Significant progression of white matter lesions and small deep (lacunar) infarcts in patients with stroke
M. van Zagten, J. Boiten, F. Kessels and J. Lodder
Department of Neurology, University of Hospital Maastricht, The Netherlands.
OBJECTIVE: To investigate whether the extent of white matter lesions (WMLs)
and the number of small deep infarcts and territorial infarcts progress
over time in patients with stroke and to test the hypothesis that WMLs are
associated with small deep infarcts. DESIGN: Computed tomographic follow-up
study in a cohort of 107 patients with ischemic stroke (median follow-up,
3.0 years). SETTING: Primary and referral care center. PATIENTS:
Sixty-three of 144 registered patients with a first-ever symptomatic
lacunar stroke and 44 of 155 with a territorial stroke entered this study.
Forty-seven (33%) of the nonparticipating patients with a lacunar stroke
and 54 (35%) of those with a territorial stroke died, and 34 (24%) and 57
(37), respectively, refused computed tomographic follow-up. MAIN OUTCOME
MEASURES: The extent of the WMLs and the number of small deep and
territorial infarcts on computed tomographic scans at study entry and at
follow-up. RESULTS: Progression of WMLs occurred in 26 patients (26%), and
multivariate regression analysis showed that it was associated with
symptomatic lacunar stroke at study entry (adjusted odds ratio [aOR], 5.0;
95% confidence interval [CI], 1.2-20.3), silent small deep infarcts at
study entry (aOR, 6.0, 95% CI, 1.0-34.6), old age (aOR, 5.5; 95% CI,
1.3-23.1), and longer follow-up (aOR, 12.7; 95% CI, 1.8-89.0). We found
progression of small deep infarcts in 41 patients (38%). The progression
was associated with symptomatic lacunar stroke at study entry (aOR, 27.7;
95% CI, 6.3-120.9) and longer follow-up (aOR, 7.7; 95% CI, 1.4-41.3).
Progression of both WMLs and small deep infarcts, which occurred in 16
patients (16%), was associated with symptomatic lacunar stroke at study
entry (aOR, 34.1; 95% CI, 2.5-471.7), silent small deep infarcts at study
entry (aOR, 12.5; 95% CI, 1.4-112.0), and longer follow-up (aOR, 29.7; 95%
CI, 1.8-501.0). The number of territorial infarcts increased in 14 patients
(13%). The increase was associated with symptomatic territorial stroke at
study entry (aOR, 7.9; 95% CI, 1.5-40.8) and a history of ischemic heart
disease (aOR, 6.6; 95% CI, 1.3-34.8). CONCLUSIONS: The marked progression
of WMLs and small deep infarcts that occurred mainly in patients with
lacunar stroke suggests that both WMLs and small deep (lacunar) infarcts
are caused by a similar vasculopathy that affects small vessels, which is
progressive despite standard stroke treatment.
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