Early differentiation of cardioembolic from atherothrombotic cerebral infarction: a multivariate analysis

The aim of this study was to determine factors predictive of cerebral infarction subtype from clinical data collected within 48 h of neurologic deficit. All cardioembolic (n = 231) and atherothrombotic infarctions (n = 369) included in prospective stroke registry of the Sagrat Cor-Alianza Hospital of Barcelona were analysed. Demographic characteristics, anamnestic findings, cerebrovascular risk factors and clinical data of patients with embolic stroke and patients with thrombotic infarction were compared. Predictors of stroke subtype were assessed by means of a logistic regression model based on 16 clinical variables. After multivariate analysis, atrial dysrhythmia and sudden onset to maximal deficit were significant predictors of embolic stroke, whereas hypertension, chronic obstructive pulmonary disease, diabetes, hypercholesterolemia and/or hypertriglyceridemia and age were independent predictive factors of atherothrombotic stroke. Setting a cut-off point of 0.50 for predicting mechanism of stroke on admission resulted in a sensitivity of 76%, specificity of 87% and total correct classification of 83%. Clinical features alone that are observed at stroke onset can help to distinguish cardioembolic from atherothrombotic infarctions.     

Large striatocapsular infarcts: clinical presentation and pathogenesis in comparison with lacunar and cortical infarcts

In a well-defined prospective series of 247 patients with a first-ever supratentorial brain infarct, 15 patients (6%; 95% confidence interval 3-9%) had a large striatocapsular infarct. Twelve (80%) had signs of cortical dysfunction, whereas risk factor profile, frequency of significant carotid stenosis, and frequency of potential cardioembolic sources did not differ between patients with striatocapsular and those with cortical infarction. However, patients with striatocapsular infarction more frequently had potential cardioembolic source and significant carotid stenosis than patients with lacunar infarction. Our findings show that large striatocapsular infarcts differ from lacunar infarcts with regard to both presenting signs and symptoms, and pathogenesis, whereas they resemble infarcts involving the cortex. Such patients should therefore be managed and treated as patients with cortical infarction.     

Ten year recurrence after first ever stroke in a Japanese community: the Hisayama study

BACKGROUND: Very few population based cohort studies have focused on the long term recurrence of stroke. OBJECTIVE: To examine 10 year cumulative recurrence rates for stroke in a Japanese cohort according to pathological type and clinical subtype of brain infarction. METHODS: During a 32 year follow up of 1621 subjects >/=40 years of age, 410 developed first ever stroke. These were followed up prospectively for 10 years after stroke onset. RESULTS: During follow up, 108 (26%) experienced recurrent stroke. The cumulative recurrence rates were 35.3% at five years and 51.3% at 10 years. The 10 year recurrence rates of subarachnoid haemorrhage (SAH), brain haemorrhage, and brain infarction were 70.0%, 55.6%, and 49.7%, respectively; the difference between SAH and brain infarction was significant (p = 0.004). Most recurrent episodes after SAH or brain haemorrhage happened within a year after the index stroke, whereas recurrence of brain infarction increased consistently throughout the observation period. Cardioembolic stroke had a higher recurrence rate (75.2%) than lacunar infarction (46.8%) (p = 0.049). The 10 year risk of stroke recurrence increased with age after lacunar or atherothrombotic brain infarction, but not after the other types or subtypes. After atherothrombotic brain infarction, cardioembolic stroke, or SAH, the type and subtype of most recurrent strokes were the same as for the index stroke, but recurrence after lacunar infarction or brain haemorrhage showed divergent patterns. CONCLUSIONS: Japanese people have higher recurrence rates of stroke than other populations. Recurrence rate after a first brain infarct increases consistently through the next 10 years.     

Lacunar versus non-lacunar infarcts: pathogenetic and prognostic differences.

