Original Paper Received: April 15, 2014 Accepted: May 30, 2014 Published online: September 2, 2014
Cerebrovasc Dis 2014;38:31–38 DOI: 10.1159/000364939
Infarct Pattern and Clinical Outcome in Acute Ischemic Stroke Following Middle Cerebral Artery Occlusion Keon-Joo Lee a, b Keun-Hwa Jung a, b Jung-Ick Byun a, b Jeong-Min Kim c Jae-Kyu Roh a
a
Department of Neurology, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, b Program in Neuroscience, Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University, and c Department of Neurology, Chung-Ang University Medical Center, College of Medicine, Chung-Ang University, Seoul, South Korea
Key Words Infarct pattern · Middle cerebral artery occlusion · Diffusion-weighted imaging · Ischemic stroke · Stroke etiology
Abstract Background: Cerebral arterial occlusion develops via two distinct mechanisms: thrombosis and embolism. Discrimination between thrombosis and embolism is an important aspect needed for further determining the etiology of stroke in a patient. This study evaluated infarct patterns and outcomes in acute stroke patients with relevant artery occlusions, focusing on features specific to each occlusion mechanism. Methods: Acute ischemic stroke patients who were consecutively registered in a tertiary hospital between 2002 and 2010 with infarctions in the middle cerebral artery territory and a corresponding M1 occlusion confirmed by magnetic resonance angiography, computed tomography angiography, or conventional angiography were enrolled. Patients with a high-risk cardioembolic source, clear recanalization, concurrent infarct in an arterial territory other than the occlusion site, or no prior occlusion in a previous imaging within 1 month were assigned to the embolic occlusion
© 2014 S. Karger AG, Basel 1015–9770/14/0381–0031$39.50/0 E-Mail [email protected] www.karger.com/ced
group, and the remaining patients were assigned to the thrombotic occlusion group. The infarct pattern was categorized into seven groups: scattered, territorial, lenticulostriatal, scattered-territorial, scattered-lenticulostriatal, territorial-lenticulostriatal, and scattered-territorial-lenticulostriatal. Data of stroke recurrence and mortality were collected through electronic medical record and the National Vital Statistics System. Results: Of 114 patients, 54 (47.4%) were classified as having an embolic occlusion. When infarct patterns were compared between the groups, any-scattered infarct pattern was more common in the thrombotic occlusion group (71.2% vs. 40.7%, p = 0.002), and any-territorial infarct pattern was more prevalent in the embolic occlusion group (55.6% vs. 28.8%, p = 0.005). In addition, scattered-withoutterritorial pattern was higher in the thrombotic occlusion group (OR: 0.25; CI: 0.11–0.57; p = 0.001). Any-territorial infarct pattern was also related to initial stroke severity (NIHSS on admission, OR: 400.98; CI: 2.94–54,741.32; p = 0.017) and poor functional outcome (modified Rankin Scale score ≥4) at discharge (OR: 14.40; CI: 1.37–152.00; p = 0.027) independent of other parameters. However, no association was found between stroke recurrence, mortality and occlusion mechanism. Conclusion: This study shows that specific infarct patterns are related to cerebral arterial occlusion mech-
Keun-Hwa Jung, MD, PhD Department of Neurology Seoul National University Hospital 101, Daehangno, Jongno-gu, Seoul 110–744 (South Korea) E-Mail jungkh @ gmail.com
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© 2014 S. Karger AG, Basel
Introduction
When considering the various pathophysiologies of arterial occlusion, the mechanisms of intracranial artery occlusion can be classified into two major categories: thrombosis that occurs in atherosclerosis of the large arteries and embolism originating from the cardiac chamber [1–3]. The time course of occlusion, arterial autoregulatory capacity, and tissue vulnerability may differ substantially between these two categories. In this regard, thrombosis usually has a slower onset, allowing enough time to facilitate collateral circulation; thus, thrombosis is a less severe form of occlusion when compared with embolism [3]. Discrimination between thrombosis and embolism is an important, basic step for further determining the etiology of stroke in a patient. Current evidence suggests that the etiology of ischemic stroke affects therapeutic strategies, clinical outcomes, and prognosis [2, 4–9]. Ischemic stroke with a cardioembolism etiology is associated with a fatal outcome, whereas small-vessel occlusion-related stroke has the lowest mortality [7–9]. On the other hand, large-artery atherosclerosis-related stroke is notable because of its high rate of early recurrence [6]. However, the identification of stroke