What causes false clinical prediction of small deep infarcts?

Lodder, J.; Bamford, John; Kappelle, Jaap; Boiten, Jelis

doi:10.1161/01.str.25.1.86

Cited by 32 publications

(30 citation statements)

References 58 publications

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“…The likelihood that a lacunar stroke might be erroneously diagnosed as a territorial infarct increases in the presence of one or more silent small deep infarcts, as we discussed elsewhere. 53 As have others, we found increasing age strongly related to the presence of silent brain infarcts, mainly due to age dependency of the silent small deep lesions. Thus, with increasing age, hypertensive patients may be at increased risk for silent small deep infarcts probably due to hypertension-related small-vessel lipohyalinosis.…”

supporting

confidence: 77%

“…Also, some patients with a lacunar syndrome but without a visible compatible lesion on CT may have an infarct in the brain stem; we recently discussed CT-negative cases that resemble those with visible symptomatic lacunar infarctions. 53 We found that the presumed lacunar index strokes with a cortical syndrome resembled the lacunar strokes. The likelihood that a lacunar stroke might be erroneously diagnosed as a territorial infarct increases in the presence of one or more silent small deep infarcts, as we discussed elsewhere.…”

mentioning

confidence: 73%

“…A small deep infarct was defined as a CT-identified lesion compatible with the occlusion of a single perforating artery (ie, a subcortical, small, sharply marginated, hypodense lesion with a diameter <20 mm) or as a clinically identified lacunar syndrome if no specific lesion was visible 53 on CT. A patient with a cortical syndrome and a lacunar infarct on CT was classified as having a symptomatic lacunar infarct, unless symptoms were completely incompatible, 26 -33 but cortical syndrome and lacunar infarct were also analyzed separately. We distinguished four lacunar syndromes: pure motor stroke, pure sensory stroke, sensorimotor stroke, and ataxic hemiparesis including dysarthria-clumsy hand cases.…”

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confidence: 99%

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Silent brain infarcts in 755 consecutive patients with a first-ever supratentorial ischemic stroke. Relationship with index-stroke subtype, vascular risk factors, and mortality.

Boon

Lodder

Raak

et al. 1994

Stroke

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117

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Background and PurposeWe wanted to establish independent associations of various clinical variables, computed tomographic (CT) scan features, presenting stroke subtypes, and outcome with the presence of silent infarcts on CT.Methods We studied 755 consecutive patients in a prospective registration of patients with first-ever supratentorial atherothrombotic, cardioembolic, or lacunar stroke or stroke of undetermined cause by multiple logistic regression analysis.Results Two hundred six patients (27%) with a first symptomatic territorial or small deep ischemic stroke had one or more silent infarcts on CT. Of all silent lesions, 169 (82%) were small and deep. Silent infarcts were significantly more strongly associated with a lacunar than atherothrombotic (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.02 to 2.47; P=.O39) or cardioembolic (OR, 1.89; 95% CI, 1.2 to 2.99; P=.OO5) index stroke. Silent territorial lesions were more strongly associated with cardioembolic than with lacunar stroke but not with atherothrombotic stroke. In this respect, no differences were found between the atherothrombotic and undetermined-cause group. Advanced age and hypertension were the only risk factors that were significantly associated with silent infarcts (OR, 1.76; 95% CI, 1.14 to 2.71; P=.0U; and OR, 1.58; 95% CI, 1.13 to 2.21; P=.001; respectively), mainly because of a strong independent association of these risk factors with silent small deep infarcts (OR, 1.75; 95% CI,

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confidence: 77%

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confidence: 73%

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confidence: 99%

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Silent brain infarcts in 755 consecutive patients with a first-ever supratentorial ischemic stroke. Relationship with index-stroke subtype, vascular risk factors, and mortality.

Boon

Lodder

Raak

et al. 1994

Stroke

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117

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“…15 mm in diameter and likely attributable to occlusion of a single perforating artery, whilst large infarcts are considered to result from embolism or intrinsic middle cerebral artery (MCA) disease [1,2,[5][6][7] . In addition to the size of deep infarcts, lacunar syndromes are reported to have important clinical value in predicting lacunar mechanisms of stroke [4,[8][9][10] .…”

