Is Investigating for Carotid Artery Disease Warranted in Non-Cortical Lacunar Infarction?

Rajapakse, Anoja; Rajapakse, Senaka; Sharma, Jagdish C.

doi:10.1161/strokeaha.110.600064

Cited by 17 publications

(11 citation statements)

References 59 publications

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“…The pathogenesis of cerebral WMLs and the chain of events causing clinical infarctions are multifactorial and remain incompletely elucidated (26,28). However, ischemic injury to the white matter presumably plays an important role in the development of WMLs.…”

Section: Discussionmentioning

confidence: 99%

Carotid-Femoral Pulse Wave Velocity Is Associated With Cerebral White Matter Lesions in Type 2 Diabetes

et al. 2013

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OBJECTIVEPatients with type 2 diabetes have a high incidence of cardiovascular events including stroke. Increased arterial stiffness (AS) predicts cardiovascular events in the general population. Cerebral white matter lesions (WMLs) are associated with an increased risk of stroke. It is unknown whether AS in patients with type 2 diabetes is associated with WMLs.RESEARCH DESIGN AND METHODSWe examined 89 patients recently diagnosed with type 2 diabetes (<5 years) and 89 sex- and age-matched controls. AS was assessed with carotid-femoral pulse wave velocity (PWV). WMLs were identified using magnetic resonance imaging and graded qualitatively with the Breteler scale (no/slight changes = 0, moderate changes = 1, severe changes = 2) and semiquantitatively.RESULTSThe diabetic population had excellent glycemic control (HbA1c, 6.5% [6.2–6.8]; median [interquartile range {IQR}]) and had, compared with the controls, lower office blood pressure (BP) (127 ± 12/79 ± 8 vs. 132 ± 14/84 ± 10 mmHg) and total cholesterol (4.3[3.9–4.7] vs. 5.6 [5.1–6.4]; mmol/L; median [IQR]), (P < 0.01 for all). Despite this, PWV was higher in the patients with diabetes compared with controls (9.3 ± 2.0 vs. 8.0 ± 1.6 m/s; P < 0.0001). PWV was associated with Breteler score (OR 1.36 [95% CI 1.17–1.58]; P < 0.001) and WML volume (OR 1.32 [95% CI 1.16–1.51]; P < 0.001) per 1 m/s increase in PWV. These associations remained significant when adjusted for age, sex, diabetes, 24-h mean arterial BP, BMI, heart rate, and use of antihypertensives and statins (Breteler score: OR 1.28 [95% CI 1.03–1.60]; P < 0.05 and WML volume: OR 1.30 [95% CI 1.06–1.58]; P < 0.05).CONCLUSIONSPWV was higher among patients with well-controlled type 2 diabetes compared with controls and was independently associated with WMLs. PWV may represent a clinically relevant parameter in the evaluation of cerebrovascular disease risk in type 2 diabetes.

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Section: Discussionmentioning

confidence: 99%

Carotid-Femoral Pulse Wave Velocity Is Associated With Cerebral White Matter Lesions in Type 2 Diabetes

et al. 2013

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“…Stenosis of extracranial carotid arteries is usually incidental even in the presence of lacunar strokes but atherosclerosis of smaller cerebral arteries is a predominant identifiable cause of lacunar stroke. [4,5] As the largest intracranial artery, middle cerebral artery (MCA) is the most frequently involved in stroke and transient ischemic attacks. MCA stenosis appears to occur with lacunar striato-capsular infarcts due to occlusion of small perforating arteries by atheroemboli.…”

Section: Introductionmentioning

confidence: 99%

Comparative Diagnostic Role of Computed Tomography Angiography (CTA) and Noncontrast Magnetic Resonance Angiography (NC-MRA) in Evaluation of Cerebrovascular Accidents

