Capsular infarcts: location, size and etiology of pure motor hemiparesis, sensorimotor stroke and ataxic hemiparesis

Role of Cortico-ponto-cerebellar Tract from Supplementary Motor Area in Ataxic Hemiparesis of Supratentorial Stroke Patients

Cortical lesions of the supplementary motor area (SMA) are important in balance control and postural recovery in stroke patients, while the role of subcortical lesions of the SMA has not been studied. This study aimed to investigate the subcortical projections of the SMA and its relationship with ataxia in supratentorial stroke patients. Thirty-three patients with hemiparesis were divided into 3 groups (severe ataxia, n = 9; mild to moderate ataxia, n = 13; no ataxia, n = 11). Ataxia severity was assessed using the Scale for Ataxia Rating Assessment. Diffusion tensor imaging analysis used the fractional anisotropy (FA) values and tract volume as parameters of white matter tract degeneration. The FA values of regions related to ataxia were analyzed, that is the SMA, posterior limb of the internal capsule, basal ganglia, superior cerebellar peduncle, middle cerebellar peduncle, inferior cerebellar peduncle, and cerebellum. Tract volumes of the corticostriatal tract and cortico-ponto-cerebellar (CPC) tract originating from the SMA were evaluated. There were significant differences among the 3 groups in FA values of the subcortical regions of the CPC tract. Furthermore, the volume of the CPC tract originating from the SMA showed significant negative correlation with ataxia severity. There was no correlation between ataxia and corticostriatal tract volume. Therefore, we found that subcortical lesions of the CPC tract originating from the SMA could contribute to ataxia severity in stroke patients with ataxic hemiparesis.

Patency of the anterior choroidal artery covered with a flow-diverter stent

OBJECT

The concept of the flow-diverter stent (FDS) is to induce aneurysmal thrombosis while preserving the patency of the parent vessel and any covered branches. In some circumstances, it is impossible to avoid dangerously covering small branches, such as the anterior choroidal artery (AChA), with the stent. In this paper, the authors describe the clinical and angiographic effects of covering the AChA with an FDS.

METHODS

Between April 2011 and July 2013, 92 patients with intracranial aneurysms were treated with the use of FDSs in the authors’ institution. For 20 consecutive patients (21.7%) retrospectively included in this study, this involved the unavoidable covering of the AChA with a single FDS during endovascular therapy. AChAs feeding the choroid plexus were classified as the long-course group (14 cases), and those not feeding the choroid plexus were classified as the short-course group (6 cases). Clinical symptoms and the angiographic aspect of the AChA were evaluated immediately after stent delivery and during follow-up. Neurological examinations were performed to rule out hemiparesis, hemihypesthesia, hemianopsia, and other cortical signs.

RESULTS

FDS placement had no immediate effect on AChA blood flow. Data were obtained from 1-month clinical follow-up in all patients and from midterm angiographic follow-up in 17 patients (85.0%), with a mean length of 9.8 ± 5.4 months. No patient in either group complained of transient or permanent symptoms related to an AChA occlusion. In all cases, the AChA remained patent without any flow changes.

CONCLUSIONS

The results of this study suggest that when impossible to avoid, the AChA may be safely covered with a single FDS during intracranial aneurysm treatment, irrespective of anatomy and anastomoses.

Lacunar stroke

Lacunar infarcts or small subcortical infarcts result from occlusion of a single penetrating artery and account for one quarter of cerebral infarctions. Patients with a lacunar infarct usually present with a classical lacunar syndrome (pure motor hemiparesis, pure sensory syndrome, sensorimotor stroke, ataxic hemiparesis or dysarthria-clumsy hand) and, less frequently, an atypical lacunar syndrome. Hypertension and diabetes mellitus are major risk factors for lacunar stroke. Lacunar infarcts show a paradoxical clinical course with a favorable prognosis in the short term, characterized by a low early mortality and reduced functional disability on hospital discharge, but with an increased risk of death, stroke recurrence and dementia in the mid- and long term. Asymptomatic progression of small-vessel disease is a typical feature of the lacunar infarcts. For this reason, lacunar infarction should be regarded as a potentially severe condition rather than a relatively benign disorder and, therefore, lacunar stroke patients require adequate and rigorous management and follow-up. Antiplatelet drugs, careful blood pressure control, the use of statins and modification of lifestyle risk factors are key elements in secondary prevention after lacunar stroke.