etiology is still challenging in a considerable proportion of patients; these patients are assigned into an undetermined etiology group, where patients with two or more etiologies, negative results, or incomplete studies are placed, leading to indecisive therapeutic strategies [10, 11]. A recent study reports that ischemic stroke patients with undetermined etiologies are associated with a high long-term mortality [10], emphasizing the importance of determining etiology in these patients. A new tool or method of classification is needed to differentiate between thrombosis and embolism in cerebral arterial occlusion-related stroke. In this study, we classified patients with middle cerebral artery (MCA) occlusion into two groups based on the occlusion mechanism. We hypothesized that infarct patterns and clinical outcomes would differ between these two mechanisms, and these might be a useful clue for differentiating stroke etiologies. 32
Cerebrovasc Dis 2014;38:31–38 DOI: 10.1159/000364939
Methods Data Collection We performed a retrospective analysis of 2,535 acute ischemic stroke patients who had been admitted to the Seoul National University Hospital Stroke Center between January 2002 and December 2010. Acute ischemic stroke patients were defined as individuals who had visited our hospital within 7 days after the index stroke event. Among them, we selected cases with infarct in the MCA territory and occlusion of the MCA stem (M1) as confirmed by magnetic resonance angiography, computed tomography angiography, or conventional angiography. Occlusion was defined by the absence of any anterograde flow distal to the occlusion site clearly shown on the imaging modalities mentioned above. A total of 114 patients were recruited in compliance with the regulations of the local ethics committee. Baseline demographic and clinical information were gathered during hospitalization, which included age, sex, body weight, vascular risk factors (hypertension, diabetes mellitus, dyslipidemia, smoking history, heart disease, and previous stroke history), and laboratory data. National Institutes of Health Stroke Scale (NIHSS) scores at admission, and modified Rankin Scale scores (mRS) at both admission and discharge were also acquired. We also checked whether the patient underwent intravenous or intra-arterial thrombolysis, and whether recanalization was achieved after reperfusion upon follow-up MR, CT, or conventional angiography. Medical records and MR images for all patients up to July 2013 were reviewed in order to gather data on stroke recurrence and cerebral artery status. The patients were followed up at our outpatient clinic on a 2- or 3-monthly basis. At discharge, the patients were educated to visit the emergency room immediately if a stroke had to recur. Data of stroke recurrence was gathered by retrospective review of medical record and follow-up image studies; only the events that were documented to have evidence of ischemic stroke in the image studies (CT or MR) were included. Stroke recurrence with respect to whether the recurrence arose in the relevant artery territory of the occlusion site or a different arterial territory was determined, and the time of recurrence was divided into a 3-week period, categorizing the events into early and late recurrence [12]. One-year mortality after index stroke event data were collected based on death certificates from the Korean National Statistical Office. Classification of Occlusion Mechanism Patients with a high-risk source of cardioembolism [2, 13], clear spontaneous recanalization in the follow-up angiography, concurrent acute infarction in other arterial territory not relevant with the occlusion site, or no occlusion or stenosis in previous angiography within 1 month were assigned to the embolic occlusion group. The patients who did not meet any of these criteria were assigned to the thrombotic occlusion group. Patients with two or more etiologies and concurrent systemic malignancy [14] were excluded for further analysis in order to retain the homogeneity of occlusion mechanism in each group. Infarct Pattern Analysis MR diffusion-weighted imaging (DWI) taken at the initial visit was reviewed. Patients who underwent an initial DWI session after intra-arterial interventional treatment were excluded, due to the risk of iatrogenic embolization during the treatment procedure, which could produce infarct patterns in DWI. Infarct pat-
Lee/Jung/Byun/Kim/Roh
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/15/2015 2:02:57 PM
anisms and are correlated with functional outcome. Otherwise, the results of our study indicates that infarct patterns on DWI might be a clue for determining ischemic stroke etiology on patients with major cerebral artery occlusion.
