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Association Between Leukoaraiosis Severity and Functional Outcomes in Patients with Subcortical Infarct

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02 Brain Neurorehabil. 2017 Sep;10(2):e18 https://doi.org/10.12786/bn.2017.10.e18 pISSN 1976-8753·eISSN 2383-9910 Brain & NeuroRehabilitation Clinical Research Association between Leukoaraiosis Severity and Functional Outcomes in Patients with Subcortical Infarct Go Eun Kim, Min Ho Chun, Min Cheol Jang, Kyung Hee Do, Su Jin Choi Received: Jul 6, 2017 Highlights Revised: Sep 21, 2017 Accepted: Sep 26, 2017 • LA is a risk factor for stroke, and in stroke patients, the severity of LA is related to clinical Correspondence to and functional outcomes. Min Ho Chun • In this study, as in previous studies, negative effects of LA on functional outcomes were Department of Rehabilitation Medicine, found in patients with a subcortical infarct. University of Ulsan College of Medicine, Asan • The severity of LA, predicts poor functional outcomes, including in ambulatory function, in Medical Center, 88 Olympic-ro 43-gil, Songpa- the subacute phase after stroke onset. gu, Seoul 05505, Korea. Tel: +82-2-3010-3800 Fax: +82-2-3010-6964 E-mail: [email protected] Copyright © 2017. Korea Society for Neurorehabilitation i 02 Brain Neurorehabil. 2017 Sep;10(2):e18 https://doi.org/10.12786/bn.2017.10.e18 pISSN 1976-8753·eISSN 2383-9910 Brain & NeuroRehabilitation Clinical Research Association between Leukoaraiosis Severity and Functional Outcomes in Patients with Subcortical Infarct Go Eun Kim ,1 Min Ho Chun ,1 Min Cheol Jang ,2 Kyung Hee Do ,3 Su Jin Choi 4 1Department of Rehabilitation Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea 2Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu, Korea 3Department of Physical Medicine and Rehabilitation, Veterans Health Service Medical Center, Seoul, Korea 4Department of Physical Medicine and Rehabilitation, Parkside Rehabilitation Hospital, Busan, Korea Received: Jul 6, 2017 ABSTRACT Revised: Sep 21, 2017 Accepted: Sep 26, 2017 To investigate the influence of leukoaraiosis (LA) on the functional outcomes of subcortical Correspondence to stroke in the subacute phase after onset. We retrospectively analyzed 41 patients with Min Ho Chun subacute subcortical infarct at a single center from 2011 to 2015. We explored the relationship Department of Rehabilitation Medicine, between LA severity at admission/transfer (initial evaluation) and functional outcome at the University of Ulsan College of Medicine, Asan time of discharge (follow-up evaluation), as assessed using the modified Rankin Scale (mRS), Medical Center, 88 Olympic-ro 43-gil, Songpa- Functional Ambulation Category (FAC), and modified Barthel Index (mBI). LA severity was gu, Seoul 05505, Korea. Tel: +82-2-3010-3800 graded as mild, moderate, or severe according to the Fazekas scale. Scores of the mRS, FAC, Fax: +82-2-3010-6964 and mBI were compared in patients grouped based on LA severity: no LA (n = 12), mild LA (n E-mail: [email protected] = 19), and moderate-to-severe LA (n = 10). Significant inter-group differences were observed in all 3 scores at both the initial and follow-up evaluations. After adjustment for age, scores Copyright © 2017. Korea Society for Neurorehabilitation at follow-up evaluation were significantly different between the 2 groups. LA is related to This is an Open Access article distributed functional outcomes of subcortical stroke in the subacute phase after onset. After adjustment under the terms of the Creative Commons for age, severe LA was correlated with poor functional outcomes in the subacute phase. Attribution Non-Commercial License (https:// creativecommons.org/licenses/by-nc/4.0) Keywords: Leukoaraiosis; Stroke; Cerebral Infarction which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. INTRODUCTION ORCID iDs Stroke is a leading cause of major disability. Most stroke patients remain moderately Go Eun Kim https://orcid.org/0000-0003-1481-1317 or severely disabled throughout life [1]. One risk factor for stroke is leukoaraiosis (LA), Min Ho Chun an age-related small-vessel disease. LA is a neuroimaging term referring to magnetic https://orcid.org/0000-0001-8666-7225 resonance imaging (MRI) white matter hyperintensities (WMHs) or periventricular white Min Cheol Jang matter disease [2]. Cerebral LA is frequently observed in patients suffering from acute https://orcid.org/0000-0002-7629-7213 stroke and is associated with increasing age, hypertension, and heart disease. Although Kyung Hee Do https://orcid.org/0000-0003-4235-8759 the pathophysiological mechanisms underlying LA are poorly understood, it is currently Su Jin Choi presumed to be the result of ischemic or hypoperfusion-induced microvascular changes. https://orcid.org/0000-0002-3443-2237 