038) and CMB (r = 0.326, P < 0.001). Morning DBP only correlated positively with the presence of CMB (r = 0.292, P < 0.001).

Conclusion

Higher SBP signficantly correlated with total CSVD burden in patients with atherosclerotic CSVD. Early morning blood pressure level is an important indicator to reflect the severity of CSVD patients.

BPV associated with imaging features of SSI on MRI

OBJECTIVES

A retrospective study was performed to investigate the relationship between blood pressure variability (BPV) and imaging features of single small infarction (SSI) on magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Two hundreds and five patients with SSI and 120 healthy subjects matched with age and sex as the control group were enrolled into this study. All subjects came from the Affiliated Hospital to Qingdao University and Qingdao Municipal Hospital from October 2011 to June 2016. Research subjects were classified into different groups. Blood pressure was measured once a day and recorded during the hospitalization period (7-10 days). The followed up data of patients after discharging from hospital was collected from the follow-up records.

RESULTS

Twenty-four hours BPV (SBP_Mean , DSBP_Max , DSBP_SD , NDBP_Max , NDBP_SD, and DDBP_CV ), day-to-day, and visit-to-visit BPV (SBP_Max , SBP_SD , DBP_Max, and DBP_SD ) in the SSI group were significantly higher than that in control group. Compared with the giant lacunar group, day-to-day BPV (SBP_Mean , SBP_Max , SBP_SD , SBP_CV , DBP_Mean , DBP_Max , DBP_SD ), and visit-to-visit BPV (SBP_Mean , SBP_Max , SBP_SD , DBP_Mean , DBP_Max , DBP_SD ) were significantly higher in the small lacunar infarct group (p < .05). The 24 hr BPV (SBP_Mean , DDBP_Max , DDBP_Mean ), day-to-day BPV (SBP_Max , SBP_SD , SBP_CV ), and visit-to-visit SBP_Max in nonround lesion group were significantly higher than that in round group (p < .05). Compared with nondeep lesion group, some parameters in day-to-day BPV and visit-to-visit BPV were significantly higher in the deep small lesion group (p < .05).

CONCLUSION

Increased BPV parameters such as day-to-day and visit-to-visit (SBP_Max , SBP_SD , DBP_Max ) were related to the SSI characterized by small lesion in deep brain region.

Twenty-Four-Hour Ambulatory Blood Pressure Variability Associated With Cerebral Small Vessel Disease MRI Burden and Its Progression in Inpatients With Cerebrovascular Disease

Background: Lacunar infarcts, white matter lesions, cerebral microbleed, enlarged perivascular space and brain atrophy are regarded as magnetic resonance imaging (MRI) manifestations of cerebral small vessel disease (cSVD). 24-hour blood pressure variability (BPV) has been reported to relate with cerebral small vessel disease, but the impact of 24-h BPV on the total MRI cSVD burden and its progression in inpatients with cerebrovascular disease has not been investigated yet. Methods: We enrolled inpatients with cerebrovascular disease, who underwent the 24-h ambulatory blood pressure monitoring (ABPM) and the brain MRI scan at baseline and had the follow-up brain MRI images stored in the clinical information system of our hospital. BPV was quantified by the calculation of standard deviation (SD), coefficient of variation (CV), weighted standard deviation (wSD) of blood pressure record. We evaluated the total cSVD score on baseline MRI and the MRI followed-up to obtain the total burden of cSVD. The cSVD burden progression was estimated through the comparison of the total cSVD score on the two MRIs. Results: A total of 140 patients with an average age of 65.6 years were finally enrolled, 82.9% (116/140) of whom had one or more cSVD markers. After a median of 4.4 years follow-up, cSVD score progression were found in 50.7% (71/140) of the patients. Both SD and CV of SBP and DBP during 24-h and daytime as well as the SBP wSD differed significantly among different total cSVD score groups. The SBP SD and CV during 24-h and daytime, the SBP SD in nighttime, the DBP SD and CV during the daytime were significantly higher in the cSVD progression group than those in the cSVD no-progression group. The SBP wSD and the DBP wSD were significantly higher in the cSVD progression group than those in the cSVD no-progression group. Logistic regression analyses revealed that daytime SBP SD and SBP wSD were independent risk factors for total cSVD burden [daytime SBP SD: OR = 1.628, 95% CI = 1.105-2.398 (per 5 mmHg increase in SD), P = 0.014; SBP wSD: OR = 2.248, 95% CI = 1.564-3.230 (per 5 mmHg increase in wSD), P < 0.001)] and SBP wSD was a significant predictor for cSVD progression [OR = 2.990, 95% CI = 1.053-8.496 (per 5 mmHg increase in wSD), P = 0.040]. Conclusion: Higher BPV were significantly related with total cSVD burden in inpatients with cerebrovascular disease. SBP SD during daytime and SBP wSD were independent risk factor for total cSVD burden and SBP wSD was an predictive factor for cSVD progression.