To characterise the pathogenetic and prognostic features of lacunar infarcts, 88 patients with these infarcts were compared with 103 patients with non-lacunar infarcts. Potential cardioembolic sources were significantly more frequent among patients with non-lacunar infarcts (p = 0.0025). Although the prevalence of hypertension was higher among lacunar infarcts, this difference was not statistically significant. However, the distribution of hypertensive patients in the two groups of lacunar and non-lacunar infarcts was influenced by the presence or absence of cardioembolic sources: hypertension was significantly associated with the presence of cardioembolic sources among non-lacunar infarcts, whereas among lacunar infarcts it was significantly more frequent in patients without a cardioembolic source. This indicates that cardioembolism may exert a confounding effect by suppressing the relation between hypertension and lacunar infarcts. In a mean follow up period of 28.1 months, lacunar infarcts had a significantly lower incidence of stroke recurrence and of myocardial infarction (age-adjusted survival analysis: p = 0.0008); mortality from all causes was also lower in patients with lacunar infarct (age-adjusted survival analysis: 0.04 less than p less than 0.05). In a multivariate regression analysis, stroke subtype was an independent predictor of new major vascular events. These findings support the lacunar hypothesis and should be considered in the planning of epidemiological and therapeutic studies in patients with cerebral infarction.     

Lacunar infarcts in patients aged 85 years and older

OBJECTIVES: To compare the occurrence of lacunar infarcts in the very elderly ( > or = 85 years of age) and in patients below 85. MATERIAL AND METHODS: Data of 374 consecutive patients with lacunar infarcts were collected from a prospective hospital-based stroke registry in which 2000 patients are included. Distinctive clinical features of lacunar infarct in the very elderly were assessed by multiple logistic regression analysis. RESULTS: Lacunar infarcts were diagnosed in 39 (15%) of the 262 very elderly patients of our stroke registry. Lacunar infarcts in the very elderly accounted for 10.5% of all lacunes. There was no statistical difference in the occurrence of different lacunar syndromes between the very elderly patients and patients below 85. However, the very old group with lacunar infarct showed a significantly higher proportion of the female sex (56.4% vs 37.3%) and history of atrial fibrillation (28.2% vs 8.7%), chronic renal disease and pathologic condition and a significantly lower proportion of hypertension (61.5% vs 77.3%), diabetes (7.7%) vs 28.4%), ischemic heart disease, hypercholesterolemia, and absence of neurologic deficit at discharge from the hospital than patients below 85. After multivariate analysis only atrial fibrillation (OR = 3.77), female gender (OR =2.52), hypertension (OR = 0.35), and diabetes (OR = 0.16) were independent clinical factors for developing lacunar infarction in the very elderly. CONCLUSION: In the very elderly the higher occurrence of atrial fibrillation, the lower prevalence of hypertension and diabetes, and the greater focal neurological impairment suggest that the cardioembolic pathogenetic mechanisms may be more frequent than generally established for lacunar infarcts in stroke patients.     

The arterial lesions underlying cerebral infarction

The arterial lesions underlying cerebral infarction were reviewed by studying the pathological materials in the National Cardiovascular Center. The major clinical cate-gories of arterial lesion (i.e. atherothrombotic, cardio-embolic and lacunar strokes) were reviewed. Arterial lesions underlying striatocapsular infarction were reviewed separately. In order to analyze the mechanisms of the development of cerebral infarction, full postmortem ex-amination of patients dying shortly after the onset of stroke is necessary. Therefore, arterial lesions observed in acute stroke patients were the topic of this review. Two mech-anisms are responsible for atherothrombotic stroke: re-duced perfusion due to obstructive changes in the arteries and embolism. Cardioembolic stroke includes a special clinicopathological entity, cerebral infarction associated with non-bacterial thrombotic endocarditis. The mechan-isms of development of lacunar stroke are not studied sufficiently because the analysis of arterial lesions respons-ible for lacunes requires meticulous effort to examine serial sections of specially prepared specimens. Embolism of the middle cerebral artery (MCA) and abnormalities of the internal carotid artery (ICA) and MCA are responsible for striatocapsular infarction. The author emphasizes the need for postmortem examination of stroke patients, especially those dying shortly after the onset of stroke.     

