Risk factors associated with progressive lacunar strokes and benefit from dual antiplatelet therapy

Abstract

Background and purpose: Early neurological deterioration (END) occurs in 20%-30% of patients with lacunar stroke and challenges their clinical management. This retrospective cohort study analyzed clinical and neuroimaging risk factors predicting the occurrence of END, the functional outcome after END and potential benefit from dual antiplatelet therapy (DAPT) in patients with lacunar strokes. Methods: Factors associated with END and benefit from DAPT were retrospectively analyzed in 308 patients with lacunar stroke symptoms and detected lacunar infarction by magnetic resonance imaging. END was defined by deterioration of ≥3 total National Institutes of Health Stroke Scale (NIHSS) points, ≥2 NIHSS points for limb paresis or documented deterioration within 5 days after admission. Patients were treated with DAPT according to inhouse standards. The primary efficacy end-point for functional outcome was fulfilled if NIHSS at discharge improved after END at least to the score at admission. Results: Male gender [odds ratio (OR) 2.08; 95% confidence interval (CI) 1.09-4.00], higher age (OR = 1.65 per 10 years; 95% CI 1.18-2.31), motor paresis (OR = 18.89, 95% CI 4.66-76.57) and infarction of the internal capsule or basal ganglia (OR = 3.58, 95% CI 1.26-10.14) were associated with an increased risk for END. A larger diameter of infarction (OR = 0.85, 95% CI 0.76-0.95), more microangiopathic lesions (OR = 0.75, 95% CI 0.57-0.99) and pontine localization (OR = 0.29, 95% CI 0.12-0.65) were factors associated with unfavorable functional outcome after END occurred. Localization in the internal capsule or basal ganglia was identified as a significant predictive factor for a benefit from DAPT after END. Conclusions: Identified clinical and neuroimaging factors predicting END occurrence, functional outcome after END and potential benefit from DAPT might improve the clinical management of patients with lacunar strokes.

The Length of an Infarcted Lesion Along the Perforating Artery Predicts Neurological Deterioration in Single Subcortical Infarction Without Any Relevant Artery Stenosis

“…Relevant artery stenosis is a known risk factor for END ( 23 ). In addition, although Berbeich et al suggested that older age and male sex were significantly associated with END ( 24 ), these two variables were not different between END and non-END groups in our study.…”

“…Fourth, acute treatment before END was not included in this analysis, which might have affected the occurrence of END. A recent study suggested that dual antiplatelet therapy could improve the outcome following END ( 24 ). Fifth, we performed MRIs and MRAs using 1.5 or 3 Tesla scanner; therefore, there could be a potential bias in the comparison of the number of DWI slices between END and non-END groups.…”

Progression in Lacunar Stroke is Related to Elevated Blood Viscosity

“…Regarding NIHSS score, recent studies have suggested that a higher NIHSS score at admission is associated with an increased risk of ND. 13,16 Eighteen patients (45%) with progressive stroke presented with NIHSS ≥4 in our study. From a therapeutic point of view, patients with NIHSS ≥4 at admission were excluded from the POINT trial.…”

“…Several studies have used diverse neurological scales and definitions when classifying patients into a progressive stroke group. 5,[13][14][15] One study reported that worsening more than 1 point in NIHSS score is reasonable since the major ND occurred in motor function. 5 Considering the criteria for NIHSS score and clinical fluctuations in LS, we defined progressive stroke as worsening by ≥2 points on the NIHSS score for motor function or ≥3 points in all NIHSS scores.…”

“…Progression was defined as worsening by ≥2 points on the NIHSS score for motor function or ≥3 points in the total NIHSS score. 13,14 The NIHSS score at admission was classified as low (NIHSS <4) or high (NIHSS ≥4), reflecting that the latter generally included severe motor weakness. Brain CT or MRI was performed on all patients at admission, and upon progressive symptoms to exclude cerebral hemorrhage and new ischemic lesions.…”