Size, shape and location of lacunar strokes and correlation with risk factors

OBJECTIVE

We evaluated a prospective cohort of 150 patients under observation in our centre for lacunar strokes. The purpose of this study was to investigate if lacunar stroke of varying size, shape and locations had different risk factors between them and possibly different mechanisms and causes.

PATIENTS AND METHODS

150 patients with a lacunar stroke were included in the present study. Infarcts were classified by size, shape and location. We evaluated the correlation between several risk factors of stroke and the radiological characteristics of the infarcts.

RESULTS

Older age was associated with the presence of a basal ganglia lesion (p < 0.001) and with the presence of a smaller lesion (trend to statistical significance, p = 0.07). Patients with infarcts >15 mm had higher NIHSS score at admission (p 0.01).

CONCLUSION

The different subtypes of lacunar infarcts have distinct pathogenesis. Further studies, with a larger numbers of patients, are necessary to confirm our data.

Increased blood pressure variability following acute stroke is associated with poor long-term outcomes: a systematic review

BACKGROUND

Blood pressure variability (BPV) in acute ischemic stroke (AIS) may be of prognostic significance. However, methodological heterogeneity of studies may contribute to inconsistent findings, and study findings are therefore not readily comparable. We investigated study methodologies which have assessed the long-term outcomes (≥7 days) of BPV post-AIS.

MATERIALS AND METHODS

The literature search was conducted in OVID Medline, Embase, The Cochrane Library, and Web of Science following a predefined search strategy. Two reviewers independently assessed study eligibility and quality, and source data were extracted.

RESULTS

Of 2044 studies identified, 19 observational studies and one case-control study were included; seven studies were additionally included. Twenty-two studies obtained good risk of bias ratings. Key findings were methodological heterogeneity and significant variability in the reporting of key criteria. Twenty-four studies reported intervals between blood pressure assessments; although 19 studies reported the monitoring device used, only eight studies reported the number of blood pressure measurements taken per visit. The majority measured supine blood pressure (n=13), and eight studies reported whether this was in the hemiparetic or unaffected arm. Sixteen studies defined BPV using SD and seven studies used only a single blood pressure parameter to quantify BPV. Increased BPV was associated with poorer neurological and functional outcomes, and death (n=23); other unfavorable outcomes included irregularly shaped lacunar infarcts, and impaired cognition (n=3).

CONCLUSION

Methodological heterogeneity is frequently observed in studies, primarily because of incomplete study reporting. However, increased BPV is associated with adverse long-term outcomes. There is a need for prospective studies investigating BPV post-AIS to report full methodologies according to standardized criteria.

Features and Determinants of Lacune Shape: Relationship With Fiber Tracts and Perforating Arteries

BACKGROUND AND PURPOSE

Lacunes are a major manifestation of cerebral small vessel disease. Although still debated, the morphological features of lacunes may offer mechanistic insights. We systematically analyzed the shape of incident lacunes in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, a genetically defined small vessel disease.

METHODS

A total of 88 incident lacunes from 57 patients were segmented from 3-dimensional T1 magnetic resonance images and 3 dimensionally reconstructed. Anatomic location, diameter, volume, surface area, and compactness of lacunes were assessed. The shape was analyzed using a size, orientation, and position invariant spectral shape descriptor. We further investigated the relationship with perforating arteries and fiber tracts.

RESULTS

Lacunes were most abundant in the centrum semiovale and the basal ganglia. Diameter, volume, and surface area of lacunes in the basal ganglia and centrum semiovale were larger than in other brain regions. The spectral shape descriptor revealed a continuum of shapes with no evidence for distinct classes of lacunes. Shapes varied mostly in elongation and planarity. The main axis and plane of lacunes were found to align with the orientation of perforating arteries but not with fiber tracts.

CONCLUSIONS

Elongation and planarity are the primary shape principles of lacunes. Their main axis and plane align with perforating arteries. Our findings add to current concepts on the mechanisms of lacunes.