Testing the validity of the lacunar hypothesis

Gan, Robert N.; Sacco, Ralph L.; Kargman, D. E.; Roberts, J. Kirk; Boden‐Albala, Bernadette; Gu, Qing

doi:10.1212/wnl.48.5.1204

Cited by 182 publications

(140 citation statements)

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“…The dramatic decrease in blood flow after the photothrombotic occlusion of penetrating arterioles is consistent with observations of pathology in human patients. Our results support the clinically based hypothesis that penetrating arterioles and arteries may be of central importance in small strokes (13,14). For example, subcortical regions are particularity vulnerable to ischemia that results in lacunar lesions, because the blood flow in these regions comes from relatively long penetrating arteries (27).…”

Section: Discussionsupporting

confidence: 85%

“…Yet this very same feature is likely to cause pronounced ischemia if the penetrating arterioles are occluded. In support of this hypothesis, the microstrokes observed in human patients are often centered around penetrating arteries and arterioles with obstructed lumens (13,14). Further, the occlusion of penetrating arterioles in animal models by the intraarterial injection of occluding particles, such as microemboli or microbeads, can result in infarcts (15)(16)(17)(18).…”

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confidence: 91%

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Penetrating arterioles are a bottleneck in the perfusion of neocortex

Nishimura

Schaffer²,

Friedman³

et al. 2007

Proc. Natl. Acad. Sci. U.S.A.

328

309

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Penetrating arterioles bridge the mesh of communicating arterioles on the surface of cortex with the subsurface microvascular bed that feeds the underlying neural tissue. We tested the conjecture that penetrating arterioles, which are positioned to regulate the delivery of blood, are loci of severe ischemia in the event of occlusion. Focal photothrombosis was used to occlude single penetrating arterioles in rat parietal cortex, and the resultant changes in flow of red blood cells were measured with two-photon laser-scanning microscopy in individual subsurface microvessels that surround the occlusion. We observed that the average flow of red blood cells nearly stalls adjacent to the occlusion and remains within 30% of its baseline value in vessels as far as 10 branch points downstream from the occlusion. Preservation of average flow emerges 350 m away; this length scale is consistent with the spatial distribution of penetrating arterioles. We conclude that penetrating arterioles are a bottleneck in the supply of blood to neocortex, at least to superficial layers.blood flow ͉ hemodynamics ͉ ischemia ͉ stroke ͉ two photon

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Section: Discussionsupporting

confidence: 85%

mentioning

confidence: 91%

Penetrating arterioles are a bottleneck in the perfusion of neocortex

Nishimura

Schaffer²,

Friedman³

et al. 2007

Proc. Natl. Acad. Sci. U.S.A.

328

309

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“…As many as 25% of patients in NOMASS who presented with clinical syndromes suggesting small-vessel disease had other significant markers of risk, such as carotid disease or possible cardiac source of embolus. 48 Therefore, evaluation of patients with apparent small-vessel disease should be at least extensive enough to identify concomitant carotid artery disease and major cardiac sources of embolism.…”

Section: Asymptomatic Chd In Patients With Atherosclerotic Carotid Stmentioning

confidence: 99%

Coronary Risk Evaluation in Patients With Transient Ischemic Attack and Ischemic Stroke

Adams¹,

Chimowitz²,

Alpert³

et al. 2003

Circulation

226

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Stroke and myocardial infarction (MI) share common risk factors and pathological mechanisms, and coronary artery disease (CHD) is an important cause of death in patients with cerebrovascular disease. This Scientific Statement addresses issues in management of the relatively healthy patient with brain ischemia (a transient ischemic attack [TIA] or an ischemic stroke) who does not have recognized CHD but often has risk factors in addition to having had a TIA or stroke that indicate an increased likelihood of disability or death from cardiac disease in the future. This Statement should not be confused with the official American College of Cardiology (ACC)/American Heart Association (AHA) practice guidelines. The reader is referred to the ACC/AHA guidelines for management of recognized and symptomatic CHD 1 and the American College of Chest Physicians (ACCP) 2 and American Stroke Association (ASA) 3-5 guidelines for evaluation of cardiac causes of TIA and stroke, which are important related but separate issues.

