Fungal sinusitis was once considered a rare disorder but is now reported with increasing frequency throughout the world. The classification of fungal sinusitis has evolved in the past two decades, and this entity is now thought to comprise five subtypes. Acute invasive fungal sinusitis, chronic invasive fungal sinusitis, and chronic granulomatous invasive fungal sinusitis make up the invasive group, whereas noninvasive fungal sinusitis is composed of allergic fungal sinusitis and fungus ball (fungal mycetoma). These five subtypes are distinct entities with different clinical and radiologic features. The treatment strategies for the subtypes are also different, as are their prognoses. An understanding of the different types of fungal sinusitis and knowledge of their particular radiologic features allow the radiologist to play a crucial role in alerting the clinician to use appropriate diagnostic techniques for confirmation. Prompt diagnosis and initiation of appropriate therapy are essential to avoid a protracted or fatal outcome.

Background Small subcortical strokes, also known as lacunar strokes, comprise more than 25% of brain infarcts, and the underlying vasculopathy is the most common cause of vascular cognitive impairment. How to optimally prevent stroke recurrence and cognitive decline in S3 patients is unclear. The aim of the Secondary Prevention of Small Subcortical Strokes study (Trial registration: NCT00059306) is to define strategies for reducing stroke recurrence, cognitive decline, and major vascular events. Methods Secondary Prevention of Small Subcortical Strokes is a randomised, multicentre clinical trial (n = 3000) being conducted in seven countries, and sponsored by the US NINDS/NIH. Patients with symptomatic small subcortical strokes in the six-months before and an eligible lesion on magnetic resonance imaging are simultaneously randomised, in a 2 × 2 factorial design, to antiplatelet therapy – 325 mg aspirin daily plus 75 mg clopidogrel daily, vs. 325 mg aspirin daily plus placebo, double-blind – and to one of two levels of systolic blood pressure targets –‘intensive’ (<130 mmHg) vs. ‘usual’ (130–149 mmHg). Participants are followed for an average of four-years. Time to recurrent stroke (ischaemic or haemorrhagic) is the primary outcome and will be analysed separately for each intervention. The secondary outcomes are the rate of cognitive decline and major vascular events. The primary and most secondary outcomes are adjudicated centrally by those unaware of treatment assignment. Conclusions Secondary Prevention of Small Subcortical Strokes will address several important clinical and scientific questions by testing two interventions in patients with recent magnetic resonance imaging-defined lacunar infarcts, which are likely due to small vessel disease. The results will inform the management of millions of patients with this common vascular disorder.

Background and Purpose Diabetes is an independent risk factor for lacunar strokes. Few data are available regarding patient features, infarct location, and recurrent vascular events for diabetic patients with lacunar stroke. Methods We compared features at study entry and prognosis during 3.6 years of follow-up of diabetic vs. non-diabetic patients with recent lacunar stroke participating in the Secondary Prevention of Small Subcortical Strokes (SPS3) randomized trial. Results Among the 3020 participants, the prevalence of diabetes was 37% with a mean duration of 11 years. Diabetes was independently associated with slightly younger age (63 years vs. 64 years, p<0·001), Hispanic ethnicity (36% vs. 28%, p<0·0001), ischemic heart disease (11% vs. 6%, p=0·002), and peripheral vascular disease (5% vs. 2%, p<0·001). Diabetic patients more frequently had intracranial stenosis ≥50% (p<0·001), infarcts involving the brainstem or cerebellum (p<0·001), and more extensive white matter abnormalities (p<0·001). Diabetic patients were almost twice as likely to have a recurrent stroke (HR 1·8; 95% CI 1·4–2·3), recurrent ischemic stroke (HR 1·8; 95% CI 1·4–2·4), disabling/fatal stroke (HR 1·8; 95% CI 1·2–2·9), myocardial infarction (HR 1·7; 95% CI 1·0–2·8) and death (HR 2·1 (95% CI 1·6–2·8) compared with non-diabetics. Conclusions Diabetic patients with lacunar stroke have a distinctive clinical profile that includes double the prevalence of systemic and intracranial atherosclerosis, preferential involvement of the posterior circulation, and a poor prognosis for recurrent stroke and death.