Dot-like Hemosiderin Spots on Gradient Echo T2*-Weighted Magnetic Resonance Imaging Are Associated With Past History of Small Vessel Disease in Patients With Intracerebral Hemorrhage

BACKGROUND AND PURPOSE: Lipohyalinosis is considered an important cause of cerebral small vessel disease (SVD), including hypertensive intracerebral hematoma (ICH) and lacunar infarction. Dot-like low-intensity spots (dot-like hemosiderin spots [dotHSs]) on gradient-echo T2*-weighted (T2*-w) magnetic resonance imaging (MRI) have been histologically diagnosed as old microbleeds associated with microangiopathies (lipohyalinosis, amyloid angiopathy) and located in territories of perforating arteries (deep dotHSs) and subcortical regions (subcortical dotHSs). If dotHSs indicate the severity of lipohyalinosis, larger numbers of deep dotHSs may be associated with past history of SVD. METHODS: The number of dotHSs was investigated in 213 patients with deep ICH (106 men, 107 women, 37 to 94 years old, mean age = 65.8 +/- 11.2 years). Patients were divided into 2 subgroups according to past history of SVD. Odds ratio (OR) for the history was estimated from logistic regression analyses of the number of deep or subcortical dotHSs, as well as other factors. RESULTS: Of 213 patients, 36 had a past history of SVD (symptomatic deep ICH in 18, symptomatic lacunar infarction in 17, and both in 1). An increased rate of history of SVD was found for patients with subcortical dotHSs. The OR per 1 subcortical dotHS was 1.09 (95% confidence internal (CI), 1.03-1.17; P =.005), and per deep dotHS, the OR was 1.07 (95% CI, 1.00-1.13; P =.039). CONCLUSIONS: The findings suggest that deep and subcortical dotHSs on T2*-w MRI may indicate the severity of microangiopathy and may predict recurrence of SVD in patients with deep ICH.     

Dynamics of Dot-Like Hemosiderin Spots on T2*-Weighted MRIs Associated with Stroke Recurrence

BACKGROUND AND PURPOSE: Dot-like low-intensity spots (dot-like hemosiderin spots: dotHSs) on gradient echo T2*-weighted (-w) brain magnetic resonance imaging (MRIs) are frequently associated with cerebral small vessel disease (SVD), including deep intracerebral hemorrhages and lacunar infarctions. This study investigated how numbers of newly appeared dotHSs contribute to recurrent SVD. METHODs: We prospectively analyzed numbers of newly appeared dotHSs in 12 patients with prior SVD (8 males, 4 females; mean 67.6 +/- 10.7 years old) readmitted with recurring SVD between October 2001 and March 2003. Numbers of appeared dotHSs per year were counted on T2*-w MRI scans after SVD recurrence and compared to previous MRIs. Seventy-one outpatients (35 males, 36 females; mean 64.3 +/- 9.6 years old) with histories of intracerebral hemorrhages (ICH) that came to the hospital during the study period served as controls. The hazard ratio (HR) for recurrence was estimated from a multivariate logistic regression model, using the number of appeared dotHSs (per year) and other risk factors. RESULTS: Multivariate analyses revealed that an elevated rate of recurrence was found in patients with substantial numbers of appeared dotHSs (>or=5/year) (HR, 7.34; P= 0.0008). We also analyzed factors associated with the numbers of appeared dotHSs. A number of appeared dotHSs (>or=5/year) was significantly and independently associated with the initial number of dotHSs (>or=10) on T2*-w MRIs following the first SVD (HR, 18.6; P= 0.0001). CONCLUSIONS: Though a small sample size limited the power of our analyses, our findings suggest that a number of newly appeared dotHSs may be associated with SVD recurrence.     