Parashar¹,

Rajul²,

Pratap³

et al. 2018

AIMDR

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Background: Cerebrovascular accidents (CVA) are a major cause of mortality and morbidity in middle and elderly agegroups. It can be ischemic or hemorrhagic and thrombotic or embolic. Digital subtraction angiography (DSA) is a gold standard investigation for evaluating patients with CVA. Due to invasive nature of DSA, computed tomography angiography (CTA) has long been used as a primary noninvasive imaging tool to evaluated patients with CVA. Angiography can also be performed with magnetic resonance imaging, both with & without contrast. Introduction: CTA serves as a primary noninvasive imaging tool in evaluation of patients with CVA as nearly half of these patients do not have treatable underlying cause. Due to increasing awareness regarding the radiation exposure, contrast-induced nephrotoxicity and iodinesensitivity, magnetic resonance angiography (MRA) is gaining more and more attention. Noncontrast MRA (NC-MRA) can be performed utilizing 3D-time of flight sequence which provides results comparable to that of CTA. Hence, we performed a study to evaluate comparable role of NC-MRA and CTA. Methods: Fifty patients with cerebrovascular accidents were evaluated with CTA & NC-MRA in tandem on the same day. The results obtained were statistically evaluated and conclusions were drawn. Results & Conclusions: Detection of aneurysm in intracranial and stenoses in intracranial as well as extracranial vessels can be detected with good accuracy by NC-MRA. The results of NC-MRA was comparable to that obtained by CTA except in very small aneurysm (<3mm) and early stenosis (20-30%) which rarely affect immediate patient management. Hence, NC-MRA can be a good substitute to CTA especially in patients where iodinated contrast is relatively or absolutely contraindicated and in combination with routine protocol for stroke imaging.

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“…Some authors have suggested that lacunar mechanism is different from the usual stroke mechanism and these infarcts may need a different approach to therapy and prevention (5). More recently, it has been controversially suggested that lacunar strokes neither warrant investigation for carotid stenosis (6) nor benefit from thrombolysis with recombinant tissue plasminogen activator (rTPA) (7, 8). It is possible that these proposals may have arisen as result of confusion between infarcts with “lacunar” phenotype and those with lacunar mechanism (9).…”

Section: Introductionmentioning

confidence: 99%

Examining Subcortical Infarcts in the Era of Acute Multimodality CT Imaging

Tan

Singhal

et al. 2016

Front. Neurol.

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BackgroundLacunar infarct has been characterized as small subcortical infarct. It is postulated to occur from “in situ microatheroma or lipohyalinosis” in small vessel or lacunar mechanism. Based on this idea, such infarcts by lacunar mechanism should not be associated with large area of perfusion deficits that extend beyond the subcortical region to the cortical region. By contrast, selected small subcortical infarcts, as defined by MR imaging in the subacute and chronic stage, may initially have large perfusion deficit or related large vessel occlusions. These infarcts with “lacunar” phenotype may also be caused by disease in the parent vessel and may have very different stroke mechanism from small vessel disease. Our aim is to describe differences in imaging characteristics between patients with small subcortical infarction with “lacunar phenotype” from those with lacunar mechanism.Materials and methodsPatients undergoing acute CT perfusion/angiography (CTP/CTA) within 6 h of symptom onset and follow-up magnetic resonance imaging (MRI) for ischemic stroke were included (2009–2013). Lacunar infarct was defined as a single subcortical infarct ≤20 mm on follow-up MRI. Presence of perfusion deficits, vessel occlusion, and infarct dimensions was compared between lacunar infarcts and other topographical infarct types.ResultsOverall, 182 patients (mean age 66.4 ± 15.3 years, 66% males) were included. Lacunar infarct occurred in 31 (17%) patients. Of these, 12 (39%) patients had a perfusion deficit compared with those with any cortical infarction (120/142, 67%), and the smallest lacunar infarct with a perfusion deficit had a diameter of <5 mm. The majority of patients with lacunar infarction (8/12, 66.7%) had a relevant vessel occlusion. A quarter of lacunar infarcts had a large artery stroke mechanism evident on acute CTP/CTA. Lacunar mechanism was present in 3/8 patients with corona radiata, 5/10 lentiform nucleus, 5/6 posterior limb of internal capsule (PLIC), 3/5 thalamic infarcts, 1/2 miscellaneous locations. There was a trend to significant with regards to finding lacunar mechanism among patients with thalamic and PLIC infarcts versus lentiform nucleus and corona radiata infarcts (p = 0.13).ConclusionDiverse stroke mechanisms were present among subcortical infarcts in different locations. When available acute CTP/CTA should be combined with subacute imaging of subcortical infarct to separate “lacunar phenotype” from those with lacunar mechanism.

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Is Investigating for Carotid Artery Disease Warranted in Non-Cortical Lacunar Infarction?

Cited by 17 publications

References 59 publications

Carotid-Femoral Pulse Wave Velocity Is Associated With Cerebral White Matter Lesions in Type 2 Diabetes

Carotid-Femoral Pulse Wave Velocity Is Associated With Cerebral White Matter Lesions in Type 2 Diabetes

Comparative Diagnostic Role of Computed Tomography Angiography (CTA) and Noncontrast Magnetic Resonance Angiography (NC-MRA) in Evaluation of Cerebrovascular Accidents

Examining Subcortical Infarcts in the Era of Acute Multimodality CT Imaging

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