Cognitive impairments in acute lacunar stroke

Background – The present study investigated the prevalence of cognitive deficits in acute lacunar stroke, validated the Mini Mental State Examination (MMSE) in detecting cognitive impairments in lacunar patients, and identified predictors of such deficits. Methods – Seventy‐one patients with lacunar stroke performed a comprehensive cognitive screening between day 2 and day 7 of their stay. The test battery included Trail Making Test A, Verbal Fluency, Object Learning Test, Ullevål Aphasia Screening, and Assessment of Stroke and other Brain Damage regarding motor apraxia, rational apraxia and visuospatial ability. Results – Exactly 57.7% scored outside cutoff in at least one of the cognitive tests. Using a rigorous cutoff for MMSE (28/29 points) and the test battery as comparison, the sensitivity and specificity of MMSE were 0.69 and 0.67, respectively. Only male sex was significantly related to the presence of cognitive deficits (pathologic score on at least one of the tests – odds ratio 4.41, 95% confidence interval 1.45–13.43). Conclusion – Many lacunar stroke patients suffer cognitive problems. Male patients are at particular risk. MMSE failed to identify 30% of the patients diagnosed with cognitive deficits, and we suggest that lacunar stroke patients be offered a comprehensive cognitive screening, even when MMSE is normal.     

Sleep-related breathing disorders in acute lacunar stroke

The purpose was to examine the occurrence of sleep-related breathing disorders (SRBD) and variables related to SRBD in patients with acute lacunar stroke. In 68 consecutive patients with radiologically proven lacunes, respiratory polygraphy within the first 48 h of stroke onset was performed. SRBDs were classified according to mutually exclusive cutoff values of the apnea/hypopnea index (AHI) as mild (AHI ≥10), moderate (AHI ≥20), and severe (AHI ≥30). Variables independently associated with SRBDs were assessed by logistic regression analysis. The mean (standard deviation) AHI was 21.9 (17.4). A total of 69.1% of patients showed AHI ≥10, 44.1% AHI ≥20, and 25% AHI ≥30. Cheyne-Stokes respiration (CSR) was present in 20.6% of patients. Smoking (>20 cigarettes/day) or location of lacunes in the internal capsule or the pons was significantly more frequent in the AHI ≥10 group than in the remaining AHI groups (80.9% vs. 57.1%, P = 0.041). AHI ≥20 and AHI ≥30 occurred more frequently in smokers or in capsular or pontine lacunes than in the remaining patients (20% vs. 2.6%, P = 0.053; 29.4% vs. 3.9%, P = 0.01, respectively). In the multivariate analysis, smoking or capsular or pontine topographies were associated with AHI ≥10 [odds ratio (OR) = 3.17, 95% confidence interval (CI) 1.02–9.79; P = 0.045]. Lacunes in the internal capsule or the pons in smokers were associated with AHI ≥20 (OR = 9.25, 95% CI 1.05–81.70; P = 0.045). Smoking (OR = 19.64, 95% CI 1.68–229.85; P = 0.010) and body mass index (OR = 1.68, 95% CI 1.13–2.50; P = 0.010) were associated with AHI ≥30. Smoker patients with capsular or pontine acute lacunar stroke should be screened for SRDB.     

Hemorrhagic lacunar stroke

A total of 17 patients with lacunar syndromes due to intracerebral hemorrhage or hemorrhagic lacunar stroke (pure motor hemiparesis 9, sensorimotor stroke 5, pure sensory stroke 3) are reported. Data from these patients were obtained from consecutive stroke patients included in the prospective Hospital Sagrat Cor-Alian?a Stroke Registry. Hemorrhagic lacunar stroke accounted for 3.8% of all cases of lacunar syndrome (n = 439) and 7.4% of all cases of intracerebral hemorrhage (n = 229) entered in the database. Demographic, anamnestic, clinical and neuroimaging variables in patients with hemorrhagic lacunar stroke, non-lacunar intracerebral hemorrhage and non-hemorrhagic lacunar stroke were compared. Predictors of hemorrhagic lacunar stroke were assessed by logistic regression analysis. Hypertension, cigarette smoking and involvement of the internal capsule were significantly more frequent in patients with hemorrhagic lacunar stroke than in those with non-lacunar intracerebral hemorrhage, whereas nausea and vomiting, altered consciousness, speech disturbances, hemianopia, and ventricular hemorrhage were significantly less frequent. As compared with non-hemorrhagic lacunar stroke, patients with hemorrhagic lacunar stroke were more likely to have hypertension, sudden stroke onset (minutes), head injury, headache, and basal ganglia involvement and less likely to have diabetes, gradual stroke onset (hours), and dysarthria. After multivariate analysis, only headache (OR 10.14), sudden onset (OR 9.89), and dysarthria (OR 0.10) were independent predictors of hemorrhagic lacunar stroke. Accordingly, the presence of headache and sudden onset of symptoms and absence of dysarthria may be useful signs for distinguishing hemorrhagic lacunar stroke from other causes of lacunar stroke.     

