Thrombolysis in patients with lacunar stroke is safe: an observational study

Research suggests that the etiology of lacunar stroke is different from that of other stroke subtypes. This could imply an altered response to thrombolysis, but data concerning the efficacy of rt-PA in lacunar stroke is limited and inconsistent. From our prospectively collected stroke database, we identified patients with an MRI-confirmed purely lacunar stroke that were treated in our Stroke Unit between 2004 and 2011. We compared both the clinical course (NIHSS, deterioration, mRS at 3 months) and the MRI findings between patients who either received or did not receive rt-PA. In comparison to patients who obtained standard medical care (n = 468), acute lacunar stroke patients treated with rt-PA (n = 69) were more severely affected on admission (median NIHSS of 5 vs. 3; p < 0.001) and presented less frequently with a lacunar syndrome (74 vs. 88 %; p = 0.003). The clinical course was more favorable in patients treated with rt-PA (median NIHSS improvement of 3 vs. 1; p < 0.001), while functional deficit after 3 months was similar in both groups (median mRS of 2; p = 0.211). Overall complication rates did not differ significantly between the two groups, but while we did not detect symptomatic intracranial hemorrhage, hemorrhagic transformation was more frequent in thrombolyzed patients (11.6 vs. 1.9 %; p = 0.001). Patients with acute lacunar stroke benefited from thrombolysis without additional complications. Thus, patients with suspected acute lacunar stroke or lacunar syndrome should not be treated differently than other stroke populations.     

腔隙性脑梗死和动脉粥样硬化血栓性脑梗死患者微量蛋白尿的研究

目的明确脑梗死患者微量蛋白尿(MA)阳性率及腔隙性脑梗死(lacunar infarction,LI)和动脉粥样硬化血栓性脑梗死(atherothrombotic infarction,AI)患者MA阳性率是否存在差别。方法采用竞争性放射免疫分析方法对未合并肝肾功能不全等影响尿蛋白排泄率(UAER)检测结果的83例LI和78例AI患者,以及40例原发性高血压对照者进行UAER测定。统计脑梗死患者MA的阳性率,比较合并高血压的LI、AI与高血压对照组MA阳性率。结果161例脑梗死患者MA阳性率为42·9%;单纯合并高血压病史的45例LI患者和34例AI患者MA阳性率分别为51·1%和58·8%,均高于高血压对照组(P<0·05),但两组间比较无统计学意义。结论脑梗死患者呈现MA高发率;合并高血压病史的LI和AI患者MA阳性率无差别;MA会增加脑梗死的发生风险。     

A case-controlled study of cognitive progression in Chinese lacunar stroke patients

OBJECTIVE: (1) To determine and compare the rates of cognitive change using global and executive psychometric measures between lacunar stroke patients and matched controls and; (2) to identify features associated with cognitive changes in patients. METHODS: Sixty-one lacunar stroke patients and 35 demographically-matched controls were followed-up for 28.6 months (range 19.4-45.9 months) with psychometric assessments performed at baseline and follow-up. RESULTS: Lacunar stroke patients were more impaired than controls in general and executive functions at both time points. Both groups had similar stability in all psychometric tests. Patients, but not controls, exhibited a trend for improvement in general cognitive functions overtime (interaction term, p=0.084). No patient who was non-demented at baseline became demented during the study period. Two (5.7%) and five (8.2%) incident cerebrovascular events occurred among the controls and patients, respectively. Linear regression analyses performed upon patients failed to identify any predictor for the cognitive change. CONCLUSION: Similar to controls, cognition in lacunar stroke patients is stable during the first 2-3 years after the stroke. There maybe a spontaneous improvement in general cognition overtime, but this awaits confirmation by future studies.     

Risk factors for lacunar stroke: a case-control transesophageal echocardiographic study

To reassess the independent risk factors for lacunar stroke and to clarify the role of potential embolic sources, we conducted a case-control study using transesophageal echocardiography and duplex ultrasonography. Among 62 consecutive patients with their first lacunar stroke and 202 normal controls, we found that hypertension (p < 0.001), smoking (p = 0.001), and aortic arch atheroma (p = 0.006) were independently associated with an increased risk of lacunar stroke. Whether proximal aortic arch atheroma is mechanistically associated with lacunar stroke or merely coexistent is uncertain.     