a
terns were categorized based on three basic patterns: scattered, territorial, and lenticulostriatal (fig. 1). A territorial pattern was defined as wedge-shaped infarctions involving the cortex and subcortex with clearly noticeable margins, while a lenticulostriatal pattern represented an infarction restricted only in MCA perforator artery territory. A scattered pattern was defined as infarct patterns that are not describable by the previous two patterns regardless of infarction size or topographical location. Infarct patterns were then further categorized into seven groups by the combination of these basic patterns, which included scattered, territorial, lenticulostriatal, scattered-territorial, scattered-lenticulostriatal, territorial-lenticulostriatal, and scattered-territorial-lenticulostriatal. We defined any-scattered pattern as the infarct pattern showing scattered portions regardless of the existence of other pattern types, which was the sum of the patients with scattered, scatteredterritorial, scattered-lenticulostriatal, and scattered-territoriallenticulostriatal patterns. Any-territorial and any-lenticulostriatal patterns were defined with the identical concept. Finally, the scattered-without-territorial pattern was defined as the infarct patterns with a scattered portion but without any territorial portion, which are scattered and scattered-lenticulostriatal patterns. Topography of the infarct site was also checked by dividing the middle cerebral artery territory into the cortex, subcortex, and deep structure (internal capsule and basal ganglia). Statistical Analysis SPSS for Windows (version 18.0; SPSS, Chicago, Ill., USA) was used for statistical analysis. In order to compare clinical features and infarct patterns between the embolic occlusion and thrombotic occlusion groups, Student’s t-tests were conducted for interval variables, and chi-square tests were used for dichotomous or nominal variables. NIHSS and mRS scores were dichotomized as follows: an NIHSS score of 10 or more, and less than 10 [15, 16], and mRS score 4 or more and less than 4 considering dependency of gait, respectively. Variables showing p < 0.1 were adjusted in the multiple logistic regression model to prove independency of each association. Statistical significance was considered at p < 0.05.
b
c
ing embolic occlusion, while the other 52 (45.6%) patients were classified as having thrombotic occlusion. Four patients who had a concomitantly cardioembolic source and proximal carotid disease, and another four with systemic malignancy were excluded from further analysis. In the embolic occlusion group, 46 patients revealed a high-risk source of cardioembolism (online suppl. table 6; for all online suppl. material, see www.karger. com/doi/10.1159/000364939), four had an additional cerebral infarct in the area different from the arterial territory relevant to the occlusion site, three showed clear spontaneous recanalization upon follow-up image, and one had a patent middle cerebral artery in the previous angiography (taken 10 days prior). Table 1 presents patient characteristics by group. Smoking (48.1% vs. 20.4%, p = 0.003), total serum cholesterol level (181.9 ± 42.9 mg·dl–1 vs. 163.2 ± 35.0 mg·dl–1, p = 0.016), and serum triglyceride level (133.6 ± 59.8 mg·dl–1 vs. 106.2 ± 38.9 mg·dl–1, p = 0.008) were higher in the thrombotic occlusion group, while heart disease (79.6% vs. 7.8%, p < 0.001) was more prevalent in the embolic occlusion group. The proportion of patients who underwent intravenous or intra-arterial thrombolysis (35.2% vs. 17.3%, p = 0.037) was higher in the embolic occlusion group when compared with the thrombotic occlusion group. The proportion of patients with NIHSS scores ≥10 on admission (72.2% vs. 28.8%, p < 0.001), which indicates that stroke severity was also significantly greater in the embolic occlusion group.
