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Pathogenetic and Prognostic Features of Lacunar Transient Ischaemic Attack Syndromes

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Pathogenetic and Prognostic Features of Lacunar Transient Ischaemic Attack Syndromes Journal ofNeurology, Neurosurgery, and Psychiaty 1993;56:1265-1270 1265 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.12.1265 on 1 December 1993. Downloaded from PAPERS Pathogenetic and prognostic features of lacunar transient ischaemic attack syndromes Gianluca Landi, Cristina Motto, Ermelinda Cella, Massimo Musicco, Susanna Lipari, Edoardo Boccardi, Mario Guidotti Abstract studies reporting a significantly lower preva- Lacunar ischaemic stroke syndromes are lence of emboligenic heart disease and of a well defined subgroup of ischaemic carotid artery stenosis among lacunar than strokes. To determine whether a similar among other ischaemic strokes.3-5 Diagnosis subgroup can be identified among of lacunar ischaemic stroke syndrome has patients with transient ischaemic attacks prognostic implications, too, as these patients (TIAs) we studied prospectively 102 con- have a more favourable long term outcome secutive patients within 24 hours of their than those with other subtypes of cerebral first TIA. Based on their history they infarction.67 Transposition of the lacunar were classified as lacunar TIA syn- hypothesis to TIAs is not straightforward, as dromes (LTIAS; n = 45) if isolated motor their short duration usually precludes objec- or sensory symptoms or their combina- tive verification of symptoms; thus, diagnosis tion had involved at least two of three of a lacunar TIA syndrome would have to body parts (face, arm, leg), whereas all rest on the patient's history and on the clini- other subjects were grouped as non-lacu- cian's possibility to fit it retrospectively into nar TIA syndromes (NLTIAS; n = 57). one of the lacunar syndromes. Despite this All patients were investigated according limitation, two papers have endeavoured to to a standardised protocol and followed distinguish a subgroup with small vessel dis- up for an average of 51 1 months. ease also among TIAs. One study considered Cardiac and arterial sources of throm- patients with TIA who had an infarct at CT: boembolism were more frequent among the authors reported a significantly higher NLTIAS (p = 0 0001). Survival curve proportion of small deep (lacunar) infarcts on analysis demonstrated that LTIAS had a CT scan among patients with unilateral iso- significantly lower long term mortality lated motor and/or sensory symptoms consis- and incidence of major vascular events. tent with a lacunar syndrome than among In a multivariate regression analysis, the patients with symptoms suggestive of cortical type of TIA (that is, NLTIAS) was an dysfunction.8 In another study, limited to independent predictor of stroke or death. patients who had undergone angiography, http://jnnp.bmj.com/ LTIAS share the same distinct patho- subjects with a lacunar TIA syndrome had a Neurological Clinic, genetic and prognostic features of lacu- significantly lower prevalence of symptomatic Ospedale Policlinico; nar ischaemic stroke syndromes. These internal carotid artery stenosis than those Milan, Italy findings have implications for manage- with a cortical TIA.9 We have studied an uns- G Landi C Motto ment of TIAs and for studies oftheir nat- elected population with TIA to determine E Cella ural history and treatment. whether lacunar TIA syndromes share the S Lipari same distinct pathogenetic and prognostic on September 30, 2021 by guest. Protected copyright. National Research U, Neurol Neurosurg Psychiatry 1993;56:1265-1270) features of lacunar ischaemic stroke syn- Council, Institute of dromes. Advanced Biomedical Technologies; Milan, Italy The customary distinction between transient M Musicco ischaemic attacks (TIAs) and ischaemic Patients and methods Department of strokes, based conventionally on duration of This prospective study includes a consecutive Neuroradiology, to or 24 series of visited from 1 September Ospedale Niguarda; symptoms up beyond hours, conveys patients Ailan, Italy no information on the pathogenesis or prog- 1983 to 31 August 1990 by one of the study E Boccardi nosis of the attack. Subdivision of ischaemic neurologists at the emergency room of the Division ofNeurology, strokes according to their clinical manifesta- Policlinico Hospital in Milan within 24 hours Ospedale Valduce, tions allows identification of lacunar stroke of their first TIA. This is the only emergency Como, Italy syndromes.' These well defined constellations room in the city's inner district where all M Guidotti with Correspondence to: of neurological signs are generally caused by patients presenting symptoms suggestive Dr Gianluca Landi, Clinica small deep cerebral infarcts, the lacunes, of cerebrovascular disease receive free neuro- Neurologica, Ospedale