Epidemiological characteristics of lacunar infarcts in a population

Emergency Carotid Thrombo-Endarterectomy after Failed Endovascular Recanalization for Acute Complete Carotid Occlusion: A Case Report

Rapid identification of the type and origin of a stroke is crucial for prompt and appropriate treatment, which can significantly influences patient outcomes. We report a multidisciplinary management case involving a 76-year-old man who presented with left-sided weakness and mild dysarthria. Imaging revealed a completely occluded right internal carotid artery. Despite multiple endovascular recanalization attempts, adequate flow could not be achieved, leading to the decision to perform an open thrombo-endarterectomy. The patient underwent carotid endarterectomy with microsurgical techniques under general anesthesia. The atheroma plaque and central thrombus were removed, which reestablished flow. Continuous intraoperative neuromonitoring was utilized to ensure patient safety. The patient woke up without new deficits and was discharged for rehabilitation. Follow-up imaging confirmed arterial patency, and the patient eventually made an excellent recovery, including being independent over one and a half years. Emergent recanalization with carotid endarterectomy following a failed endovascular recanalization is both safe and feasible, emphasizing the need for collaboration between different treatment providers to ensure optimal patient outcomes. Our report highlights the importance of a multidisciplinary approach and the advantages of a hybrid operating room in the treatment of acute complete carotid artery occlusion.

The Untargeted Metabolomics Reveals Differences in Energy Metabolism in Patients with Different Subtypes of Ischemic Stroke

AIMS

Ischemic stroke (IS) is the most common subtype of stroke. The risk factors and pathogenesis of IS are complex and varied due to different subtypes. Therefore, we used metabolomics technology to investigate the biomarkers and potential pathophysiological mechanisms of different subtypes of IS.

METHODS

We included 126 IS patients and divided them into two groups based on the TOAST classification: large-artery atherosclerosis (LAA) group (n = 87) and small-vessel occlusion (SVO) group (n = 39). Plasma metabolomics analysis was performed using liquid chromatography-high-resolution mass spectrometry (LC-HRMS) to identify metabolic profiles in LAA and SVO subtype IS patients and to determine metabolic differences between patients with the two subtypes of IS.

RESULTS

We identified 26 differential metabolites between LAA and SVO subtype IS. A multiple prediction model based on the plasm metabolites had good predictive ability for IS subtyping (AUC = 0.822, accuracy = 77.8%), with 12,13-DHOME being the most important differential metabolite in the model. The differential metabolic pathways between the two subtypes of IS patients included tricarboxylic acid (TCA) cycle, alanine, aspartate and glutamate metabolism, and pyruvate metabolism, mainly focused on energy metabolism.

CONCLUSION

12,13-DHOME emerged as the primary discriminatory metabolite between LAA and SVO subtypes of IS. In LAA subtype IS patients, energy metabolism, encompassing pyruvate metabolism and the TCA cycle, exhibited lower activity levels when compared to patients with the SVO subtype IS. The utilization of targeted metabolomics holds the potential to improve diagnostic accuracy for distinguishing stroke subtypes.

Emerging frontiers of artificial intelligence and machine learning in ischemic stroke: a comprehensive investigation of state-of-the-art methodologies, clinical applications, and unraveling challenges

At present, stroke remains the second highest cause of death globally and a leading cause of disability. From 1990 to 2019, the absolute number of strokes worldwide increased by 70.0%, and the prevalence of stroke increased by 85.0%, causing millions of deaths and disability. Ischemic stroke accounts for the majority of strokes, which is caused by arterial occlusion. Effective primary prevention strategies, early diagnosis, and timely interventions such as rapid reperfusion are in urgent implementation to control ischemic stroke. Otherwise, the stroke burden will probably continue to grow across the world as a result of population aging and an ongoing high prevalence of risk factors. To help with the diagnosis and management of ischemic stroke, newer techniques such as artificial intelligence (AI) are highly anticipated and may bring a new revolution. AI is a recent fast-growing research area which aims to mimic cognitive processes through a number of techniques such as machine learning (ML) methods of random forest learning (RFL) and convolutional neural networks (CNNs). With the help of AI, several momentous milestones have already been attained across diverse dimensions of ischemic stroke. In the context of predictive, preventive, and personalized medicine (PPPM/3PM), we aim to transform stroke care from a reactive to a proactive and individualized paradigm. In this way, AI demonstrates strong clinical utility across all three levels of prevention in ischemic stroke. In this paper, we synoptically illustrated the history and current situation of AI and ML. Then, we summarized their clinical applications and efficacy in the management of stroke. We finally provided an outlook on how AI approaches might contribute to enhancing favorable outcomes after stroke and proposed our suggestions on developing AI-based PPPM strategies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-023-00343-3.

Prevalence and distribution of lacunar stroke in China: a cross-sectional study using self-reported survey data

OBJECTIVES

To report the prevalence and distribution of lacunar stroke in different regions of China, as well as the demographical characteristics of symptomatic and asymptomatic lacunar stroke.

DESIGN

Cross-sectional study.

SETTING

Data were derived from NESS-China Study that was conducted in 157 sites covering all 31 provinces, including 64 urban and 93 rural areas in mainland China between 1 September 2013 and 31 December 2013. Lacunar stroke was defined as being previously diagnosed according to the participants' medical history. Patients were further divided into symptomatic or asymptomatic groups, depending on whether they were initially diagnosed with neurological symptoms.

PARTICIPANTS

458 833 participants aged ≥20 years were enrolled in this study.

RESULTS

A total of 7520 participants (1.63%) were diagnosed with lacunar stroke. The peak rate of diagnosis was between the ages of 70 and 79 years in both men and women. Geographically, the age-standardised and sex-standardised prevalence was highest in Northeast China (2495.3/100 000 persons) and lowest in Southeast China (599.7/100 000 persons), showing a geographical disparity. Over 90% of patients with lacunar stroke were diagnosed in secondary or tertiary hospitals. Patients with symptomatic lacunar stroke had significantly different demographic characteristics in age, sex and geographical regions compared with those who were asymptomatic.

CONCLUSIONS

In this study, the prevalence and distribution of lacunar stroke were reported at population level across China. Special attention and prevention should be given to the age, sex and geographical groups that are vulnerable to lacunar stroke.

Long-term mortality and recurrent vascular events in lacunar versus non-lacunar ischaemic stroke: A cohort study

Introduction

Studies of differences in very long-term outcomes between people with lacunar/small vessel disease (SVD) versus other types of ischaemic stroke report mixed findings, with limited data on myocardial infarction (MI). We investigated whether long-term mortality, recurrent stroke and MI risks differ in people with versus without lacunar/SVD ischaemic stroke.

Patients and methods

We included first-ever strokes from a hospital-based stroke cohort study recruited in 2002–2005. We compared risks of death, recurrent stroke and MI during follow-up among lacunar/SVD versus other ischaemic stroke subtypes using Cox regression, adjusting for confounding factors.

