Background: Current clinical tools to identify lacunar infarct patients at risk of deterioration are inadequate, and imaging techniques to predict fluctuation and deterioration would be of value. We sought to determine the occurrence of MRI perfusion-weighted imaging (PWI) abnormalities in lacunes, and whether they help predict clinical and radiological outcome. Methods: Patients with lacunar stroke or TIA were selected from a prospective MR imaging study. MRI was performed within 24 h of the event and follow-up imaging completed at 30 or 90 days. Baseline perfusion maps were qualitatively assessed and infarct volumes measured. Early clinical deterioration (NIHSS worsening of ≥3 points within 72 h of event) and 90-day modified Rankin Scale score (mRS) were recorded. Results: Twenty-two patients were included. Fifteen (68.2%) had abnormal PWI at the site of the diffusion-weighted imaging lesion. Patients with abnormal PWI were more likely to have stroke than TIA as their index event (RR 2.2, 95% CI 0.9–5.2, p = 0.02). Early clinical deterioration occurred in 4 patients (18.2%), all of whom had abnormal PWI. PWI lesions were not associated with a higher 90-day NIHSS or mRS score, nor did they predict infarct volume growth. Conclusions: MR-PWI abnormalities are seen in two thirds of lacunar infarcts, and are associated with stroke rather than TIA. Normal PWI identifies patients at low risk of early clinical deterioration.

Keywords:
Stroke, Transient ischemic attack, Lacunes, Capsular warning syndrome, Perfusion, Magnetic resonance imaging
1.
Bamford JM, Warlow CP: Evolution and testing of the lacunar hypothesis. Stroke 1988;19:1074–1082.
2.
Mohr JP, Caplan LR, Melski JW, et al: The Harvard Cooperative Stroke Registry: a prospective registry. Neurology 1978;28:754–762.
3.
Nakamura K, Saku Y, Ibayashi S, Fujishima M: Progressive motor deficits in lacunar infarction. Neurology 1999;52:29–33.
4.
Tei H, Uchiyama S, Ohara K, Kobayashi M, Uchiyama Y, Fukuzawa M: Deteriorating ischemic stroke in 4 clinical categories classified by the Oxfordshire Community Stroke Project. Stroke 2000;31:2049–2054.
5.
Donnan GA, O’Malley HM, Quang L, Hurley S, Bladin PF: The capsular warning syndrome: pathogenesis and clinical features. Neurology 1993;43:957–962.
6.
Latchaw RE, Yonas H, Hunter GJ, Yuh WT, Ueda T, Sorensen AG, Sunshine JL, Biller J, Wechsler L, Higashida R, Hademenos G; Council on Cardiovascular Radiology of the American Heart Association: Guidelines and recommendations for perfusion imaging in cerebral ischemia. Stroke 2003;34:1084–1104.
7.
Yamada M, Yoshimura S, Kaku Y, Iwama T, Watarai H, Ando T, Sakai N: Prediction of neurologic deterioration in patients with lacunar infarction in the territory of the lenticulostriate artery using perfusion CT. Am J Neuroradiol 2004;25:402–408.
8.
Gerraty RP, Parsons MW, Barber PA, Darby DG, Desmond PM, Tress BM, Davis SM: Examining the lacunar hypothesis with diffusion and perfusion magnetic resonance imaging. Stroke 2002;33:2019–2024.
9.
Ay H, Furie KL, Singhal A, Smith WS, Sorensen AG, Koroshetz WJ: An evidence-based causative classification system for acute ischemic stroke. Ann Neurol 2005;58:688–697.
10.
Kosior JC, Frayne R: PerfTool: a software platform for investigating bolus-tracking perfusion imaging quantification strategies. J Magn Reson Imaging 2007;25:653–659.
11.
Campos CR, Choi YB, Khan F, Kosior J, Hill MD, Demchuk AM, Coutts SB: The Assessment of Lesion Volumes in TIA and Minor Stroke Patients (poster). Stroke 2008;39:586.
12.
Gaudinski MR, Henning EC, Miracle A, Luby M, Warach S, Latour LL: Establishing final infarct volume. stroke lesion evolution past 30 days is insignificant. Stroke 2008;39:2765–2768.
13.
Yamamoto H, Bogousslavsky J, van Mell G: Different predictors of neurological worsening in different causes of stroke. Arch Neurol 1998;55:481–486.
14.
Lodder J, Gorsselink EL: Progressive stroke caused by CT-verified small deep infarcts: relation with the size of the infarct and clinical outcome. Acta Neurol Scand 1985;71:328–330.
15.
Terasawa Y, Iguchi Y, Kimura K, Kobayashi K, Aoki J, Matsumoto N, Shibazaki K, Inoue T, Kaji R: Neurological deterioration in small vessel disease may be associated with increase of infarct volume. J Neurol Sci 2008;269:35–40.
16.
Chalela JA, Ezzedine M, Latour L, Warach S: Reversal of perfusion and diffusion abnormalities after intravenous thrombolysis for a lacunar infarction. J Neuroimaging 2003;13:152–154.
© 2009 S. Karger AG, Basel
2009
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.