Risk factor for cerebral hemorrhage for the patient with lacunar infarction: investigation of 5 cases associated with both of symptomatic hemorrhagic and ischemic strokes]

BACKGROUND AND PURPOSE: Microangiopathy is regarded as an important cause of intracerebral hematoma(ICH) and lacunar infarction. Dot-like low intensity spots on T2-weighted echo planar image(EPI) have been regarded as hemosiderin deposit associated with microangiopathy. However, clinical significance of dot-like hemosiderin spot(dotHS) is still debated. Therefore, we analyzed the number of dotHS on EPI of symptomatic lacunar infarction associated with ICH. METHODS: To investigate how the dotHS or risk factors contributed to hemorrhagic strokes for patients with lacunar infarction, the number of dotHS and various risk factors were made a comparison between 20 cases with symptomatic lacunar infarctions(lacunar group) and 5 cases with both symptomatic lacunar infarction and symptomatic ICH(complicated group). In addition to EPI, fluid attenuated inversion recovery image, and T1- and T2-weighted MR images were performed for differential diagnosis of dot HS. RESULTS: EPI demonstrated that asymptomatic ICH was significantly more frequent in complicated group (60%) than in lacunar group(10%), and dotHS were significantly more frequent in complicated group(100%) than in lacunar group(50%). The number of dotHS of complicated group was 14.6 +/- 4.3, which was significantly larger than that of lacunar group(4.1 +/- 9.2). No significant difference between two groups were founded in other risk factors including hypertension, diabetes mellitus, hyperlipidemia, and smoking. CONCLUSION: These results suggested that dotHS was one of the risk factors for ICH for patients with symptomatic lacunar infarction, and an increasing number of dotHS was one of the predictive factors of symptomatic and/or asymptomatic ICH.     

Dot-Like Hemosiderin Deposition on T2*-Weighted MR Imaging Associated with Nonhypertensive Intracerebral Hemorrhage

BACKGROUND AND PURPOSE: Microangiopathy, a disorder often related to hypertension, is an important cause of deep intracerebral hematoma (ICH). The microangiopathy is associated with dot-like low-intensity spots (a dot-like hemosiderin spot: dotHS) on gradient-echo T2*-weighted MR images that have been histologically diagnosed as old microbleeds. The locations of dotHS are consistent with deep ICH. METHODS: To investigate how dotHS or other risk factors contribute to nonhypertensive deep ICH, the number and location of dotHSs, as well as other risk factors were examined in 213 deep ICH patients (106 males, 107 females, age: 37-94 (65.8 +/- 11.2) years) consecutively admitted to Hakodate Municipal Hospital. Patients were divided into two subgroups according to the presence or absence of hypertension. DotHSs were also divided into deep and subcortical dotHS and investigated independently. Odds ratios (ORs) were estimated from logistic regression analyses. Furthermore, nonhypertensive ICH patients were compared with nonhypertensive healthy volunteers matched for age and sex. RESULTS: No risk factors were identified in the 31 nonhypertensive deep ICH patients that differed from those found in the 182 hypertensive deep ICH patients. Deep dotHS > or = 1 (OR: 25.5; 95% CI: 4.76-137; P = .0002), subcortical dotHS > or = 1 (OR: 9.0; 95% CI: 1.79-44.9; P = .046), diabetes mellitus (OR: 9.0; 95% CI: 1.53-52.3; P = .015), and smoking (OR, 9.6; 95% CI; 1.8-49.8, P = .007) significantly elevated the risk of nonhypertensive ICH, compared to the healthy volunteers. CONCLUSIONS: Our findings suggest that deep and subcortical dotHSs may be risk factors for the development of non-hypertensive deep ICH.     