White matter hyperintensities and quality of life in acute lacunar stroke

White matter hyperintensities (WMH) are common in stroke. The influence of WMH on health-related quality of life (HRQoL) following a lacunar stroke is unknown. This study evaluated the impact of WMH on HRQoL in acute lacunar stroke. A cohort of 160 patients with acute lacunar stroke admitted to the stroke unit of a university-affiliated regional hospital in Hong Kong was recruited. Three months after the index stroke, a research assistant administered the Short Form-36 (SF-36) to assess HRQoL. The severity of WMH was evaluated with magnetic resonance imaging (MRI). In univariate analysis, the severity of deep WMH (DWMH) negatively correlated with patients’ vitality (VT; p < 0.05), social function (SF; p < 0.001), role-emotional (RE; p < 0.01), mental health (MH; p < 0.01), and mental component summary (MCS; p < 0.001) scores of HRQoL. DWMH was independently associated with all of the above five SF-36 scores (p < 0.05) in linear regression analysis. These findings suggest that DWMH has a significant impact on the HRQoL of stroke survivors. The importance of DWMH in the long-term HRQoL in lacunar stroke warrants further investigation.     

Haptoglobin polymorphism and lacunar stroke

Haptoglobin (Hp) 2-2 phenotype has been associated with peripheral and coronary artery disease and risk of vascular complications in diabetic patients, but any association of Hp polymorphism with cerebrovascular disease has not been explored so far. We aimed to study Hp polymorphism in a sample of 124 patients with a rather homogeneous type of cerebrovascular disease, namely first symptomatic lacunar stroke due to small vessel disease, in comparison with a large (n=918) control group. Hp phenotypes were determined using starch gel electrophoresis. Hp1 allele frequency was significantly higher in patients than in controls (0.480 vs. 0.395, p<0.05), mainly due to a lower Hp2-2 phenotype frequency (25.0 vs. 36.3 %; OR 0.59; 95%CI 0.38-0.90; p<0.05). This was even more pronounced in younger (相似文献   

The electroencephalogram and acute ischemic stroke. Distinguishing cortical from lacunar infarction

One hundred consecutive cases of clinically diagnosed, acute forebrain infarction were studied using computerized tomography (CT) and electroencephalography (EEG). Computed tomography confirmed brain infarction in 91 patients and was normal in the remaining nine. Each EEG was read independently by two experienced electroencephalographers without knowledge of CT or clinical details and their findings were compared with those of CT. Lateralized theta and/or delta activity predicted ipsilateral cortical infarction with a sensitivity of 76% and specificity of 82%. In contrast, cerebral hemisphere lacunae produced similar EEG abnormalities in only a few cases (9%). Electroencephalography is particularly useful following stroke if the initial CT excludes hemorrhage but does not detect infarction. In conjunction with clinical details, the EEG can then be used to indicate the likelihood of cortical involvement and thus suggest the likely pathophysiologic mechanism of infarction.     

Frailty and outcomes in lacunar stroke

BackgroundLacunar strokes (LS) are ischemic strokes of the small perforating arteries of deep gray and white matter of the brain. Frailty has been associated with greater mortality and attenuated response to treatment after stroke. However, the effect of frailty on patients with LS has not been previously described.ObjectiveTo analyze the association between frailty and outcomes in LS.MethodsPatients with LS were selected from the National Inpatient Sample (NIS) 2016-2019 using the International Classification of Disease, 10^th edition (ICD-10) diagnosis codes. The 11-point modified frailty scale (mFI-11) was used to group patients into severely frail and non-severely frail cohorts. Demographics, clinical characteristics, and complications were defined. Health care resource utilization (HRU) was evaluated by comparing total hospital charges and length of stay (LOS). Other outcomes studied were discharge disposition and inpatient death.ResultsOf 48,980 patients with LS, 10,830 (22.1%) were severely frail. Severely frail patients were more likely to be older, have comorbidities, and pertain to lower socioeconomic status categories. Severely frail patients with LS had worse clinical stroke severity and increased rates of complications such as urinary tract infection (UTI) and pneumonia (PNA). Additionally, severe frailty was associated with unfavorable outcomes and increased HRU.ConclusionSevere frailty in LS patients is associated with higher rates of complications and increased HRU. Risk stratification based on frailty may allow for individualized treatments to help mitigate adverse outcomes in the setting of LS.     

