Original Article
Diagnostic Accuracy and Risk Factors of the Different Lacunar Syndromes

https://doi.org/10.1016/j.jstrokecerebrovasdis.2014.03.014Get rights and content

Background

The lacunar syndrome is characterized by pure motor, pure sensory, or sensorimotor hemisymptoms without cortical deficits. It may be less predictable for a lacunar infarct (LI) than previously believed. The aims of the present study were to evaluate the diagnostic accuracy of the different lacunar syndromes and investigate factors associated with acute LI on diffusion-weighted imaging (DWI).

Methods

Consecutive patients presenting with an acute lacunar syndrome who were admitted to the stroke unit were enrolled. The patients were examined clinically and underwent magnetic resonance imaging. The sensitivity and specificity of the different lacunar syndromes were assessed using DWI as reference test, and we estimated positive and negative predictive values. Patients were divided into a LI group and a group without LI. Between-group differences were analyzed by χ2 test, t test, and Mann–Whitney U test, as appropriate. Logistic regression was performed to analyze predictors of LI. Candidate variables were pure motor syndrome, age, gender, hypertension, precerebral or intracerebral stenosis, atrial fibrillation, diabetes, coronary heart disease, and smoking.

Results

Eighty-six patients with lacunar syndrome underwent DWI. The positive predictive value of the lacunar syndrome was 65.1% and 75% for the pure motor syndrome. Of the candidate variables, only pure motor syndrome and male gender had significant associations with LI on imaging.

Conclusions

The clinical diagnosis of patients with lacunar syndromes is inaccurate, especially among patients with sensorimotor syndrome. DWI is mandatory for obtaining an accurate diagnosis of the infarct.

Section snippets

Materials and Methods

We recruited 119 consecutive patients presenting with an acute lacunar syndrome who were admitted to the stroke unit of Akershus University Hospital from February 2011 to January 2013. The patients underwent standard examination at our stroke unit including blood samples, electrocardiogram (ECG) records, cerebral computed tomography (CT) at admittance, and color duplex of precerebral and intracranial arteries. Presence of symptomatic carotid or middle cerebral artery stenosis greater than or

Results

A total of 119 patients presenting with a lacunar syndrome were recruited. Because of capacity problems in MRI scanning, 33 patients underwent only CT scanning and were excluded, see Figure 1. The baseline characteristics and risk factors of these patients did not differ from that of the included patients, except for a significantly higher prevalence of diabetes and higher proportion of women. Eighty-six patients underwent both CT and MRI scanning. Of these, 51 patients had pure motor syndrome,

Discussion

In the present study, a lacunar syndrome has an overall low PPV (65.1%) for predicting an acute LI on DWI. This is in accordance with previous DW-MRI studies.8, 9 The PPV was particularly low among patients with a sensorimotor syndrome. Previous reports,12, 26, 27 which showed a high diagnostic accuracy of the lacunar syndrome, did not use DWI, but only CT or conventional MRI. In these studies, patients with no verified infarct on CT/MRI were either excluded or classified as lacunar infarction,

References (33)

  • J. Bamford et al.

    Classification and natural history of clinically identifiable subtypes of cerebral infarction

    Lancet

    (1991)
  • C.M. Fisher

    Lacunar strokes and infarcts: a review

    Neurology

    (1982)
  • V. Caso et al.

    Clinical significance of detection of multiple acute brain infarcts on diffusion weighted magnetic resonance imaging

    J Neurol Neurosurg Psychiatr

    (2005)
  • C.M. Fisher

    Lacunes: small, deep cerebral infarcts

    Neurology

    (1965)
  • A. Hiraga et al.

    Diffusion weighted imaging in ataxic hemiparesis

    J Neurol Neurosurg Psychiatr

    (2007)
  • W.J. Schonewille et al.

    Diffusion-weighted MRI in acute lacunar syndromes. A clinical-radiological correlation study

    Stroke

    (1999)
  • R.I. Lindley et al.

    Interobserver reliability of a clinical classification of acute cerebral infarction

    Stroke

    (1993)
  • N. Asdaghi et al.

    Oxfordshire community stroke project classification poorly differentiates small cortical and subcortical infarcts

    Stroke

    (2011)
  • L.J. Lee et al.

    Impact on stroke subtype diagnosis of early diffusion-weighted magnetic resonance imaging and magnetic resonance angiography

    Stroke

    (2000)
  • F. Moreau et al.

    Cavitation after acute symptomatic lacunar stroke depends on time, location, and MRI sequence

    Stroke

    (2012)
  • G.M. Potter et al.

    Counting cavitating lacunes underestimates the burden of lacunar infarction

    Stroke

    (2010)
  • R. Gan et al.

    Testing the validity of the lacunar hypothesis: the Northern Manhattan Stroke Study experience

    Neurology

    (1997)
  • R.P. Gerraty et al.

    Examining the lacunar hypothesis with diffusion and perfusion magnetic resonance imaging

    Stroke

    (2002)
  • A. Lindgren et al.

    Clinical lacunar syndromes as predictors of lacunar infarcts. A comparison of acute clinical lacunar syndromes and findings on diffusion-weighted MRI

    Acta Neurol Scand

    (2000)
  • H. Naess et al.

    Clinical presentation and diffusion weighted MRI of acute cerebral infarction. The Bergen Stroke Study

    BMC Neurol

    (2009)
  • T. Seifert et al.

    Acute small subcortical infarctions on diffusion weighted MRI: Clinical presentation and aetiology

    J Neurol Neurosurg Psychiatr

    (2005)

    • Cited by (0)

    Supported by the South-Eastern Norway Regional Health Authority Grant number 2010091.

    View full text
    Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.