(Stroke. 1996;27:842-846.)
© 1996 American Heart Association, Inc.
Articles |
Functional Outcome in Patients With Lacunar Infarction
From the Department of Neurology, Örebro Medical Center Hospital (M.S., G.B.O.), and the Department of International Health and Social Medicine, Karolinska Institute, Stockholm (B.S.), Sweden.
Correspondence to Margareta Samuelsson, MD, Department of Neurology, Örebro Medical Center Hospital, S-701 85 Örebro, Sweden.
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Abstract |
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 Top Abstract IntroductionSubjects and MethodsResultsDiscussionReferences |
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Background and Purpose Little is known about the prognosis and the predictive factors for functional outcome after lacunar infarction. Our aim was to analyze this issue in more detail and with a longer follow-up than in previous reports.
Methods Functional outcome was assessed in 81 consecutive patients with a first-ever stroke and clinical and MRI findings compatible with lacunar infarction. We measured impairment (motor, sensory, and cognitive function), disability (Katz's Index of Activities of Daily Living [ADL] and four instrumental activities), and handicap (Oxford Handicap Scale). The patients were followed up for 3 years.
Results During follow-up, 6% of the patients died and 21% had recurrent strokes, mostly new lacunar infarcts. A fast initial recovery was found in most patients. At 1 year, 12% were dependent in personal ADL, which after 3 years had increased to 24%, mostly as a result of the effects of recurrent strokes. In a logistic multivariate regression model, moderate or severe hemiparesis 1 month after stroke onset was the strongest predictor of physical dependence or death at 3 years (P<.001), followed by white matter hyperintensities on MRI (P<.01). Age, vascular risk factors, and recurrent stroke were not statistically significant independent predictors of functional outcome.
Conclusions Functional outcome regarding physical independence was favorable in most patients. Motor impairment and white matter disease were the strongest predictors of a poor functional outcome. Recurrent stroke increased disability and handicap but was not a statistically significant independent risk factor. Measurements of personal ADL alone were insensitive in detecting the consequences of stroke in many patients with preserved self-care ability, who still experienced disability and handicap.
Key Words: activities of daily living • lacunar infarction • stroke outcome
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Lacunar infarcts are small deep infarcts caused by occlusion of the penetrating branches of the major cerebral arteries. Several recent studies have analyzed associated risk factors and the prognosis for recurrent stroke and survival,1 2 3 4 5 6 7 but functional outcome has received less attention. A modified Rankin Scale was used in the Oxfordshire Community Stroke Project2 and in two hospital-based studies,5 7 in which outcome was categorized as functional independence or dependence. The Barthel Index was used in a hospital-based study by Clavier et al.6 A favorable functional outcome was reported: 1 year after stroke onset 66% to 79% of the patients were functionally independent (by the modified Rankin Scale), and 74% were independent in P-ADL (Barthel score, 100). However, only single scales were used, and the measurements were confined to the first year after stroke onset.
The aim of the present study was to analyze functional outcome after lacunar infarction in more detail, with the use of scales for impairment, disability, and handicap and a more extended follow-up, and to investigate possible prognostic factors.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Between August 1989 and February 1992, we prospectively examined 100 consecutive patients with a first-ever stroke presenting with a lacunar syndrome. Of these patients, 81 had MRI findings compatible with lacunar infarction (including 12 cases without a relevant lesion identified) and form the basis of the present report. To analyze predictive factors for functional outcome, we also recorded the presence of clinically "silent" infarcts and diffuse WMH on T2-weighted MRI, according to the classification of van Swieten et al.8 Details of the investigation protocol and baseline patient characteristics have previously been reported.7 9
Functional outcome was assessed by a neurologist (M.S.) and an occupational therapist (G.B.O.) and included measurements of impairment, disability, and handicap. The assessments were performed within the first week after stroke onset; after 1, 6, and 12 months; and annually thereafter. The initial assessments were based on examinations, observations, and interviews with the patient in the hospital ward. During follow-up, most assessments were performed with the patient at the outpatient clinic and were in a few cases based on telephone interviews. In patients with a recurrent stroke during follow-up, functional outcome was assessed approximately 3 months after onset of the new stroke. The patients were followed up for 3 years.
