Role of Acute Lesion Topography in Initial Ischemic Stroke Severity and Long-Term Functional Outcomes

Wu, Ona; Cloonan, Lisa; Mocking, Steven J. T.; Bouts, Mark J. R. J.; Copen, William A.; Cougo-Pinto, Pedro Telles; Fitzpatrick, Kaitlin; Kanakis, Allison; Schaefer, Pamela W.; Rosand, Jonathan; Furie, Karen L.; Rost, Natalia S.

doi:10.1161/strokeaha.115.009643

Cited by 133 publications

(146 citation statements)

References 24 publications

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“…This result is in agreement with the recent data from Wu et al, 37 who showed using VLSM maps on mRS that several locations highlighted as eloquent are no longer significant after accounting for age and stroke volume. This suggests that the impact of stroke location is decreased if other established predictors are considered.…”

Section: Discussionsupporting

confidence: 93%

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Stroke Location Is an Independent Predictor of Cognitive Outcome

Munsch

Sagnier

Asselineau

et al. 2016

Stroke

111

103

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Background and Purpose-On top of functional outcome, accurate prediction of cognitive outcome for stroke patients is an unmet need with major implications for clinical management. We investigated whether stroke location may contribute independent prognostic value to multifactorial predictive models of functional and cognitive outcomes. Methods-Four hundred twenty-eight consecutive patients with ischemic stroke were prospectively assessed with magnetic resonance imaging at 24 to 72 hours and at 3 months for functional outcome using the modified Rankin Scale and cognitive outcome using the Montreal Cognitive Assessment (MoCA). Statistical maps of functional and cognitive eloquent regions were derived from the first 215 patients (development sample) using voxel-based lesion-symptom mapping. We used multivariate logistic regression models to study the influence of stroke location (number of eloquent voxels from voxel-based lesion-symptom mapping maps), age, initial National Institutes of Health Stroke Scale and stroke volume on modified Rankin Scale and MoCA. The second part of our cohort was used as an independent replication sample. Results-In univariate analyses, stroke location, age, initial National Institutes of Health Stroke Scale, and stroke volume were all predictive of poor modified Rankin Scale and MoCA. In multivariable analyses, stroke location remained the strongest independent predictor of MoCA and significantly improved the prediction compared with using only age, initial National Institutes of Health Stroke Scale, and stroke volume (area under the curve increased from 0.697-0.771; difference=0.073; 95% confidence interval, 0.008-0.155). In contrast, stroke location did not persist as independent predictor of modified Rankin Scale that was mainly driven by initial National Institutes of Health Stroke Scale (area under the curve going from 0.840 to 0.835). Similar results were obtained in the replication sample. Conclusions-Stroke location is an independent predictor of cognitive outcome (MoCA) at 3 months post stroke.

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Section: Discussionsupporting

confidence: 93%

“…This suggests that the impact of stroke location is decreased if other established predictors are considered. Furthermore, Wu et al 37 did not include initial NIHSS as a covariate. Nevertheless, NIHSS has clearly emerged as an independent predictor and is usually recommended in core outcome predictive model.…”

Section: Discussionmentioning

confidence: 99%

Stroke Location Is an Independent Predictor of Cognitive Outcome

Munsch

Sagnier

Asselineau

et al. 2016

Stroke

111

103

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“…Recent research emphasized the importance of lesion topography in initial stroke severity and long-term functional outcome rather than simple ischemic lesion volume or pattern. 31 Authors speculate that the discrepancy between ischemic lesion pattern and functional outcome in this study, at least in part, could be explain by the role of lesion topography on clinical outcome in patients with acute ischemic stroke.…”

Section: Strokementioning

confidence: 56%

Previous Statin Use and High-Resolution Magnetic Resonance Imaging Characteristics of Intracranial Atherosclerotic Plaque

Chung

Hwang

Lee

et al. 2016

Stroke

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Background and Purpose-Although statin use has been linked to the stabilization of systemic atherosclerosis, its effect on symptomatic intracranial atherosclerotic plaques has yet to be explored. We hypothesized that premorbid statin use is associated with plaque instability in intracranial arteries and may lead to differential patterns (size and distribution) of ischemic lesions in patients with acute intracranial atherosclerotic stroke. Methods-One hundred and thirty-six patients with acute infarcts caused by intracranial atherosclerotic stroke underwent high-resolution magnetic resonance imaging. Patients were categorized into 3 groups based on their premorbid statin use: nonuser, low-dose user, and high-dose user, according to the 2013 American College of Cardiology/American Heart Association guidelines on blood cholesterol. Symptomatic lesions in intracranial arteries were analyzed using highresolution magnetic resonance imaging for vascular morphology (degree of stenosis, remodeling index, and wall index) and plaque activation (pattern and volume of enhancement). The cortical distribution and volume of ischemic brain lesions were measured using diffusion-weighted imaging. Results-Among the enrolled patients, 38 (27.94%) were taking statins before the index stroke (22 low-dose statins and 16 high-dose statins). The degree of stenosis, remodeling index, and wall index did not differ between the 3 groups. However, the volume of plaque enhancement was significantly lower in statin users (nonuser, 33.26±40.72; low-dose user, 13.15±17.53; high-dose user, 3.13±5.26; P=0.002). Premorbid statin use was associated with a higher prevalence of nonembolic stroke and a decrease in large cortical infarcts (P=0.012). Conclusions-Premorbid

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“…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: 98%

“…Compared to the larger institutional dataset of AIS patients with brain MRI on admission, there was no significant difference in age, admission stroke severity, distribution of the TOAST subtypes, nWMHv, or poststroke mRS score (data not shown). 18 In univariable analysis, hypertension (b 5 (table 2). There was no association between the metrics of diffusivity anisotropy and acute infarct volume.…”

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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Role of Acute Lesion Topography in Initial Ischemic Stroke Severity and Long-Term Functional Outcomes

Cited by 133 publications

References 24 publications

Stroke Location Is an Independent Predictor of Cognitive Outcome

Stroke Location Is an Independent Predictor of Cognitive Outcome

Previous Statin Use and High-Resolution Magnetic Resonance Imaging Characteristics of Intracranial Atherosclerotic Plaque

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

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