Restricted pain and thermal sensory loss in a patient with pontine lacunar infarction: a clinical MRI study

Pure sensory syndrome (PSS) is characterized by hemisensory symptoms without other major neurological signs. It was initially attributed to thalamic lacunar infarction, but several reports have shown the PSS can be due to small infarcts involving the posterior part of the internal capsula, the cerebral cortex and the brainstem. Paramedian and lateral pontine infarctions are associated respectively with lemniscal and spinothalmic (ST) sensory impairment. We describe a patient with an isolated impairment of the ST modalities caused by a segmental paramedian pontine infarction.     

Recurrent pontine base infarction: a controlled study

OBJECTIVES: To assess the clinical features of and risk factors for recurrent pontine base infarction. METHODS: This study includes 5 patients with unilateral pontine base infarction who developed another infarction on the opposite side and, for comparison, 10 follow-up period-matched patients with unilateral pontine base infarction who did not develop recurrent pontine infarction. MRI and angiogram studies were performed in all cases. The two groups were compared. RESULTS: The patients with recurrent pontine base infarction developed quadriparesis, dysarthria and dysphagia. MRI showed bilateral infarcts abutting on the basal surface of the pons. Angiogram studies revealed diseased basilar artery in 3 patients. There were no differences regarding age, gender, angiogram findings and frequency of hypertension, diabetes mellitus, cigarette smoking and hypercholesterolemia between the patients with recurrent stroke and those without. However, the former had a significantly higher number of risk factors for atherosclerosis (p < 0.05) and higher frequency of coronary heart disease (p < 0.05) than the latter. CONCLUSIONS: The number of risk factors for atherosclerosis and a concomitant presence of coronary heart disease may be factors related to recurrent pontine base infarction in patients with unilateral pontine infarction. The main pathogenesis of recurrent pontine base infarction seems to be basilar artery branch atherothrombosis.     

Depression in silent lacunar infarction: a cross-sectional study of its association with location of silent lacunar infarction and vascular risk factors

Most previous studies reported a close link between fresh infarcts and post-stroke depression. However, studies on the relation of depression and silent lacunar infarction (SLI) are limited. This study aims to analyze the effects of SLI and the vascular risk factors on depression. A total of 243 patients with SLI were divided into depression and non-depression groups. The presence and location of SLI were evaluated with magnetic resonance imaging. Depression was assessed with the Patient Health Questionnaire-9 and vascular risks factors were collected. We used t tests and χ ² test to compare the baseline characteristics of the two groups and the multivariate logistic regression model to identify the risk factors for depression. Univariate analysis results showed that the proportion of patients with SLI in basal ganglia was significantly higher in the depression group (65.0 versus 32.8 %; P < 0.001) than in the non-depression group, and multiple prevalent factors had significant differences between the two groups. However, on multivariate logistic analysis, some of these factors were eliminated, and SLI in basal ganglia remained an independent predictor of depression with an odds ratio of 3.128 (P = 0.018). In addition, vascular risk factors, including high body mass index level, presence of inflammation markers (e.g., CRP, TNF-α, Hs-CRP, and IL-6), and lack of physical activity, were associated with depression. Our findings suggest that SLI in basal ganglia is associated with a higher risk of depression. Vascular risk factors, which are intertwined, may propose the pathological basis of depression in SLI.     

Carotid angiography in patients with lacunar infarction. A prospective study

We prospectively studied the results of carotid angiography in 45 patients with transient or nondisabling neurologic deficits caused by lacunar infarction in the internal capsule or corona radiata and demonstrated by computed tomography. An ipsilateral stenosis at the bifurcation of the internal carotid artery was found in 14 patients (31%, 95% confidence limits 18-47%), seven of whom also had stenosis of the contralateral internal carotid artery. In previous studies an average of 65% of patients with transient hemispheric deficit had internal carotid artery stenosis or occlusion. Hypertension and hypertensive retinal vasculopathy assessed by fundus photographs were found in most patients, but not significantly more often in the patients without internal carotid artery stenosis. Our findings support the notion that small vessel disease rather than emboli from the carotid bifurcation is the most common cause of lacunar infarction.     

Depressive symptoms following ischemic stroke: a study of 207 patients

Depression is a frequent and important problem for patients who have experienced strokes. The purpose of this study was to assess the prevalence of depressive symptoms, their clinical correlations, and the effects of depressive symptoms on stroke recovery. A consecutive cohort of 207 ischemic stroke patients with a mean age of 64 years, were studied for ascertaining any correlation between potential risk factors and the incidence of post-stroke depression (PSD). Depressive symptoms were relatively common (34.3% Hamilton depression rating scale > 10), but the prevalence of severe depression (HDRS > 17) was only 7.7%. Patients with depressive symptoms were more likely to be female, have a family history of depression, and a poor functional outcome. There were no significant differences between depressive symptoms and age, marital status, location of stroke lesion, and duration after stroke onset. Our findings indicate that depressive symptoms occurred in about one third of post stroke patients. There is a negative correlation between depressive symptoms and functional status of the patients.     