Homogeneity of large and small vessel disease over time: Arguments from a study on recurrent stroke in 998 patients with first cerebral infarct

Background: Data on subtype and location of recurrent stroke after a first cerebral infarct may be relevant for prognosis and for understanding progression of the vascular disease underlying stroke subtypes over time. Therefore, we studied 30-day case fatality, stroke subtype, and stroke location in first and recurrent stroke, accounting for stroke subtype. Methods: We conducted a cross-sectional follow-up of 998 patients with first cerebral infarct registered in a hospital-based stroke registry. Results: After a follow-up of 691 ± 521 (SD) days, there were 138 (13.8%) first recurrent strokes, 84 (61%) of which had computed tomography. Recurrent stroke was of the same subtype as the first stroke in 27 (57%) of 339 lacunar, 38 (83%) of 435 atherothrombotic, and 33 (94%) of 224 cardioembolic cerebral infarcts. The annual stroke recurrence rate was about 7% for the whole group. Logistic regression analysis showed lacunar first stroke and hypertension as independent predictors for recurrent lacunar stroke, and atherothrombotic first stroke type for recurrent atherothrombotic stroke. Stroke recurrences that were of the same type as the first stroke occurred in the same brain area as the first stroke in 70% of lacunar and 79% of atherothrombotic cases. This was more frequent when compared with nonsimilar recurrence types: odds ratio (OR) 4.38, 95% confidence interval (CI) 1.09–15.79; and OR 5.63, 95% CI 1.38–22.92, respectively. Only 33% of cardioembolic recurrent strokes occurred in the same area. The 30-day case fatality in index and recurrent stroke was, respectively, 2% and 14% (OR 7.90, 95% CI 2.78–22.48) for lacunar, 10% and 26% (OR 3.27, 95% CI 1.62–6.60) for atherothrombotic, and 23% and 31% (OR 1.47, 95% CI 0.55–3.93) for cardioembolic index infarcts. Conclusions: The annual stroke recurrence rate after a first brain infarcts is about 7%. Early case fatality after recurrent stroke is higher than after first stroke, with marked differences between stroke subtypes. Progression of small and large vessel disease, and the brain area of their location, are rather homogeneous over time.     

Clinical study of 222 patients with pure motor stroke

The objective was to assess the frequency of pure motor stroke caused by different stroke subtypes and to compare demographic, clinical, neuroimaging, and outcome data of pure motor stroke with those of patients with other lacunar stroke as well as with those of patients with non-lacunar stroke. Data from 2000 patients with acute stroke (n=1761) or transient ischaemic attack (n=239) admitted consecutively to the department of neurology of an acute care 350 bed teaching hospital were prospectively collected in the Sagrat Cor Hospital of Barcelona stroke registry over a 10 year period. For the purpose of the study 222 (12.7%) patients with pure motor stroke were selected. The other study groups included 218 (12.3%) patients with other lacunar strokes and 1321 (75%) patients with non-lacunar stroke. In relation to stroke subtype, lacunar infarcts were found in 189 (85%) patients, whereas ischaemic lacunar syndromes not due to lacunar infarcts occurred in 23 (10.4%) patients (atherothrombotic stroke in 12, cardioembolic stroke in seven, infarction of undetermined origin in three, and infarction of unusual aetiology in one) and haemorrhagic lacunar syndromes in 10 (4.5%). Patients with pure motor stroke showed a better outcome than patients with non-lacunar stroke with a significantly lower number of complications and in hospital mortality rate, shorter duration of hospital stay, and a higher number of symptom free patients at hospital discharge. After multivariate analysis, hypertension, diabetes, obesity, hyperlipidaemia, non-sudden stroke onset, internal capsule involvement, and pons topography seemed to be independent factors of pure motor stroke in patients with acute stroke. In conclusion, about one of every 10 patients with acute stroke had a pure motor stroke. Pure motor stroke was caused by a lacunar infarct in 85% of patients and by other stroke subtypes in 15%. Several clinical features are more frequent in patients with pure motor stroke than in patients with non-lacunar stroke.     

Multicenter survey on clinical features and regional variations in acute brain infarction]

To assess the clinical features and regional variations in clinical profile of and managements for acute ischemic stroke patients, 14,864 patients with 3 major clinical categories of brain infarction (lacunar, atherothrombotic and cardioembolic stroke), among the acute ischemic stroke patients registered by 156 representative hospitals all over Japan (Japan Multicenter Stroke Investigators' Collaboration: J-MUSIC) during a period of one year from May 1999 to April 2000, were subjected to the study. Data were analyzed in each 7 geographic district (Hokkaido, Tohoku, Kanto, Chubu, Kinki, Chugoku/Shikoku and Kyushu). As for overall proportions of 3 major categories, lacunar stroke was the most common type (41.3%), followed by atherothrombotic (35.4%) and cardioembolic stroke (23.3%). In Kanto, Kinki and Chugoku/Shikoku Districts, however, proportion of atherothrombotic stroke was larger than that of lacunar stroke, which seemed to correspond to the higher frequency of patients with diabetes mellitus and hyperlipidemia in these 3 districts. Drug treatments, care and hospital facilities varied among districts considerably. Nation-wide consensus for ideal treatments by each stroke category is therefore needed.     