Several studies have shown that LA presence or degree is related to post-stroke function Conflict of Interest The authors have no potential conflicts of and cognition in patients suffering from ischemic stroke. Podgorska et al. [3] has reported interest to disclose. lower survival rates and Mini-Mental State Examination (MMSE) scores in patients with LA than in those without LA at 1 year after stroke onset. In a large cohort study performed in https://e-bnr.org 1/7 02 Leukoaraiosis and Functional Outcomes in Stroke Patients Brain & NeuroRehabilitation 2009 [4], LA was associated with poor functional recovery, worse quality of life, and higher psychological distress in post-stroke periods. In a recent study [5], the relationship between LA severity and rehabilitation outcomes was explored using the Functional Independence Measure, and the resulting scores had a significant relationship with LA degree. In this study, we examined overall functional outcomes, including gait function, in patients suffering from subacute subcortical stroke. MATERIALS AND METHODS Subjects We retrospectively analyzed 152 patients with subcortical infarct (corona radiata with or without basal ganglia infarct) at a single center from September 2011 to May 2015. Patients who had undergone a brain MRI with diffusion-weighted imaging performed within the first 24 hours of symptom onset that confirmed a clinically relevant infarct were eligible. The inclusion criteria were as follows: patients aged > 20 years who were admitted/transferred to the Department of Rehabilitation Medicine during the subacute phase of stroke. Patients with the following characteristics were excluded: those with a previous history of stroke or previous disability (modified Rankin Scale [mRS] ≥ 2) [1] and those who experienced dementia or cognitive impairment before the current ischemic stroke. In total, 41 patients were enrolled. Measures Data on patient baseline characteristics, including age, sex, LA presence and severity, and admission duration, were collected. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS), and additional information suggesting stroke status, such as the location of the lesion (whether it involved corona radiata with or without basal ganglia) and the side of brain where lesion was located, was recorded. Previous medical history of hypertension and/or diabetes mellitus was also documented. Imaging study The Fazekas scale, which is used to grade the WMH lesions and has been shown to have good reliability, was used to categorize LA lesions [6]. Periventricular WMH (PVWMH) and deep WMH (DWMH) were not considered separately [7]. LA lesions were categorized into 3 groups based on LA severity using the modified Fazekas criteria for periventricular hyperintensity and DWMH on T2-weighted or fluid-attenuated inversion recovery images [8]. Mild LA (single lesions of < 10-mm diameter; areas of grouped lesions of < 20-mm diameter); moderate LA (single hyperintense lesions of 10–20-mm diameter; areas of grouped lesions of ≥ 20 mm in any diameter; no more than “connecting bridges” between individual lesions); and severe LA (single lesions or confluent areas of hyperintensity of ≥ 20 mm in any diameter) (Fig. 1) [8]. LA severity of the final cohort of enrolled patients was as follows: no LA, 28.6% (n = 12); mild LA, 45.2% (n = 19); moderate LA, 19.0% (n = 8); and severe LA, 4.8% (n = 2). Subjects were then grouped according to LA presence/severity: no or mild LA and moderate-to-severe LA. Functional outcomes Functional outcomes were assessed at the time of admission or transfer to the Department of Rehabilitation Medicine (initial evaluation) and at discharge (follow-up evaluation). The mean time interval between the initial and follow-up evaluations was 23.1 days. Functional https://e-bnr.org https://doi.org/10.12786/bn.2017.10.e18 2/7 02 Leukoaraiosis and Functional Outcomes in Stroke Patients Brain & NeuroRehabilitation A B C Fig. 1. LA severity according to the modified scale of Fazekas et al. [7]. (A) Mild, (B) moderate, and (C) severe LA. LA, leukoaraiosis. outcomes were measured using the mRS, Functional Ambulation Category (FAC), and modified Barthel Index (mBI). The mRS is a measure of the degree of dependence or disability in performing daily activities [9] and ranges from 0 to 6, with lower scores indicating less disability. The FAC was used to describe dependence on gait assistance [10]. It categorizes patients based on basic motor skills necessary for functional ambulation and is scored on a scale ranging from 0 to 5, with higher scores representing less assistance needed for ambulation. The mBI is used to measure the performance of activities of daily living (ADL) [11] and ranges from 0 to 100, with higher
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