Patient Characteristics In total, 114 patients with MCA stroke and M1 occlusion were selected by medical record and image review. Among them, 54 (47.4%) patients were classified as hav-
Infarct Pattern on DWI Table 2 summarizes the difference in infarct patterns visible on brain DWI between the embolic occlusion group and thrombotic occlusion group. More territorial patterns (odds ratio [OR]: 4.62; 95% confidence interval [CI]: 1.42–15.0; p = 0.010) were seen in the embolic occlusion group, while the scattered pattern was more prevalent in the thrombotic occlusion group when compared with the embolic occlusion group (OR: 0.20;
Infarct Pattern and Outcome in MCA Occlusion
Cerebrovasc Dis 2014;38:31–38 DOI: 10.1159/000364939
Results
33
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Fig. 1. Three basic infarct patterns. a Scattered. b Territorial. c Lenticulostriatal.
Table 1. Characteristics of the study population
Embolic occlusion (n = 54) Male sex, n (%) Mean age (years ± SD) Smoking, n (%) Body weight (kg ± SD) BMI (kg/m2 ± SD) Concomitant disease, n (%) Hypertension Diabetes Hyperlipidemia Heart disease Previous stroke history Laboratory data (mg·dl–1 ± SD) FBS HbA1c (% ± SD) Total cholesterol LDL cholesterol HDL cholesterol Triglyceride Interventional treatment, n (%) IV or IA thrombolysis Recanalization Time to visit (h ± SD) NIHSS ≥10, n (%) Discharge mRS ≥4, n (%)
Thrombotic occlusion (n = 52)
p value
34 (63.0) 67.43±14.35 11 (20.4) 62.62±12.48 20.50±8.01
35 (67.3) 63.64±13.42 25 (48.1) 67.85±17.87 29.51±48.98
0.639 0.163 0.003** 0.085* 0.196
32 (59.3) 20 (37.0) 8 (14.8) 43 (79.6) 13 (24.1)
35 (68.6) 13 (25.5) 16 (30.8) 4 (7.8) 10 (19.6)
0.318 0.203 0.050*
Cerebrovasc Dis 2014;38:31–38 DOI: 10.1159/000364939
Infarct Pattern and Clinical Outcome in Acute Ischemic Stroke Following Middle Cerebral Artery Occlusion Keon-Joo Lee a, b Keun-Hwa Jung a, b Jung-Ick Byun a, b Jeong-Min Kim c Jae-Kyu Roh a
a
Department of Neurology, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, b Program in Neuroscience, Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University, and c Department of Neurology, Chung-Ang University Medical Center, College of Medicine, Chung-Ang University, Seoul, South Korea
Key Words Infarct pattern · Middle cerebral artery occlusion · Diffusion-weighted imaging · Ischemic stroke · Stroke etiology
Abstract Background: Cerebral arterial occlusion develops via two distinct mechanisms: thrombosis and embolism. Discrimination between thrombosis and embolism is an important aspect needed for further determining the etiology of stroke in a patient. This study evaluated infarct patterns and outcomes in acute stroke patients with relevant artery occlusions, focusing on features specific to each occlusion mechanism. Methods: Acute ischemic stroke patients who were consecutively registered in a tertiary hospital between 2002 and 2010 with infarctions in the middle cerebral artery territory and a corresponding M1 occlusion confirmed by magnetic resonance angiography, computed tomography angiography, or conventional angiography were enrolled. Patients with a high-risk cardioembolic source, clear recanalization, concurrent infarct in an arterial territory other than the occlusion site, or no prior occlusion in a previous imaging within 1 month were assigned to the embolic occlusion
© 2014 S. Karger AG, Basel 1015–9770/14/0381–0031$39.50/0 E-Mail [email protected] www.karger.com/ced
group, and the remaining patients were assigned to the thrombotic occlusion group. The infarct pattern was categorized into seven groups: scattered, territorial, lenticulostriatal, scattered-territorial, scattered-lenticulostriatal, territorial-lenticulostriatal, and scattered-territorial-lenticulostriatal. Data of stroke recurrence and mortality were collected through electronic medical record and the National Vital Statistics System. Results: Of 114 patients, 54 (47.4%) were classified as having an embolic occlusion. When infarct patterns were compared between the groups, any-scattered infarct pattern was more common in the thrombotic occlusion group (71.2% vs. 40.7%, p = 0.002), and any-territorial infarct pattern was more prevalent in the embolic occlusion group (55.6% vs. 28.8%, p = 0.005). In addition, scattered-withoutterritorial pattern was higher in the thrombotic occlusion group (OR: 0.25; CI: 0.11–0.57; p = 0.001). Any-territorial infarct pattern was also related to initial stroke severity (NIHSS on admission, OR: 400.98; CI: 2.94–54,741.32; p = 0.017) and poor functional outcome (modified Rankin Scale score ≥4) at discharge (OR: 14.40; CI: 1.37–152.00; p = 0.027) independent of other parameters. However, no association was found between stroke recurrence, mortality and occlusion mechanism. Conclusion: This study shows that specific infarct patterns are related to cerebral arterial occlusion mech-