The Barcelona Stroke Registry

The Barcelona Stroke Registry was established to collect clinical data of hospitalized patients with stroke, in order to study their clinical characteristics and outcome. Data were collected over a 17-year period in 3,577 consecutive patients with first-ever stroke admitted to a stroke unit in two university hospitals in the city of Barcelona (Catalonia, Spain). Patients were generally admitted within 48 h from stroke onset, were evaluated by a neurologist, and clinical data were collected using a standardized protocol. All subjects underwent computerized tomography (CT) examination. Data on the 3,577 patients revealed the following stroke subtypes: cerebral infarction (81%), corresponding to the varieties of atherothrombotic (39.5%), cardioembolic (17.5%), lacunar (11%), unusual (5%), or unknown (8%); and cerebral hemorrhage. We analyzed age distribution (mean age 66 years); risk factors (the most frequent being hypertension, present in 54% of cerebral infarctions and in 65% of hemorrhages); clinical manifestations (the most salient being abrupt onset in one half of the cases; high frequency of decreased consciousness in cardioembolic infarction; headache, seizures and nuclear palsy in 'unusual' cerebral infarctions; vomiting and coma in hemorrhage); localizations by vascular territories; mechanisms of the various stroke subtypes; complications (present in one third of patients, with a mortality of 14%), and outcome. Two out of 3 hospitalized stroke patients are first-ever stroke sufferers. Neuroimaging shows a cerebral infarct in 86.5% of cases. Clinical and laboratory investigations cannot determine the mechanism of 8% of infarcts and of 23% of hemorrhages. The high frequency of medical complications, mortality, and disability highlights the need to establish stroke units and stroke registries in order to perform further research into the diagnosis and management of patients with cerebrovascular disease.     

Sensorimotor stroke; clinical features, MRI findings, and cardiac and vascular concomitants in 32 patients

Background and purpose – Sensorimotor stroke (SMS) is often included among the lacunar syndromes, although the underlying cause of this stroke-subtype is less well documented. To this end we analysed 32 patients presenting with a sensorimotor syndrome. Methods – The study protocol included vascular risk factors, echocardiography, Doppler sonography of carotid arteries, CT scan and MRI of the brain. Results – There were 23 men and 9 women, mean age 65.7 years. Hypertension was present in 28% and diabetes in 19%. In all, 63% had sensorimotor deficit of faciobrachiocrural areas and 37% had faciobrachial or brachiocrural deficits. MRI disclosed a presumably relevant infarct in 26 patients (81 YO); 20 patients (62%) localized to the territory of small perforating arteries, 3 patients (9.5%) in the internal borderzone, and 3 patients (9.5%) in cortical territories. Eight of 20 deep infarcts were larger than 15 mm. No hemorrhage or non-vascular lesion was found. A potential cardioembolic source was present in 5 patients (l6%), whereas 2 patients (6%) had an ipsilateral carotid stenosis >50%. Conclusions – Small vessel disease was the most likely cause in 69% of our patients with SMS, whereas 31% had a potential cardioembolic source, large artery disease or infarcts not compatible with perforating artery disease.     

Differences between hypertensive and non-hypertensive ischemic stroke

We compared risk factors, clinical features, neuroimaging data, and outcome between hypertensive and non-hypertensive ischemic stroke patients. Differential features of ischemic stroke patients with hypertension (n = 768) and without hypertension (n = 705) were assessed by bivariate analysis. Independent predictors of hypertensive ischemic stroke were determined by multivariate analysis. Atherothrombotic infarction and lacunar infarct were significantly more common in the hypertensive group, in which older age and a higher occurrence of previous cerebral infarction, hyperlipidemia, acute stroke onset, lacunar syndrome, and pons topography was also observed. Age of 85 years or older, valvular heart disease, and decreased consciousness were more common in non-hypertensive patients. After multivariate analysis, lacunar syndrome, female gender, and previous infarction were directly associated with hypertensive ischemic stroke. Age of 85 years or older and valvular heart disease were inversely associated with hypertensive ischemic stroke. Hypertension was the main cardiovascular risk factor only for lacunes and atherothrombotic infarction, that is, ischemic stroke associated with small- and large-artery disease.     