Hematoma Size in Deep Intracerebral Hemorrhage and its Correlation with Dot-Like Hemosiderin Spots on Gradient Echo T2*-Weighted MRI

BACKGROUND AND PURPOSE: Dot-like low intensity spots (dot-like hemosiderin spots: dotHSs) on gradient echo T2*-weighted MRI have been histologically diagnosed to represent old cerebral microbleeds associated with microangiopathies. They have also been correlated to the fragility of small vessels and the tendency to bleed. Therefore, a substantial number of dotHSs might be associated with a large-sized, deep intracerebral hematoma (ICH). On the other hand, dotHSs may reflect old microbleeds that did not enlarge to symptomatic size. METHODS: To investigate how dotHSs are related to the size (maximal diameter) of primary deep ICH, we analyzed the diameter and the number of dotHSs in 151 patients with deep ICH not associated with subarachnoid hemorrhage or intraventricular hemorrhage (75 males and 76 females, age ranged from 37 to 90 [65.7 +/- 11.3 years old] who were consecutively admitted to Hakodate Municipal Hospital. The hazard ratio (HR) for a maximal diameter of deep ICH < or =2 cm was estimated, using the number of dotHSs and risk factors for stroke. RESULTS: The number of dotHSs associated with the diameter < or =2 cm was 9.2 +/- 11.5, significantly larger than that with the diameter > or =2 cm (4.7 +/- 7.0, P= .012). Multivariate analysis revealed that a maximal diameter of deep ICH of < or =2 cm was found in patients with dotHS (HR, 3.7; 95% confidence interval [CI], 1.4-10.1; P= .009). CONCLUSION: Though small sample size limited the power of our analyses, these findings suggest that the number of dotHSs may be associated with a small diameter of deep ICH.     

Association of Ultrasonography and MRI Findings with Stroke Recurrence: Differences Between Patients with Past Histories of Atherothrombotic Versus Lacunar Infarctions

Objective: This study investigated the association of MRI and ultrasonography findings with stroke recurrence in patients with past histories of atherothrombotic infarctions (ATIs) or lacunar infarctions (LIs). Methods: We prospectively analyzed the incidence of stroke recurrence. Deep and lobar cerebral microbleeds (MBs), asymptomatic lacunae, asymptomatic intracerebral hemorrhages (ICHs), severe white matter lesions (WML), and intima-media thickness (IMT) were investigated on enrollment. Stroke recurrence rates were compared by using the log-rank test. The odds ratios for recurrent strokes were derived using multivariate logistic regression models, adjusted for risk factors. Results: We evaluated the stroke recurrence rate in 362 ATI patients and 309 LI patients. The log-rank test and multivariate analyses revealed that the incidence of recurrent stroke was significantly higher in ATI patients with mean IMT greater than or equal to 1.1 mm, asymptomatic ICHs, or lobar MBs than in those without. The incidence was significantly higher in LI patients with asymptomatic ICHs, asymptomatic LIs, and severe WMLs than in those without. In ATI patients, those with strictly lobar MBs or mixed MBs (deep and lobar MBs) had significantly higher recurrence rates than those without MB. In LI patients, those with strictly deep MBs or mixed MBs had higher recurrence rates than those without MB, and the incidences of those with mixed MBs was larger than those with strictly deep MBs. Conclusions: There were differences between ATI and LI patients in terms of the association of MRI and ultrasonography findings, in particularly strictly lobar or deep MBs, with the incidence of stroke recurrence.     

Association of Left Ventricular Hypertrophy and Atrial Fibrillation with Hemorrhagic Evolution of Small Vessel Disease