Results

We included 812 participants, 283 with lacunar/SVD ischaemic stroke and 529 with other stroke. During a median of 9.2 years (interquartile range 3.1–11.8), there were 519 deaths, 181 recurrent strokes and 79 MIs. Lacunar/SVD stroke was associated with lower mortality (adjusted HR 0.79, 95% CI 0.65 to 0.95), largely due to markedly lower all-cause mortality in the first year. From one year onwards this difference attenuated, with all-cause mortality only slightly and not statistically significantly lower in the lacunar/SVD group (0.86, 95% CI 0.70 to 1.05). There was no clear difference in risk of recurrent stroke (HR 0.84, 95% CI 0.61–1.15) or MI (HR 0.83, 95% CI 0.52–1.34).

Conclusion

Long-term risks of all-cause mortality, recurrent stroke and MI are similar, or only slightly lower, in patients with lacunar/SVD as compared to other ischaemic stroke. Patients and physicians should be as vigilant in optimising short- and long-term secondary prevention of vascular events in lacunar/SVD as for other stroke types.

Efficacy and Safety of Intravenous rtPA in Ischemic Strokes Due to Small-Vessel Occlusion: Systematic Review and Meta-Analysis

Intravenous recombinant tissue plasminogen activator (iv-rtPA) has been routinely used to treat ischemic stroke for 25 years, following large clinical trials. However, there are few prospective studies on the efficacy and safety of this therapy in strokes attributed to cerebral small vessel disease (SVD). We evaluated functional outcome (modified Rankin scale, mRS) and symptomatic intracerebral hemorrhage (sICH) using all available data on the effects of iv-rtPA in SVD-related ischemic stroke (defined either using neuroimaging, clinical features, or both). Using fixed-effect and random-effects models, we calculated the pooled effect estimates with regard to excellent and favorable outcomes (mRS=0-1 and 0-2 respectively, at 3 months), and the rate of sICH. Twenty-three studies fulfilled the eligibility criteria, 11 of which were comparative, and there were only 3 randomized clinical trials. In adjusted analyses, there was an increased odds of excellent outcome (adjusted OR=1.53, 95% CI: 1.29-1.82, I2: 0%) or favorable outcome (adjusted OR=1.68, 95% CI: 1.31-2.15,I2: 0%) in patients who received iv-rtPA compared with placebo. Across the six studies which reported it, the incidence of sICH was higher in the treatment group (M-H RR = 8.83, 95% CI: 2.76-28.27). The pooled rate of sICH in patients with SVD administered iv-rtPA was only 0.72% (95% CI: 0.12%-1.64%). We conclude that when ischemic stroke attributed to SVD is considered separately, available data on the effects of iv-rtPA therapy are insufficient for the highest level of recommendation, but it seems to be safe. Although further therapeutic trials in SVD-related ischemic stroke appear to be justified, our findings should not prevent its continued use for this group of patients in clinical practice.

Isolated dysarthria due to hypoglossal palsy caused by supratentorial ischemic stroke: Radiological and electropsyological analysis

OBJECTIVES

Isolated dysarthria caused by stroke is a rare condition and generally seen in infratentorial lesions, especially in cerebellar lesions. Isolated dysarthria associated with supratentorial ischemic lesions are also very rare and, these conditions were shown in only a few cases. In this study, six patients characterized by IHP due to supratentorial ischemic lesions are presented.

PATIENTS AND METHODS

Physical examinations of patients were done by two different neurologists. The risk factors for stroke were determined. Localisations of lesions were identified by using magnetic resonance images(MRI). Corticolingual tract affection without sensorial and other corticospinal tract involvement was confirmed using Somatosensory evoked potentials(SEPs) and Transcranial Magnetic Stimulation(TMS).

RESULTS

Unilateral lingual paresis was detected in all of the patients. The lesions were demonstrated on MRI slices. All lesions were on the same localization. The affection of the corticolingual tract without any other motor and sensory tract involvement was proven electrophysiologically.

CONCLUSION

Corticospinal and corticobulbar fibers are very close to each other. Therefore common involvement is expected in cerebrovascular diseases. However, six patients with IHP caused by supratentorial ischemic lesions were reported in this study. Thus, a possible map of the corticolingual tract was drawn.

Transcatheter embolic coils to treat peridevice leaks after left atrial appendage closure

BACKGROUND

Left atrial appendage closure (LAAC) has proven to be an effective alternative to long-term oral anticoagulation in the prevention of thromboembolic events in patients with atrial fibrillation. In a minority of patients, inadequate seal may result in persistent peridevice flow and inability of the appendage to fully thrombose, thereby representing a potential source for thromboembolism.

OBJECTIVE

The purpose of this study was to study the use of endovascular coiling of the appendage to address persistent peridevice leak in patients undergoing LAAC with the Watchman device.

METHODS

This is a retrospective single-center analysis involving patients who underwent placement of a LAAC device and returned for endovascular coiling to address persistent device leak between 2018 and 2020. Baseline characteristics, procedural outcomes, and follow-up echocardiograms were analyzed to demonstrate the feasibility and safety of this technique.

RESULTS

Patients (N = 20) were identified with a mean leak size of 3.8 ± 1.3 mm (range 2.5-7 mm), all of whom had a non-thrombosed appendage. Acute procedural success was achieved in 95% of patients. Complete or significant reduction in flow beyond the LAAC device was achieved in 61% and 33% of patients, respectively. The 1 procedure-related adverse event was a pericardial effusion before coil deployment, requiring percutaneous drainage.

CONCLUSION

The clinical impact of residual peridevice leak post-Watchman implantation is a matter of continuing investigation. However, appendage coiling represents a new therapeutic tool to address this potential source for thromboembolism. Further studies should address the clinical impact of this technique, including the safety of discontinuing anticoagulation after successful coiling.

Risk Factors in Ischemic Stroke Subtypes: A Community-Based Study in Brno, Czech Republic

BACKGROUND

It is not known if risk factors differ between ischemic stroke (IS) subtypes in Central and Eastern Europe.

AIMS

We performed a community-based analysis of risk factors in patients admitted with IS over a 1 year period in Brno, the second largest city in the Czech Republic (CR).

METHODS

Based on the National Register of Hospitalized Patients, all patients with IS admitted in Brno in 2011 were identified. Comprehensive discharge summaries from hospital admissions were collected and reviewed. IS subtype and relevant risk factors were ascertained for all patients. The age- and sex-adjusted association of risk factors with IS subtypes was determined.

RESULTS

Overall, 682 patients with IS were admitted in 2011 to Brno hospitals. The distribution of IS subtypes was: 35% cardioembolism, 28% large-artery atherosclerosis, 23% small-artery occlusion, 7% stroke of undetermined etiology, 7% stroke of other determined etiology. Several of the risk factors showed high prevalence in the overall sample - e.g. hypertension (84%) and hyperlipidemia (61%). Cardioembolism as compared to other subtypes was positively associated with a history of myocardial infarction, cardiac failure, and atrial fibrillation. Small-artery occlusion was positively associated with history of dementia. No significant association was found between IS subtypes and history of IS, hypertension, diabetes, obesity, alcohol abuse or smoking.

CONCLUSIONS

We found high frequency of stroke risk factors in all IS subtypes. These findings have implications for stroke prevention strategies in the CR and across Central Europe.

