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      Vascular Risk Factor Profiles Differ Between Magnetic Resonance Imaging-Defined Subtypes of Younger-Onset Lacunar Stroke

      , PhD, , DM

      Stroke

      Lippincott Williams & Wilkins

      population control, risk factors, smoking, stroke, white matter

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          Abstract

          Supplemental Digital Content is available in the text.

          Abstract

          Background and Purpose—

          Differing associations of vascular risk factors with lacunar infarct have been reported, which is likely because of diagnostic differences and possible heterogeneity in the pathogenesis underlying lacunar infarction. In a large magnetic resonance imaging–verified cohort of lacunar infarct patients, we investigated the risk factor profile of lacunar infarction and magnetic resonance imaging characteristics.

          Methods—

          One thousand twenty-three patients with lacunar infarction (mean age, 56.7; SD, 8.5) were recruited from 72 stroke centers throughout the United Kingdom as part of the UK Young Lacunar Stroke DNA Study. Risk factor profiles were compared with 1961 stroke-free population controls with similar age. Furthermore, we tested risk factor profiles of lacunar stroke patients for association with the presence of multiple lacunar infarcts, white matter hyperintensities (WMH), and location of the acute lacunar infarct.

          Results—

          Hypertension (odds ratio [OR], 2.21; 95% confidence interval [CI], 1.85–2.64), diabetes mellitus (OR, 2.10; 95% CI, 1.61–2.73), hyperlipidemia (OR, 1.74; 95% CI, 1.46–2.07), and smoking (OR, 1.65; 95% CI, 1.39–1.96) were independently associated in lacunar infarct patients compared with healthy controls. Patients with multiple lacunar infarcts were more likely to be men (OR, 2.53; 95% CI, 1.81–3.53) and have hypertension (OR, 1.54; 95% CI, 1.12–2.04) compared with patients with a single lacunar infarct, independent of other vascular risk factors. The presence of moderate-to-severe WMH versus no or mild WMH was independently associated with increased age (OR, 1.54; 95% CI, 1.12–2.04), hypertension (OR, 2.06; 95% CI, 1.44–2.95), and impaired renal function (OR, 0.90; 95% CI, 0.82–0.98).

          Conclusions—

          In this magnetic resonance imaging–verified lacunar stroke population, we identified a distinct risk factor profile in the group as a whole. However, there were differing risk factor profiles according to the presence of multiple lacunar infarcts and confluent WMH. The association of hypertension, smoking, and renal impairment with the presence of multiple lacunar infarcts and confluent WMH might reflect a diffuse small vessel arteriopathy.

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          Most cited references 23

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          Classification and natural history of clinically identifiable subtypes of cerebral infarction.

          We describe the incidence and natural history of four clinically identifiable subgroups of cerebral infarction in a community-based study of 675 patients with first-ever stroke. Of 543 patients with a cerebral infarct, 92 (17%) had large anterior circulation infarcts with both cortical and subcortical involvement (total anterior circulation infarcts, TACI); 185 (34%) had more restricted and predominantly cortical infarcts (partial anterior circulation infarcts, PACI); 129 (24%) had infarcts clearly associated with the vertebrobasilar arterial territory (posterior circulation infarcts, POCI); and 137 (25%) had infarcts confined to the territory of the deep perforating arteries (lacunar infarcts, LACI). There were striking differences in natural history between the groups. The TACI group had a negligible chance of good functional outcome and mortality was high. More than twice as many deaths were due to the complications of immobility than to direct neurological sequelae of the infarct. Patients in the PACI group were much more likely to have an early recurrent stroke than were patients in other groups. Those in the POCI group were at greater risk of a recurrent stroke later in the first year after the index event but had the best chance of a good functional outcome. Despite the small anatomical size of the infarcts in the LACI group, many patients remained substantially handicapped. The findings have important implications for the planning of stroke treatment trials and suggest that various therapies could be directed specifically at the subgroups.
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            Subcortical ischaemic vascular dementia.

