Large Subcortical Infarcts

Halkes, Patricia H.A.; Kappelle, L. Jaap; Gijn, J. van; Wijk, Iris van; Koudstaal, Peter J.; Algra, Ale

doi:10.1161/01.str.0000226993.88307.ff

Cited by 20 publications

(27 citation statements)

References 22 publications

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“…[97][98][99][100][101][102][103][104] Cardioembolic stroke may be expected to have a higher likelihood of CHD events, perhaps related to the underlying presence of cardiac disease. The European Atrial Fibrillation Trial (EAFT) provides some evidence on this point, although the study did not report results for MI alone as an outcome.…”

Section: Importance Of Stroke Subtypes/special Situations Stroke Hetementioning

confidence: 99%

Inclusion of Stroke in Cardiovascular Risk Prediction Instruments

Lackland¹,

Elkind²,

D’Agostino³

et al. 2012

Stroke

122

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Background and Purpose— Current US guideline statements regarding primary and secondary cardiovascular risk prediction and prevention use absolute risk estimates to identify patients who are at high risk for vascular disease events and who may benefit from specific preventive interventions. These guidelines do not explicitly include patients with stroke, however. This statement provides an overview of evidence and arguments supporting (1) the inclusion of patients with stroke, and atherosclerotic stroke in particular, among those considered to be at high absolute risk of cardiovascular disease and (2) the inclusion of stroke as part of the outcome cluster in risk prediction instruments for vascular disease. Methods and Results— Writing group members were nominated by the committee co-chairs on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee and the AHA Manuscript Oversight Committee. The writers used systematic literature reviews (covering the period from January 1980 to March 2010), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and, when appropriate, formulate recommendations using standard AHA criteria. All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. The guideline underwent extensive AHA internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. There are several reasons to consider stroke patients, and particularly patients with atherosclerotic stroke, among the groups of patients at high absolute risk of coronary and cardiovascular disease. First, evidence suggests that patients with ischemic stroke are at high absolute risk of fatal or nonfatal myocardial infarction or sudden death, approximating the ≥20% absolute risk over 10 years that has been used in some guidelines to define coronary risk equivalents. Second, inclusion of atherosclerotic stroke would be consistent with the reasons for inclusion of diabetes mellitus, peripheral vascular disease, chronic kidney disease, and other atherosclerotic disorders despite an absence of uniformity of evidence of elevated risks across all populations or patients. Third, the large-vessel atherosclerotic subtype of ischemic stroke shares pathophysiological mechanisms with these other disorders. Inclusion of stroke as a high-risk condition could result in an expansion of ≈10% in the number of patients considered to be at high risk. However, because of the heterogeneity of stroke, it is uncertain whether other stroke subtypes, including hemorrhagic and nonatherosclerotic ischemic stroke subtypes, should be considered to be at the same high levels of risk, and further research is needed. Inclusion of stroke with myocardial infarction and sudden death among the outcome cluster of cardiovascular events in risk prediction instruments, moreover, is appropriate because of the impact of stroke on morbidity and mortality, the similarity of many approaches to prevention of stroke and these other forms of vascular disease, and the importance of stroke relative to coronary disease in some subpopulations. Non-US guidelines often include stroke patients among others at high cardiovascular risk and include stroke as a relevant outcome along with cardiac end points. Conclusions— Patients with atherosclerotic stroke should be included among those deemed to be at high risk (≥20% over 10 years) of further atherosclerotic coronary events. Inclusion of nonatherosclerotic stroke subtypes remains less certain. For the purposes of primary prevention, ischemic stroke should be included among cardiovascular disease outcomes in absolute risk assessment algorithms. The inclusion of atherosclerotic ischemic stroke as a high-risk condition and the inclusion of ischemic stroke more broadly as an outcome will likely have important implications for prevention of cardiovascular disease, because the number of patients considered to be at high risk would grow substantially.