Impairment
Impairment was assessed by clinical examination. Motor
impairment was graded as mild, moderate, or severe hemiparesis. Mild
hemiparesis was defined as motor dysfunction that permitted a full
range of movement but with reduced strength, and the patient was able
to perform all ordinary motor activities without aids. Moderate
hemiparesis was present when the arm and leg could be elevated
against gravity and skilled movement of the hand and walking were
clearly affected but the patient could walk with or without aid. Severe
hemiparesis was present when the arm and leg could not be elevated
against gravity, the hand could not be used functionally, and walking
with aid was not possible. When there was a difference in grading
between arm and leg, the hemiparesis was graded according to leg and
ambulation.
In patients with sensory impairment on clinical testing, the investigation was supplemented by quantification of perception thresholds for cold, warmth, and heat pain by means of the Marstock method, with the nonaffected side used for comparison.10
The MMSE11 was used as a screening test for cognitive function and was performed at 1 month and 1 and 2 years after stroke onset and also after a recurrent stroke. A MMSE score less than 24 was used as a cutoff point.12 13 In patients with scores below this level, a further clinical evaluation was performed. The clinical diagnosis of dementia required decline in memory and two other cognitive domains (orientation, abstract reasoning, language, visuospatial function) severe enough to cause functional impairment in daily living.12
Disability
Disability was assessed by Katz's Index of ADL.14
This index measures performance in six P-ADL: bathing,
dressing, toileting, transfer, continence, and feeding. It contains
seven categories (A to G) ranked from least to greatest dependence,
plus a miscellaneous category for unclassifiable patients (O). From the
follow-up assessment at 6 months and onward, P-ADL was supplemented
by four instrumental activities (I-ADL; cooking, transportation,
shopping, and cleaning), organized into a hierarchical scale of
dependence as defined by Åsberg and Sonn.15 16 The
assessments were based on the person's ability to perform the
activities without assistance by another person. Patients living with a
partner were considered independent if they were able to perform the
activity when left alone; they were dependent if another person had to
provide help with the activity.
Handicap
For a global assessment of handicap, the OHS was
used.17 18 The purpose was to achieve an overall view of
the patient's functional state, also considering limitations in the
patient's social role.19 OHS is scored from 0 to 5 and
represents a modification of the Rankin Scale with some changes
in the wording, making it more suitable for the measurement of
handicap, and also with the deletion of ambulation as a
criterion.20 The assessments were performed by an
occupational therapist with information on ADL as a checklist for
scoring. In cases of uncertainty, the scorings were based on a joint
assessment by the two investigators (G.B.O. and M.S.).
Statistical Analyses
The data were analyzed in contingency tables, with
statistical significance of differences tested by
2. Goodman-Kruskal's 
was used for
analysis of correlations between ordinal variables. The
relationship between outcome and independent variables was tested
by means of logistic multivariate regression models. A
level of P<.05 was considered statistically significant.
All data analyses were performed with SPSS (SPSS, Inc).
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Our study included 81 patients (51 men, 30 women) with a mean age of 66 years (range, 40 to 86 years). The lacunar syndromes were pure motor stroke in 53 patients, sensorimotor stroke in 13, pure sensory stroke in 10, and ataxic hemiparesis in 5. The symptoms included face, arm, and leg in 39 patients and were partial, ie, faciobrachial and brachiocrural, in 42. The right side was affected in 44 patients and the left in 37 patients.
Prestroke Disability and Handicap
Before the onset of stroke, all patients were independent in
P-ADL, whereas 9 of the 81 patients were dependent in one or more of
the four I-ADL activities. None of the patients were considered to have
a handicap corresponding to OHS grades 3 to 5, whereas 9 experienced
restrictions in lifestyle (OHS grade 2), mainly as a result of
cardiovascular disease or arthritis.
Recurrent Stroke or Death During Follow-up
During follow-up, 5 patients (6%) died (1 patient during the
first year, 2 patients each during the second and third years). Causes
of death were myocardial infarction (2 patients), stroke, heart
failure, and malignancy (1 patient each). Seventeen patients (21%) had
recurrent strokes during follow-up (5 patients during the first
year, 3 during the second year, and 9 during the third year). Eleven
patients had recurrent lacunar infarcts, 4 cortical infarcts, and 2
deep intracerebral hemorrhages.21
All patients were treated with 75 to 160 mg
acetylsalicylic acid at the time of recurrent
stroke. Rehabilitation care was given to all patients when needed.