            Vascular dementia is the second most common type of dementia. The subcortical ischaemic form (SIVD) frequently causes cognitive impairment and dementia in elderly people. SIVD results from small-vessel disease, which produces either arteriolar occlusion and lacunes or widespread incomplete infarction of white matter due to critical stenosis of medullary arterioles and hypoperfusion (Binswanger's disease). Symptoms include motor and cognitive dysexecutive slowing, forgetfulness, dysarthria, mood changes, urinary symptoms, and short-stepped gait. These manifestations probably result from ischaemic interruption of parallel circuits from the prefrontal cortex to the basal ganglia and corresponding thalamocortical connections. Brain imaging (computed tomography and magnetic resonance imaging) is essential for correct diagnosis. The main risk factors are advanced age, hypertension, diabetes, smoking, hyperhomocysteinaemia, hyperfibrinogenaemia, and other conditions that can cause brain hypoperfusion such as obstructive sleep apnoea, congestive heart failure, cardiac arrhythmias, and orthostatic hypotension. Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL)and some forms of cerebral amyloid angiopathy have a genetic basis. Treatment is symptomatic and prevention requires control of treatable risk factors.
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              Comparable studies of the incidence of stroke and its pathological types: results from an international collaboration. International Stroke Incidence Collaboration.

               C Warlow,  Anna Sudlow (1997)
              Comparing stroke rates in different parts of the world may increase our understanding of both etiology and prevention. However, comparisons are meaningful only if studies use standard definitions and methods, with comparably presented data. We compared the incidence of stroke and its pathological types (cerebral infarction, primary intracerebral hemorrhage, and subarachnoid hemorrhage) in recent studies from around the world. Studies with a midyear of 1984 or later, fulfilling standard criteria for a comparable, community-based study, provided original data for comparative analyses. By mid-1995, data were available from 11 studies in Europe, Russia, Australasia, and the United States, comprising approximately 3.5 million person-years and 5575 incident strokes. Age- and sex-standardized annual incidence rates for subjects aged 45 to 84 years were similar (between approximately 300/100,000) and 500/100,000) in most places but were significantly lower in Dijon, France (238/100,000), and higher in Novosibirsk, Russia (627/100,000). In subjects aged 75 to 84 years, however, Novosibirsk no longer ranked higher than the other studies. The distribution of pathological types, when these were reliably distinguished, did not differ significantly between studies. The similarities in stroke incidence and pathological types are perhaps not surprising given that all the populations were westernized and mainly white. The higher rates in Novosibirsk, disappearing in the elderly, and the lower rates in Dijon have several potential explanations. These include methodological artifact and different patterns of population risk factors. Further work is needed to explore these possibilities and to extend our knowledge of stroke incidence to other parts of the world, especially developing countries.
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                Author and article information

                Journal
                Stroke
                Stroke
                STR
                Stroke
                Lippincott Williams & Wilkins
                0039-2499
                1524-4628
                September 2017
                01 August 2017
                : 48
                : 9
                : 2405-2411
                Affiliations
                From the Department of Clinical Neurosciences, Stroke Research Group, University of Cambridge, United Kingdom.
                Author notes
                Correspondence to Loes C.A. Rutten-Jacobs, PhD, Department of Clinical Neurosciences, University of Cambridge, CB2 0QQ Cambridge, United Kingdom. E-mail lr406@ 123456medschl.cam.ac.uk
                Article
                00015
                10.1161/STROKEAHA.117.017813
                5571884
                28765289
                © 2017 The Authors.

                Stroke is published on behalf of the American Heart Association, Inc., by Wolters Kluwer Health, Inc. This is an open access article under the terms of the Creative Commons Attribution License (CC-BY), which permits use, distribution, and reproduction in any medium, provided the original work is properly cited.

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                10071
                10129
                10173
                Original Contributions
                Clinical Sciences
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                population control, white matter, stroke, smoking, risk factors

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