J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.70.3.344 on 1 March 2001. Downloaded from 344 J Neurol Neurosurg Psychiatry 2001;70:344–349 Atrial fibrillation with small subcortical infarcts D K Jung, G Devuyst, P Maeder, J Bogousslavsky Abstract causes should not be overlooked.3–13 In lacunar Objectives—To evaluate the characteris- infarction, a prevalence of up to 18% of cardi- tics of cardioembolic small (maximum oembolism has been reported,14 and several lesion diameter<1.5 cm) subcortical inf- case reports provide radiological and patho- arcts (SSI) in patients with atrial fibrilla- logical evidence for embolic lacunar tion (AF). infarction.15–18 By contrast, other studies sug- Methods—Twenty seven patients with gest that embologenic cardiac disease is chronic AF and an isolated SSI estab- unlikely to be the cause of lacunar lished by CT/MRI in the anterior circula- infarction.19–23 Using data from the Lausanne tion (SSI-AF group) were evaluated and Stroke Registry for 27 patients with chronic their characteristics compared with those atrial fibrillation (AF), one of the main cardiac of 45 age matched (±1 year) patients with sources of embolism, and an isolated, small SSI, but no arterial or cardiac embolic (maximal lesion diameter<1.5 cm) subcortical source (SSI-control group). Using the cri- infarct, established by CT/MRI, we systemati- terion of the presence or absence of estab- cally evaluated the epidemiology, risk factors lished risk factors (hypertension or for SAD, and clinicoradiological characteristics diabetes mellitus) for small artery disease of SSI lesions probably attributable to a cardi- (SAD), the SSI-AF group we also subdiv- oembolic mechanism. ided into two groups, SSI-AF-SAD+ (n=22) and SSI-AF-SAD− (n=5) and their Methods characteristics compared. The SSI-AF group consisted of patients with Results—Although the lack of any signifi- an isolated small (maximal lesion diam- cant diVerence in the distribution of eter<1.5 cm) subcortical cerebral infarct— hypertension and diabetes mellitus be- proved by CT or MRI—in the territory of the tween the SSI-AF and SSI-control groups internal carotid system and chronic AF. These emphasises SAD as a common cause of patients were part of the Lausanne Stroke infarct in SSI-AF, the presence of AF— Registry and were admitted to our primary together with the higher frequency of care centre between 1991 and 1997. In this neuropsychological disturbances in the study, all patients with first ever stroke were SSI-AF group versus the SSI-control examined by a neurologist and the systematic group (15% v 2%; p=0.066)—favours car- investigations for each patient included brain dioembolism as a potential cause of CT (up to four examinations, the first within infarct in several patients. The character- 7 days of the stroke) or MRI, with or http://jnnp.bmj.com/ istic factors seen more often in the without contrast, Doppler ultrasonography SSI-AF-SAD− group compared with the with spectral frequency analysis and B mode SSI-AF-SAD+ group were secondary echotomography, 12 lead electrocardiography, haemorrhagic transformation, faciobra- blood tests (blood counts, liver, and renal chial pure motor weakness, subinsular function tests, venereal disease research labo- involvement, and better recovery of ratory test, total cholesterol, glucose, and sedi- neurological deficits. mentation rate), and two dimensional echo- Conclusions—The study suggests that ei- cardiography. Atrial fibrillation was diagnosed on September 30, 2021 by guest. Protected copyright. ther SAD or cardioembolism can be the on the basis of either ECG results or 24–48 cause of SSI in patients with AF. Atrial Department of hour three lead ECG monitoring, together Neurology, Centre fibrillation is not always coincidental in with history. Hospitalier patients with SSI and a clinical lacunar Hypertension was defined by history before Universitaire Vaudois, stroke. Certain clinical and radiological stroke or high blood pressure (two or more CH-1011, Lausanne, findings may be useful in diVerentiating blood pressure values>160/95 mm Hg) during Switzerland cardioembolism from SAD in patients D K Jung stay in hospital with the evidence of target G Devuyst with SSI. organ damage (left ventricular hypertrophy, ( 2001; :344–349) J Bogousslavsky J Neurol Neurosurg Psychiatry 70 retinopathy, renal dysfunction) without previ- Keywords: small subcortical infarcts; atrial fibrillation; ously recognised hypertension, diabetes melli- Department of tus (two or more fasting glucose concentra- Radiology cardioembolic infarcts P Maeder tions>6 mmol/l), and hypercholesterolaemia (two or more fasting cholesterol concentra- Correspondence to: Small subcortical infarcts (SSI) are commonly tions>6.5 mmol/l). Concomitant factors, such Dr D K Jung considered to be synonymous with lacunar inf- as regular cigarette smoking, a history of Denise.Allasia@ chuv.hospvd.ch arction caused by in situ small artery disease migraine, or vascular claudication, were re- (SAD). However, although a large proportion corded according to the