Clinical study of lacunar infarcts in non-hypertensive patients

Lacunar infarcts in non-hypertensive patients have been scantly assessed. The objective of this study was to determine clinical features of lacunar infarct in patients without hypertension (n = 91) in comparison with characteristics of lacunar infarcts occurring in patients with hypertension (n = 283) collected from a prospective hospital-based stroke registry in which 2000 patients with acute stroke are included. Predictors of lacunar infarct in patients without hypertension were assessed by multiple logistic regression analysis. The group of non-hypertensive patients with lacunar infarction showed a significantly higher frequency of male gender, age 85 years or older, history of atrial fibrillation, chronic obstructive pulmonary disease and diabetes mellitus, and a significantly lower frequency of female gender and absence of limitation at hospital discharge than hypertensive patients with lacunar infarct. Differences between hypertensive and non-hypertensive patients in relation to frequency of the different lacunar syndromes were not observed. After multivariate analysis, age 85 years or older (odds ratio 3.13), diabetes (odds ratio 2.57), and male gender (odds ratio 1.99) seemed to be independent factors associated with lacunar infarct in patients without hypertension. Lacunar infarct in non-hypertensive patients showed some differential clinical features compared to the remaining lacunar infarctions because it occurred more frequently in male patients aged 85 years or older. In this group, diabetes was the most important modificable risk factor. These results suggest an ealier effect of arteriopathy caused by hypertension favoring lacunar brain ischemia, whereas in non-hypertensive patients, arteropathy responsible for small vessel disease would take a more prolonged time in causing lacunar infarction.     

Different vascular risk factor profiles in ischemic stroke subtypes: a study from the "Sagrat Cor Hospital of Barcelona Stroke Registry"

OBJECTIVES: To characterize the vascular risk factor profiles in different subtypes of ischemic stroke. MATERIAL AND METHODS: The study population consisted of 1473 consecutive ischemic stroke patients collected in a prospective stroke registry. The prevalence of vascular risk factors in each stroke subtype was analyzed independently and in comparison with other subtypes of stroke pooled together by means of univariate analysis and logistic regression models. RESULTS: Hypertension was present in 52% of patients followed by atrial fibrillation in 27% and diabetes in 20%. The pattern of risk factors associated with atherothrombotic stroke included chronic obstructive pulmonary disease (COPD) (odds ratio [OR] = 2.63), hypertension (OR = 2.55), diabetes (OR = 2.26), transient ischemic attack (OR = 1.61), and age (OR = 1.03). Previous cerebral hemorrhage (OR = 4.72), hypertension (OR = 4.29), obesity (OR = 2.45), and diabetes (OR = 1.73) were strong predictors of lacunar stroke. In the case of cardioembolic stroke, atrial fibrillation (OR = 22.24), valvular heart disease (OR = 10.97), and female gender (OR = 1.66) occurred more frequently among patients with this stroke subtype than among the other stroke subtypes combined. CONCLUSION: Different potentially modifiable vascular risk factor profiles were identified for each subtype of ischemic stroke, particularly COPD in the case of atherothrombotic stroke and previous cerebral hemorrhage and hypertension in the case of lacunar infarction.     

Cardiovascular risk factors in patients aged 85 or older with ischemic stroke

OBJECTIVES: To define a cardiovascular risk factor profile in very old patients with ischemic stroke. PATIENTS AND METHODS: Data from a prospective hospital-based stroke registry was collected. Demographic characteristics and cardiovascular risk factors in individuals aged 85 years or older with ischemic stroke (n=303) were compared with patients under 85 years (n=1537). RESULTS: The study population accounted for 16.5% of all cases of ischemic stroke. The mean (S.D.) age was 88.2 (2.8) years (70% women). Hypertension occurred in 44.9% of patients, atrial fibrillation in 42.6%, diabetes in 16.2%, and congestive heart failure in 15.5%. The most frequent stroke subtypes were cardioembolic (36%) and atherothrombotic (31.4%) infarction. Congestive heart failure (odds ratio [OR]=3.62), chronic renal disease (OR=2.54), female sex (OR=2.27), previous cerebrovascular disease (OR=1.71), and atrial fibrillation (OR=1.38) were significantly associated with ischemic stroke, whereas diabetes (OR=0.68), hypertension (OR=0.61), hyperlipidemia (OR=0.45), and heavy smoking (OR=0.21) occurred more frequently in patients under 85 years. CONCLUSION: Adequate treatment of potentially modifiable risk factors, including congestive heart failure, chronic renal disease, and atrial fibrillation may contribute to prevent ischemic stroke in very old people.     

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.     

