Huang Yen-Chu, Weng Hsu-Huei, Lin Leng-Chieh, Lee Jiann-Der, Yang Jen-Tsung, Tsai Yuan-Hsiung, Chen Chao-Hui
Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chiayi 613, Taiwan.
College of Medicine, Chang-Gung University, Taoyuan 333, Taiwan.
Neurol Int. 2024 Oct 21;16(5):1164-1174. doi: 10.3390/neurolint16050088.
BACKGROUND/OBJECTIVES: Small-vessel occlusion, previously referred to as lacunar infarcts, accounts for approximately one-third of all ischemic strokes, using an axial diameter of less than 20 mm on diffusion-weighted imaging. However, this threshold may not adequately differentiate small-vessel occlusion from other pathologies, such as branch atheromatous disease (BAD) and embolism. This study aimed to assess the clinical significance and pathological implications of acute small subcortical infarctions (SSIs) based on infarct diameter.
We conducted a retrospective case-control study using data from stroke patients recorded between 2016 and 2021 of the Stroke Registry in Chang Gung Healthcare System. Patients with acute SSIs in penetrating artery territories were included. Key variables such as patient demographics, stroke severity, and medical history were collected. Infarcts were categorized based on size, and the presence of early neurological deterioration (END) and favorable functional outcomes were assessed.
Among the 855 patients with acute SSIs, the median age was 70 years and the median National Institutes of Health Stroke Scale (NIHSS) score at arrival was four. END occurred in 97 patients (11.3%). Those who experienced END were significantly less likely to achieve a favorable functional outcome compared to those who did not (18.6% vs. 59.9%, < 0.001). The incidence of END increased progressively with infarct sizes of 15 mm or larger, with the optimal threshold for predicting END identified as 15.5 mm and for BAD, it was 12.1 mm. A multiple logistic regression analysis revealed that motor tract involvement [adjusted odds ratio (aOR) 2.3; 95% confidence interval (CI) 1.1-4.7], an initial heart rate greater than 90 beats per minute (aOR 2.3; 95% CI 1.2-4.3), and a larger infarct size (15 mm to less than 20 mm vs. 10 mm to less than 15 mm; aOR 3.0; 95% CI 1.4-6.3) were significantly associated with END.
Our findings suggest that setting the upper limit for small-vessel occlusion at 15 mm would be more effective in distinguishing it from BAD. However, these findings should be interpreted in the context of the retrospective design and study population. Further multi-center research utilizing high-resolution vessel wall imaging is necessary to refine this threshold and enhance diagnostic accuracy.
背景/目的：小血管闭塞，以前称为腔隙性梗死，在所有缺血性卒中中约占三分之一，在扩散加权成像上轴径小于20毫米。然而，这个阈值可能无法充分区分小血管闭塞与其他病理情况，如分支动脉粥样硬化疾病（BAD）和栓塞。本研究旨在评估基于梗死直径的急性皮质下小梗死（SSIs）的临床意义和病理影响。
我们进行了一项回顾性病例对照研究，使用了长庚医疗系统卒中登记处2016年至2021年期间记录的卒中患者数据。纳入穿透动脉区域急性SSIs患者。收集患者人口统计学、卒中严重程度和病史等关键变量。根据梗死大小对梗死进行分类，并评估早期神经功能恶化（END）的存在情况和良好的功能结局。
在855例急性SSIs患者中，中位年龄为70岁，入院时美国国立卫生研究院卒中量表（NIHSS）中位评分为4分。97例患者（11.3%）发生END。与未发生END的患者相比，发生END的患者获得良好功能结局的可能性显著降低（18.6%对59.9%，<0.001）。END的发生率随着梗死大小达到15毫米或更大而逐渐增加，预测END的最佳阈值确定为15.5毫米，预测BAD的阈值为12.1毫米。多因素logistic回归分析显示，运动束受累[调整优势比（aOR）2.3；95%置信区间（CI）1.1 - 4.7]、初始心率大于90次/分钟（aOR 2.3；95%CI 1.2 - 4.3）以及较大的梗死大小（15毫米至小于20毫米对10毫米至小于15毫米；aOR 3.0；95%CI 1.4 - 6.3）与END显著相关。
我们的研究结果表明，将小血管闭塞的上限设定为15毫米能更有效地将其与BAD区分开来。然而，这些发现应结合回顾性设计和研究人群来解释。有必要开展进一步的多中心研究，利用高分辨率血管壁成像来完善这个阈值并提高诊断准确性。