Anterior choroidal artery infarction: a clinical, etiologic and prognostic study

OBJECTIVES

To analyze the clinical, etiologic and prognostic profile of anterior choroidal artery (AChA) infarcts.

METHODS

42 consecutive patients with AChA infarction were included. Symptoms, etiology and scores on neurological and functional scales were analyzed on admission, discharge and at 3-month follow-up. A comparative study was performed between deep (n = 23) and deep + superficial (n = 19) infarcts.

RESULTS

Lacunar syndrome was present in 83.3% of patients. Etiology was large-vessel disease in 38.1% and cryptogenic in 38.1%. Ten patients had a National Institute of Health Stroke Scale score >7 on admission. At discharge, 45.3% had an modified Rankin Scale >2 (35.7% after 3 months). Infarcts involving superficial territory were more severe at admission (P = 0.034) and were associated with a worse functional status at discharge (P = 0.0008).

CONCLUSION

AChA infarcts usually present with lacunar syndrome, although they are often not lacunar infarcts. At discharge, almost half of the patients are dependent in their activities of daily living, and most remain so at 3-month follow-up. Infarcts involving superficial territory are associated with worse prognosis.

Acute isolated capsular stroke. A clinical study of 148 cases

The objectives of the study were to assess differential features between capsular stroke of ischemic and hemorrhagic origin, and to compare capsular strokes with all other (non-capsular) strokes. Data of 148 patients with isolated capsular stroke were collected from a prospective hospital-based stroke registry in which 2000 consecutive acute stroke patients were included. Isolated capsular stroke accounted for 8.4% of strokes included in the registry (8.4% of ischemic strokes and 10.5% of intracerebral hemorrhages). Capsular stroke of hemorrhagic origin (n = 24) was more severe than ischemic capsular stroke (n = 124) as determined by a significantly higher in-hospital mortality, length of stay, and lower number of patients free of functional deficit at discharge. After multivariate analysis, limb weakness, sudden onset, and sensory symptoms were independently associated with capsular hemorrhage, whereas pure motor hemiparesis appeared to be associated with capsular infarction. In summary, one of each 12 patients with acute ischemic stroke and one of each 10 patients with acute intracerebral hemorrhage had an isolated capsular stroke. Lacunar syndrome was the most frequent clinical presentation being more common (particularly pure motor hemiparesis) in ischemic than in hemorrhagic capsular stroke. Capsular hemorrhage and capsular infarction showed identical risk factor profiles suggesting the same underlying vascular pathology for both conditions.

Hemiparesia atáxica: estudio de 23 pacientes

BACKGROUND AND OBJECTIVE

To characterize the clinical features, etiology and prognosis in ataxic hemiparesis syndrome.

PATIENTS AND METHOD

Descriptive study of 23 patients with ataxic hemiparesis included in the Sagrat Cor Hospital of Barcelona Stroke Registry over a 12 year period.

RESULTS

Ataxic hemiparesis was caused by a lacunar infarct in 87% of patients, by atherothrombotic infarcts in 8.7% and by cardioembolic infarct in 4.3%. Ataxic hemiparesis accounted for 0.9% of all acute strokes (n = 2,500), 1.25% of all cerebral infarcts (n = 1,840), and 4.1% of all lacunar infarcts (n = 484). Internal capsule (22%), pons (13%), and corona radiata involvement (9%) were the most frequent cerebral topographies. Absence of in hospital mortality and absence of neurological deficit at discharge from the hospital were present in 39% of the patients.

CONCLUSIONS

Lacune hypothesis is present in ataxic hemiparesis syndrome. Ataxic hemiparesis is caused by a lacunar infarct in 87% of patients. The internal capsule topography is the most frequent and the prognosis in ataxic hemiparesis is good.

Carotid disease in acute stroke: A review

This article reviews the literature about carotid disease in acute stroke. Several conclusions are drawn. First, carotid disease is an important cause of ipsilateral cortical strokes, with significant ipsilateral disease found in about one fourth of patients. Second, the role of carotid disease in lacunar stroke is less certain but probably causes a small number of lacunar infarcts. Third, the majority of infarcts that occur with severe carotid stenosis or acute carotid occlusion are caused by cerebral emboli, whereas most infarcts with preexisting occlusion are probably caused by hemodynamic factors. Fourth, the optimal timing of carotid surgery in acute stroke is uncertain. Clinical trials of endarterectomy in acute stroke are now required.