Treatment Approaches to Lacunar Stroke

Lacunar strokes are appropriately named for their ability to cavitate and form ponds or "little lakes" (Latin: lacune -ae meaning pond or pit is a diminutive form of lacus meaning lake). They account for a substantial proportion of both symptomatic and asymptomatic ischemic strokes. In recent years, there have been several advances in the management of large vessel occlusions. New therapies such as non-vitamin K antagonist oral anticoagulants and left atrial appendage closure have recently been developed to improve stroke prevention in atrial fibrillation; however, the treatment of small vessel disease-related strokes lags frustratingly behind. Since Fisher characterized the lacunar syndromes and associated infarcts in the late 1960s, there have been no therapies specifically targeting lacunar stroke. Unfortunately, many therapeutic agents used for the treatment of ischemic stroke in general offer only a modest benefit in reducing recurrent stroke while adding to the risk of intracerebral hemorrhage and systemic bleeding. Escalation of antithrombotic treatments beyond standard single antiplatelet agents has not been effective in long-term lacunar stroke prevention efforts, unequivocally increasing intracerebral hemorrhage risk without providing a significant benefit. In this review, we critically review the available treatments for lacunar stroke based on evidence from clinical trials. For several of the major drugs, we summarize the adverse effects in the context of this unique patient population. We also discuss the role of neuroprotective therapies and neural repair strategies as they may relate to recovery from lacunar stroke.

Demographic, Systemic, and Ocular Factors Associated with Nonarteritic Anterior Ischemic Optic Neuropathy

OBJECTIVE

Nonarteritic anterior ischemic optic neuropathy (NAION) is a devastating ocular condition causing permanent vision loss. Little is known about risk factors for developing this disease. We assessed demographic, systemic, and ocular factors associated with NAION.

DESIGN

Retrospective longitudinal cohort study.

PARTICIPANTS

Beneficiaries between 40 and 75 years old without NAION at baseline enrolled in a large U.S. managed care network.

METHODS

Enrollees were monitored continuously for ≥2 years between 2001 and 2014 to identify those newly diagnosed with NAION (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] code 377.41). All persons were under ophthalmic surveillance and all cases had ≥1 confirmatory ICD-9-CM code for NAION during follow-up.

MAIN OUTCOME MEASURES

Multivariable Cox regression modeling was used to generate hazard ratios (HRs) with 95% confidence intervals (CIs) to describe the statistical relationship between selected demographic characteristics, systemic and ocular conditions, and the hazard of developing NAION.

RESULTS

Of 1 381 477 eligible enrollees, 977 (0.1%) developed NAION during a mean ± standard deviation (SD) follow-up of 7.8±3.1 years. The mean ± SD age for NAION cases at the index date was 64.0±9.2 years vs. 58.4±9.4 years for the remainder of the beneficiaries. After adjustment for confounding factors, each additional year older was associated with a 2% increased hazard of NAION (HR = 1.02; 95% CI: 1.01-1.03). Female subjects had a 36% decreased hazard of developing NAION (HR = 0.64; 95% CI: 0.55-0.74) compared with male subjects. Compared with whites, Latinos had a 46% decreased hazard of developing NAION (HR = 0.54; 95% CI: 0.36-0.82), whereas African ancestry was not significantly associated with NAION (HR = 0.91; 95% CI: 0.72-1.15). Systemic diseases associated with NAION included hypertension (HR = 1.62; 95% CI: 1.26-2.07) and hypercoagulable states (HR = 2.46; 95% CI: 1.51-4.00). Although diabetes mellitus (DM) was not significantly associated with NAION compared with those without DM (P = 0.45), patients with end-organ involvement from DM had a 27% increased hazard of NAION relative to those with uncomplicated DM (HR = 1.27; 95% CI: 1.01-1.59). Ocular diseases associated with NAION were age-related macular degeneration (HR = 1.29; 95% CI: 1.08-1.54) and retinal vein occlusion (HR = 3.94; 95% CI: 3.11-4.99).

CONCLUSIONS

Our study identified several modifiable risk factors that may be associated with NAION. Should future studies confirm these findings, they may offer opportunities to prevent or treat this debilitating condition.

Inflammatory and metabolic markers and short-time outcome in patients with acute ischemic stroke in relation to TOAST subtypes

The aim of this study was to evaluate the association between inflammatory and metabolic markers and short-time outcome with acute ischemic stroke subtypes. A total of 121 patients was classified according to TOAST criteria, such as large artery atherosclerosis (LAAS), lacunar infarct (LAC), cardioembolic infarct (CEI), other determined etiology (ODE), and undetermined etiology (UDE). The functional impairment was evaluated within the first eight hours of stroke and the outcome after three-month follow-up using the modified Rankin Scale. Blood samples were obtained up to 24 h of stroke. Compared with 96 controls, patients with LAAS, CEI, and LAC subtypes showed higher levels of white blood cells, high-sensitivity C-reactive protein (hsCRP), interleukin 6 (IL-6), metalloproteinase 9 (MMP-9), glucose, and iron (p < 0.05); and lower high-density lipoprotein cholesterol (HDL-C) (p < 0.0001); platelets, insulin, insulin resistance, and homocysteine were higher in LAC (p < 0.0001); ferritin was higher in LAAS (p < 0.0001); and total cholesterol (TC) was lower in LAAS and CEI (p < 0.01). When stroke subtypes were compared, insulin was higher in LAAS vs. LAC and in LAC vs. CEI (p < 0.05); and TC was lower in LAAS vs. LAC (p < 0.05). Outcome and rate of mortality after three-month were higher in LAAS vs. LAC (p < 0.001 and p = 0.0391 respectively). The results underscored the important role of the inflammatory response and metabolic changes in the pathogenesis of ischemic stroke subtypes that might be considered on the initial evaluation of stroke patients to identify those that could benefit with individualized therapeutic strategies that taken into account these markers after acute ischemic event.

Magnetic Resonance Imaging in Ischemic Stroke and Cerebral Venous Thrombosis

Imaging is indispensable in the evaluation of patients presenting with central nervous system emergencies. Although computed tomography (CT) is the mainstay of initial assessment and triage, magnetic resonance imaging (MRI) has become vital in expanding diagnostic capabilities, refining management strategies, and developing our understanding of disease processes. Ischemic stroke and cerebral venous thrombosis are 2 areas wherein MRI is actively revolutionizing patient care. Familiarity with the imaging manifestations of these 2 disease processes is crucial for any radiologist reading brain MR studies. In this review, the fundamentals of image interpretation will be addressed in-depth. Furthermore, advanced imaging techniques which are redefining the role of emergency MRI will be outlined, with a focus on the pathophysiological mechanisms that underlie image interpretation. In particular, emerging data surrounding the use of MR perfusion imaging in acute stroke management portend dramatic shifts in neurointerventional management. To this end, a review of the recent stroke literature will hopefully enhance the radiologist's role in both meaningful reporting and multidisciplinary teamwork.

Characteristics of dynamic cerebral autoregulation in cerebral small vessel disease: Diffuse and sustained

Cerebral small vessel disease is a major cause of stroke and vascular dementia; however, the pathogenesis is largely unclear. In this study, we investigated the characteristics of the impairment of dynamic cerebral autoregulation (dCA) in lacunar infarction patients. Seventy-one lacunar infarction patients were enrolled in the study, including 46 unilateral middle cerebral artery (MCA) territory stroke patients and 25 unilateral posterior cerebral artery (PCA) territory stroke patients. Each group of patients was randomly divided into two subgroups. Group 1 underwent dCA assessments in the bilateral MCAs, and Group 2 underwent dCA assessments in the bilateral PCAs. All patients were followed up for 6 months. Transfer function analysis was applied to derive the autoregulatory parameters of gain and phase difference. In the unilateral MCA territory stroke patients, impairments of dCA were observed in both the MCAs and PCAs, and the same results were observed in the unilateral PCA territory stroke patients. These impairments remained unchanged during the 6-month follow-up. In lacunar infarction, which is most prevalent type of cerebral small vessel disease, though patients with unilateral MCA territory/PCA territory stroke, the impairments of dCA were global and sustained. This finding suggests that the physiological changes associated with lacunar infarction were diffuse.