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Section: Importance Of Stroke Subtypes/special Situations Stroke Hetementioning

confidence: 99%

Inclusion of Stroke in Cardiovascular Risk Prediction Instruments

Lackland¹,

Elkind²,

D’Agostino³

et al. 2012

Stroke

122

View full text Add to dashboard Cite

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“…Infarctions with diameters ≥15 mm located in deep penetrating arteries are called giant lacunae or LSCI [1, 2]. In clinical practice, patients with LSCI who present with progressive stroke conditions (stroke-in-evolution) in the acute phase are encountered frequently.…”

Section: Introductionmentioning

confidence: 99%

Long-Term Prognosis of Patients with Large Subcortical Infarctions

et al. 2009

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Aim: We assessed the long-term prognosis of patients with large subcortical infarctions (LSCI). Methods: We defined LSCI as lesions ≥15 mm confined to deep penetrating arteries without a cardioembolic or atherothrombotic source. Patients with acute ischemic strokes were consecutively registered and followed for 751 ± 441 days. The clinical characteristics and long-term prognoses of patients with LSCI were compared to those of patients with lacunar (LACI), atherothrombotic (ATI) and cardioembolic infarctions (CEI). Results: At discharge from the hospital, the proportion of good outcomes (modified Rankin Scale ≤2) for patients with LSCI (52.1%) was similar to that for ATIs (47.2%), but worse than that for LACIs (73.2%). After a 3-year follow-up period, the mortality rates from LSCI, LACIs, ATIs and CEIs were 8.4, 8.2, 22.3 and 41.1%, respectively; the recurrence rates were 9.3, 14.1, 16.6 and 23.8%, respectively. Conclusions: The short-term prognosis of functional outcomes for LSCI was worse than that for LACIs, but similar to acute-phase ATI outcomes. The long-term prognosis after a LSCI is good, and recurrence tends to be lower than for LACIs.

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“…9,35 A Dutch trial reviewed patients with LSI of presumed noncardioembolic origin on CT. 9 Clinical features and risk factor profiles were similar in patients with LSI as compared with those with LIs or CIs. Clinical outcomes were not assessed, but stroke recurrence rates were similar.…”

Section: Downloaded Frommentioning

confidence: 99%

“…[3][4][5][6][7][8] One exception was a Dutch trial, where no differences were found regarding clinical features or risk factor profiles in patients with LSIs as compared with lacunar (LIs) or cortical infarctions (CIs) diagnosed with computed tomography (CT). 9 Because several patients with stroke are without sign of infarction on CT, stroke localization and classification may be inaccurate.…”

mentioning

confidence: 99%

A Dark Side of Subcortical Diffusion-Weighted Lesions?

Kvistad

Øygarden

Logallo

et al. 2014

Stroke

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Background and Purpose— Diffusion-weighted imaging (DWI) is highly accurate in identifying and locating ischemic stroke injury. Few studies using DWI have investigated large subcortical infarctions (LSIs). We aimed to study clinical characteristics, cause, and outcome in patients with ischemic stroke with LSI diagnosed on DWI and compare these with those who had lacunar DWI lesions or DWI lesions located elsewhere. Methods— Patients with stroke admitted between February 2006 and July 2013 were prospectively registered in a stroke database and examined with DWI. Patients with DWI lesions classified as LSI (subcortical, ≥15 mm) were compared with those with lacunar lesions (subcortical, <15 mm, lacunar infarction [LI]), cortical lesions (cortical infarction [CI]), or no LSI, which included LI, CI, mixed cortical–subcortical, cerebellar, brain stem, and combined lesion locations. Results— A total of 1886 patients with ischemic stroke were included, of which 128 patients (6.8%) had LSI, 317 (16.8%) LI, and 544 (28.8%) CI. The no LSI group included 1758 patients. Occlusive pathology in the proximal middle cerebral artery was more frequent in patients with acute stroke with LSI. Lacunar syndrome was associated with LSI when compared with CI and no LSI. Unknown cause was frequent in the LSI group (60.4%) and independently associated with LSI in the LSI versus LI ( P <0.001), LSI versus CI ( P =0.002), and LSI versus no LSI population ( P <0.001). LSI was independently associated with unfavorable outcome, whether compared with LI ( P =0.002), CI ( P <0.001), or no LSI ( P =0.002). Conclusions— LSI is associated with distinct clinical characteristics, unknown cause, and unfavorable outcome, which separates this stroke entity from patients with lacunar subcortical DWI lesions or DWI lesions located elsewhere.

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Large Subcortical Infarcts

Cited by 20 publications

References 22 publications

Inclusion of Stroke in Cardiovascular Risk Prediction Instruments

Inclusion of Stroke in Cardiovascular Risk Prediction Instruments

Long-Term Prognosis of Patients with Large Subcortical Infarctions

A Dark Side of Subcortical Diffusion-Weighted Lesions?

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