Capsular Warning Syndrome: Clinical Analysis and Treatment

Abstract

Background: Capsular warning syndrome (CWS) was a rare clinical syndrome, which was defined as recurrent transient lacunar syndromes. The mechanism and clinical management of CWS were not clear. The purpose of this study was to discuss the clinical characteristics, treatment and prognosis of the CWS. Methods: This was a multicenter retrospective study that involved three medical centers, we collected clinical data from patients with CWS between January 2013 and December 2018. We analyzed the clinical characteristics of the CWS. Patients with CWS were divided into two groups: rt-PA and no rt-PA groups. We analyzed the therapeutic effects and prognosis between different groups. Results: This study included 72 patients, 27 in rt-PA group, 45 in no rt-PA group, hypertension and dyslipidemia were the most common risk factors. The mean number of episodes before an irreversible neurological impairment or the symptoms completely disappeared was 5 times(3-11). 59 (81.94%) patients had acute infarction lesions on the diffusion weighted imaging (DWI). The most common infarct location was the internal capsule (76.38%,55), followed by the thalamus and pons. The difference in therapeutic effects between rt-PA, single and double antiplatelet groups was not significant(P>0.05). A good prognosis was observed in 61 (84.72%) patients at 3-month, 23 (23/27, 85.19%) patients in rt-PA group and 38 (38/45,84.44%) patients in no rt-PA group(P>0.05). After 3 months of follow-up, 2 patients had recurrent ischemic stroke. Conclusions: The most effective treatment of CWS remains unclear. Despite the high incidence of infarction in CWS patients, more than 80% patients had favorable functional prognosis

Early Neurologic Deterioration in Lacunar Stroke

“…hours of hospitalization and the presence of capsular warning syndrome, which was defined as a fluctuating one-sided weakness in the 48h preceding admission. 15…”

Attack Interval Is the Key to the Likely Pathogenesis of Multiple Transient Ischemic Attacks

“…The original definition of CWS was 3 or more events of motor, sensory, or sensorimotor symptoms affecting face, arm, and leg simultaneously, with no cortical signs, all within 24 h [4]. Due to the infrequency of CWS; however, the original definition has been modified by a number of investigators to extend the time period beyond 24 h [3, 14, 15] or reduce number of events [7, 16]. Even so, the prevalence of CWS is less than 10% among all TIAs (Table 3).…”

“…Therapeutic resistance was mentioned as a consistent feature of CWS [4]. Since then, various strategies, such as blood pressure augmentation [22], anticoagulation [21, 22], antiplatelet therapy [15, 16, 23], and these in combination [21, 24] have been administered to attenuate crescendo attacks and to prevent a subsequent stroke. In the presence of an attack with disabling symptom not resolving within minutes, intravenous thrombolysis may be considered, as occurred in one patient in this study [15].…”

“…Since then, various strategies, such as blood pressure augmentation [22], anticoagulation [21, 22], antiplatelet therapy [15, 16, 23], and these in combination [21, 24] have been administered to attenuate crescendo attacks and to prevent a subsequent stroke. In the presence of an attack with disabling symptom not resolving within minutes, intravenous thrombolysis may be considered, as occurred in one patient in this study [15]. Recently, dual antiplatelet therapy with a loading dose has been established as an effective early management of patients with TIA [25], which is may also be a promising therapeutic approach in CWS [24].…”

“…Among 30 patients with a DWI-positive lesion, 26 did not have permanent neurological deficits, and even 4 patients with a subsequent stroke had a favorable functional outcome at 90 days (modified Rankin Scale one in 2 patients and 2 in 2 patients). In a recent study of CWS in which patients were frequently treated with combination antithrombotic therapy, it was shown that these patients had a favorable prognosis in spite of the high frequency of a DWI-positive lesion [15]. Hence, an aggressive therapeutic intervention such as this may reduce the risk of subsequent stroke in CWS patients.…”