Symptoms and probabilistic anatomical mapping of lacunar infarcts

Abstract

Background: The anatomical distribution of acute lacunar infarcts has mainly been studied for supratentorial lesions. In addition, little is known about the association with distinct stroke symptoms, not summarized as classical lacunar syndromes. We aimed to describe the spatial lesion distribution of acute supra- and infratentorial lacunar infarcts and their association with stroke symptoms in patients eligible for thrombolysis.

Methods: All patients enrolled in the WAKE-UP trial (efficacy and safety of magnetic resonance imaging [MRI]-based thrombolysis in wake-up stroke) were screened for lacunar infarcts on diffusion-weighted imaging (DWI). The relationship between the anatomical distribution of supra- and infratentorial lacunar infarcts, their demographic characteristics and acute stroke symptoms, defined by the National Institutes of Health Stroke Scale (NIHSS) score, were correlated and compared.

Results: Maps of lesion distribution from 224 lacunar infarct patients (76 [33.9%] females, mean age [standard deviation] of 63.4 [11.5] years) were generated using computational image mapping methods. Median infarct volume was 0.73 ml (interquartile range [IQR] 0.37-1.15 ml). Median NIHSS sum score on hospital arrival was 4 (IQR 3-6). 165 (73.7%) patients had lacunar infarcts in the supratentorial deep white or grey matter, while 59 (26.3%) patients had infratentorial lacunar infarcts. Patients with supratentorial lacunar infarcts presented with a significantly lower occurrence of deficits in the NIHSS items gaze (p < 0.001) and dysarthria (p = 0.008), but had more often a paresis of the left arm (p = 0.009) and left leg (p = 0.068) compared to patients with infratentorial infarcts.

Conclusions: The anatomical lesion distribution of lacunar infarcts reveals a distinct pattern and supports an association of localization with different stroke symptoms.

Trial registration: NCT01525290.

Keywords: Lacunar infarct; Lesion distribution; Magnetic resonance imaging; Probabilistic atlas; WAKE-UP.

Conflict of interest statement

Competing interestsEB, AK, MEb, MEn, JBF, JF, VT, RL, KWM, NN, SP, CZS, CG, GT and BC report grants from European Union 7th Framework Program during the conduct of the study. FB reports grants from University Medical Center Hamburg-Eppendorf during the conduct of the study. MEn reports grants from Bayer and fees paid to the Charité from Bayer, Boehringer Ingelheim, BMS/Pfizer, Daiichi Sankyo, Amgen, Sanofi, Covidien, outside the submitted work. JBF reports consulting and advisory board fees from BioClinica, Cerevast, Artemida, Brainomix, Biogen, BMS, and EISAI, outside the submitted work. VT reports personal fees and non-financial support from Boehringer Ingelheim, Pfizer/BMS, Bayer, Sygnis, Amgen and Allergan, outside the submitted work. RL reports fees paid to VIB/KU Leuven from Bayer, Boehringer Ingelheim, Medtronic, Ischemiaview and Genentec, outside the submitted work. KWM reports personal fees and non-financial support from Boehringer Ingelheim, outside the submitted work. CZS reports grants from Novo Nordisk Foundation and personal fees from Bayer outside the submitted work. CG reports personal fees from AMGEN, Bayer Vital, BMS, Boehringer Ingelheim, Sanofi Aventis, Abbott, and Prediction Biosciences outside the submitted work. Personal fees from Acandis, Boehringer Ingelheim, BMS/Pfizer, Stryker, Daiichi Sankyo, grants and personal fees from Bayer, grants from Corona Foundation, German Innovation Fonds and Else Kroener Fresenius Foundation, outside the submitted work. All remaining authors declare that they have no competing interests.

© The Author(s) 2020.

Figures

Fig. 1

Probability distribution maps of acute lacunar infarcts. Illustration of the distribution of all lacunar infarcts in the axial plane in a standard MNI space superimposed on a mean image of spatially normalized non-diffusion-weighted (b = 0) images of all 224 patients. Z coordinates are given in millimeters

Fig. 2

Standardized Jonckheere-Terpstra (J-T) statistics. DWI, diffusion weighted imaging; NIHSS, National Institute of Health Stroke Scale. Standardized Jonckheere-Terpstra (J-T) statistics (Z scores) depicting strength and direction of associations between supratentorially located infarcts and individual independent variables. Positive values (right section of bar graph) signify symptoms more commonly observed in supratentorial lacunar lesions. Negative values (left side of bar graph) indicate symptoms predominantly occurring in infratentorial lacunar lesions. The broken red lines mark the levels where P = 0.05