Gender differences in upper extremity motor performance of older persons

BACKGROUND

Motor performance declines with age. Although gender differences in motor strength and speed have been widely reported, the extent to which these differences are maintained in old age has not been well established.

METHODS

Upper extremity motor performance was assessed in 234 men and 530 women Catholic clergy members aged 65 years or older with no clinical evidence of dementia who were participants in the Religious Orders Study. As part of a uniform clinical evaluation, upper extremity motor performance including strength (grip and pinch dynamometry), movement speed including finger tapping and Purdue pegboard and muscle bulk of the arm were collected.

RESULTS

Men were stronger than women at all ages but this difference became less prominent at older ages. Women scored higher on the Purdue Pegboard than men whereas men had faster maximal finger tapping rates than women. Gender differences in speed were not modified by age. Men had greater muscle bulk than women at all ages and these differences were not modified by age. These relationships were not modified by participants with a clinical diagnosis of Parkinson's disease or stroke or by hormone replacement therapy in women.

CONCLUSIONS

Gender differences in upper extremity speed and muscle bulk appear to be relatively stable with increasing age, whereas gender differences in strength were reduced in the oldest old. Longitudinal studies are needed to determine if men and women differ in the rate of decline of strength in old age.

European Stroke Prevention Study 2: A study of low-dose acetylsalicylic acid and of high dose dipyridamole in secondary prevention of cerebro-vascular accidents

In spite of some data being added to our knowledge of the effect of antiplatelets in secondary prevention of brain ischemic lesion in recent years, the main reasons to perform a second European Stroke Prevention Study (ESPS 2), which started in 1987-1988, were: (a) clarify the relative roles of aspirin (ASA) and dipyridamole (DP) alone or in combination; (b) confirm the efficacy of small doses of ASA and, so doing, decrease the number of drop-outs due to ASA side effects; (c) join information to the effect of antiplatelets in complete stroke. General characteristics of the sample of 6602 patients are presented and compared with other major trials and series. The patients in the four treatment arms (aspirin, dipyridamole, aspirin + dipyridamole and placebo) are compared. The more relevant features and risk factors known to influence long term prognosis are described and discussed. The small proportion of patients included with TIA (23.7%) and the comparability among treatment groups are stressed. No relevant differences have been found, among groups, on the sex or age distribution, prevalence of hypertension, diabetes, previous vascular events or atrial fibrillation, nor in the characteristics of the accident leading to the inclusion in trial.

Incidence of cerebrovascular lesions in pure autonomic failure

In pure autonomic failure (PAF) - a rare form of primary dysautonomia - some patients show cerebrovascular lesions usually found in hypertensive subjects. In an autonomic laboratory records of patients with a definitive diagnosis of PAF having had cerebral imaging (cMRI, cCT) were analysed retrospectively. Tilt table data (supine/tilted), 24 hour blood pressure recordings (day/night) and serum catecholamine levels were correlated with cerebrovascular lesions and also compared to published normal values. 50 PAF patients (23 female, 27 male) were identified, mean age 67 years (sd 9.5). Out of these 35 (70%) had pathologic cerebral scans showing white matter lesions (WML) in 30, lacunar strokes in 5 and hemispheric stroke and microbleeds each in 1. Age and supine systolic blood pressure were significantly elevated in patients with pathologic scans (70 compared to 61 years [p=0.007], and 170 compared to 154 mmHg [p=0.045]). Out of 28 patients with WML and ambulatory blood pressure recordings available 24 were non-dippers. The data show that the frequency of WML is lower in PAF patients aged 60 to 80 years compared to age matched community based samples. Although PAF usually results in hypotension, a frequent complication is supine hypertension. Although the overall frequency of WML seems to be reduced in PAF, a number of patients with elevated supine systolic blood pressure (>160 mmHg) develop WML and some of these suffer stroke.

Carotid artery stenosis as a cause of stroke

BACKGROUND

Population-based studies have estimated that about 15% of ischemic strokes are caused by large-vessel cerebrovascular disease. We determined the types of large-vessel atherosclerosis responsible for ischemic strokes in a population-based stroke study.

METHODS

Patients with first-ever or recurrent ischemic stroke in the Greater Cincinnati area were identified during 2005 at all local hospitals. Study physicians assigned ischemic stroke subtypes. Overall event rates and incidence rates for first-ever events were calculated, and age-, race- and sex-adjusted to the 2000 US population.

RESULTS

There were 2,204 ischemic strokes, including 365 strokes of large-vessel subtype (16.6% of all ischemic strokes). Extracranial internal carotid artery (ICA) stenosis was associated with 8.0% of all ischemic strokes, while extracranial ICA occlusion and intracranial atherosclerosis were each associated with 3.5% of strokes. The annual rate of first-ever and recurrent stroke attributed to extracranial ICA was 13.4 (11.4-15.4) per 100,000 persons. We conservatively estimate that about 41,000 strokes may be attributed to extracranial ICA stenosis annually in the United States.

CONCLUSIONS

Large-vessel atherosclerosis is an important cause of stroke, with extracranial ICA stenosis being significantly more common than extracranial ICA occlusion or intracranial atherosclerotic disease.

Risk factors and outcome of patients with symptomatic intracranial stenosis presenting with lacunar stroke

BACKGROUND AND PURPOSE

We hypothesized that patients with intracranial stenosis with lacunar stroke presentations would face lower risks of recurrent stroke than those with index nonlacunar strokes, and that their recurrent strokes would predominantly be lacunar.

METHODS

We analyzed subjects enrolled with an index stroke into the Warfarin Aspirin Symptomatic Intracranial Disease (WASID) trial. The index stroke was classified as lacunar or nonlacunar. The primary end point was recurrent ischemic stroke. Cox proportional hazard models were generated with stratification for severity of stenosis.

RESULTS

Three hundred forty-seven subjects were enrolled after an index stroke; 38 were lacunar and 309 were nonlacunar. Over a mean follow-up of 1.8 years, there was no significant difference in stroke recurrence between patients whose index stroke was lacunar (7 of 38 [18%]) versus nonlacunar (69 of 309 [22%]; hazard ratio, 0.79; 95% CI, 0.36-1.71). Furthermore, no significant differences were found when groups were stratified by 50% to 69% stenosis (hazard ratio, 0.50; 95% CI, 0.12-2.1) and ≥ 70% stenosis (hazard ratio, 0.87; 95% CI, 0.34-2.2). Of the 7 recurrent strokes in patients whose index stroke was lacunar, all 7 were nonlacunar and 3 were in the territory of the stenotic artery.