ObjectivesCerebral small vessel disease (SVD) is often associated with hypertension and may evolve towards intracerebral hemorrhage (ICH) or lacunar ischemic stroke. However, the factors favoring the evolution towards ICH or lacunar stroke are not well understood.Materials and MethodsThis retrospective study included 326 consecutive patients (71.1±13.2 years, 38% women): 143 with deep ICH and 183 with lacunar lesions (LL) <2 cm, which were visible in a deep location on brain CT scan. Among LL patients, 143 had a small-artery occlusion (SAO) stroke according to the TOAST classification. Clinical characteristics plus laboratory and neuroradiological variables of these patients had been prospectively collected and a subgroup underwent echocardiography.ResultsIn multivariate analysis, ICH patients (97% hypertensive), compared to SAO patients (89% hypertensive), had greater left ventricular wall thickness (LVWT; OR 4.15, 95%CI 1.64-10.53, for those with LVWT ≥ 1.4 cm, 70% of whom were hemorrhagic) and lower prevalence of white matter lesions (OR 0.30, 95%CI 0.13-0.70), ever smokers (OR 0.39, 95%CI 0.18–0.82) and diabetics (OR 0.29, 95% CI 0.10-0.84). Moreover, ICH patients had a greater prevalence of atrial fibrillation than LL patients (OR 3.14, 95%CI 1.11-8.93), and so they were more often anticoagulated.ConclusionsMost SVD patients were hypertensive, but those evolving towards ICH were characterized by organ damage at the cardiac level (increase in LVWT and atrial fibrillation), while those evolving towards lacunar stroke were characterized by a higher prevalence of smokers and diabetics, and by organ damage at the cerebral level (white matter lesions).     

The renin-angiotensin-aldosterone system in cerebral small vessel disease

INTRODUCTION: Cerebral small vessel disease (SVD) appears on magnetic resonance imaging (MRI) as leukoaraiosis (LA), état criblé (EC), and multiple lacunar infarctions (MLI). Although the pathophysiology of SVD is poorly understood, there is evidence of a genetic contribution. We sought to analyze the influence of the renin-angiotensin-aldosterone system (RAAS) on SVD in symptomatic patients from the Génétique de l'Infarctus Cérébral (GENIC) study, including RAAS polymorphisms and circulating angiotensin converting enzyme (ACE). METHODS: Caucasian patients (n=510) with acute brain infarction (BI) were recruited and MRIs were evaluated for SVD, including LA, EC, and MLI. We considered ACE levels and several polymorphisms, including ACE, angiotensinogen, aldosterone synthase CYP11B2, and angiotensin II receptor type I. RESULTS: Among the polymorphisms, there were marginal negative associations between aldosterone synthase CYP11B2 -344C against severe EC (adjusted OR, 0.57; 95% CI, 0.31-1.05) and severe LA (adjusted OR, 0.54; 95% CI, 0.30-0.95), both considering -344C dominant. In addition, the frequency of -344C decreased with the number of SVD abnormalities (p=0.016). Mean plasma ACE was elevated in patients with MLI, but not with LA or EC. The risk of MLI increased gradually with increasing plasma ACE (adjusted OR, 1.25; 95% CI, 1.02-1.53). CONCLUSIONS: This exploratory study found no strong evidence for RAAS involvement in severe SVD in this population. The whole spectrum of SVD, including EC, MLI, and LA, can be considered as phenotypes for genetic studies.     

Impaired cerebrovascular reactivity as a risk marker for first-ever lacunar infarction: A case-control study.

BACKGROUND AND PURPOSE: Functional assessment of small arteries and arterioles could provide valuable information regarding the extent of diffuse arteriolosclerosis in patients with small-vessel disease. Therefore we attempted to clarify the role of cerebrovascular reactivity (CVR) as a risk marker for first-ever symptomatic lacunar infarction. METHODS: Forty-six patients with lacunar infarction and 46 sex- and age-matched control subjects were prospectively evaluated. Cerebral hemodynamics were studied with transcranial Doppler ultrasonography. CVR was examined by calculating the percent increase in mean flow velocity occurring after 15 mg/kg acetazolamide administration (Diamox test). RESULTS: CVR was significantly (P<0.0001, Student's t test) lower in cases (50.0+/-12. 7%) as compared with control subjects (65.2+/-12.4%). A multiple logistic regression analysis identified male sex (odds ratio [OR] 2. 3, P=0.02), age (OR 3.6, P<0.005), and the presence of lacunar infarction on magnetic resonance imaging (OR 5.3, P<0.001) as significant and independent factors associated with a reduction of CVR. Moreover, a cut-point of 55.6% (sensitivity 67%, specificity 82%) was established as the threshold value for distinguishing between pathological and normal CVR. CVR was significantly (P=0.02) lower in patients with multiple (46.38+/-12.6%) than with single (54. 83+/-11.58%) lacunar infarction. In addition, a trend of negative correlation was found between CVR and the number of lacunar infarctions (r=-0.26, P=0.08). In the multiple logistic model, history of hypertension (OR 7.24; 95% confidence interval 2.95 to 17. 79) and CVR (OR 0.8; 95% confidence interval 0.81 to 0.93) emerge as significant and independent predictors of first-ever lacunar infarction. CONCLUSIONS: These data suggest that impaired CVR is a risk marker for first-ever lacunar infarction.     