Keun-Hwa Jung, MD, PhD Department of Neurology Seoul National University Hospital 101, Daehangno, Jongno-gu, Seoul 110–744 (South Korea) E-Mail jungkh @ gmail.com
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/15/2015 2:02:57 PM
© 2014 S. Karger AG, Basel
Introduction
When considering the various pathophysiologies of arterial occlusion, the mechanisms of intracranial artery occlusion can be classified into two major categories: thrombosis that occurs in atherosclerosis of the large arteries and embolism originating from the cardiac chamber [1–3]. The time course of occlusion, arterial autoregulatory capacity, and tissue vulnerability may differ substantially between these two categories. In this regard, thrombosis usually has a slower onset, allowing enough time to facilitate collateral circulation; thus, thrombosis is a less severe form of occlusion when compared with embolism [3]. Discrimination between thrombosis and embolism is an important, basic step for further determining the etiology of stroke in a patient. Current evidence suggests that the etiology of ischemic stroke affects therapeutic strategies, clinical outcomes, and prognosis [2, 4–9]. Ischemic stroke with a cardioembolism etiology is associated with a fatal outcome, whereas small-vessel occlusion-related stroke has the lowest mortality [7–9]. On the other hand, large-artery atherosclerosis-related stroke is notable because of its high rate of early recurrence [6]. However, the identification of stroke etiology is still challenging in a considerable proportion of patients; these patients are assigned into an undetermined etiology group, where patients with two or more etiologies, negative results, or incomplete studies are placed, leading to indecisive therapeutic strategies [10, 11]. A recent study reports that ischemic stroke patients with undetermined etiologies are associated with a high long-term mortality [10], emphasizing the importance of determining etiology in these patients. A new tool or method of classification is needed to differentiate between thrombosis and embolism in cerebral arterial occlusion-related stroke. In this study, we classified patients with middle cerebral artery (MCA) occlusion into two groups based on the occlusion mechanism. We hypothesized that infarct patterns and clinical outcomes would differ between these two mechanisms, and these might be a useful clue for differentiating stroke etiologies. 32
Cerebrovasc Dis 2014;38:31–38 DOI: 10.1159/000364939
Methods Data Collection We performed a retrospective analysis of 2,535 acute ischemic stroke patients who had been admitted to the Seoul National University Hospital Stroke Center between January 2002 and December 2010. Acute ischemic stroke patients were defined as individuals who had visited our hospital within 7 days after the index stroke event. Among them, we selected cases with infarct in the MCA territory and occlusion of the MCA stem (M1) as confirmed by magnetic resonance angiography, computed tomography angiography, or conventional angiography. Occlusion was defined by the absence of any anterograde flow distal to the occlusion site clearly shown on the imaging modalities mentioned above. A total of 114 patients were recruited in compliance with the regulations of the local ethics committee. Baseline demographic and clinical information were gathered during hospitalization, which included age, sex, body weight, vascular risk factors (hypertension, diabetes mellitus, dyslipidemia, smoking history, heart disease, and previous stroke history), and laboratory data. National Institutes of Health Stroke Scale (NIHSS) scores at admission, and modified Rankin Scale scores (mRS) at both admission and discharge were also acquired. We also checked whether the patient underwent intravenous or intra-arterial thrombolysis, and whether recanalization was achieved after reperfusion upon follow-up MR, CT, or conventional angiography. Medical records and MR images for all patients up to July 2013 were reviewed in order to gather data on stroke recurrence and cerebral artery