Impairment
The degree of hemiparesis from the time of maximum deficit to 3
years after stroke onset in the 71 patients with motor impairment is
shown in Table 1
. At 1 month, 58 (82%) of the patients
had none or only a mild hemiparesis. This proportion was similar by 3
years, but at that time a moderate or severe hemiparesis was due to the
effects of recurrent strokes in 7 of 11 patients. Among the 5 patients
who died during follow-up, 4 had a moderate or severe hemiparesis
after the index stroke.
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Twenty-three patients (13 with sensorimotor stroke, 10 with pure sensory stroke) had sensory impairment on clinical testing, which also was confirmed by quantitative sensory testing. Three patients with pure sensory stroke developed painful dysesthesia on the affected side during the first months after stroke onset, and the pain persisted during follow-up. Otherwise, sensory impairment did not cause disability or handicap.
MMSE scores indicating cognitive impairment (<24) were found in 6 patients at 1 month, in 7 patients at 1 year, and in 8 patients at 2 years. Two patients at 1 year and 4 patients at 2 years had MMSE scores lower than 18, indicating severe cognitive impairment. None of the patients fulfilled clinical criteria of dementia when assessed in connection with the index stroke, while 4 (5%) of the surviving patients were considered demented at 1 year and 8 (11%) at 3 years. In 3 patients, the dementia developed in conjunction with recurrent strokes.
Disability
At the time of maximum deficit, 52 (64%) of the patients were
independent in P-ADL (Katz A), and 29 (36%) were dependent (Katz B=7,
C=1, D=2, E=11, G=3). One month after stroke onset, 66 (81%) were
independent, and none of the patients was dependent in all six
activities (Katz G). At 1 year, 51 (64%) of the patients were
independent in I- and P-ADL, while 19 (24%) were dependent in I-ADL
only, and 10 patients (12%) were dependent in both I- and P-ADL (Table 2). By the end of the third year, the degree of
dependency had increased as a result of dementia, progressive heart
failure, arthritis, visual loss, and most commonly as a result of the
effects of recurrent strokes. Of 15 patients with recurrent stroke
surviving at that time, 10 needed help in P-ADL, 2 needed help in I-ADL
only, and only 3 patients were independent.
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Handicap
There was a high degree of consistency between P- and
I-ADL and the handicap grade according to OHS (Goodman-Kruskal's ,
0.85 to 0.87). All patients independent in P- plus I-ADL were graded
OHS 0 to 2, and all patients dependent in P- plus I-ADL were graded OHS
3 to 5. Functional outcome, assigned as physical independence (OHS
grades 0 to 2), physical dependence (OHS grades 3 to 5), and death in
patients with and without recurrent stroke, is shown in the
Figure.
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Approximately 10% of the patients on each testing occasion were independent in P- and I-ADL but still had a handicap that restricted lifestyle (OHS grade 2). These were patients with a residual motor impairment, central stroke pain, or coexisting diseases that prevented customary social relations, employment, and recreational activities. Because of social and environmental factors, approximately the same proportion of patients were not considered to have a handicap that significantly restricted lifestyle and made them functionally dependent (OHS grade >2), although according to scale criteria they were dependent in one or more of the instrumental activities.
The most frequently encountered minor symptoms (OHS grade 1) were a slight residual motor dysfunction, emotional lability, and subtle subjective impairment of cognitive function. Reduced speed of mental processing was a frequent complaint. At 3 years, 24% of the surviving patients were still asymptomatic and free from handicap (OHS grade 0).
Predictive Factors for Functional Outcome
In a multivariate logistic regression model, we
correlated outcome at 3 years, in terms of OHS grades 3 to 5 and death,
with demographic data, vascular risk factors, initial MRI findings,
motor impairment 1 month after the index stroke, and the occurrence of
a recurrent stroke (Table 3). The effect of age was
examined as a continuous variable. Handicap grade, MRI findings,
and motor impairment were dichotomized as follows: OHS grades 0 to 2
versus OHS grades 3 to 5 and death; no silent infarct versus one or
more; WMH grades 0 to 2 versus grades 3 to 4; and no/mild hemiparesis
versus moderate/severe. Poor functional outcome (ie, physical
dependence or death) was significantly correlated to motor impairment
(P<.001) and WMH grades 3 to 4 (P<.01).
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Similar to previous studies,22 23 we found a fast initial recovery of stroke-related impairment in most patients with a first-ever lacunar infarct. One month after stroke onset, 82% of the patients had no or only minor motor deficit. The prognosis for sensory impairment was also favorable in our series, except in the few patients who developed central pain syndromes.