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“…A consensus of stroke neurologists assessed stroke subtype using modified Stroke Data Bank criteria and all available information, as described in previous publications. 22,23 Stroke neurologists also determined brain side of index stroke, presence of aphasia, and parietal lobe dysfunction.…”

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confidence: 99%

Quality of life declines after first ischemic stroke

Dhamoon

Moon²,

Paik³

et al. 2010

Neurology

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Objectives: Quality of life (QOL) after stroke is poorly characterized. We sought to determine long-term natural history and predictors of QOL among first ischemic stroke survivors without stroke recurrence or myocardial infarction (MI). Methods:In the population-based, multiethnic Northern Manhattan Study, QOL was prospectively assessed at 6 months and annually for 5 years using the Spitzer QOL index (QLI), a 10-point scale. Functional status was assessed using the Barthel Index (BI) at regular intervals, and cognition using the Mini-Mental State Examination at 1 year. Generalized estimating equations estimated the association between patient characteristics and repeated QOL measures over 5 years. Follow-up was censored at death, recurrent stroke, or MI.Results: There were 525 incident ischemic stroke patients Ն40 years (mean age 68.6 Ϯ 12.4 years). QLI declined after stroke (annual change Ϫ0.10, 95% confidence interval Ϫ0.17 to Ϫ0.04), after adjusting for age, sex, race-ethnicity, education, insurance, depressed mood, stroke severity, bladder continence, and stroke laterality. This decline remained when BI Ն95 was added to the model as a time-dependent covariate, and functional status also predicted QLI. Changes in QLI over time differed by insurance status (p for interaction ϭ 0.0017), with a decline for those with Medicaid/no insurance (p Ͻ 0.0001) but not Medicare/private insurance (p ϭ 0.98). Conclusions:In this population-based study, QOL declined annually up to 5 years after stroke among survivors free of recurrence or MI and independently of other risk factors. QLI declined more among Medicaid patients and was associated with age, mood, stroke severity, urinary incontinence, functional status, cognition, and stroke laterality. Neurology ® 2010;75:328 -334 GLOSSARY BI ϭ Barthel Index; CAD ϭ coronary artery disease; CHF ϭ congestive heart failure; CI ϭ confidence interval; CUMC ϭ Columbia University Medical Center; DM ϭ diabetes mellitus; GEE ϭ generalized estimating equation; HTN ϭ hypertension; MI ϭ myocardial infarction; MMSE ϭ Mini-Mental State Examination; NIHSS ϭ NIH Stroke Scale; NOMAS ϭ Northern Manhattan Study; QOL ϭ quality of life; QLI ϭ quality of life index.Stroke causes a significant decrease in quality of life (QOL), even among those who have no poststroke disability.1 Prior studies examining QOL in stroke survivors have been limited by hospitalized samples, 2 cross-sectional design, 3 small sample sizes, 2 and samples with both hemorrhagic and ischemic strokes. 1,2,4,5 Longitudinal studies have been limited by short follow-up and enrollment of patients in different stages of early poststroke recovery. Few long-term population-based studies have systematically examined QOL after stroke. Those studies have been limited by few follow-up assessments 5,6 and significant loss to follow-up. 5 No study, to our knowledge, has censored recurrent vascular events, and the natural history and determinants of long-term QOL after a single ischemic stroke are not known. Finally, the effect of acce...

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Testing the validity of the lacunar hypothesis

Cited by 182 publications

References 0 publications

Penetrating arterioles are a bottleneck in the perfusion of neocortex

Penetrating arterioles are a bottleneck in the perfusion of neocortex

Coronary Risk Evaluation in Patients With Transient Ischemic Attack and Ischemic Stroke

Quality of life declines after first ischemic stroke

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