status. The patients were followed up at our outpatient clinic on a 2- or 3-monthly basis. At discharge, the patients were educated to visit the emergency room immediately if a stroke had to recur. Data of stroke recurrence was gathered by retrospective review of medical record and follow-up image studies; only the events that were documented to have evidence of ischemic stroke in the image studies (CT or MR) were included. Stroke recurrence with respect to whether the recurrence arose in the relevant artery territory of the occlusion site or a different arterial territory was determined, and the time of recurrence was divided into a 3-week period, categorizing the events into early and late recurrence [12]. One-year mortality after index stroke event data were collected based on death certificates from the Korean National Statistical Office. Classification of Occlusion Mechanism Patients with a high-risk source of cardioembolism [2, 13], clear spontaneous recanalization in the follow-up angiography, concurrent acute infarction in other arterial territory not relevant with the occlusion site, or no occlusion or stenosis in previous angiography within 1 month were assigned to the embolic occlusion group. The patients who did not meet any of these criteria were assigned to the thrombotic occlusion group. Patients with two or more etiologies and concurrent systemic malignancy [14] were excluded for further analysis in order to retain the homogeneity of occlusion mechanism in each group. Infarct Pattern Analysis MR diffusion-weighted imaging (DWI) taken at the initial visit was reviewed. Patients who underwent an initial DWI session after intra-arterial interventional treatment were excluded, due to the risk of iatrogenic embolization during the treatment procedure, which could produce infarct patterns in DWI. Infarct pat-
Lee/Jung/Byun/Kim/Roh
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/15/2015 2:02:57 PM
anisms and are correlated with functional outcome. Otherwise, the results of our study indicates that infarct patterns on DWI might be a clue for determining ischemic stroke etiology on patients with major cerebral artery occlusion.
a
terns were categorized based on three basic patterns: scattered, territorial, and lenticulostriatal (fig. 1). A territorial pattern was defined as wedge-shaped infarctions involving the cortex and subcortex with clearly noticeable margins, while a lenticulostriatal pattern represented an infarction restricted only in MCA perforator artery territory. A scattered pattern was defined as infarct patterns that are not describable by the previous two patterns regardless of infarction size or topographical location. Infarct patterns were then further categorized into seven groups by the combination of these basic patterns, which included scattered, territorial, lenticulostriatal, scattered-territorial, scattered-lenticulostriatal, territorial-lenticulostriatal, and scattered-territorial-lenticulostriatal. We defined any-scattered pattern as the infarct pattern showing scattered portions regardless of the existence of other pattern types, which was the sum of the patients with scattered, scatteredterritorial, scattered-lenticulostriatal, and scattered-territoriallenticulostriatal patterns. Any-territorial and any-lenticulostriatal patterns were defined with the identical concept. Finally, the scattered-without-territorial pattern was defined as the infarct patterns with a scattered portion but without any territorial portion, which are scattered and scattered-lenticulostriatal patterns. Topography of the infarct site was also checked by dividing the middle cerebral artery territory into the cortex, subcortex, and deep structure (internal capsule and basal ganglia). Statistical Analysis SPSS for Windows (version 18.0; SPSS, Chicago, Ill., USA) was used for statistical analysis. In order to compare clinical features and infarct patterns between the embolic occlusion and thrombotic occlusion groups, Student’s t-tests were conducted for interval variables, and chi-square tests were used for dichotomous or nominal variables. NIHSS and mRS scores were dichotomized as follows: an NIHSS score of 10 or more, and less than 10 [15, 16], and mRS score 4 or more and less than 4 considering dependency of gait, respectively. Variables showing p < 0.1 were adjusted in the multiple logistic regression model to prove independency of each association. Statistical significance was considered at p < 0.05.
