Huang Yen-Chu, Lee Jiann-Der, Lin Leng-Chieh, Weng Hsu-Huei, Yang Jen-Tsung, Tsai Yuan-Hsiung, Chen Chao-Hui
Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chiayi, Taiwan.
College of Medicine, Chang-Gung University, Taoyuan, Taiwan.
Cerebrovasc Dis. 2024;53(6):649-656. doi: 10.1159/000535936. Epub 2023 Dec 21.
Acute small subcortical infarctions (SSIs) result from occlusions of small penetrating arteries, and the underlying pathological factors can have different clinical implications. The objective of this study was to assess the clinical relevance of acute SSIs based on their sizes and morphologies.
This retrospective case-control study analyzed clinical and imaging data of stroke patients with acute SSIs in penetrating artery territories who underwent magnetic resonance imaging within 5 days of stroke onset, registered between 2016 and 2020. We categorized these patients into three groups based on size and morphology: diameter <20 mm, diameter ≥20 mm, and separated lesions. We then evaluated their clinical characteristics and outcomes.
We analyzed 726 stroke patients with SSIs, among whom 573 had a diameter <20 mm, 99 had a diameter ≥20 mm, and 54 had separated lesions. The patients had a median age of 70 years and a median National Institutes of Health Stroke Scale (NIHSS) score of 4 on arrival. Patients who experienced early neurological deterioration (END) had a significantly lower chance of good functional outcomes (27.3% vs. 64.4%, p < 0.001). Patients with a diameter ≥20 mm had the most severe NIHSS on arrival and at day 3, the highest rate of END, and the lowest rate of good outcome at 3 months. The incidence of cardioembolism did not differ between patients with diameters of ≥20 mm and <20 mm. However, multiple logistic regression analysis revealed that separated lesions were more likely to be associated with cardioembolic stroke (adjusted odds ratio [aOR], 7.6; 95% confidence interval [CI], 2.0-28.5) and parent artery stenosis >50% (aOR, 3.8; 95% CI, 2.1-7.0) than a diameter of <20 mm. Moreover, SSIs with a diameter of ≥20 mm were found to be associated with an increased risk of END compared to those with a diameter of <20 mm (aOR, 2.9; 95% CI, 1.7-5.2).
Our study suggests that the sizes and morphologies of acute SSIs may indicate different underlying pathologies and be linked to diverse clinical outcomes. Our findings also challenge the current imaging criteria for embolic stroke of undetermined source, as we did not find a link between large subcortical infarction and cardioembolic stroke.
急性小的皮质下梗死（SSIs）是由小的穿支动脉闭塞引起的，其潜在的病理因素可能具有不同的临床意义。本研究的目的是根据急性SSIs的大小和形态评估其临床相关性。
这项回顾性病例对照研究分析了2016年至2020年间登记的、在卒中发作5天内接受磁共振成像检查的、累及穿支动脉区域的急性SSIs卒中患者的临床和影像数据。我们根据大小和形态将这些患者分为三组：直径<20mm、直径≥20mm和分离性病变。然后我们评估了他们的临床特征和预后。
我们分析了726例SSIs卒中患者，其中573例直径<20mm，99例直径≥20mm，54例有分离性病变。患者的中位年龄为70岁，入院时美国国立卫生研究院卒中量表（NIHSS）评分中位数为4分。发生早期神经功能恶化（END）的患者获得良好功能预后的机会显著降低（27.3%对64.4%，p<0.001）。直径≥20mm的患者入院时和第3天时NIHSS评分最严重，END发生率最高，3个月时良好预后率最低。直径≥20mm和<20mm的患者心源性栓塞的发生率无差异。然而，多因素logistic回归分析显示，与直径<20mm的病变相比，分离性病变更可能与心源性栓塞性卒中（校正优势比[aOR]，7.6；95%置信区间[CI]，2.0-28.5）和大脑中动脉狭窄>50%（aOR，3.8；95%CI，2.1-7.0）相关。此外，发现直径≥20mm的SSIs与直径<20mm的SSIs相比，END风险增加（aOR，2.9；95%CI，1.7-5.2）。
我们的研究表明，急性SSIs的大小和形态可能提示不同的潜在病理情况，并与不同的临床结局相关。我们的研究结果也对目前不明来源栓塞性卒中的影像学标准提出了挑战，因为我们没有发现大脑中动脉梗死与心源性栓塞性卒中之间的联系。
