Leukoaraiosis Burden Significantly Modulates the Association Between Infarct Volume and National Institutes of Health Stroke Scale in Ischemic Stroke

Helenius, Johanna; Henninger, Nils

doi:10.1161/strokeaha.115.009258

Cited by 64 publications

(84 citation statements)

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“…Ischemic infarcts on DWI were manually outlined using careful windowing to achieve the maximal visual extent of the acute DWI (b1000 trace weighted) infarct and with reference to the apparent diffusion coefficient image to avoid regions of T2 shine-through and to allow for reliable distinction from leukoaraiosis. 12 Leukoaraiosis was defined as supratentorial white matter hypoattenuation on fluid-attenuated inversion recovery MRI according to the STandards for ReportIng Vascular changes on nEuroimaging criteria 17 and graded according to the Fazekas scale on the basis of visual assessment both periventricular (0=absent, 1=caps or pencil lining, 2=smooth halo, and 3=irregular periventricular hyperintensities extending into deep white matter) and subcortical areas (0=absent, 1=punctuate foci, 2=beginning confluence of foci, and 3=large confluent areas). 12 The total Fazekas score was calculated by adding the periventricular and subcortical scores.…”

Section: Image Review and Analysismentioning

confidence: 99%

“…[7][8][9] However, whether age, or age-related phenomena, affect the hemispheric lateralization of the NIHSS deficit is presently unclear. In this respect, leukoaraiosis is of particular interest because it commonly present among the elderly, 10,11 worsens functional deficit severity after ischemic stroke, 12,13 and decreases white matter tract and functional network integrity. 14,15 Accordingly, age-related leukoaraiosis could represent an easily accessible imaging marker that affects the association between deficit severity and side of infarction as assessed by the NIHSS.…”

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confidence: 99%

“…12 NIHSS scores were assessed at the time of presentation by members of the stroke team certified in NIHSS. The modified Rankin Scale (mRS) score was assessed at 90 days by a stroke-trained physician or stroke study nurse certified in mRS via in-person or phone interview.…”

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confidence: 99%

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Impact of Leukoaraiosis Burden on Hemispheric Lateralization of the National Institutes of Health Stroke Scale Deficit in Acute Ischemic Stroke

Helenius

Goddeau

Moonis

et al. 2016

Stroke

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BACKGROUND AND PURPOSE: The National Institutes of Health Stroke Scale (NIHSS) awards higher deficit scores for infarcts in the dominant hemisphere when compared with otherwise similar infarcts in the nondominant hemisphere. This has been shown to adversely affect stroke recognition, therapeutic decisions, and outcome. However, factors modifying the association between infarct side and deficit severity are incompletely understood. Thus, we sought to determine whether age and age-related leukoaraiosis alter the relation between NIHSS deficit score and the side and volume of infarction. METHODS: We studied 238 patients with supratentorial, nonlacunar ischemic infarcts prospectively included in our stroke registry between January 2013 and January 2014. NIHSS deficit severity was assessed at the time of presentation. Infarct volumes were assessed by manual planimetry on diffusion-weighted imaging. Leukoaraiosis burden was graded on fluid-attenuated inversion recovery images according to the Fazekas scale and dichotomized to none-to-mild (0-2) versus severe (3-6). Multivariable linear regression with backward elimination was used to identify independent predictors of the admission NIHSS. RESULTS: Left-hemispheric infarction (P \u3c 0.001), severe leukoaraiosis (P=0.001), their interaction term (P=0.005), infarct volume (P \u3c 0.001), and sex (P=0.013) were independently associated with the NIHSS deficit. Analysis of the individual NIHSS components showed that severe leukoaraiosis was associated with an increase of the lateralizing components of the NIHSS in patients with right-hemispheric infarction (P\u3c0.05). CONCLUSIONS: Severe leukoaraiosis substantially attenuates the classic hemispheric lateralization of the NIHSS deficit by relating to greater NIHSS scores of components that are typically assigned to left hemisphere function