How often is non-valvular atrial fibrillation the cause of brain infarction?

Summary To calculate how often non-valvular atrial fibrillation should be considered as the cause of ischaemic stroke rather than an incidental finding as in primary cerebral haemorrhage, the frequency of non-valvular atrial fibrillation in 75 consecutive patients with primary intracerebral haemorrhage was compared with that in 63 patients with cortical infarcts and 44 patients with lacunar infarcts who were taken at random from 1487 consecutive patients with cerebral infarcts admitted during the same period. The frequency of non-valvular atrial fibrillation in lacunar infarcts did not differ from that in primary intracerebral haemorrhage (odds ratio: 1.28; 95% confidence interval: 0.32–5.1) (P=1.0), whereas it was significantly higher in cortical infarcts (odds ratio: 5.57; 95% confidence interval 2.00–15.4) (P=0.0001). Our findings suggest that non-valvular atrial fibrillation in lacunar infarcts, as in primary intracerebral haemorrhage, is unlikely to be the cause of this type of stroke, whereas perhaps 30% of all cortical infarcts are not caused by non-valvular atrial fibrillation when present. These data are important for the planning and explanatory evaluation of trials on the preventive effect of anticoagulants in stroke patients with non-valvular atrial fibrillation.     

Clinical characteristics of acute lacunar stroke in women: emphasis on gender differences

There are few studies analyzing features of ischemic stroke subtypes in women. We assessed gender differences in lacunar stroke subtype based on data collected from a prospective stroke registry in Barcelona, Spain. Lacunar ischemic stroke was diagnosed in 310 (8.1 %) women and 423 (11.1 %) men of a total of 3,808 consecutive stroke patients included in a prospective hospital-based stroke registry, in Barcelona, Catalonia (Spain), over a period of 19 years. Independent factors for lacunar stroke in women were assessed by multivariate analysis. Women accounted for 42 % of all lacunar stroke patients (n = 733) in the registry and 11.4 % of all patients with ischemic stroke (n = 2,704). Very old age (85 years or older) was found in 20.3 % in women versus 11.1 % in men (P < 0.0001). In the logistic regression analysis, obesity [odds ratio (OR) = 4.24], prolonged hospital stay (>12 days) (OR = 1.59), arterial hypertension (OR = 1.50), and age (OR = 1.06) were significant variables independently associated with lacunar stoke in women, whereas peripheral vascular disease (OR = 0.51), chronic obstructive pulmonary disease (OR = 0.46), renal dysfunction (OR = 0.13), and heavy smoking (OR = 0.04) were independent variables for lacunar stroke in men. Women with lacunar stroke were remarkably older and presented with obesity and hypertension more frequently than did men. Lacunar stroke severity was similar in men and women. These findings in lacunar stroke patients could be explained by differences in gender for ischemic stroke in general.     

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.     

Risk factors and subtype analysis of acute ischemic stroke

Background and Purpose: Stroke risk factors and subtypes were examined for associations with mortality and recurrence rate in Taiwanese patients with first-ever and recurrent stroke. Methods: This study examined patients with initial and recurrent stroke from 2003 to 2005 for risk factors, demographic data, Bamford subtypes and transient ischemic attack. Results: One thousand and twenty-one patients with 1,085 stroke episodes were recruited. Significant factors associated with recurrent stroke were hyperlipidemia, atrial fibrillation and smoking. A significant incidence of lacunar infarction was noted in the patient population (37.82% in all patients; 41.02% in first stroke vs. 35.67% in recurrent stroke patients). Patients with diabetes mellitus were more likely to have lacunar rather than total anterior circulation infarction (TACI) or partial anterior circulation infarction (PACI). Hyperlipidemia was more often attributable to lacunar stroke than PACI. Atrial fibrillation was significantly associated with nonlacunar infarcts, TACI and PACI but not lacunar stroke. Conclusions: The incidence of lacunar infarction was significantly higher in initial rather than recurrent stroke patients. Diabetes mellitus or hyperlipidemia was highly associated with lacunar infarction. Atrial fibrillation was associated with nonlacunar infarction in Taiwan, similar to the result of White and Black populations in the UK.     

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.     