Effect of the Ca antagonist nilvadipine on stroke occurrence or recurrence and extension of asymptomatic cerebral infarction in hypertensive patients with or without history of stroke (PICA Study). 1. Design and results at enrollment

BACKGROUND: We examined the effect of a Ca antagonist (nilvadipine) on the occurrence or recurrence of symptomatic stroke in hypertensive patients with MRI-defined asymptomatic cerebral infarction (ACI), periventricular hyperintensity (PVH), and deep and subcortical white matter hyperintensity (DSWMH), with or without a history of stroke, and evaluated the effect of long-term treatment on the lesions. METHODS: Patients with hypertension and incidental ACI were divided into those with (group B, 235 patients) or without (group A, 181 patients) a history of symptomatic stroke, and were given nilvadipine 4-8 mg/day for 3 years. Primary evaluation points were occurrence of symptomatic ischemic stroke and development or extension of asymptomatic ischemic lesions. RESULTS: Male sex, hyperuricemia, diabetes, maximum diameter of infarction and PVH severity were stronger risk factors for group B. Numbers of cerebral infarctions were 31 +/- 28 (group A) and 42 +/- 32 (group B) at enrollment (p < 0.001). Infarctions were larger and located more frequently on the internal capsule, putamen, thalamus and brainstem in group B. The severity of PVH and DSWMH paralleled the number of cerebral infarctions in both groups. CONCLUSION: The study design and status of asymptomatic ischemic brain lesions in hypertensive subjects at enrollment are presented.     

Intracerebral hemorrhage in CADASIL

BackgroundIntracerebral hemorrhage (ICH) has been reported in few cases of Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL), mostly in hypertensive patients. We aimed to assess the clinical and radiological characteristics of patients with CADASIL who presented with ICH.MethodsA retrospective analysis of all neuroimaging exams of CADASIL patients hospitalized in our academic neurology department for acute cerebrovascular events was performed to find ICH. A systematic review of the literature was performed on this topic.ResultsIncluding our five patients, a total number of 52 subjects with CADASIL and ICH (mean age: 56 years, SD 11, 36–69%- male) were reported. Intracerebral hemorrhages were mainly deep (34 subjects), followed by lobar (8 subjects), infratentorial (6 subjects) and mixed locations (4 subjects). Three ICHs were asymptomatic. Fourteen patients were taking antithrombotic medication, 18 had no regular antiplatelet or anticoagulant treatment while in 20 patients medical treatment was not detailed. Arterial hypertension was present in 37 out of 51 patients with available information. Neuroimaging showed extensive FLAIR hyperintensities in all CADASIL subjects with ICH, cerebral microbleeds in all but three patients, and lacunar infarction in 19 out of 25 subjects with available information.ConclusionsIntracerebral hemorrhage represents a possible yet uncommon manifestation of CADASIL and should be considered as a possibility in patients with ICH associated with leukoencephalopathy and microbleeds, even in the absence of other clinical symptoms.     