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confidence: 99%

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confidence: 99%

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Impact of Leukoaraiosis Burden on Hemispheric Lateralization of the National Institutes of Health Stroke Scale Deficit in Acute Ischemic Stroke

Helenius

Goddeau

Moonis

et al. 2016

Stroke

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“…However, both NIHSS score and small vessel (TOAST) stroke subtype were independently associated with acute infarct volume, consistent with prior reports. 1,22 Interestingly, small vessel stroke subtype was not associated with mRS score, which is likely a consequence of insufficient power of this portion of the analysis (n 5 29 patients with stroke attributed to small vessel occlusion), or alternatively, it is suggestive of a complex relationship between clinical outcome and stroke subtype, which may involve additional variables such as interaction with stroke lesion topography. 18 Overall, the role of WM microstructural integrity in the acute ischemic tissue outcomes warrants further investigation.…”

Section: Resultsmentioning

confidence: 92%

“…22 In addition, WMH burden deleteriously affects functional outcomes at 1 to 12 months after ischemic stroke and is associated with greater likelihood of long-term disability. [3][4][5][23][24][25] There is a growing body of evidence, however, that clinically significant WM injury may exist that is subthreshold of T2 FLAIR detection and that represents a form of microstructural injury.…”

Section: Resultsmentioning

confidence: 99%

Integrity of normal-appearing white matter and functional outcomes after acute ischemic stroke

Etherton

Cougo

et al. 2017

Neurology

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Objective: To characterize the effect of white matter microstructural integrity on cerebral tissue and long-term functional outcomes after acute ischemic stroke (AIS).Methods: Consecutive AIS patients with brain MRI acquired within 48 hours of symptom onset and 90-day modified Rankin Scale (mRS) score were included. Acute infarct volume on diffusion-weighted imaging (DWIv) and white matter hyperintensity volume (WMHv) on T2 fluidattenuated inversion recovery MRI were measured. Median fractional anisotropy (FA), mean diffusivity, radial diffusivity, and axial diffusivity values were calculated within normal-appearing white matter (NAWM) in the hemisphere contralateral to the acute lesion. Regression models were used to assess the association between diffusivity metrics and acute cerebral tissue and longterm functional outcomes in AIS. Level of significance was set at p , 0.05 for all analyses.Results: Among 305 AIS patients with DWIv and mRS score, mean age was 64.4 6 15.9 years, and 183 participants (60%) were male. Median NIH Stroke Scale (NIHSS) score was 3 (interquartile range [IQR] 1-8), and median normalized WMHv was 6.19 cm 3 (IQR 3.0-12.6 cm 3 ). Admission stroke severity (b 5 0.16, p , 0.0001) and small vessel stroke subtype (b 5 21.53, p , 0.0001), but not diffusivity metrics, were independently associated with DWIv. However, median FA in contralesional NAWM was independently associated with mRS score (b 5 29.74, p 5 0.02), along with age, female sex, NIHSS score, and DWIv.Conclusions: FA decrease in NAWM contralateral to the acute infarct is associated with worse mRS category at 90 days after stroke. These data suggest that white matter integrity may contribute to functional recovery after stroke. Neurology ® 2017;88:1701-1708 GLOSSARY AD 5 axial diffusivity; AIS 5 acute ischemic stroke; DTI 5 diffusion tensor imaging; DWIv 5 diffusion-weighted imaging volume; FA 5 fractional anisotropy; FLAIR 5 fluid-attenuated inversion recovery; IQR 5 interquartile range; MD 5 mean diffusivity; MNI 5 Montreal Neurological Institute; mRS 5 modified Rankin Scale; nDWIv 5 normalized diffusion-weighted imaging volume; NAWM 5 normal-appearing white matter; NIHSS 5 NIH Stroke Scale; nWMHv 5 normalized white matter hyperintensity volume; RD 5 radial diffusivity; TOAST 5 Trial of Org 10172 in Acute Stroke Treatment; tPA 5 tissue plasminogen activator; WM 5 white matter; WMH 5 white matter hyperintensity; WMHv 5 white matter hyperintensity volume.The role of white matter hyperintensity (WMH), or leukoaraiosis, in outcomes after acute ischemic stroke (AIS) is increasingly recognized through its link to larger acute infarct lesions, 1 likelihood of infarct expansion, 2 and association with worse functional poststroke outcomes. [3][4][5] However, a growing body of evidence suggests that macrostructural white matter (WM) disease burden, quantified as WMH on T2-weighted fluid-attenuated inversion recovery (FLAIR) MRI, may not adequately reflect the total extent of WM injury and that microstructural injury to normal-appear...