CONCLUSIONS

In patients with symptomatic intracranial stenosis, the risk of recurrent stroke was similar in patients who presented with lacunar and nonlacunar strokes, and recurrent strokes in patients presenting with lacunar stroke were typically nonlacunar. These findings suggest that the pathophysiology of these strokes is related to the stenosis rather than small vessel disease. Patients presenting with lacunar strokes should be included in trials investigating secondary prevention for symptomatic intracranial stenosis.

Retrospective analysis of aspirin and ticlopidine in preventing recurrent stroke following an initial lacunar infarct

Of 73 patients with initial lacunar stroke subsequently treated with aspirin, 13 (18%) developed recurrent stroke (11 lacunar infarcts and 2 nonlacunar infarcts), and 4 (5%) died within 1 year. Of the aspirin-treated lacunar infarct patients, 58 received 325 mg or lower-dose aspirin, and 15 received 600-1,300 mg of aspirin. Thirteen aspirin-treated patients who developed recurrent ischemic stroke received 80 mg or 325 mg of aspirin, whereas recurrent stroke did not occur in 15 patients treated with 600-1,300 mg of aspirin daily. Of 25 patients with lacunar stroke who were subsequently treated with 250 mg of ticlopidine twice daily, 1 patient (4%) developed recurrent lacunar infarct, and none died within 1 year. Of 10 patients who had an initial lacunar stroke and subsequently received no antiplatelet medication, 4 (40%) developed recurrent lacunar stroke, and 1 (10%) died within 1 year.

Advances in the diagnosis of etiologic subtypes of ischemic stroke

A fundamental goal of etiologic stroke classification is to generate subgroups with discrete phenotypic, therapeutic, and prognostic features. Accurate stroke classification requires integration of multiple aspects of diagnostic stroke evaluation in a standardized manner. Diagnostic test findings can be simply organized into major etiologic groups to create a phenotypic subtype, or they can be reduced to a single causative subtype through a decision-making process. It is essential for a classification system to provide consistent results across different raters in different clinical settings. Comparability of subtype assignments is the key to valid communication of research results across the field. This article highlights important theoretical aspects of etiologic stroke classification and reviews major etiologic classification systems that have benefited from recent advances in etiologic stroke evaluation.

Stroke subtypes and risk factors in patients living in southern Seoul, Korea: the impact of hypertension control on stroke subtypes

BACKGROUND AND PURPOSE

The prevalence of hypertension (HT) does not explain the relatively high incidence of hemorrhagic stroke in Korea and other Asian countries, and whether HT has a greater impact on development of the intracerebral hemorrhage (ICH) than cerebral infarction (CI) remains unclear. It may be speculated that the adequacy of HT control is related to the subtype differences. The present study was aimed to elucidate (1) whether various risk factors exert a different impact on stroke subtypes and (2) whether the adequacy of HT control in patients with a previous history of HT is related to different subtypes in stroke patients from southern Seoul, Korea.

METHODS

We prospectively studied 602 consecutive patients with acute stroke (CI and ICH) admitted to the Asan Medical Center and analyzed their stroke subtypes and risk factors. The mode of HT treatment before the stroke onset was specifically asked. We examined whether various risk factors were related to subtype differences in these patients. We also attempted, in patients with a prior history of HT, to see whether the mode of HT control was related to the subtype differences.

RESULTS

75.8% of the patients had CI (large vessel infarction 33.8%, small vessel infarction 22.1%) and 24.2% had ICH; 75% of the patients had HT of whom the presence of HT was previously unidentified in 8%. Previous treatment of HT was considered adequate in 32.4% and inadequate in the others. On multiple logistic analysis, diabetes mellitus and alcohol drinking were independently related to CI (v ICH), whereas HT did not favor any stroke subtypes. However, in patients with a prior history of HT, previous mode of HT control was a significant factor related to subtype differences in a way that inadequate treatment favored ICH. There were no specific risk factors that independently discriminate large vessel infarction versus small vessel infarction.

CONCLUSIONS

Apparently, HT was not a risk factor that preferentially favors any specific stroke subtypes in patients from southern Seoul. However, in patients with HT, previous mode of HT control was an important factor influencing the subtypes. Inadequate treatment of HT may play a role, at least in part, on the relatively prevalent ICH and hence the greater significance of stroke as a cause of death in Korea compared with Western countries.

Long-term prognosis of Chinese patients with a lacunar infarct associated with small vessel disease: a five-year longitudinal study

RATIONALE

Lacunar infarct associated with small vessel disease is a common stroke subtype in China and has a favorable short-term prognosis. Data on its long-term prognosis among Chinese patients are lacking.

AIMS

We aimed to study its long-term prognosis and predictors for poor outcomes.

DESIGN

We followed up to 75 consecutive Chinese stroke patients who had a lacunar infarct for a period of 5 years. Clinical outcomes with respect to mortality and recurrent stroke were noted. We evaluated baseline clinical and imaging predictors for such outcomes using the Cox regression analysis.

STUDY OUTCOMES

Sixteen (21.3%) patients died and 12 (16%) patients had recurrent stroke during follow-up. Twenty-one (28%) patients had combined events of either death and/or recurrent stroke. Univariate Cox regression analysis showed that age, literacy, National Institute of Health Stroke Scale, incident stroke/transient ischemic attack, and white matter lesion volume predicted survival, while, age, National Institute of Health Stroke Scale, systolic blood pressure, hyperhomocysteinemia, silent lacunes, microbleeds, and white matter lesion volume predicted recurrent stroke. Multivariate Cox regression analysis showed that National Institute of Health Stroke Scale (HR 1.25, 95% CI 1.05-1.48) and white matter lesion volume (HR 1.46, 95% CI 1.11-1.92) predicted combined events of mortality and/or recurrent stroke after age adjustment.

CONCLUSION

Approximately one in four patients either died and/or had recurrent stroke within 5 years after a lacunar infarct. Age, stroke severity, and volume of white matter lesion predict a poor long-term prognosis.

Organized inpatient (stroke unit) care in very old patients

BACKGROUND AND PURPOSE

It is unclear whether very old patients benefit from organized inpatient (stroke unit) care. The aim of this work was to compare the clinical outcome of patients with first-ever ischemic stroke aged either >or=80 or <80 years who were treated conservatively (without cerebral revascularization) in a university-based stroke unit.

PATIENTS AND METHODS

We included 147 (11%) patients >or=80 years and 1241 (89%) patients, <80 years. All patients underwent clinical examination, blood tests, electrocardiography (ECG), brain imaging and cerebrovascular ultrasound. Additional investigations were done at the discretion of the treating physician. The modified Rankin scale (mRS) score was used to assess the 3-month outcome (favorable: mRS, 0-1; poor: mRS, 2-6; death of any cause).

RESULTS

Stroke severity did not differ between both groups [median National Institutes of Health Stroke Scale (NIHSS) score, 4]. Younger patients underwent magnetic resonance (MR) imaging of the brain, MR and catheter angiography and echocardiography (p<0.001) more frequently, whereas older patients underwent computed tomography of the brain and 24-hour ECG (p<0.001) more frequently. Stroke prevention included clopidogrel (p<0.001) and heparin (p=0.047) more often in older patients and aspirin (p=0.016) in younger patients. Recurrent ischemic events were similarly frequent in old (7%) and young (5%) patients. Favorable outcome was equally prevalent in old (71%) and young (76%) patients, whereas mortality was higher in older patients (7 and 3%, p=0.007). Admission NIHSS score >or=12 was the only independent predictor of unfavorable outcome (odds ratio, 19.6; 95% confidence interval, 9.7-39.6; p<0.001).

