Skip to main content

Advertisement

SpringerLink
Log in

Clinical Characteristics and Outcome of Patients with Lacunar Infarcts and Concurrent Embolic Ischemic Lesions

  • Original Article
  • Published:
Clinical Neuroradiology Aims and scope Submit manuscript

Abstract

Purpose

Lacunar infarcts are thought to result from occlusion of small penetrating arteries due to microatheroma and lipohyalinosis, pathognomonic for cerebral small vessel disease (CSVD). Concurrent embolic ischemic lesions indicate a different stroke mechanism. The purpose of this study was to examine the clinical characteristics and outcome of patients with lacunar infarcts and concurrent embolic infarcts on diffusion-weighted imaging (DWI).

Methods

All patients screened for the WAKE-UP trial (ClinicalTrials.gov number, NCT01525290) were reviewed for acute lacunar infarcts and concurrent embolic lesions on baseline DWI. Clinical characteristics and outcome were compared between lacunar infarct patients with and without concurrent embolic lesions.

Results

Of 244 patients with an acute lacunar infarct, 20 (8.2%) had concurrent acute embolic infarcts. Compared to patients with a lacunar infarct only, patients with concurrent embolic infarcts were older (mean age 69 years vs. 63 years; p = 0.031), more severely affected (median National Institutes of Health Stroke Scale [NIHSS] score 5 vs. 4; p = 0.046), and—among those randomized—had worse functional outcome at 90 days (median modified Rankin Scale [mRS] 3 vs. 1; p = 0.011).

Conclusion

Approximately 8% of lacunar infarct patients show concurrent embolic lesions suggesting a stroke etiology other than CSVD. These patients are more severely affected and have a worse functional outcome illustrating the need for a thorough diagnostic work-up of possible embolic sources even in patients with an imaging-defined diagnosis of lacunar infarcts.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Sudlow CL, Warlow CP. Comparable studies of the incidence of stroke and its pathological types: results from an international collaboration. International Stroke Incidence Collaboration. Stroke. 1997;28:491–9.

    Article  CAS  Google Scholar 

  2. Wardlaw JM, Smith EE, Biessels GJ, Cordonnier C, Fazekas F, Frayne R, Lindley RI, O’Brien JT, Barkhof F, Benavente OR, Black SE, Brayne C, Breteler M, Chabriat H, Decarli C, de Leeuw FE, Doubal F, Duering M, Fox NC, Greenberg S, Hachinski V, Kilimann I, Mok V, Oostenbrugge R, Pantoni L, Speck O, Stephan BC, Teipel S, Viswanathan A, Werring D, Chen C, Smith C, van Buchem M, Norrving B, Gorelick PB, Dichgans M, nEuroimaging STfRVco. Neuroimaging standards for research into small vessel disease and its contribution to ageing and neurodegeneration. Lancet Neurol. 2013;12:822–38.

    Article  Google Scholar 

  3. Fisher CM. Lacunes: small, deep cerebral infarcts. Neurology. 1965;15:774–84.

    Article  CAS  Google Scholar 

  4. Caso V, Budak K, Georgiadis D, Schuknecht B, Baumgartner RW. Clinical significance of detection of multiple acute brain infarcts on diffusion weighted magnetic resonance imaging. J Neurol Neurosurg Psychiatry. 2005;76:514–8.

    Article  CAS  Google Scholar 

  5. Takahashi K, Kobayashi S, Matui R, Yamaguchi S, Yamashita K. The differences of clinical parameters between small multiple ischemic lesions and single lesion detected by diffusion-weighted MRI. Acta Neurol Scand. 2002;106:24–9.

    Article  CAS  Google Scholar 

  6. Ay H, Oliveira-Filho J, Buonanno FS, Ezzeddine M, Schaefer PW, Rordorf G, Schwamm LH, Gonzalez RG, Koroshetz WJ. Diffusion-weighted imaging identifies a subset of lacunar infarction associated with embolic source. Stroke. 1999;30:2644–50.

    Article  CAS  Google Scholar 

  7. Thomalla G, Simonsen CZ, Boutitie F, Andersen G, Berthezene Y, Cheng B, Cheripelli B, Cho TH, Fazekas F, Fiehler J, Ford I, Galinovic I, Gellissen S, Golsari A, Gregori J, Gunther M, Guibernau J, Hausler KG, Hennerici M, Kemmling A, Marstrand J, Modrau B, Neeb L, Perez de la Ossa N, Puig J, Ringleb P, Roy P, Scheel E, Schonewille W, Serena J, Sunaert S, Villringer K, Wouters A, Thijs V, Ebinger M, Endres M, Fiebach JB, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Gerloff C, WAKE-UP Investigators. MRI-guided Thrombolysis for stroke with unknown time of onset. N Engl J Med. 2018;379:611–22. https://doi.org/10.1056/NEJMoa1804355

    Article  Google Scholar 

  8. von Kummer R, Broderick JP, Campbell BC, Demchuk A, Goyal M, Hill MD, Treurniet KM, Majoie CB, Marquering HA, Mazya MV, San Román L, Saver JL, Strbian D, Whiteley W, Hacke W. The Heidelberg bleeding classification: classification of bleeding events after Ischemic stroke and Reperfusion therapy. Stroke. 2015;46:2981–6.

