Improving Clinical Detection of Acute Lacunar Stroke

Abstract

Background and Purpose— We aim to identify factors associated with imaging-confirmed lacunar strokes and improve their rapid clinical identification early after symptom onset using data from the IST-3 (Third International Stroke Trial). Methods— We selected patients likely to have lacunar infarcts as those presenting with: Oxfordshire Community Stroke Project lacunar syndrome; a random sample with National Institutes of Health Stroke Scale (NIHSS) score <7; and recent lacunar infarct identified on imaging by IST-3 central blinded expert panel. An independent reviewer rated brain scans of this sample and classified visible infarcts according to type, size, and location. We investigated factors associated with presence of lacunar infarct on a 24 to 48 hour follow-up scan using multivariable logistic regression and calculated sensitivity and specificity of Oxfordshire Community Stroke Project alone and in combination with NIHSS score <7. Results— We included 568 patients (330 lacunar syndrome; 147 with NIHSS score <7; 91 with lacunar infarct on baseline imaging, numbers exclude overlaps between groups), mean (±SD) age, 73.2 (±13.6) years, 316 (56%) males, and median NIHSS score 5 (IQR, 4–8). On 24 to 48 hour scan, 138 (24%) patients had lacunar infarcts, 176 (31%) other infarct subtypes, 254 (45%) no visible infarct. Higher baseline systolic blood pressure (odds ratio, 1.01 [95% CI, 1.01–1.02]) and preexisting lacunes (odds ratio, 2.29 [95% CI, 1.47–3.57) were associated with recent lacunar infarcts. Sensitivity and specificity of lacunar syndrome was modest (58% and 45%, respectively), but adding NIHSS score <7 increased specificity (99%), positive and negative predictive values (97% and 87%, respectively). Conclusions— In patients presenting within 6 hours of stroke onset, adding NIHSS score <7 to Oxfordshire Community Stroke Project lacunar syndrome classification may increase specificity for identifying lacunar stroke early after stroke onset. Our findings may help selection of patients for clinical trials of lacunar stroke and should be validated externally. Registration— URL: http://www.controlled-trials.com/ ; Unique identifier: ISRCTN25765518.

Intensive versus guideline‐recommended blood pressure reduction in acute lacunar stroke with intravenous thrombolysis therapy: The ENCHANTED trial

“…Contrary to prior reports [4,24], no significant differences in baseline SBP and history of hypertension were seen between lacunar and non-lacunar AIS. However, giving priority to adjudicated imaging findings in our pre-specified definition of lacunar AIS might have improved upon limitations of TOAST in including risk factors of hypertension or diabetes mellitus as one of the criteria [25].…”

Low-Dose vs Standard-Dose Alteplase in Acute Lacunar Ischemic Stroke

“…Given that the clinical diagnosis of lacunar syndrome plus baseline NIHSS score <7 had a high specificity to predict imaging-confirmed lacunar stroke in IST-3, 16 probable lacunar and nonlacunar AIS were discriminated mainly by baseline NIHSS scores and final diagnosis in the situation that there was no acute infarct lesion identified on images or the images were not collected from the sites. For those with conflicting clinical and adjudicated imaging information that compromised the confidence of discrimination, we classified as possible lacunar or nonlacunar AIS according to the clinical diagnosis and LVO status.…”

Overview of The Head CT-Scan in Stroke Patients who was Treated at Muhammadiyah Hospital Palembang

“…Based on this position, the subtypes of ischemic stroke found at the Muhammadiyah Palembang Hospital are mostly lacunar types (16). However, this matter must be proven further using MRI (Magnetic Resonance Imaging) (17)(18)(19). Research conducted by Arboix (2009) states that the topography that is often seen in lacunar infarcts in the lenticular nucleus, thalamus, white matter frontal lobe, pons, basal ganglia, internal capsule, and caudate nucleus (18).…”