CONCLUSION

Our work provides further evidence that also the oldest patients may benefit from conservative stroke unit care.

Transesophageal echocardiography findings in lacunar stroke

BACKGROUND

Transesophageal echocardiography (TEE) constitutes a valuable tool in patients with stroke and cardiac embolization, but its indication is controversial in lacunar stroke. The purpose of this study was to assess the findings of TEE in lacunar stroke.

METHODS

Initial symptoms, brain computed tomography or magnetic resonance imaging, and TEE were performed for all patients with ischemic stroke admitted consecutively to our department of neurology. The subtype of ischemic stroke (lacunar v large-vessel stroke) was also reviewed.

RESULTS

In all, 124 patients with ischemic stroke were identified and lacunar syndrome occurred in 46. Major risk factor of embolization in patients with lacunar stroke and indication for anticoagulation were detected in 20% (9 of 46). We compared findings in both groups (lacunar v nonlacunar stroke) to evaluate the differences in the presence of major risk factor for embolization, Chi square = 0.07, P = .8 (odds ratio 95% CI = 0.35-2.18). Characteristics of the 9 patients with lacunar stroke and major risk of embolization show that history of lacunar ischemic stroke was present in all the patients of this group.

DISCUSSION

The results of the study suggest that TEE may be necessary to obtain a complete evaluation to optimize preventive treatment in patients with clinical and radiologic presentation that suggest lacunar infarct, particularly in cases with a history of ischemic stroke, in which a potential cardiac source of embolization may be detected.

Stroke in Qatar: a first prospective hospital-based study of acute stroke

BACKGROUND

Stroke is a major cause of morbidity and mortality in Qatar.

OBJECTIVES

The aim of our study was to determine types of strokes, the associated risk factors, clinical presentation, outcome, and time to hospital admission among Qatari and non-Qatari patients as well as young and nonyoung patients.

METHODS

We conducted a hospital-based prospective observational study including all patients admitted to Hamad Medical Corporation with first-ever stroke from September 15, 2004, to September 14, 2005. A stroke was defined according to World Health Organization criteria.

RESULTS

Stroke was confirmed in 270 patients of whom 217 (80.4%) had ischemic stroke and 53 (19.6%) had hemorrhagic stroke. Male patients predominated in all types of stroke. The main risk factors for stroke were hypertension and diabetes, whereas lacunar infarct was the most common subtype of ischemic stroke. Risk factor profiles were similar between Qatari and non-Qatari patients except for hypercholesterolemia, which was observed with a higher frequency in Qatari compared with non-Qatari patients with ischemic stroke. There were significant differences between the young and nonyoung patients with ischemic stroke with respect to risk factors, ejection fraction, ventricular wall-motion abnormalities, time to hospital admission, and outcome. Most patients arrived at the hospital more than 3 hours from stroke onset because of unawareness of stroke symptoms. The overall in-hospital mortality was 9.3%.

CONCLUSIONS

Hypertension and diabetes mellitus were the main risk factors for stroke in Qatar, whereas lacunar infarct was the most common subtype. Significant differences between the young and nonyoung patients were observed with respect to risk factors, ejection fraction, ventricular wall-motion abnormalities, time to hospital admission, and outcome.

Need for extensive diagnostic work-up for patients with lacunar stroke

OBJECTIVE

Small-vessel disease is the most frequent cause of lacunar stroke. The aims of this study were to evaluate: 1) alternative causes of lacunar stroke other than small-vessel disease; 2) functional outcome of lacunar strokes due to small vessel disease compared to lacunar strokes due to alternative causes.

METHODS

Consecutive patients with first-ever ischemic lacunar stroke were prospectively followed-up for at least 3 months. At discharge patients were divided into 2 groups: lacunar stroke due to small vessel disease (L-SVD) and lacunar stroke due to possible other etiologies (L-non SVD) (e. g. cardioembolism, atherosclerosis or other causes). Main outcome measures were the combined end point of death or disability (mRS >or= 3) and recurrent stroke at the end of follow-up.

RESULTS

535 patients with acute stroke were seen during the study period. Out of these, 196 patients (126 males) with a mean age of 71.6 years (SD = 10) had lacunar stroke. L-SVD was seen in 142 patients (72.4 %) and L-nonSVD in 54 patients (27.6 %). After 16.4 months, 12 patients had died (6.2%; annual mortality rate 4.4 %), 63 were disabled (32.5 %) and 27 had stroke recurrence (13.9%; annual recurrence rate 9.9 %). Forty-nine patients with L-SVD (34.7 %) and 26 with L-nonSVD (49%) had died or become disabled. Sixteen patients with L-SVD (11.3 %) and 11 with L-nonSVD (20.4 %) had stroke recurrence. On multivariate analysis, L-nonSVD (OR = 2.87, 95% CI 1.08-7.65; p = 0.034) and age (OR = 1.07, 95 % CI 1.02-1.12; p = 0.01) were associated to more severe outcome. L-nonSVD was independently associated with recurrence (OR = 5.03, 95% CI 1.54-16.44; p = 0.006).

CONCLUSIONS

Twenty-seven percent of patients with lacunar stroke have causes other than small vessel disease. These patients have a severe outcome in terms of recurrence,mortality or disability. These findings support the need for a comprehensive diagnostic work-up for patients with lacunar stroke.

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.

Comparative changes in the blood-brain barrier and cerebral infarction of SHR and WKY rats

Hypertension is involved in the exacerbation of stroke. It is unclear how blood-brain barrier (BBB) tight-junction (TJ) and ion transporter proteins critical for maintaining brain homeostasis contribute to cerebral infarction during hypertension development. In the present study, we investigated cerebral infarct volume following permanent 4-h middle cerebral artery occlusion (MCAO) and characterized the expression of BBB TJ and ion transporter proteins in brain microvessels of spontaneously hypertensive rats (SHR) compared with age-matched Wistar-Kyoto (WKY) rats at 5 wk (prehypertension), 10 wk (early-stage hypertension), and 15 wk (later-stage hypertension) of age. Hypertensive SHR show increased infarct volume following MCAO compared with WKY control rats. BBB TJ and ion transporter proteins, known to contribute to edema and fluid volume changes in the brain, show differential protein expression patterns during hypertension development. Western blot analysis of TJ protein zonula occludens-2 (ZO-2) showed decreased expression, while ion transporter, Na+/H+exchanger 1 (NHE-1), was markedly increased in hypertensive SHR. Expression of TJ proteins ZO-1, occludin, actin, claudin-5, and Na+-K+-2Cl−cotransporter remain unaffected in SHR compared with control. Selective inhibition of NHE-1 using dimethylamiloride significantly attenuated ischemia-induced infarct volume in hypertensive SHR following MCAO, suggesting a novel role for NHE-1 in the brain in the regulation of ischemia-induced infarct volume in SHR.

Segmental left ventricular wall motion abnormalities are associated with lacunar ischemic stroke

OBJECTIVE

The aim of this study was to determine whether segmental left ventricular wall motion abnormalities (SLVWMA) are a potential cause of ischemic stroke.