Relationship between obstructive sleep apnea and neuroimaging signatures of cerebral small vessel disease in community-dwelling older adults. The Atahualpa Project

Background/ObjectivesEvidence of a relationship between obstructive sleep apnea (OSA) and neuroimaging signatures of cerebral small vessel disease (SVD) is limited. The present study aimed to evaluate this association in older adults living in rural Ecuador, where small vessel disease is a major pathogenetic mechanism underlying stroke.MethodsA representative random sample of Atahualpa residents aged ≥60 years enrolled in the Atahualpa Project neuroimaging substudy underwent a single-night diagnostic polysomnography. We evaluated whether OSA associates with severity of white matter hyperintensities (WMH), silent lacunar infarctions and deep cerebral microbleeds, using multivariate models adjusted for relevant confounders.ResultsOf 351 candidates, 104 (30%) were randomly selected. Of these, 97 individuals (mean age 72.3 ± 7 years, 65% women) had adequate recordings and were included. Mean apnea/hypopnea index was 13.8 ± 14.1 episodes per hour; 27 persons (28%) had ≥15 episodes per hour and were considered to have moderate-to-severe OSA. Moderate-to-severe WMH were noticed in 25 individuals (25.8%), silent lacunar infarctions in 22 (22.7%) and deep cerebral microbleeds in 12 (12.4%). In multivariate models, OSA was associated with moderate-to-severe WMH (OR: 3.94; 95% C.I.: 1.09–14.97; p = 0.037), but not with silent lacunar infarctions (p = 0.195) or deep cerebral microbleeds (p = 0.405). A linear regression model confirmed the independent association between the apnea/hypopnea index and moderate-to-severe WMH (β: −7.14; 95% C.I.: −13.6 to −0.69; p = 0.031).ConclusionsIndividuals with moderate-to-severe OSA are almost four times more likely to have diffuse subcortical damage of vascular origin than those with none-to-mild OSA, independently of demographics and cardiovascular risk factors.     

MRI findings of small subcortical “lacunar-like” infarction resulting from large vessel disease

Small subcortical infarctions resulting from large-vessel disease are often observed. It is important to distinguish these from pure lacunar infarction resulting from small-vessel disease because the investigations and examinations differ. We investigated the differences on brain magnetic resonance imaging (MRI) between small subcortical "lacunar-like" infarcts resulting from large-vessel disease and pure lacunar infarcts. Thirteen subjects with small lacunar-like infarcts (size < 2 cm), resulting from large-vessel disease, and 30 subjects with lacunar infarcts (< 2 cm), without large-vessel disease were studied. We measured infarction size using a 1.5-T MRI device and evaluated silent subcortical hyperintensity lesions using the modified Scheltens' score. Large-vessel lesion was confirmed by conventional angiography, duplex carotid scan, and magnetic resonance angiography. There was no difference in the mean age of the two groups. Cerebrovascular risk factors and atherosclerotic complications were also comparable for the two groups. Progressive stroke was more common in the lacunar-like infarction group than in the lacunar infarction group (P = 0.004). Scores for periventricular hyperintensity, white matter hyperintensity, basal ganglia hyperintensity, and total subcortical hyperintensity scores were significantly higher in the lacunar infarction group than in the lacunar-like infarction group. The difference in basal ganglia hyperintensity scores was remarkable (P = 0.001). The enlargement of the perivascular space was also significantly greater in the lacunar infarction group than in the lacunar-like infarction group. These findings seem to reflect differences in the pathogenesis of infarction between the two groups. Silent subcortical hyperintensity lesions and enlargement of perivascular space are useful for between distinguishing small lacunar-like infarct resulting from large-vessel disease and pure lacunar infarction. This may have significant implications for the management of patients with lacunar-sized infarctions. It suggests that the pathogenesis of lacunar-sized infarction is variable.     