Should computed tomography appearance of lacunar stroke influence patient management?

Patients with a lacunar stroke syndrome may have cortical infarcts on brain imaging rather than lacunar infarcts, and patients with the clinical features of a small cortical stroke (partial anterior circulation syndrome, PACS) may have lacunar infarcts on imaging. The aim was to compare risk factors and outcome in lacunar syndrome (LACS) with cortical infarct, LACS with lacunar infarct, PACS with cortical infarct, and PACS with lacunar infarct to determine whether the clinical syndrome should be modified according to brain imaging. As part of a hospital stroke registry, patients with first ever stroke from 1990 to 1998 were assessed by a stroke physician who assigned a clinical classification using clinical features only. A neuroradiologist classified recent clinically relevant infarcts on brain imaging as cortical, posterior cerebral artery territory or lacunar. Of 1772 first ever strokes, there were 637 patients with PACS and 377 patients with LACS who had CT or MRI. Recent infarcts were seen in 395 PACS and 180 LACS. Atrial fibrillation was more common in PACS with cortical than lacunar infarcts (OR 2.3, 95% confidence interval (95% CI) 0.9-5.5), and in LACS with cortical than lacunar infarcts (OR 3.9, 1.2-12). Severe ipsilateral carotid stenosis or occlusion was more common in PACS with cortical than lacunar infarcts (OR 3.5, 1.3-9.5); and in LACS with cortical than lacunar infarcts (OR 3.7, 1.1-12). In conclusion, patients with cortical infarcts are more likely to have severe ipsilateral carotid stenosis or atrial fibrillation than those with lacunar infarcts irrespective of the presenting clinical syndrome. Brain imaging should modify the clinical classification and influence patient investigation.     

Early clinical differentiation of cerebral infarction from severe atherosclerotic stenosis and cardioembolism.

BACKGROUND AND PURPOSE: Hyperacute cerebral infarction trials require early differentiation of infarction subtype. Our aim was to determine clinical factors predictive of infarction subtype from data collected in the early hours of admission. METHODS: Using the 1,273 patients enrolled in the Stroke Data Bank, stroke risk factors and demographic, clinical, and radiological features were compared between the 246 cardioembolic and 113 large-vessel atherosclerotic cerebral infarcts. RESULTS: Stroke Data Bank definitions ensured more transient ischemic attacks in atherosclerotic infarcts and more cardiac disease in cardioembolic infarcts, but the diagnosis was distinguished further using a logistic regression model. Fractional arm weakness (shoulder different from hand) (odds ratio 3.1, 95% confidence interval [CI] 1.6-5.8), hypertension (odds ratio 2.8, CI 1.4-5.3), diabetes (odds ratio 2.5, CI 1.2-5.1) and male gender (odds ratio = 2.2, CI 1.2-4.1) occurred more frequently in patients with atherosclerotic than cardioembolic infarcts. Reduced consciousness (odds ratio = 3.2, CI 1.4-7.3) was more frequent in cardioembolism. For a male patient with hypertension, diabetes, and fractional arm weakness, the estimated odds of an atherosclerotic infarction were 47-fold that of a cardioembolic infarction. Patients with atherosclerotic infarcts were more likely to have a fractional arm weakness regardless of infarct size, whereas, for those with cardioembolic infarctions, fractional weakness was more frequent in infarcts less than 20 cc in volume. CONCLUSIONS: Clinical features that are observed at stroke onset can help distinguish cerebral infarction subtypes and may allow for early stratification in therapeutic trials.     