the and it is Policlinico, Via F Sforza 35, which in turn are attributed to a distinct vas- logical evaluation around clock, 20122 Milano, Italy. culopathy leading to occlusion of small perfo- often resorted to for urgent specialist exami- Received 5 October 1992 rating arteries.2 The hypothesis that lacunar nation bypassing the lengthy waiting lists of and in revised form TIA as an 19 March 1993. ischaemic strokes are caused by small vessel the local health service. We defined Accepted 26 March 1993 disease has been strengthened by several acute focal loss of cerebral or ocular function 1266 Landi, Motto, Cella, Musicco, Lipani, Boccardi, Guidotti J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.12.1265 on 1 December 1993. Downloaded from attributed to ischaemia with symptoms lasting symptoms. They were further subdivided into less than 24 hours. Isolated vertigo, diplopia, superficial and deep; the latter were diag- dysphagia or dysarthria, drop attacks, tran- nosed as lacunar infarcts if their maximum sient global amnesia, as well as focal symp- diameter did not exceed 15 mm on no more toms associated with migrainous headache or than two adjacent 10 mm tissue sections. spreading with a pattern suggestive of Cerebral angiography was carried out in 24 epilepsy or migraine were not accepted as evi- potential candidates for carotid endarterec- dence of TIA. We excluded patients with pre- tomy (14 with LTIAS and 10 with NLTIAS). vious stroke, even if it had occurred in the Four of them were randomised in the interval between TIA and emergency room European carotid surgery trial and two of evaluation. A detailed history of the attack them underwent carotid endarterectomy (one was obtained, and the clinical features of all with LTIAS and one with NLTIAS); no patients were reviewed and discussed with a other patient had carotid endarterectomy. second study neurologist to improve diagnos- There were no angiographic or surgical com- tic interobserver reliability.10 Based on his- plications. tory, patients were subdivided in lacunar TIA Emergency room examination was taken as syndromes (LTIAS) and non-lacunar TIA zero time from which event-free survival was syndromes (NLTIAS). LTIAS were diag- measured. All patients were followed up for nosed if symptoms of isolated unilateral at least 12 months or until death (average, motor or sensory deficit or their combination 51i1 months), and all survivors were re- had involved at least two of three body parts examined by one of us in September 1991. (face, arm, leg), partially or completely. Antiplatelet treatment with aspirin (300 to Occurrence of dysarthria did not exclude a 500 mg/day) or with ticlopidine (500 mg/day) LTIAS if the symptom was attributed to was generally prescribed with the exception of supranuclear weakness of the mouth or five patients with NLTIAS who received oral tongue. All other episodes consistent with anticoagulants. We considered patients as diagnosis of TIA, as established by accepted treated with antithrombotic drugs if they had criteria," were grouped as NLTIAS. One taken this therapy for at least half of their patient who had experienced both types of total follow up time. Control of vascular risk attack before evaluation was included in the factors was pursued in all cases. Occurrence NLTIAS group. of new cerebrovascular events (which were All patients were screened for the presence classified as TIAs or strokes according to of vascular risk factors: hypertension (blood duration of symptoms up to or beyond 24 pressure repeatedly higher than 160/90 mmHg hours) was recorded; a CT scan was per- or regular use of antihypertensive drugs); dia- formed whenever possible in case of stroke. betes (fasting blood sugar higher than Stroke disability was evaluated at approxi- 140 mg/100 ml or regular use of antidiabetic mately 3 months by the modified Rankin drugs); smoking (at least 10 cigarettes daily scale,"3 and strokes were classified as follows: during the previous 6 months), hyperlipi- not disabling (Rankin grades 0-1); partially daemia (fasting plasma cholesterol and/or disabling (grades 2-3); severely disabling triglycerides higher than 240 mg/100 ml and (grades 4-5); or fatal. Occurrence of myocar- 170 mg/i 00 ml, respectively, or regular use of dial infarction was also recorded. Diagnosis lipid-lowering drugs). A continuous wave was accepted if at least two of the following Doppler study of the extracranial vessels was criteria were fulfilled: typical chest pain, con- http://jnnp.bmj.com/ performed as described by Buedingen et al.12 cordant ECG changes, and enzymatic alter- ECG, chest radiograph, and cardiological ations. Causes of death were ascertained by evaluation were carried out in all cases; reviewing clinical records and necropsy depending on specific diagnostic needs, M- reports; if the cause remained uncertain, rela- mode and
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