前循环急性多发脑梗死危险因素及病因分析

目的:了解前循环急性多发脑梗死(AMBI)发病危险因素及病因分析.方法:连续收入73例前循环AMBI患者为试验组,随机收集73例同期入院的前循环急性单发脑梗死(ASBI)患者为对照组.对可能影响AMBI发病的14个危险因素分别进行单因素分析及多元Logistic逐步回归分析.病因分型采用改良TOAST分型方法.结果:AMBI组与ASBI组相比,高血压病、糖尿病、心房颤动、吸烟、年龄及入院时收缩压等危险因素两组间差异有统计学意义.Logistic回归分析显示,年龄(OR=1.03,95%CI:1.01~1.13)、高血压(OR=2.78,95%CI:1.06~7.58)、心房颤动(OR=3.19,95%CI:1.13~9.07)为AMBI发病独立危险因素.与ASBI患者相比,48例一侧半球AMBI患者,动脉粥样硬化血栓形成是其主要病因(P=0.03); 25例双侧半球AMBI患者,心源性栓塞是其主要病因(P=0.01).结论:年龄,高血压病、心房颤动为AMBI发病独立危险因素.动脉粥样硬化血栓形成是一侧半球AMBI患者主要病因;心源性栓塞是双侧半球AMBI患者主要病因.     

Magnetic resonance imaging white matter hyperintensities and mechanism of ischemic stroke.

BACKGROUND AND PURPOSE: We sought to determine the relations between infarct subtype and white matter hyperintensities (WMHIs) on MRI. MATERIALS AND METHODS: We studied 395 ischemic stroke patients with 1. 0-T MRI. The number of lacunar, border-zone, and cortical infarcts was registered. WMHIs were analyzed in 6 areas. Univariate and multivariate statistical analyses were used to find the risk factors for different infarct subtypes and to study the connections between WMHIs and brain infarcts. RESULTS: Lacunar infarcts were associated with hypertension (odds ratio [OR], 1.79; 95% CI, 1.17 to 2.73), alcohol consumption (OR, 1.96; 95% CI, 1.17 to 3.28), and age (OR, 1. 03; 95% CI, 1.00 to 1.06). Border-zone infarcts were associated with carotid atherosclerosis (OR, 2.20; 95% CI, 1.15 to 4.19). Atrial fibrillation (OR, 3.02; 95% CI, 1.66 to 5.50) and carotid atherosclerosis (OR, 1.94; 95% CI, 1.12 to 3.36) were independent positive predictors, and history of hyperlipidemia (OR, 0.44; 95% CI, 0.26 to 0.75) and migraine (OR, 0.48; 95% CI, 0.25 to 0.93) were negative predictors for cortical infarcts. Patients with lacunar infarcts had more severe WMHIs than patients with nonlacunar infarcts in all WM areas (P相似文献   

80岁以上高龄患者急性脑梗塞的临床特点分析

目的:探讨超过80岁的高龄急性脑梗塞患者的临床特点。方法:58例高龄(均≥80岁)急性脑梗塞患者,大多数行头颅MRI平扫加弥散加权成像(DWl),少数行CT检查。依影像学结果按梗塞病灶的大小分为两组:大面积梗塞(直径>1.5cm)及小面积梗塞(直径≤1.5cm,主要为腔隙性梗塞)组。回顾比较两组间发病特点;糖尿病、高血压、颈动脉硬化、冠心病、房颤的发生率;治疗方法、平均住院时间、30天病死率、日常生活活动能力(ADL)等临床指标。结果:大面积梗塞组占16例(27.6%),小面积梗塞组占42例(72.4%)。首发症状中大面积梗塞组以意识障碍(87.5%vs23.8%;P=0.018)、严重偏瘫(93.8%vs28.6%;P=0.012)、头痛(43.8%vs14.3%;P=0.026)、言语障碍等症状为主,小面积梗塞以以肢体无力、行走不稳(64.3%vs6.3%;P=0.001)、头昏、眩晕(52.4%vs25.0%;P=0.028)、言语不清、感觉障碍等症状为主。大面积梗塞组房颤高发(43,8%vs14.3%;P=0.030),小面积梗塞组高血压(88.1%vs56.3%;P=0.041)、糖尿病(54.8%vs18.8%;P=0.021)高发。在大面积梗塞组急性期用低分子肝素抗凝较多(75.0%vs40,5%;P=0.035),两组均以口服抗血小板药物为主。大面积梗塞组的并发症较多,平均住院日为小面积梗塞组的近二倍,死亡率较后者明显增高(25.0%vs4.8%;P=0.035)。结论:高龄急性脑梗塞患者以较小面积的腔隙性脑梗塞多见。小面积梗塞组高血压、糖尿病的发生较高。大面积梗塞组房颤的发生较高,有较高的死亡率,预后较差,需要更积极的综合诊治管理。常规尽早行头颅MRI加DWI有助于急性脑梗塞的早期诊断治疗。     

Factors predisposing to small lacunar versus large non-lacunar cerebral infarcts: is left ventricular mass involved?