In-hospital myocardial infarction following acute ischaemic stroke: an observational study

Background and purpose: Acute myocardial infarction is expected to be an important medical complication following ischaemic stroke. We sought to describe the frequency and clinical impact of in‐hospital myocardial infarction following acute ischaemic stroke. Methods: Consecutive patients with acute ischaemic stroke were identified from the Registry of the Canadian Stroke Network (2003–2006). Stroke severity was measured using the Canadian Neurological Scale (CNS). Functional status at discharge was measured with the modified‐Rankin Scale, and categorized into strokes with no or mild‐moderate dependency (m‐Rankin 0–3) and those with severe dependence or death (m‐Rankin 4–6). Multivariable logistic regression was used to determine the association between myocardial infarction and clinical outcome (death or severe dependence at hospital discharge and 1 year mortality), independent of co‐morbidities and in‐hospital medical complications. Results: In total, 9180 patients with acute ischaemic stroke were included. The mean age was 72 years (SD 13.9) and 48% were female. Overall, 211 (2.3%) patients were reported to have myocardial infarction during hospitalization. At hospital discharge, 64.9% of patients with in‐hospital myocardial infarction had died or were severely disabled, compared with 35.8% in the entire cohort. Mortality at 1 year after ischaemic stroke was 56.4% in patients with myocardial infarction and 21.9% in the entire cohort. On multivariable analyses, myocardial infarction was also associated with death or severe dependence at discharge (OR 2.51; 95%CI 1.75–3.59) and mortality within 1 year (HR 1.83; 95%CI 1.51–2.23). Previous history of myocardial infarction (OR 1.50; 95%CI 1.05–2.15), diabetes mellitus (OR 1.55; 95%CI 1.42–2.10), stroke severity (OR 1.13; 95% CI 1.09–1.17) and peripheral vascular disease (OR 1.61; 95%CI 1.04–2.49) were independently associated with myocardial infarction during hospitalization. Conclusions: Myocardial infarction is an important medical complication after acute ischaemic stroke.     

腔隙性脑梗死的临床特点及病因分析

目的探讨腔隙性脑梗死的临床特点,并分析脑梗死发生的原因。方法对102例腔隙性脑梗死患者的临床资料进行回顾性分析。结果本组病例中,腔隙性脑梗死的发病年龄30～82岁,男女比例为1.68:1;梗死发生的部位以基底节区最多,占56.9%,多发性腔隙性脑梗死占60.8%;在发病因素中,以合并高血压者最多,为84例,占82.4%;血管影像学检查发现,患者多存在颅内或颅外动脉粥样硬化,且以颈内动脉系统多见。结论腔隙性脑梗死临床表现多样,高血压、糖尿病、心脏病、动脉粥样硬化等在腔隙性脑梗死的发病中起重要作用。     

A novel embolic stroke model resembling lacunar infarction following proximal middle cerebral artery occlusion in beagle dogs

It is estimated that lacunar infarcts account for 25% of all ischemic strokes, but its exact etiology is still on debating. The existing controversies include whether the embolisms can indeed cause lacunar stroke in humans or animal models. We hypothesized that lacunar infarction can be induced by the proximal middle cerebral artery (MCA) segmental occlusion involving the orifices of lenticulostriate arteries in animal models, which have abundant distal cerebral collateral anastomosis. Our work here establishes a proximal MCA occlusion model using thrombi (autologous blood clots about 1.7 mm in diameter and 5 mm in length) in 8 beagle dogs, evaluates the progression of ischemic lesions at 30 min interval within 6 h after embolization using the diffusion weighted imaging (DWI), and discusses the potential mechanisms of lacunar infarction. Our results indicate that the left proximal MCAs can be successfully occluded in all dogs using interventional single-thrombus method. The small solitary or multiple ischemic lesions shown in DWI were observed in the deep brain area, with the mean detecting time of 1.21 ± 0.45 h using DWI and diameter of 6.62 ± 0.60mm in 6h-DWI after procedure. In conclusion, our method established an ischemic model which can recapitulate the radiologic and histologic changes in lacunar infarcts, suggesting that emboli can cause lacunar infarcts in animal model.