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confidence: 99%

Clinical MRI Cutoff Points for Predicting Lacunar Stroke May Not Exist: Need for a Grading rather than a Dichotomizing System

et al. 2007

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Background: Lacunar stroke has been defined as an infarct <15 mm in diameter in the presence of symptoms of lacunar syndromes. We investigated a new approach in predicting whether a deep infarct is caused by small arterial occlusion. Methods: A total of 319 consecutive patients with acute symptomatic infarcts within the striatocapsular territory underwent diffusion-weighted imaging (DWI) and diagnostic workups, including vascular and cardiological studies. Predictors for nonlacunar mechanisms were evaluated by logistic regression analysis, with the size of infarct (1-mm increase) and stroke syndrome (traditional vs. atypical lacunar syndrome vs. cortical syndrome) graded rather than dichotomized. Results: Amongst the 171 patients who did not meet the established criteria for lacunar stroke, that is, deep infarct of ≧15 mm or presenting symptoms of nontraditional lacunar syndrome, a documented etiology could not be determined in 97 (56.7%) patients. In contrast, amongst the 148 patients who met the criteria, 27 (18.2%) had nonlacunar mechanisms. Logistic regression analysis identified the variables that predicted nonlacunar stroke mechanisms with statistical significance as nontraditional lacunar syndromes (OR 2.19 for atypical lacunar syndrome, and OR 6.72 for cortical syndrome), infarct size on DWI (OR 1.05 per 1-mm increase), and unilateral multiple deep infarcts on DWI (OR 2.22, p < 0.05 in all cases). Receiver operating characteristic curves showed that discrimination power of the model derived from logistic regression analysis (grading system) was better than that of the previously established dichotomizing criterion in predicting nonlacunar mechanisms (p = 0.004). Conclusions: A clinically significant proportion of clinical MRI lacunae are associated with underlying nonlacunar mechanisms. Decisions regarding the extent of diagnostic procedures in patients with subcortical infarcts can be guided by the point value in terms of the stroke syndrome and infarct patterns, as well as the size of infarct.

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“…The other "classic" lacunar syndromes were variably associated with larger lesions. 33 The usefulness of clinical lacunar syndromes to predict small, deep cerebral infarcts was evaluated 34 and found to be quite accurate (88%), using all 4 classic lacunar syndromes (pure motor stroke, pure sensory stroke, sensorimotor stroke, and AH). Ataxic hemiparesis was the most accurate of the 4 syndromes, with a predictive ability of 100%.…”

Section: Gorman Et Al December 1998mentioning

confidence: 99%

Ataxic Hemiparesis

Gorman

Dafer

Levine

1998

Stroke

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Background and Purpose-Ataxic hemiparesis is a well-recognized lacunar syndrome involving homolateral ataxia with accompanying corticospinal tract impairment. Despite 30 years of clinical experience there continues to be some doubt as to the defining clinical characteristics, precise neuroanatomic localization of the syndrome, and etiologic mechanisms. Methods-We now present 45 new cases that have been analyzed for clinico-radiologic correlation and etiology. Also, all published cases from the English literature known to the authors are reviewed. Results-We found that the clinical syndrome of ataxic hemiparesis accurately predicts a small deep infarction, generally in the pons or internal capsule. Sensory loss is highly associated with a capsular localization. We found that 47% of the cases were attributed to small-vessel disease, 11% to cardioembolism, and only 7% to artery-to-artery embolism (all in the basilar artery); 1 case was attributed to thrombocytosis, 1 to multiple sclerosis, and the rest either had negative or incomplete evaluation. Approximately two thirds of the infarctions occurred in patients with neuroimaging evidence of other ischemic brain lesions. Conclusions-Ataxic hemiparesis is a distinct clinical syndrome that accurately predicts a small deep infarction, most commonly in the pons or internal capsule. Only sensory loss accurately predicts a capsular localization. Etiology in nearly half of the cases can be attributed to small-vessel disease. Furthermore, ataxic hemiparesis appears to be a good marker for generalized asymptomatic cerebrovascular disease. (Stroke. 1998;29:2549-2555.)

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What causes false clinical prediction of small deep infarcts?

Cited by 32 publications

References 58 publications

Silent brain infarcts in 755 consecutive patients with a first-ever supratentorial ischemic stroke. Relationship with index-stroke subtype, vascular risk factors, and mortality.

Silent brain infarcts in 755 consecutive patients with a first-ever supratentorial ischemic stroke. Relationship with index-stroke subtype, vascular risk factors, and mortality.

Clinical MRI Cutoff Points for Predicting Lacunar Stroke May Not Exist: Need for a Grading rather than a Dichotomizing System

Ataxic Hemiparesis

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