Mechanisms Involved in Lacunar Infarction and Their Role in Early Neurological Deterioration

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.

Dual Antiplatelet Therapy With Cilostazol for Secondary Prevention in Lacunar Stroke: Subanalysis of the CSPS.com Trial

BACKGROUND

The effectiveness of long-term dual antiplatelet therapy (DAPT) to prevent recurrent strokes in patients with lacunar stroke remains unclarified. Therefore, this study aimed to compare and to elucidate the safety and effectiveness of DAPT and single antiplatelet therapy (SAPT) in preventing recurrence in chronic lacunar stroke.

METHODS

CSPS.com (Cilostazol Stroke Prevention Study for Antiplatelet Combination) was a prospective, multicenter, randomized controlled trial. In this prespecified subanalysis, 925 patients (mean age, 69.5 years; 69.4% men) with lacunar stroke were selected from 1884 patients with high-risk noncardioembolic stroke, enrolled in the CSPS.com trial after 8 to 180 days following stroke. Patients were randomly assigned to receive either SAPT or DAPT using cilostazol and were followed for 0.5 to 3.5 years. The primary efficacy outcome was the first recurrence of ischemic stroke. The safety outcomes were severe or life-threatening bleeding.

RESULTS

The DAPT group receiving cilostazol and either aspirin or clopidogrel and SAPT group receiving aspirin or clopidogrel alone comprised 464 (50.2%) and 461 (49.8%) patients, respectively. Ischemic stroke occurred in 12 of 464 patients (1.84 per 100 patient-years) in the DAPT group and 31 of 461 patients (4.42 per 100 patient-years) in the SAPT group, during follow-up. After adjusting for multiple potential confounding factors, ischemic stroke risk was significantly lower in the DAPT group than in the SAPT group (hazard ratio, 0.43 [95% CI, 0.22-0.84]). The rate of severe or life-threatening hemorrhage did not differ significantly between the groups (2 patients [0.31 per 100 patient-years] versus 6 patients [0.86 per 100 patient-years] in the DAPT and SAPT groups, respectively; hazard ratio, 0.36 [95% CI, 0.07-1.81]).

CONCLUSIONS

In patients with lacunar stroke, DAPT using cilostazol had significant benefits in reducing recurrent ischemic stroke incidence compared with SAPT without increasing the risk of severe or life-threatening bleeding.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT01995370. URL: https://www.umin.ac.jp/ctr; Unique identifier: UMIN000012180.

Vasomotor reactivity in patients with cerebral small vessel disease vs. internal border zone infarction and its correlation with disease outcome

Background

Available data collected from patients of different types of cerebrovascular strokes can detect risk factors, severity and clinical outcome of these patients. Differentiating between different types of strokes is mandatory for early diagnosis and proper management. The aim of this study is to compare between cerebral small vessel disease with lacunar infarctions and internal border zone infarctions regarding vasomotor reactivity by using transcranial color-coded duplex and its correlation with their MRI perfusion, disease severity and outcome.

Results

On admission, 56.7% of patients in lacunar stroke had impaired reactivity vs. 100% of patients in internal border zone group. At 3 months follow-up, this number dropped to 23.3% in lacunar group, but persisted as 100% in internal border zone group. On comparing the 3 perfusion parameters between the 2 groups, there was statistically significant impairment in all parameters in patients with internal border zone infarction than patients with lacunar infarction (longer time to peak, decreased cerebral blood flow and cerebral blood volume). By comparing the severity of the stroke by using National Institute of Health and Stroke Scale, it was found that patients with internal border zone infarction had higher disability than patients with lacunar infarction on admission and on discharge. At 3 months follow-up, the lacunar group had a better outcome than of the border zone group.

Conclusion

Patients having internal border zone infarction had higher clinical disability and worse prognosis, together with more impairment in vasomotor reactivity and MRI perfusion parameters than patients having lacunar infarction.

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.