METHODS

Demographics, cardiovascular risk factors and echocardiographic parameters of patients with ischemic stroke (with and without SLVWMA) were collected and compared with those of patients who had SLVWMA but without history of ischemic stroke.

RESULTS

Two hundred and fifty nine patients with ischemic stroke were identified: 187 patients without SLVWMA, and 72 with SLVWMA. The cardiac group consisted of 79 patients. Compared with the stroke patients with SLVWMA, stroke patients without SLVWMA were slightly but significantly younger (59 versus 63 years of age). Furthermore, the number of risk factors in stroke patients without SLVWMA was significantly lower compared with stroke patients with SLVWMA (2.7 versus 3.7). There was no difference in age or gender between stroke patients with SLVWMA and the cardiac patients. However, the number of risk factors was significantly higher in the cardiac patients compared with stroke patients with SLVWMA (4.4 versus 3.7). The ejection fraction was normal in both groups of stroke patients but significantly lower in the cardiac patients (37%). Significantly more lacunar ischemic strokes were observed in stroke patients with SLVWMA than in those without SLVWMA (76% versus 68%).

CONCLUSION

Our data indicate that in ischemic stroke patients with multiple cardiovascular risk factors and SLVWMA a higher frequency of lacunar strokes can be found. The latter could be a marker of small-vessel disease and/or be a potential contributing factor, perhaps through a mechanism of cardiac microembolism, in the development of lacunar ischemic stroke. The mechanisms of the association between SLVWMA and lacunar ischemic stroke remain however unclear.

High prevalence of previous antiplatelet drug use in patients with new or recurrent ischemic stroke: Buffalo metropolitan area and Erie County stroke study

STUDY OBJECTIVE

To determine the proportion of patients in a large metropolitan population who developed ischemic stroke despite having received antiplatelet drug therapy, and their associated characteristics and in-hospital outcomes.

DESIGN

Retrospective, cross-sectional study.

SETTING

Eleven hospitals in western New York State.

PATIENTS

One thousand five hundred eighty-two patients with new or recurrent ischemic stroke who were admitted to one of the 11 study hospitals between January 1 and December 31, 2000, and for whom data were available regarding previous drug therapy.

MEASUREMENTS AND MAIN RESULTS

The proportion of patients taking antiplatelet drugs before the onset of stroke was determined. Demographic and clinical characteristics, stroke subtypes, in-hospital bleeding complications, mortality, and discharge drugs were compared between patients with and those without previous antiplatelet drug use. Previous use of antiplatelet drugs was observed in 642 (41%) of the 1582 patients admitted with ischemic stroke. The antiplatelet drugs were aspirin alone (494 patients), clopidogrel alone (70), aspirin and clopidogrel (36), aspirin in combination with other antiplatelet drugs (20), and others (22). Patients with previous use of antiplatelet drugs were older and more likely to have hypertension, diabetes mellitus, hyperlipidemia, and a history of cardiovascular disease. The proportion of patients with large-vessel disease was greater among patients with previous use of antiplatelet drugs. Patients with previous use of antiplatelet drugs were more likely to be discharged with aspirin, clopidogrel, and an aspirin-dipyridamole combination.

CONCLUSION

The relatively high proportion of patients who developed ischemic stroke despite taking antiplatelet drugs observed in this regional hospital-based study mandates clinical trials specifically addressing therapeutic intervention for this group of patients.

Analysis of the lesion distributions and mechanism of acute middle cerebral artery infarctions involving the striatocapsular region

BACKGROUND AND PURPOSE

There is no clear description about the patterns of each mechanism of striatocapsular infarctions. The aims of our study were to elucidate differences in the distributions of lesions of acute middle cerebral artery (MCA) infarctions involving the striatocapsular region and to compare those following embolic striatocapsular infarctions with those originating from MCA disease.

METHODS

We prospectively enrolled patients with acute infarcts located in the lenticulostriate artery territory that were not lacunar infarcts. Brain coronal diffusion-weighted imaging (DWI) was obtained and magnetic resonance angiography (MRA) was carried out to evaluate the distribution of infarct lesions and MCA stenosis in all patients. The types of infarct distribution were divided into three categories: (1) dominant in the distal territory (DD), (2) distributed equally between the distal and proximal territories (DE), and (3) dominant in the proximal territory. We performed tests for embolic sources (transthoracic echocardiography, transesophageal echocardiography, Holter monitoring, and contrast-enhanced MRA including the aortic arch) in most patients. Stroke mechanisms were classified into stroke from proximal embolism, MCA disease, and stroke of undetermined etiology.

RESULTS

A total of 47 patients (28 men and 19 women; mean age, 62 years) were recruited. A proximal embolic source was significantly more prevalent in patients with a DE lesion than in those with a DD lesion. The most common proximal embolic source was of cardiac origin. In contrast, symptomatic MCA stenoses were more common in patients with a DD lesion than in those with a DE lesion.

CONCLUSIONS

These results suggest that the dominant area of striatocapsular infarction on coronal DWI is an important clue for stroke etiology. Coronal DWI could therefore be helpful to determining the mechanisms in patients with striatocapsular infarctions that are currently described as having an "undetermined etiology" according to the Trial of Org 10172 in Acute Stroke Treatment classification.

Ethnic Variations in Risk Factor Profile, Pattern and Recurrence of Non-Cardioembolic Ischemic Stroke

BACKGROUND

Ischemic stroke is influenced by ethnic and geographical variations. The aim of this study was to identify the risk factor profiles, subtypes and recurrence of non-cardioembolic ischemic stroke for the two largest subpopulations, the Arab and South Asians, at the only stroke-admitting hospital in Qatar.

METHODS

Data on stroke patients admitted to Hamad Medical Corporation from January through December 2001 were reviewed in January 2005. Only patients with non-cardioembolic ischemic stroke and complete work-up were included.

RESULTS

A total of 303 patients with ischemic non-cardioembolic stroke fit the entry criteria. Sixty seven percent of the overall patient population (sex ratio 2:6, M/F) was of Arab origin, and 32% were South Asians. Hypertension was the most commonly encountered risk factor followed by dyslipidemia, diabetes mellitus, and obesity. Significant differences between the Arab and South Asian subgroup of patients were observed with respect to number of risk factors and occurrence of obesity and diabetes. Carotid artery stenotic lesions, ventricular wall motion abnormalities and stroke recurrence were observed with a higher frequency in the Arab subgroup of patients compared with the South Asians. The majority of strokes were lacunar hemispheric strokes (68%), followed by lacunar brainstem strokes (15%) and large-vessel hemispheric infarctions (10%). Patients with a previous history of stroke had a higher frequency of carotid artery stenosis (p = 0.05) and risk of stroke recurrence (p = 0.04).

CONCLUSIONS

Unlike in other studies originating from the Arabian Gulf, lacunar stroke is the most common subtype of non-cardioembolic ischemic stroke in both the Arabs and South Asians in Qatar. Significant ethnic differences in age of occurrence, risk factor profile, and cardiovascular variables were observed.

Time to hospital arrival, use of thrombolytics, and in-hospital outcomes in ischemic stroke

OBJECTIVE

To determine the interval between symptom onset and hospital arrival and its relationship to baseline clinical characteristics, use of thrombolysis, and in-hospital outcomes in patients with acute ischemic stroke admitted to the 11 hospitals in the Buffalo metropolitan area and Erie County.