    Article  Google Scholar 

  9. Norrving B. Long-term prognosis after lacunar infarction. Lancet Neurol. 2003;2:238–45.

    Article  Google Scholar 

  10. Fisher CM. Capsular infarcts: the underlying vascular lesions. Arch Neurol. 1979;36:65–73.

    Article  CAS  Google Scholar 

  11. Laloux P, Brucher JM. Lacunar infarctions due to cholesterol emboli. Stroke. 1991;22:1440–4.

    Article  CAS  Google Scholar 

  12. Futrell N, Millikan C, Watson BD, Dietrich WD, Ginsberg MD. Embolic stroke from a carotid arterial source in the rat: pathology and clinical implications. Neurology. 1989;39:1050–6.

    Article  CAS  Google Scholar 

  13. Macdonald RL, Kowalczuk A, Johns L. Emboli enter penetrating arteries of monkey brain in relation to their size. Stroke. 1995;26:1247–50. discussion 50–1.

    Article  CAS  Google Scholar 

  14. Futrell N. Lacunar infarction: embolism is the key. Stroke. 2004;35:1778–9.

    Article  Google Scholar 

  15. Kang DW, Chalela JA, Ezzeddine MA, Warach S. Association of ischemic lesion patterns on early diffusion-weighted imaging with TOAST stroke subtypes. Arch Neurol. 2003;60:1730–4.

    Article  Google Scholar 

  16. Chowdhury D, Wardlaw JM, Dennis MS. Are multiple acute small subcortical infarctions caused by embolic mechanisms? J Neurol Neurosurg Psychiatry. 2004;75:1416–20.

    Article  CAS  Google Scholar 

  17. Seifert T, Enzinger C, Storch MK, Pichler G, Niederkorn K, Fazekas F. Acute small subcortical infarctions on diffusion weighted MRI: clinical presentation and aetiology. J Neurol Neurosurg Psychiatry. 2005;76:1520–4.

    Article  CAS  Google Scholar 

  18. Del Bene A, Makin SD, Doubal FN, Inzitari D, Wardlaw JM. Variation in risk factors for recent small subcortical infarcts with infarct size, shape, and location. Stroke. 2013;44:3000–6.

    Article  Google Scholar 

  19. Simonsen CZ, Sørensen LH, Karabegovic S, Mikkelsen IK, Schmitz ML, Juul N, Yoo AJ, Andersen G. MRI before intraarterial therapy in ischemic stroke: feasibility, impact, and safety. J Cereb Blood Flow Metab. 2014;34:1076–81.

    Article  Google Scholar 

  20. Parody E, Pedraza S, García-Gil MM, Crespo C, Serena J, Dávalos A. Cost-utility analysis of magnetic resonance imaging management of patients with acute Ischemic stroke in a Spanish hospital. Neurol Ther. 2015;4:25–37.

    Article  Google Scholar 

Download references

Funding

Funding

The WAKE-UP trial received funding from the European Union Seventh Framework Program (FP7/2007–2013) under grant agreement n°278276 (WAKE-UP).

Author information

Authors and Affiliations

  1. Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany

    Ewgenia Barow, Bastian Cheng, Alina Nickel, Christian Gerloff & Götz Thomalla

  2. Service de Biostatistique, Hospices Civils de Lyon, 69003, Lyon, France

    Florent Boutitie & Pascal Roy

  3. Department of Stroke Medicine, CREATIS CNRS UMR 5220-INSERM U1206, INSA-Lyon, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France

    Tae-Hee Cho & Norbert Nighoghossian

  4. Centrum für Schlaganfallforschung Berlin (CSB), Charité—Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117, Berlin, Germany

    Martin Ebinger, Matthias Endres, Jochen B. Fiebach & Ivana Galinovic

  5. Neurologie, Rehaklinik Medical Park Humboldtmühle, An der Mühle 2–9, 13507, Berlin, Germany

    Martin Ebinger

  6. Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117, Berlin, Germany

    Matthias Endres

  7. Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany

    Jens Fiehler

  8. Robertson Centre for Biostatistics, University of Glasgow, University Avenue, G12 8QQ, Glasgow, UK

    Ian Ford

  9. Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut d’Investigació Biomèdica de Girona (IDIBGI), Parc Hospitalari Martí i Julià de Salt—Edifici M2, 17190, Salt, Girona, Spain

    Josep Puig & Salvador Pedraza

  10. Department of Neurology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium

    Anke Wouters & Robin Lemmens

  11. Department of Neurosciences, Experimental Neurology, KU Leuven—University of Leuven, Oude Markt 13, bus 5005, 3000, Leuven, Belgium