Progression in lacunar stroke is related to elevated acute phase parameters

BACKGROUND AND PURPOSE: Despite the small size of lacunar infarcts, progression of neurological deficits is a common problem in this stroke subtype. This investigation studied the frequency and the course of neurological deterioration as well as predictors and possible underlying pathomechanisms of early progression in lacunar stroke. METHODS: Fourty-six consecutive patients with acute lacunar stroke were prospectively evaluated by daily clinical neurological examination including the National Institutes of Health Stroke Scale (NIHSS) and follow-up using the Barthel Index after 3 months. Progressive neurological deficit was defined as worsening by > or =1 point in the NIHSS for motor function. Progressive and stable patients were compared regarding clinical profile, inflammatory parameters (leukocytes, body temperature, C-reactive protein), coagulation parameters (fibrinogen, D-dimer, vWF, PTT), and glutamate plasma concentration, as well as blood glucose and blood pressure. RESULTS: Eleven patients (23.9%) showed progression of stroke symptoms, 9 of these within the first 24 h after admission. The score on the NIHSS on admission was similar in patients with progressive stroke and stable patients, but significantly higher in the progressive stroke group on days 2 (p = 0.01), 3 (p = 0.001) and at discharge (p = 0.003). Deterioration was significantly associated with a higher leukocyte count (p = 0.012), higher body temperature (p = 0.031) and a higher fibrinogen concentration (p = 0.046) on admission. Barthel Index at discharge (p = 0.001) and after 90 days (p < 0.001) was significantly worse in the progressive stroke group. CONCLUSIONS: Progression in lacunar stroke usually occurs within 24 h and may be related to an acute-phase response. The long-term prognosis of progressive stroke patients is persistently worse compared with patients with nonprogressive stroke.     

Carotid stenosis in lacunar stroke.

The prevalence of extracranial carotid stenosis in patients with a clinical syndrome of lacunar stroke has not been extensively studied using noninvasive methods. We performed carotid duplex sonography on 168 patients referred to the neurosonology laboratory with a diagnosis of ischemic stroke. Strokes were independently classified as lacunar or nonlacunar hemispheric infarction without knowledge of the ultrasound results. We excluded patients with infarcts that were clearly vertebrobasilar, presumed to be cardioembolic, or had occurred greater than 1 year earlier, and patients for whom classification of the nature and location of the event was not possible. Fifty-five patients had lacunar and 54 had nonlacunar stroke. No differences in age, sex, distribution, or prevalence of hypertension, diabetes, prior ischemia, or Hispanic surname existed between the two groups. Tobacco use was more frequent in the nonlacunar group (p less than 0.01). The prevalence of important extracranial carotid stenosis (greater than or equal to 50% diameter reduction) in the lacunar stroke group was 13% (seven of 55) in the ipsilateral and 4% (two of 55) in the contralateral carotid artery. Of the 54 patients with nonlacunar hemispheric stroke, 41% (22) had ipsilateral (p less than 0.01) and 26% (14) had contralateral (p less than 0.01) carotid stenosis. This study suggests that important carotid stenosis is infrequent among patients presenting with a clinical syndrome of lacunar stroke. These data impact on decisions regarding cerebrovascular work-up in such patients.     

Hemiparesthesias in lacunar pontine ischemic stroke

Isolated paresthesia, or paresthesia not accompanied by sensory and/or motor deficits, is an extremely rare manifestation of a cerebrovascular accident. Lacunar pure sensory stroke (PSS) confined to thalamus is characterized by persistent or transient numbness, tingling, pain, burning, or another unpleasant sensation on one side of the body. However, in this condition a sensory loss to all primary modalities in the contralateral face and body is very often encountered. Also previous reported cases of PSS due to lacunar stroke in regions other than thalamus are characterized by the presence of sensory loss together with positive sensory symptoms, none of them reporting isolated paresthesia as the only clinical feature of PSS. We present a case of isolated paresthesia as only clinical manifestation of a lacunar PSS involving both trigeminal and medial lemniscus in dorsal paramedian pontine region. A PSS manifesting with isolated paresthesias may be secondary not only to a thalamic lacunar stroke, but also to a small ischemic lesion confined to both trigeminal and medial lemniscus in dorsal paramedian pontine region.     

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.