METHODS

The medical records of 1,590 patients were reviewed to determine the severity of the neurologic deficits (NIH Stroke Scale [NIHSS]), in-hospital mortality, favorable outcome (modified Rankin Scale score of < or = 2 at discharge), and strata of time interval between symptom onset and hospital arrival.

RESULTS

The time interval between symptom onset and hospital arrival was 0 to 3 hours in 337 (21%) patients, 3 to 6 hours in 177 (11%) patients, 6 to 24 hours in 301 (19%) patients, > 24 hours in 420 (26%) patients, and undetermined in 355 (22%) patients. IV (n = 23) and intra-arterial (n = 4) thrombolysis was used in 27 (8%) of the 337 patients that presented within 3 hours of symptom onset. In 1,235 patients with known time interval between symptom onset and hospital arrival, an association (p = 0.008) was observed between strata of increasing time interval and higher proportion of favorable outcomes at discharge. The initial NIHSS score was higher with decreasing interval between symptom onset and hospital arrival (p < 0.0001).

CONCLUSIONS

A small proportion of patients who present within 3 hours of symptom onset receive thrombolytic therapy. The observation that patients with more severe neurologic deficits and subsequently worse in-hospital outcomes appear to present early after symptom onset to the hospital may have implications for clinical studies.

Left-hemispheric dominance for articulation: a prospective study on acute ischaemic dysarthria at different localizations

Dysarthria is a frequent symptom in cerebral ischaemia. However, speech characteristics of these patients have not previously been investigated in relation to lesion site in a prospective study. We investigated the auditory perceptual features in 62 consecutive patients with dysarthria due to a single, non-space-occupying cerebral infarction confirmed by MRI. Standardized speech samples of all patients were stored within 72 h after stroke onset using a digital tape recorder. Speech samples were assessed independently by two experienced speech therapists, who were unaware of the clinical and neuroradiological findings, using an interval scale ranging from 0 to 6. Separately assessed were features of articulation, phonation, prosody, and the global severity for a total of 31 items. Extracerebellar infarctions (85.5%) were located in the lower motor cortex (14.5%), striatocapsular region (46.8%) and base of the pons (24.2%). Isolated cerebellar infarctions were present in 14.5% of patients. There was a strong correlation between the findings of both examiners, showing identical scores, or only minor differences (<1 on the assessment scale) for 80% of all items. The average severity of dysarthria was 2.9 +/- 1.3. Articulatory abnormalities were the predominant deviation characteristics, affecting in particular the production of consonants. However, phonatory and prosodic abnormalities were also frequently observed speech characteristics. As revealed by factor analysis of speech characteristics the total severity of dysarthria was mainly influenced by the impairment of articulation. Speech parameters describing characteristics of articulation and prosody showed significant side-to-side and area differences, while this effect was lacking for any voice parameter. Left cerebral lesions showed a more severe overall impairment of speech and articulation, independent of lesion topography. Thirty-eight of 62 patients were available for follow-up. Speech evaluation showed normal speech within weeks in 15 out of 38 patients (39.5%). In the other 23 patients overall severity of dysarthria was mild. This is the first prospective study which describes speech characteristics of dysarthria due to acute unilateral cerebral infarctions. We could demonstrate that dysarthria in extracerebellar infarctions was more frequently caused by left-sided lesions and that the severity of dysarthria was more pronounced in left-sided lesions independent from lesion topography. All extracerebellar lesions were located along the course of the cortico-bulbar tract fibres. Compatible with a common pathophysiological basis of dysarthria in these patients, none of the 31 speech items differed significantly between subcortical and brainstem lesions.

Comparing risks of death and recurrent vascular events between lacunar and non-lacunar infarction

Differences in prognosis of lacunar and non-lacunar infarction patients might support distinct arterial pathological processes underlying these two subtypes of ischaemic stroke. We performed a systematic review in which we identified cohort studies with ischaemic stroke subtype-specific follow-up data on death, recurrent stroke and/or myocardial infarction (MI). We calculated risks of death and recurrent stroke at 1 month, 1-12 months and 1-5 years, as well as risks of MI and cardiac death. We compared non-lacunar with lacunar infarction, using study-specific and summary odds ratios. We also compared the pattern of recurrent stroke subtypes after lacunar and non-lacunar infarction. One month odds of death and of recurrent stroke were significantly greater following non-lacunar than lacunar infarction, but the difference decreased thereafter (1 month mortality: OR 3.81, 95% CI 2.77-5.23; 1-12 month mortality: OR 2.32, 95% CI 1.74-3.08; 1-5 year mortality: OR 1.77, 95% CI 1.28-2.45; 1 month stroke recurrence: OR 2.11, 95% CI 1.20-3.69; 1-12 month stroke recurrence: OR 1.24, 95% CI 0.85-1.83; 1-5 year stroke recurrence: OR 1.61, 95% CI 0.96-2.70). Recurrent strokes were more likely to be lacunar if the index event was lacunar. Few studies reported on the risk of MI, but we found no significant difference in risk of cardiac death in non-lacunar versus lacunar infarction. Thus, although early mortality and stroke recurrence risks are higher among non-lacunar than lacunar infarct patients, the risks appear not to differ in the longer term and the risks of cardiac outcomes are similar, although data are limited. There is some evidence that recurrent ischaemic stroke subtypes breed true. These results provide limited support for a distinct arterial pathology underlying lacunar infarction.

Clinical characteristics of patients with ischemic ocular nerve palsies and lacunar brain infarcts: a retrospective comparative study

BACKGROUND

Ischemic ocular motor nerve palsies (IOMP) and lacunar brain infarcts share a similar pathological mechanism. The clinical characteristics of patients as well as the protective role of aspirin should therefore be similar in both conditions.

METHODS

The medical records of 107 consecutive patients with IOMP and 160 patients with lacunar cerebrovascular accidents (CVA) were reviewed and analyzed with respect to patient characteristics, vascular risk factors, and aspirin intake. The data on patients with and without aspirin were compared within each group as well as between both groups.

RESULTS

Hyperlipidemia, smoking, high carotid stenosis (>70%) and the presence of more than one vascular risk factor in an individual patient were found to be more common in patients with lacunar brain infarcts regardless of aspirin intake. Absence of vascular risk factors was encountered more in IOMP patients. The recurrence of lacunar CVA was significantly higher than recurrence of IOMP. A history of Bell's palsy was more common in IOMP patients than in patients with lacunar CVA. Within the IOMP group, the prevalence of vascular risk factors did not differ between the aspirin and non-aspirin group. Ischemic heart disease (IHD), CVA and recurrence were found more often in the aspirin group. Within the CVA group hypertension, IHD, cardiac arrhythmia and recurrence rate were more common in the aspirin group whereas smoking was found to be more common in the non-aspirin group of patients.

CONCLUSIONS

Arteriosclerosis is the main cause of lacunar CVA and IOMP. However, IOMP depends less on the presence of vascular risk factors than does lacunar CVA. Furthermore, aspirin - at least at low doses - does not seem to have a protective effect on either of these conditions, but more extensive prospective studies of homogeneous groups of patients are needed to clarify the preventive role of antiplatelet agents in IOMP.