Clinical-computed tomographic correlations of lacunar infarction in the Stroke Data Bank

Lacunar stroke was diagnosed in 337 (26%) of the 1,273 patients with cerebral infarction among the 1,805 total in the Stroke Data Bank. We analyzed the 316 patients with classic lacunar syndromes. Among these, 181 (57%) had pure motor hemiparesis, 63 (20%) sensorimotor syndrome, 33 (10%) ataxic hemiparesis, 21 (7%) pure sensory syndrome, and 18 (6%) dysarthria-clumsy hand syndrome. No striking differences were found among the risk factors for the lacunar subtypes, but differences were found between lacunar stroke as a group and other types of infarcts. Compared to 113 patients with large-vessel atherosclerotic infarction, those with lacunar stroke had fewer previous transient ischemic attacks and strokes. Compared to 246 with cardioembolic infarction, patients with lacunar stroke more frequently had hypertension and diabetes and less frequently had cardiac disease. We found a lesion in 35% of the lacunar stroke patients' computed tomograms, with most lesions located in the internal capsule and corona radiata. The mean infarct volume was greater in patients with pure motor hemiparesis or sensorimotor syndrome than in those with the other lacunar stroke subtypes. In patients with pure motor hemiparesis and infarcts in the posterior limb of the internal capsule, there was a correlation between lesion volume and hemiparesis severity except for the few whose infarct involved the lowest portion of the internal capsule; in these patients severe deficits occurred regardless of lesion volume. Taken together, the computed tomographic correlations with the syndromes of hemiparesis showed only slight support for the classical view of a homunculus in the internal capsule.     

Role of a stroke data bank in evaluating cerebral infarction subtypes: patterns and outcome of 1,776 consecutive patients from the Besançon stroke registry

The purpose of this study was to estimate the frequency of various risk factors, courses and outcome of infarct subtypes in a large hospital-based stroke registry. METHODS: From 1987 to 1994, 1,776 stroke patients with a first-ever infarction were included in the Besan?on Stroke Registry. All patients were evaluated by a standard protocol (risk factors, stroke onset, stroke courses, clinical characteristics, neuroimaging, Doppler ultrasonography and cardiac investigations). Outcome was evaluated at 30 days using the Rankin scale. RESULTS: There were 1,012 men (mean age 67.2 +/- 13.7 years) and 764 women (mean age 71.4 +/- 15.6 years). At least two neuroimaging examinations were performed in 81.4% (n = 1,446) of the patients and an infarct was visible in 80.9% (n = 1,436). The second neuroimaging examination (CT or MRI) was performed after 8.2 +/- 1.6 days. 85.4% of patients were admitted on the first day of the stroke: 28.3% within 3 h and 48.4% within 6 h. In addition, stroke severity was well correlated with the short time interval between stroke onset and admission. Past medical history of hypertension was the major risk factor occurring in 57.5% of all types of infarction. While diabetes was more frequently found in small deep infarct, atrial fibrillation and history of heart failure were found in anterior circulation infarcts. The distribution of clinical presentations was conventional. Hemorrhagic transformation was found in 14.9% of the patients, especially in MCA and PCA infarcts. In all patients, logistic regression analysis determined independent predictive factors for death: clinical deterioration at the 48th hour (OR 7.5, 95% CI 4.9-11.3), initial loss of consciousness (OR 3. 3, 95% CI 2.1-4.9), age (OR 1.05, 95% CI 1.03-1.06), complete motor deficit (OR 2.6, 95% CI 1.7-3.8), history of heart failure (OR 1.9, 95% CI 1.3-3.0), lacunar syndrome (OR 0.25, 95% CI 0.10-0.60) and regressive stroke onset (OR 0.24, 95% CI 0.10-0.52). However, the outcome was clearly correlated with the infarct location. The in-hospital mortality rate was lowest in patients with small deep infarct (2.9%) or border zone infarcts (3.4%) and the highest in patients with total middle cerebral artery infarct (47.4%) or multiple infarcts (27.6%). CONCLUSION: Our registry appears to be a useful tool to understand the course and outcome of a large group of nonselected patients with subtypes of infarction. It can also help to analyze the influence of specific stroke management in the different categories of stroke types.     

