Capsular warning syndrome: clinical analysis and treatment

Abstract

BackgroundCapsular warning syndrome (CWS) is a rare clinical syndrome, which is defined as a recurrent transient lacunar syndrome. The mechanism and clinical management of CWS remain unclear. The aim of the study was to discuss the clinical characteristics of CWS and evaluate the different outcome between rt-PA and no rt-PA therapy.MethodsThe present multicenter retrospective study involved three medical centers, and the clinical data were collected from patients with CWS between January 2013 and December 2018. The clinical characteristics of CWS were analyzed. Patients were divided into two groups: rt-PA and no rt-PA groups. The therapeutic effects and prognosis of these two groups were analyzed. A good prognosis was defined as 3-month modified Rankin Scale (mRS) ≤ 2.ResultsOur study included 72 patients, 27 patients were assigned to rt-PA group, 45 in no rt-PA group. Hypertension and dyslipidemia were the most common risk factors. The mean number of episodes before irreversible neurological impairment or the symptoms completely disappeared was five times (range: 3–11 times). A total of 58 (80.55%) patients had acute infarction lesions on the diffusion weighted imaging (DWI). The most common infarct location was the internal capsule (41,70.69%), followed by the thalamus and pons. The difference in therapeutic effects between the rt-PA, single and double antiplatelet groups was not statistically significant (P > 0.05). A good prognosis was observed in 61 (84.72%) patients after 3 months, in which 23 (23/27, 85.19%) patients were from the rt-PA group and 38 (38/45,84.44%) patients were from the no rt-PA group (P > 0.05). After 3 months of follow-up, two patients had recurrent ischemic stroke.ConclusionThe most effective treatment of CWS remains unclear. Intravenous thrombolysis is safe for CWS patients. Regardless of the high frequency of infarction in CWS patients, more than 80% patients had a favorable functional prognosis.

The Potential Impact of Neuroimaging and Translational Research on the Clinical Management of Lacunar Stroke

“…Other studies described lacunar strokes with a similar clinical stuttering course, in other anatomical regions as the pons [58,59]. Several mechanistic interpretations of the capsular warning syndrome have been formulated, including hemodynamic failure in the presence of a stenotic perforating artery, arteriolar vasospasm, and peri-infarct depolarization [56,60]. However, the fluctuating insufficiency of a residual blood flow compensation through collateral vessels from nearby perforating arteries would also be consistent with the clinical stuttering presentation.…”

‘Crescendo transient ischemic attack’—an uncommon presentation of a very common disease: a case report on capsular warning syndrome

“…CWS characteristically do not have any cortical signs [ 1 ]. This is because CWS commonly affect the internal capsule area [ 3 ], or in some cases, the pons, midbrain and thalamus [ 3 , 4 ].…”

“…There were studies that relate co-morbidities with hypertension, diabetes, dyslipidaemia, cigarette smoking and other stroke risk factors to developing CWS, which suggest that atherosclerosis of the small-penetrating arteries may be involved in the pathogenesis [ 4 , 5 ]. There was also some speculation that CWS was associated with small-penetrating arterial disease where intermittent hemodynamic changes due to structural arterial changes or hypertension leading to ischaemia [ 4 ]. However, the reasons behind fluctuations of symptoms are still yet to be discover.…”

“…It has been an ongoing debate whether CWS should undergo thrombolysis or not. Some studies shown thrombolysis was effective in making the symptoms disappear [ 6 , 7 ], whereas other studies showed there was no significant different in functional outcome between CWS patient that undergone thrombolysis and those who did not [ 4 ]. However, IV thrombolysis has been safe for CWS patients, and there was no bleeding complication have been reported.…”

Case Report: Dual Antiplatelet in Capsular Warning Syndrome

“…There is no definitive treatment for CWS. To our knowledge, various treatments were available for CWS, such as intravenous thrombolysis, single or double antiplatelet (DAPT), anticoagulant and vasopressor however there was no conclusive data [3] [6]- [12].…”