During the 3 years of follow-up, 11% of our patients developed
dementia, one third occurring in connection with a recurrent stroke. In
a prospective study by Tatemichi et al24 on patients
without dementia 3 months after the onset of ischemic stroke,
approximately 25% developed dementia during the first 3 years of
follow-up, and recurrent stroke accounted for approximately one
fifth of the cases. The higher incidence of dementia in their series
might have several explanations, including older patients (all 
60
years), inclusion of patients with prior strokes, and more
comprehensive testing.
At 1 year, 88% of our patients were independent in P-ADL. The corresponding proportion in the study by Clavier et al,6 in which the Barthel Index was used, was 74%. A high degree of agreement between the two scales has previously been found.25 However, the Katz ADL Index, as well as other scales measuring P-ADL, lacks sensitivity in the upper range of ability, rendering a "ceiling" effect.26 Addition of the four instrumental activities improved the discriminative value of the ADL scale. When tested in an elderly general population in Sweden, the ADL "staircase" was found to have a good validity and reliability,15 16 but we are unaware of its use in any previous study of patients with stroke. However, there is currently no agreement as to which specific items are most useful in assessing I-ADL in stroke patients,27 and the problem of limited generalizability to other socioeconomic and cultural societies must also be considered.
The ADL staircase was used by Sonn 28 on an unselected population of 70-year-old persons in Göteborg, Sweden; 83% were independent, 13% were dependent in I-ADL, and 4% were dependent in I- plus P-ADL. The slightly higher percentage of independent persons before the stroke (89%) in our series might be due to a lower mean age (66 years) and the fact that ADL was estimated in retrospect. After the occurrence of stroke, the percentage of independent persons was lower on all assessments (64% to 58%), indicating that a first-ever lacunar infarction increases the risk for disability during the following 3 years compared with an unselected population of approximately the same age and similar living conditions.
The modified Rankin Scale and the OHS have been criticized for mixing impairment, disability, and handicap assessments rather than being true handicap scales.18 26 29 30 31 An acceptable interobserver reliability has been found for the modified Rankin Scale.20 The OHS has not been formally assessed for reliability, but the scales are very similar. The addition of OHS made it possible to include domains of life that are important to functional outcome other than physical dependence. Approximately 10% of our patients received an OHS score of 2, ie, they were physically independent but still had symptoms that clearly affected lifestyle. These patients could not be identified by the use of ADL measures alone. The use of a handicap assessment also made it possible to identify those patients who were dependent in one or more of the ADLs, but in whom the disability was not considered to render a handicap. As recommended by van Swieten et al,20 we used our information on ADL in the handicap scoring to overcome the subjective nature of the score, and a high degree of agreement between physical dependence and handicap grade was found. A handicap scale based on stated criteria would have been preferable, but difficulties were encountered in finding an appropriate measure, since the concept of handicap is even more dependent on environmental factors than extended ADL functions.
Motor impairment and WMH were significantly correlated to physical dependence and death independent of age, vascular risk factors, and recurrent stroke. WMH has been associated with dementia, vascular risk factors, and lacunar infarction, but it is also a common incidental finding, particularly in the elderly, and its pathological significance is unclear.32 The relationship between WMH and functional outcome in lacunar infarction has not been studied to a great extent, but Miyao et al33 found a higher degree of dependence in lacunar infarct patients with leukoaraiosis on CT compared with those without leukoaraiosis. Subclinical dementia and motility disorders characteristic of Binswanger's disease34 may be of importance, but our findings require confirmation from investigations in larger studies.
In conclusion, we found that functional outcome regarding physical independence was favorable in most patients. Motor impairment and severe WMH were the strongest predictors of a poor functional outcome. Recurrent stroke contributed to increased disability and handicap at 3 years but failed to reach statistical significance as an independent prognostic factor. Measurements of P-ADL alone were too insensitive to detect the consequences of stroke in many of our patients with preserved self-care ability who still experienced disability and handicap. It is important to design appropriate measures of extended ADL and handicap for future use.
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Selected Abbreviations and Acronyms |
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Acknowledgments |
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This study was supported by the Örebro County Council. We wish to thank Assistant Prof Bo Norrving for his valuable comments and advice.
Received October 16, 1995; revision received December 14, 1995; accepted January 29, 1996.
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