Clustering of risk factors increases the incidence of echolucent carotid plaque in stroke patients

BACKGROUND: The purpose of this study was to assess the influence of clusters of risk factors on the incidence of echolucent carotid plaque in stroke patients. METHODS: A retrospective analysis of 413 stroke patients who had undergone carotid ultrasonography was performed. High-resolution B-mode ultrasonography was used to evaluate the characteristics of carotid plaque. We investigated the relationships between the incidence of echolucent carotid plaque and clustering of risk factors (hypertension, diabetes mellitus and hyperlipidemia) and stroke subtypes and transient ischemic attack (TIA). RESULTS: Echolucent plaques were present in 10.5% of patients free of risk factors, in 18.8% with a single risk factor (NS), in 27.7% with two risk factors (p <0.01) and in 50.0% with three risk factors (p <0.001), and were significantly more common in patients with multiple risk factors (odds ratio 1.79; 95% CI, 1.05-3.06; p = 0.045). Echolucent plaques were observed in 41.2% of patients with atherothrombotic infarction, in 17.6% with lacunar infarction, in 11.5% with cardioembolic stroke, and in 25.0% with TIA, and were significantly more common in patients with atherothrombotic infarction than in those with lacunar infarction or cardioembolic stroke (p<0.001), or in those with TIA (p <0.05). CONCLUSIONS: The clustering of risk factors increased the incidence of echolucent carotid plaque. Patients with multiple risk factors were at increased risk of echolucent plaque, and these had a significant relationship with atherothrombotic infarction compared with other stroke subtypes and TIA.     

Significance of serum soluble thrombomodulin level in acute cerebral infarction

The purpose of the present study was to investigate sequential changes in serum soluble thrombomodulin (sTM) concentrations in patients with acute cerebral infarction (ACI), and to correlate sTM concentrations with the severity of ACI evaluated by Japan Stroke Scale. Eighty-three consecutive patients with ACI were enrolled, and blood examinations were carried out soon after admission and 1 month after. sTM concentrations at admission in patients with cardioembolic infarction (3.2 +/- 1.2 ng/ml) were significantly lower than those of lacunar infarction (3.9 +/- 1.2) (P < 0.05). Serial examinations revealed that sTM concentrations increased significantly 1 month after admission (3.8 +/- 1.2), compared with those at admission (3.6 +/- 1.2) (P = 0.02). Of three ACI subtypes, sTM concentrations during 1 month significantly increased in atherothrombotic infarction (P = 0.002) or, not significantly, in cardioembolic infarction (P = 0.09). The sTM concentrations at admission showed a significant inverse correlation with the severity of ACI (P = 0.04). Although sTM concentrations serve as a useful marker for endothelial cell damage, they are decreased in patients with severe ACI, especially in atherothrombotic and cardioembolic infarctions. Lower sTM concentrations may play some important role in disease progression or in the recurrence following ACI, although the exact mechanism of this unique result should be clarified.     

High prevalence of unrecognized cerebral infarcts in first-ever stroke patients with cardioembolic sources

Background:  With magnetic resonance imaging (MRI) analysis, we investigated the prevalence, clinical significance, and factors related to the presence of unrecognized cerebral infarcts in patients with first-ever ischaemic stroke.
Methods:  We consecutively included patients who were admitted with first-ever stroke. Unrecognized cerebral infarct was defined as an ischaemic infarction or primary intracerebral hemorrhage on MRI irrelevant to the index stroke, without acute lesions on diffusion-weighted image.
Results:  Of the total 203 patients, 78 (39.4%) patients were observed as having unrecognized cerebral infarct. Patients with high-risk cardioembolic sources (e.g., atrial fibrillation) more frequently had unrecognized stroke than those without ( P  = 0.008, 21/36 [58.3%] vs. 57/167 [34.1%]). On univariate analysis, male sex ( P  = 0.027) and cardioembolic source ( P  = 0.008) were associated with the presence of unrecognized cerebral infarcts. After adjustment for gender, age and risk factors, the presence of cardioembolic sources independently increased the risk of unrecognized cerebral infarct ( P  = 0.002, odds ratio 3.56, 95% confidence interval 1.58–8.02). Regarding clinical outcome at 3 months, the presence of unrecognized cerebral infarct was not associated with the poor clinical outcome.
Conclusion:  In our study, the presence of cardioembolic sources was an independent risk factor for the unrecognized cerebral infarct in patients with first-ever stroke.     

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.