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Association of Ischemic Stroke Incidence, Severity, and Recurrence With Dementia in the Atherosclerosis Risk in Communities Cohort Study

et al. 2022

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IMPORTANCE Ischemic stroke is associated with increased risk of dementia, but the association of stroke severity and recurrence with risk of impaired cognition is not well known.OBJECTIVE To examine the risk of dementia after incident ischemic stroke and assess how it differed by stroke severity and recurrence. DESIGN, SETTING, AND PARTICIPANTSThe Atherosclerosis Risk in Communities (ARIC) study is an ongoing prospective cohort of 15 792 community-dwelling individuals from 4 US states (Mississippi, Maryland, Minnesota, and North Carolina). Among them, 15 379 participants free of stroke and dementia at baseline (1987 to 1989) were monitored through 2019. Data were analyzed from April to October 2021. Associations between dementia and time-varying ischemic stroke incidence, frequency, and severity were studied across an average of 4.4 visits over a median follow-up of 25.5 years with Cox proportional hazards models adjusted for sociodemographic characteristics, apolipoprotein E, and vascular risk factors.EXPOSURES Incident and recurrent ischemic strokes were classified by expert review of hospital records, with severity defined by the National Institutes of Health Stroke Scale (NIHSS; minor, Յ5; mild, 6-10; moderate, 11-15; and severe, Ն16).MAIN OUTCOMES AND MEASURES Dementia cases adjudicated through expert review of in-person evaluations, informant interviews, telephone assessments, hospitalization codes, and death certificates. In participants with stroke, dementia events in the first year after stroke were not counted.RESULTS At baseline, the mean (SD) age of participants was 54.1 (5.8) years, and 8485 of 15 379 participants (55.2%) were women. A total of 4110 participants (26.7%) were Black and 11 269 (73.3%) were White. A total of 1378 ischemic strokes (1155 incident) and 2860 dementia cases were diagnosed 1 year or more after incident stroke in participants with stroke, or at any point after baseline in participants without stroke, were identified through December 31, 2019. NIHSS scores were available for 1184 of 1378 ischemic strokes (85.9%). Risk of dementia increased with both the number and severity of strokes. Compared with no stroke, risk of dementia by adjusted hazard ratio was 1.76 (95% CI, 1.49-2.00) for 1 minor to mild stroke, 3.47 (95% CI, 2.23-5.40) for 1 moderate to severe stroke, 3.48 (95% CI, 2.54-4.76) for 2 or more minor to mild strokes, and 6.68 (95% CI, 3.77-11.83) for 2 or more moderate to severe strokes. CONCLUSIONS AND RELEVANCEIn this study, risk of dementia significantly increased after ischemic stroke, independent of vascular risk factors. Results suggest a dose-response association of stroke severity and recurrence with risk of dementia.

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Leukoaraiosis Burden Significantly Modulates the Association Between Infarct Volume and National Institutes of Health Stroke Scale in Ischemic Stroke

Cited by 64 publications

References 33 publications

Impact of Leukoaraiosis Burden on Hemispheric Lateralization of the National Institutes of Health Stroke Scale Deficit in Acute Ischemic Stroke

Impact of Leukoaraiosis Burden on Hemispheric Lateralization of the National Institutes of Health Stroke Scale Deficit in Acute Ischemic Stroke

Integrity of normal-appearing white matter and functional outcomes after acute ischemic stroke

Association of Ischemic Stroke Incidence, Severity, and Recurrence With Dementia in the Atherosclerosis Risk in Communities Cohort Study

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