Initial microbleeds at MR imaging can predict recurrent intracerebral hemorrhage

Abstract Background Intracerebral microbleeds (MBs) are frequently observed in intracerebral hemorrhage (ICH) patients. Although MBs have been shown to be pathogenetically related with ICH, it is not known whether MBs are predictors of recurrent ICHs. Methods Among 220 acute symptomatic primary ICH patients, 112 patients who underwent gradient-echo T2*-weighted MR imaging (GRE) within 10 days after symptom onset were considered for this study. Among them, the final 63 patients who consented to follow-up clinical, laboratory and GRE studies were included. The presence and number of ICHs (mean diameter >5 mm) and MBs on baseline and follow-up GRE were evaluated. The relationship of recurrent ICHs with initial and follow-up clinical and laboratory data as well as the MBs was assessed. Results Among 63 patients, 43 (68.3%) had MBs (median, 2; range, 1 to 17) on baseline GRE. Seven (11.1%) patients (6 with initial MBs; 1 without initial MBs) developed recurrent ICHs, and 19 (30.2%) had new MBs during a median 23.3 months (range, 8.3 to 33.0) of follow-up. The number of initial MBs on baseline GRE was significantly (p < 0.0001) associated with development of recurrent ICHs whereas other clinical and laboratory data were not. Conclusions Recurrent ICHs and MBs are common after long-term follow-up of primary ICH. The number of MBs on baseline GRE may predict the recurrence of the ICH.     

Visual search in patients with subcortical vascular dementia: short fixations but long reaction times

Visual search is a cognitive function of high ecological relevance. It involves rapid alternations between allocating and shifting attention. In patients with Alzheimer's disease, the duration of fixations during visual search increases already in the early stage of the illness. Subcortical vascular dementia (SVD), a newly defined subgroup of vascular dementia, has not yet been examined in this respect. SVD affects patients with a history of lacunar infarctions and/or transient ischemic attacks, focal neurological signs and evidence of subcortical white matter lesions as well as lacunes in the deep grey matter. Here, we report our findings from tracking eye movements during a visual search task with different array sizes in 9 patients with SVD and compare the number and duration of eye fixations they made with the values obtained in 9 healthy elderly control subjects. While patients with SVD were significantly slower in the tasks with longer center to target distances (mean reaction time), the number and duration of fixations they made did not differ from those in controls. Impairment of visual search in patients with SVD seems to be an effect of general cognitive slowing in more demanding arrays of visual search rather than a specific deficit in parameters of eye fixation.     

Cerebrovascular disease. Its characteristics from autopsy series in the Tokyo Metropolitan Geriatric Hospital during recent 30 years]

Of approximately 2,000 pathologically confirmed symptomatic CVD patients, atherothrombotic infarctions were found in 23%, lacunar infarctions in 18%, cardioembolic infarctions in 17%, hypertensive cerebral hemorrhages in 16%, lobar type hemorrhages in 3%, subarachnoid hemorrhages in 4%, progressive subcortical vascular encephalopathy of the Binswanger type (PSVE) in 8%, and others. Among 3 periods from 1975-1984, 1985-1994, 1995-2004, PSVE cases decreased during the last period, but there was no significant difference in the relative proportions of the other types of CVD during these 30 years. History of hypertension was recorded in 2/3-3/4 of the atherothrombotic infarction, in 3/4-4/5 of the lacunar infarction, and in 3/4-4/5 of the cerebral hemorrhage. Severe atherosclerosis in the main stem of cerebral arteries was found in about 3/4 of the atherothrombotic infarction, in about half of the lacunar infarction. Most frequent cardiogenic embolic source was nonvalvular atrial fibrillation showing about 3/4 of the embolic infarctions. The incidence of cerebral arterial aneurysm and of subarachnoid hemorrhage was higher in females than in males.     