b
c
ing embolic occlusion, while the other 52 (45.6%) patients were classified as having thrombotic occlusion. Four patients who had a concomitantly cardioembolic source and proximal carotid disease, and another four with systemic malignancy were excluded from further analysis. In the embolic occlusion group, 46 patients revealed a high-risk source of cardioembolism (online suppl. table 6; for all online suppl. material, see www.karger. com/doi/10.1159/000364939), four had an additional cerebral infarct in the area different from the arterial territory relevant to the occlusion site, three showed clear spontaneous recanalization upon follow-up image, and one had a patent middle cerebral artery in the previous angiography (taken 10 days prior). Table 1 presents patient characteristics by group. Smoking (48.1% vs. 20.4%, p = 0.003), total serum cholesterol level (181.9 ± 42.9 mg·dl–1 vs. 163.2 ± 35.0 mg·dl–1, p = 0.016), and serum triglyceride level (133.6 ± 59.8 mg·dl–1 vs. 106.2 ± 38.9 mg·dl–1, p = 0.008) were higher in the thrombotic occlusion group, while heart disease (79.6% vs. 7.8%, p < 0.001) was more prevalent in the embolic occlusion group. The proportion of patients who underwent intravenous or intra-arterial thrombolysis (35.2% vs. 17.3%, p = 0.037) was higher in the embolic occlusion group when compared with the thrombotic occlusion group. The proportion of patients with NIHSS scores ≥10 on admission (72.2% vs. 28.8%, p < 0.001), which indicates that stroke severity was also significantly greater in the embolic occlusion group.
Patient Characteristics In total, 114 patients with MCA stroke and M1 occlusion were selected by medical record and image review. Among them, 54 (47.4%) patients were classified as hav-
Infarct Pattern on DWI Table 2 summarizes the difference in infarct patterns visible on brain DWI between the embolic occlusion group and thrombotic occlusion group. More territorial patterns (odds ratio [OR]: 4.62; 95% confidence interval [CI]: 1.42–15.0; p = 0.010) were seen in the embolic occlusion group, while the scattered pattern was more prevalent in the thrombotic occlusion group when compared with the embolic occlusion group (OR: 0.20;
Infarct Pattern and Outcome in MCA Occlusion
Cerebrovasc Dis 2014;38:31–38 DOI: 10.1159/000364939
Results
33
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/15/2015 2:02:57 PM
Fig. 1. Three basic infarct patterns. a Scattered. b Territorial. c Lenticulostriatal.
Table 1. Characteristics of the study population
Embolic occlusion (n = 54) Male sex, n (%) Mean age (years ± SD) Smoking, n (%) Body weight (kg ± SD) BMI (kg/m2 ± SD) Concomitant disease, n (%) Hypertension Diabetes Hyperlipidemia Heart disease Previous stroke history Laboratory data (mg·dl–1 ± SD) FBS HbA1c (% ± SD) Total cholesterol LDL cholesterol HDL cholesterol Triglyceride Interventional treatment, n (%) IV or IA thrombolysis Recanalization Time to visit (h ± SD) NIHSS ≥10, n (%) Discharge mRS ≥4, n (%)
Thrombotic occlusion (n = 52)
p value
34 (63.0) 67.43±14.35 11 (20.4) 62.62±12.48 20.50±8.01
35 (67.3) 63.64±13.42 25 (48.1) 67.85±17.87 29.51±48.98
0.639 0.163 0.003** 0.085* 0.196
32 (59.3) 20 (37.0) 8 (14.8) 43 (79.6) 13 (24.1)
35 (68.6) 13 (25.5) 16 (30.8) 4 (7.8) 10 (19.6)
0.318 0.203 0.050*