Abstract

Objectives:

To find some specific determinants of lacunar strokes (LS), this study compared LS and non-LS patients using the size and location of cerebral lesions as discriminant between the two groups.

Methods:

The main cardiovascular risk factors and some echocardiographic parameters were assessed in 225 ischemic stroke patients aged 75·1±11·4 (SD) years, including 101 patients with symptoms and lesions of lacunar type (deep hypodensities with diameter ≤ 1·5 cm) and 124 patients with non-lacunar lesions.

Results:

LS patients tended to be younger and had a higher prevalence of smokers than non-LS patients. In a subgroup undergoing echocardiogram, those with LS had a higher left ventricular mass index (LVMI) than non-LS patients (141·6±44·9 vs. 115·1±31·8 g/m², P = 0·005). The prevalence of hypertension, diabetes, and carotid stenoses > 50% was similar in the two groups. In multivariable analysis the ever-smoker status (OR = 1·9, P = 0·02), atrial fibrillation (inverse association, OR = 0·5, P = 0·03), LVMI ≧ 130 g/m² (OR = 6·6, P = 0·001), and age ≤ 72 years (OR = 5·9, P = 0·003) remained independently associated with LS.

Conclusions:

The patients with lacunar cerebral lesions had a greater left ventricular mass than those with non-lacunar lesions, while blood pressure values did not differ. Lacunar lesions were also associated with smoking and a younger age.     

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.     

Transoesophageal echocardiographic findings in patients with ischemic lacunar and nonlacunar stroke.

The aim of this study was to compare risk factors and concomitant potential cardioembolic sources detected by transthoracic (TTE) and transoesophageal echocardiography (TEE) in patients with lacunar and nonlacunar infarcts. Clinical data of 139 patients with a first episode of ischemic stroke who underwent both TTE and TEE were analysed. Patients were divided into two groups, lacunar (LACI=36), and nonlacunar infarcts (NLACI=103); then the latter group was divided into two subgroups, anterior (ACI=76) and posterior circulation infarct (POCI=27). Presence of hypertension and diabetes mellitus were not significantly different between LACI and NLACI groups. The rate of potential cardioembolic risk factors detected by echocardiography was similar in the NLACI groups. At least one potential cardiac source of embolism was identified in 44% (n=16) of LACI, 52.6% (n=40) of ACI and 55.5% (n=15) of POCI patients. Atrial fibrillation was significantly frequent in the ACI group. No significant differences were found between all groups regarding age, sex, hyperlipidemia, and smoking. Our findings demonstrate that hypertension and diabetes mellitus are equally important in the pathogenesis of both LACI and NLACI groups and there is a need for careful cardiac evaluation in cases even with lacunar infarct.     

Early recurrence of ischemic stroke in Japanese patients: the Japan standard stroke registry study

BACKGROUND: To determine the factors that contribute to early ischemic stroke recurrence in Japanese patients. METHODS: A multicenter stroke registration study based on a computerized database from 54 Japanese institutes, involving 8,036 patients with brain infarction who were hospitalized within 48 h after symptom onset between January 2000 and March 2004. RESULTS: Within 30 days after the initial stroke, 395 patients (4.9%) developed a recurrent stroke. Recurrence most frequently occurred in atherothrombotic patients (6.6%), followed by cardioembolic patients (6.2%). Overall, hypertension (OR 1.348, 95% CI 1.071-1.696) and atrial fibrillation (OR 1.503, 95% CI 1.177-1.918), but not diabetes mellitus, were independently predictive of early recurrence. In atherothrombotic patients, diabetes mellitus (OR 1.485, 95% CI 1.058-2.085) and atrial fibrillation (OR 1.998, 95% CI 1.231-3.244) were independently related to early recurrence. At hospital discharge, the modified Rankin Scale score was higher in patients who had an early recurrence (p < 0.0001). CONCLUSIONS: This study was based on a large number of Japanese patients and confirmed that hypertension and atrial fibrillation contribute to early ischemic stroke recurrence. In addition, analysis by stroke subtype showed that diabetes mellitus was independently related to early recurrence in atherothrombotic patients.     