Is 15 mm size criterion for lacunar infarction still valid? A study on strictly subcortical middle cerebral artery territory infarction using diffusion-weighted MRI

BACKGROUND AND PURPOSE: The 'lacunar hypothesis' has been challenged, since small (diameter <15 mm) subcortical infarcts can be produced by middle cerebral artery disease (MCAD) or cardioembolism (CE), while a larger infarct can occur without evidence of MCAD or CE. We sought to assess whether the lacunar hypothesis based on size is still valid. METHODS: We studied 118 patients who were admitted within 72 h after stroke onset and had acute deep subcortical MCA territory infarcts detected by diffusion-weighted MRI, and who had undergone angiography (mostly MR angiography). Stroke mechanisms were arbitrarily categorized regardless of lesion size: (1) MCAD when there was a corresponding MCA lesion; (2) internal carotid artery disease (ICAD) when there was a significant (>50%) ipsilateral ICAD; (3) CE when there was emboligenic heart disease without MCAD or ICAD, and (4) small vessel disease (SVD) when there was neither CE nor MCAD. SVD was further divided into definite SVD (dSVD, longest diameter <15 mm) or probable SVD (pSVD, longest diameter > or =15 mm). RESULTS: Seventy-three patients (62%) had SVD, of which 38 (32%) had pSVD and 35 (30%) dSVD. Thirty-three patients (28%) had MCAD, five (4%) CE, and seven (6%) ICAD. The infarct diameter in MCAD was not larger than in SVD (p = 0.35), and there was no difference in clinical features or risk factors between MCAD and SVD, or between pSVD and dSVD. CE was distinguished from SVD by its larger size and cortical symptoms. CONCLUSIONS: There are no clinical and lesion-size differences between MCAD and SVD, suggesting that there seems to be no rationale for the 15 mm size criterion for lacunar or small-vessel infarction.     

大脑中动脉狭窄脑深部小梗死发病机制的研究

目的 研究大脑中动脉粥样硬化性狭窄患者脑深部小梗死的发生频率和发病机制。方法86例发病时间〈1周的急件脑梗死患者，行经颅多普勒超声、彩色超声、磁共振血管造影及功能磁共振成像等检查方法被明确诊断为症状性大脑中动脉粥样硬化性狭窄，并排除颈内动脉病变、心源性栓塞以及非动脉粥样硬化性狭窄。利用磁共振扩散加权成像观察梗死灶的形态学表现及特点，分析其发病机制。结果37例（43．02％）症状性大脑中动脉粥样硬化性狭窄患者存在深部小梗死，多呈孤立性单发病灶。其中内囊纹状体梗死及巨大腔隙者18例（20．93％），梗死灶体积多超过两个层面，少数病灶呈多灶分布的特点；直径较小的腔隙性梗死19例（22．09％），梗死灶体积〈15mm，多位于一个层面内。伴有大脑中动脉粥样硬化性狭窄的深部小梗死的患者，病情多不稳定，预后较差。所有脑深部小梗死患者均伴有大脑中动脉主干支狭窄，且梗死灶体积与大脑中动脉粥样硬化性狭窄程度有关，内囊纹状体梗死多见于大脑中动脉重度狭窄者。结论约50％大脑中动脉粥样硬化性狭窄患者存在脑深部小梗死，其发病机制与大脑中动脉粥样硬化斑块或斑块残端血栓蔓延堵塞深穿支动脉入口有关。对此类患者的治疗不同于经典的腔隙性脑梗死。     

Intracerebral hemorrhage in young people: analysis of risk factors, location, causes, and prognosis

BACKGROUND AND PURPOSE: The frequency of intracerebral hemorrhages (ICHs) in people aged 31 years (odds ratio, 3.48), and those with ICH that resulted from arteriovenous malformations were aged <20 years (odds ratio, 2.80). The final outcome was considered favorable in 60%. CONCLUSIONS: ICHs in young people are mainly lobar in location and result from vascular malformation. Hypertension causes most cases in which the ICH is located in the basal ganglia. Mortality and morbidity in the acute phase are low and are related to hypertension as the cause of ICH.