    Anke Wouters & Robin Lemmens

  12. Laboratory of Neurobiology, Campus Gasthuisberg, VIB, Center for Brain & Disease Research, Herestraat 49, bus 602, 3000, Leuven, Belgium

    Anke Wouters & Robin Lemmens

  13. Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, 245 Burgundy Street, VIC 3084, Heidelberg, Victoria, Australia

    Vincent Thijs

  14. Department of Neurology, Austin Health, 145 Studley Road, VIC 3084, Heidelberg, Australia

    Vincent Thijs

  15. Institute of Neuroscience & Psychology, University of Glasgow, University Avenue, G12 8QQ, Glasgow, UK

    Keith W. Muir

  16. Department of Neurology, Aarhus University Hospital, 8000, Aarhus, Denmark

    Claus Z. Simonsen

  17. Université Lyon 1, 69100, Villeurbanne, France

    Florent Boutitie & Pascal Roy

  18. CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, 69100, Villeurbanne, France

    Florent Boutitie & Pascal Roy

Authors
  1. Ewgenia Barow
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Florent Boutitie
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Bastian Cheng
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Tae-Hee Cho
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Martin Ebinger
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Matthias Endres
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jochen B. Fiebach
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Jens Fiehler
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Ian Ford
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Ivana Galinovic
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Alina Nickel
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Josep Puig
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Pascal Roy
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Anke Wouters
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Vincent Thijs
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Robin Lemmens
    View author publications

    You can also search for this author in PubMed Google Scholar

  17. Keith W. Muir
    View author publications

    You can also search for this author in PubMed Google Scholar

  18. Norbert Nighoghossian
    View author publications

    You can also search for this author in PubMed Google Scholar

  19. Salvador Pedraza
    View author publications

    You can also search for this author in PubMed Google Scholar

  20. Claus Z. Simonsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  21. Christian Gerloff
    View author publications

    You can also search for this author in PubMed Google Scholar

  22. Götz Thomalla
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

WAKE-UP investigators

Corresponding author

Correspondence to Ewgenia Barow.

Ethics declarations

Conflict of interest

E. Barow received grants from the European Union 7th Framework Program during the conduct of the study and grants from the German Parkinson Society and ACTELION Pharmaceuticals Deutschland GmbH, outside the submitted work. F. Boutitie received grants from the University Medical Center Hamburg-Eppendorf during the conduct of the study. M. Ebinger received grants from the European Union 7th Framework Program during the conduct of the study. M. Endres received grants from European Union 7th Framework Program during the conduct of the study, grants from the Bayer and fees paid to the Charité from Bayer, Boehringer Ingelheim, BMS/Pfizer, Daiichi Sankyo, Amgen, GlaxoSmithKlineGSK, Sanofi, Covidien, Ever, Novartis, all outside the submitted work. J.B. Fiebach received grants from the European Union 7th Framework Program during the conduct of the study and personal fees from Bioclinica, Artemida, Cerevast, and Nicolab outside the submitted work. I. Galinovic received grants from the European Union 7th Framework Program during the conduct of the study. A. Nickel received grants from European Union 7th Framework Program during the conduct of the study. P. Roy received grants from the European Union 7th Framework Program during the conduct of the study. V. Thijs received grants from the European Union 7th Framework Program and personal fees and non-financial support from Boehringer Ingelheim, Pfizer/BMS, Bayer, Sygnis, Amgen and Allergan outside the submitted work. K.W. Muir received grants from the European Union 7th Framework Program during the conduct of the study, personal fees and non-financial support from Boehringer Ingelheim outside the submitted work. S. Pedraza received grants from the European Union 7th Framework Program during the conduct of the study. C.Z. Simonsen received grants from Novo Nordisk Foundation and personal fees from Bayer outside the submitted work. C. Gerloff received from the European Union 7th Framework Program during the conduct of the study, personal fees from AMGEN, Bayer Vital, BMS, Boehringer Ingelheim, Sanofi Aventis, Abbott, and Prediction Biosciences outside the submitted work. G. Thomalla received grants from the European Union 7th Framework Program during the conduct of the study, personal fees from Acandis, Boehringer Ingelheim, BMS/Pfizer, Stryker, Daiichi Sankyo, grants and personal fees from Bayer, grants from Corona Foundation, German Innovation Fonds and Else Kroener Fresenius Foundation outside the submitted work. B. Cheng, T.-H. Cho, J. Fiehler, I. Ford, J. Puig, A. Wouters, R. Lemmens and N. Nighoghossian declare that they have no competing interests.

Caption Electronic Supplementary Material

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Barow, E., Boutitie, F., Cheng, B. et al. Clinical Characteristics and Outcome of Patients with Lacunar Infarcts and Concurrent Embolic Ischemic Lesions. Clin Neuroradiol 30, 511–516 (2020). https://doi.org/10.1007/s00062-019-00800-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00062-019-00800-5

Keywords

Search

Navigation