guidelines in our Received 25 January 2000 of subcortical infarcts are accounted for by registry. Neck Doppler findings were grouped and in revised form 12 2 October 2000 lacunar infarction, other forms may occur. into four categories of normal, stenosis<50%, Accepted 11 October 2000 Cardiac embolism, carotid disease, and other stenosis>50%, and occlusion. Coexisting www.jnnp.com J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.70.3.344 on 1 March 2001. Downloaded from Atrial fibrillation with small subcortical infarcts 345 Table 1 Age, sex, and factors for SAD in the SSI-AF and (±1 year) patients with SSI in the anterior cir- SSI-control groups culation without cardiac embologenic source or significant internal corotid artery stenosis Group SSI-AF SSI-controls (>50%), was selected from patients with first No 27 45 stroke consecutively admitted to our hospital Sex (M/F) 13/14 21/24 Mean age (y) 77 77 over the same period. The clinical characteris- Range 56–87; SD 7 Range 55–87; SD 7 tics and concomitant factors of the SSI-AF HTN 21 (78) 39 (87) group were compared with those in the DM 4 (15) 9 (20) Smoking 5 (19) 10 (22) SSI-control group. To assess the potential role HC 3 (11) 8 (18) of AF itself as a probable cause in SSI, we Raised PCV 4 (15) 6 (13) compared the characteristics of patients with Claudication 3 (11) 3 (7) and without presumed SAD (presence of at Values in parentheses are %. least one of the two established risk factors for HTN=Hypertension; DM=diabetes mellitus; HC=hyper- SAD—that is, hypertension or diabetes). The cholesterolaemia; PCV=packed cell volume; SAD=small artery 2 disease. ÷ test and Fisher’s exact test were used for sta- tistical comparisons. cardiac sources of embolism on two dimen- Results sional echocardiography included mitral or The SSI-AF and SSI-control groups consisted aortic valvular disease, prosthetic valves, aki- of 27 and 45 patients, respectively; their mean netic left ventricular segment with or without ages and sex distributions are shown in table 1. thrombus, and global cardiac hypokinesia. The SSI-AF-SAD− and SSI-AF-SAD+ sub- The radiologically identified SSIs were all groups consisted of five (men/women 4/1) and relevant to the presenting clinical manifesta- 22 (men/women 9/13) patients with mean ages tions, including, but not limited to the four of 72 and 78 years, respectively. lacunar syndromes of pure motor hemiparesis, sensory motor stroke, ataxic hemiparesis, or VASCULAR CONCOMITANTS pure sensory stroke. During a stay in hospital, Hypertension was the dominant factor for all patients underwent several neuropsycho- SAD in the SSI-AF (78%) and SSI-control logical tests from a standard battery per- (87%) groups, which contained four (15%) formed in our institution24 by experienced and nine (20%) patients with diabetes mellitus neurologists or neuropsychologists. Associated respectively (table 1). No statistical diVerence visuospatial dysfunction (hemineglect and in the distribution of other risk factors hemianosognosia) and speech disturbance (cigarette smoking, hypercholesterolaemia, were recorded. Tests of hemineglect usually raised packed cell volume, and limb claudica- included observation of the patient’s response tion) was seen between the SSI-AF and to environmental stimuli, bilateral simultane- SSI-control groups. The internal carotid artery ous sensory and visual stimulation, simple fig- Doppler ultrasound examinations showed that ure copying, drawing spontaneously, line no patient had significant disease (steno- bisection, picture scanning, and article read- sis>50% or occlusion) on both sides except ing. The number, frequency, side, duration, one SSI-AF-SAD+ who had ipsilateral occlu- and time before stroke of transient ischaemic sion. http://jnnp.bmj.com/ attacks, and the pattern of stroke onset were recorded according to the protocol of the COEXISTING CARDIAC SOURCES Lausanne Stroke Registry.25 Functional status The echocardiographic findings are summa- was measured on discharge using a five point rised in table 2. A cardiac pacemaker was scale, with 1 as no disability, 2 as mild disabil- implanted in one patient in the SSI-AF-SAD− ity (able to return to all activities, but with dif- group because of third degree atrioventricular ficulty for certain activities), 3 as moderate block. Echocardiography was not performed disability (able to return with diYculty to only on one SSI-AF-SAD+ patient because of asso- on September 30, 2021 by guest. Protected copyright. certain main activities), 4 as severe disability ciated pulmonary disease. Valvular disorders (not able to return to most activities), and 5 as were found in three (17%) patients, two of death. whom had prosthetic mitral valve or rheumatic To determine whether the clinicoradiologi- mitral sclerosis. Coexisting myocardial abnor- cal features of SSI with AF could be dis- malities were found in 12 (44%) patients. Nor- tinguished from those of SSI due to SAD, an mal or non-significant aortic stenosis findings SSI-control group, consisting of age matched were found in seven (26%) patients.