Risk factors and outcome of patients with carotid artery stenosis presenting with lacunar stroke. North American Symptomatic Carotid Endarterectomy Trial Group

OBJECTIVE: To examine the relationship between carotid artery stenosis, other risk factors, and lacunar stroke. BACKGROUND: Carotid artery stenosis in patients presenting with lacune stroke may be coincidental or causal. The distinction by risk factor profile is uncertain. The risk and cause of subsequent stroke, and benefit of carotid endarterectomy (CE) is unknown. METHODS: Stroke in patients entering the North American Symptomatic Carotid Endarterectomy Trial were classified as nonlacunar, possible lacune (symptoms without CT lacunae), or probable lacune (symptoms with CT lacunae). RESULTS: Of 1,158 patients with hemispheric stroke, 493 had features of lacunar stroke (283 possible and 210 probable). Lacunar stroke presented more commonly in patients with milder (<50%) degrees of internal carotid artery (ICA) stenosis (p = 0.003). History of diabetes and hyperlipidemia, not hypertension, were associated independently even after accounting for the degree of stenosis. Medically treated patients presenting with nonlacunar stroke had a low risk of subsequent lacunar events of 2.9% at 3 years in comparison with 9.2% for probable lacunar presentation (p = 0.03). For patients with 50 to 99% ICA stenosis, the relative risk reductions (RRRs) in stroke from CE were 35% when the presenting stroke was probable lacunar versus 61% when the stroke was nonlacunar. Patients presenting with a possible lacunar stroke had a 53% RRR. CONCLUSIONS: History of diabetes and hyperlipidemia were more important than arterial hypertension as risk factors for patients with lacunar stroke. Patients presenting with lacunar stroke more often had milder ICA stenosis. Although CE reduced the risk of stroke in all patients with 50 to 99% ICA stenosis, lesser benefits were observed in patients presenting with lacunar stroke.     

卒中及短暂性脑缺血发作患者不同部位脑萎缩的危险因素

目的脑萎缩是卒中后痴呆的重要危险因素,探索卒中及短暂性脑缺血发作患者不同部位脑萎缩的危险因素,为降低卒中后痴呆发的发生提供潜在干预靶点。方法纳入连续住院的卒中及短暂性脑缺血发作(transient ischemic attack,TIA)患者,采集患者一般危险因素及血管性危险因素,完成头颅MRI和/或头颅CT扫描及半定量测定,包括陈旧性腔隙性脑梗死数量、额叶萎缩、顶叶萎缩、颞中叶萎缩及广泛脑萎缩的程度。结果共519例卒中及TIA患者完成4种脑萎缩的测量。Logistic回归分析结果显示:除年龄外,女性(比数比OR=2.447,P=0.007)、腔隙性脑梗塞病灶数(OR=1.414,P=0.027)是额叶萎缩的独立危险因素;缺血性卒中病史(OR=2.224,P=0.024)是顶叶萎缩的独立危险因素;颅内/外大血管狭窄(OR=2.584,P=0.015)、脑白质变性评分(OR=1.112,P=0.007)及腔隙性脑梗塞病灶数(OR=1.158,P=0.042)是颞中叶萎缩的独立危险因素;而糖尿病(OR=2.109,P=0.001)、心房纤颤(OR=1.934,P=0.015)、脑白质变性评分(OR=1.098,P=0.002)是广泛脑萎缩的独立危险因素。结论糖尿病、心房纤颤、腔隙性脑梗塞数及脑白质变性是卒中及TIA患者脑萎缩的危险因素,可对对上述高危人群尽早干预,减小此类患者发生痴呆的可能。     

Plasma amyloid beta, apolipoprotein E, lacunar infarcts, and white matter lesions

Lacunar brain infarcts and cerebral white matter lesions are frequently observed on magnetic resonance imaging scans in elderly subjects. These lesions are also frequent in patient with cerebral amyloid angiopathy. We examined whether plasma amyloid beta peptide (Abeta) levels are associated with lacunar infarcts and white matter lesions in the general population, and whether the apolipoprotein E (APOE) genotype modifies these associations. We studied 1,077 participants within the population-based Rotterdam Scan Study, who were 60 to 90 years of age and free of dementia. Cross-sectional associations were analyzed by regression models with adjustments for age, sex, creatinine levels, and hypertension. In APOE epsilon4 carriers, plasma Abeta levels were positively associated with lacunar infarcts and white matter lesions, whereas in noncarriers no associations were observed. Per standard deviation increase in Abeta(1-40) and Abeta(1-42) levels the odds ratios for lacunar infarcts were 1.72 (95% confidence interval [CI] = 1.22-2.43) and 1.93 (95% CI = 1.31-2.85), the periventricular white matter lesion grade increased by 0.32 (95% CI = 0.08-0.57) and 0.29 (95% CI = 0.00-0.57), and the subcortical white matter lesion volume increased by 0.48 ml (95% CI = 0.04-0.91) and 0.24 ml (95% CI = -0.27-0.75). Higher Abeta levels are associated with more lacunar infarcts and white matter lesions in elderly subjects who carry an APOE epsilon4 allele.