(Stroke. 1997;28:1458-1460.)
© 1997 American Heart Association, Inc.
Articles |
Cerebral Blood Flow in Single and Multiple Lacunar Infarctions
From the Department of Neurology, Nihon University School of Medicine, Tokyo, Japan.
Correspondence to Yoko Mochizuki, MD, Department of Neurology, Nihon University Nerima Hikarigaoka Hospital, 2-11-1 Hikarigaoka, Nerima-ku, Tokyo 179, Japan. E-mail LEF00015{at}niftyserve.or.jp
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Abstract |
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 Top Abstract IntroductionSubjects and MethodsResultsDiscussionReferences |
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Background and Purpose Single and multiple lacunar infarctions may have some difference in underlying diseases and cerebral blood flows. To determine the difference, we investigated underlying diseases and cerebral blood flows in single and multiple lacunar infarctions.
Methods Fifteen cases of lacunar infarction, 10 cases of multiple lacunar infarctions, and 16 control subjects were studied. Regional cerebral blood flow was measured within 14 days after stroke onset with the stable xenon CT method.
Results The rate of association of diabetes mellitus was higher in the multiple lacunar infarctions group than in the single lacunar infarction group. The blood flow in the cerebral cortex was significantly lower in the multiple lacunar infarctions group than in the single lacunar infarction group. The blood flow change by acetazolamide in the cerebral cortex was significantly lower in the multiple lacunar infarctions group than in the single lacunar infarction group.
Conclusions There is some difference in underlying diseases and cerebral blood flows between single and multiple lacunar infarctions.
Key Words: acetazolamide • cerebral blood flow • lacunar infarction • xenon
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Lacunar infarcts are small infarcts (<1.5 cm in greatest diameter) that result from involvement of deep, small, penetrating arteries.1 Fisher2 considered that lacunar infarction is usually due to lipohyalinosis or atheromatous or embolic occlusion of a penetrating vessel. Boiten et al3 reported that patients with asymptomatic lacunar infarcts had hypertension significantly more often and had leukoaraiosis significantly more often than those with only a symptomatic lacunar infarct and postulated a hypothesis that there are two clinically distinct lacunar infarct entities: patients with a single symptomatic lacunar infarct and patients with multiple lacunar infarcts with a high frequency of hypertension and leukoaraiosis, in which the underlying small-vessel vasculopathy might be different.
We investigated the difference in underlying diseases, cerebral blood flows, and cerebrovascular acetazolamide reactivity between the two types of lacunar infarction.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Subjects
Fifteen cases of single lacunar infarction, 10 cases of multiple lacunar infarctions, and 16 control subjects in whom CT did not show any infarction were studied with their informed consent. Case subjects were equally matched for age and sex. Subcortical cystic infarctions with a diameter of less than 1.5 cm were classified as lacunar infarctions. The patients with supratentorial lacunar infarction were investigated. Single lacunar infarction was defined as a case of first attack lacunar infarction in which CT shows single lacunar infarction compatible with the symptoms. Multiple lacunar infarctions were defined as a case of first attack lacunar infarction in which CT shows multiple lacunar infarctions, including an asymptomatic infarction. Clinical profiles of our subjects are summarized in Table
1.
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Methods
Regional cerebral blood flow (rCBF) was measured within 14 days
after stroke onset with the stable xenon CT method.4 5 The
mean±SD time from onset of infarction until the rCBF examination was
6.0±4.7 days in the single lacunar infarction group and 7.6±4.5 days
in the multiple lacunar infarctions group. We examined two CT sections,
parallel to the orbitomeatal line, that showed cerebral infarction. A
gas mixture of 30% xenon and 50% oxygen was inhaled for 3 minutes,
followed by room air. For each section, CT scanning was performed once
before the xenon inhalation, 3 times during the xenon inhalation, and 5
times after the xenon inhalation. The picture analysis was
performed with AZ-7000 equipment (Anzai Medical). rCBF was
measured6 7 8 by placing the round ROI (region of interest)
on the cerebral cortex and cerebral white matter in the hemisphere
contralateral to the infarction, where there is no direct nerve fiber
connection with the infarct area (Fig 1). The ROI in the
cerebral white matter was not placed on or near the
periventricular hyperintensity seen on MRI and was not
placed on the periventricular area, where the partial
volume effect may decrease accuracy. rCBF was measured before and 20
minutes after intravenous injection of 17 mg/kg
acetazolamide.
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Statistical analysis was performed with the Mann-Whitney U test to compare data from various groups and with Fisher's exact probability tests for comparison of risk factors among the three groups.
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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The rate of association of hypertension was significantly higher in the single and multiple lacunar infarctions groups than in the control group, and the rate of association of alcoholism was significantly higher in the multiple lacunar infarctions group than in the control group. The rate of association of diabetes mellitus was higher in the multiple lacunar infarctions group than in the single lacunar infarction group (Table 1
).
Fig 2 shows the actual records of xenon CT before
and after intravenous injection of
acetazolamide. Table 2 shows the mean±SD
values of rCBF and rCBF changes by acetazolamide. Before
the intravenous injection of acetazolamide,
rCBFs in the cerebral cortex and cerebral white matter were
significantly lower in the single and multiple lacunar infarctions
groups than in the control group. In addition, blood flow in the
cerebral cortex was significantly lower in the multiple lacunar
infarctions group than in the single lacunar infarction group. The
blood flow changes by acetazolamide in the cerebral cortex
and cerebral white matter were significantly less in the single and
multiple lacunar infarctions groups than in the control group. The
blood flow change by acetazolamide in the cerebral cortex
was significantly less in the multiple lacunar infarctions group than
in the single lacunar infarction group.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Although MRI is more sensitive than CT in the diagnosis of lacunar infarction, patchy small white matter lesions in T2-weighted images of MRI are more often due to état criblé than lacunar infarction.9 10 Therefore, we investigated using low-density lesions on CT in the present study.
rCBF may be reduced not only in infarcts and the ischemic penumbra but also in regions experiencing diaschisis.11 Xenon CT has an advantage in that rCBF measurements correspond closely to anatomic structures on CT.12 13 Because we measured blood flows in the cerebral cortex and cerebral white matter, where the influence of lacunar infarction is minimal, the influence of diaschisis was also minimal. Xenon CT with the wash-in/washout protocol has been reported to show considerable reliability in measuring blood flow in the cerebral white matter5 and has been used in patients with pathological conditions.6 7 8 Using the same instrument and the same method of xenon CT as ours, Haku et al14 reported a significant correlation (r=.68, P<.001) between rCBF values (10 to 30 mL/100 g per minute) of the white matter area obtained by xenon CT and those of 133Xe single-photon emission CT, which has been accepted as a standard method for the measurement of rCBF. Because the cerebral white matter blood flow in the present study is approximately 10 to 20 mL/100 g per minute in the patients, the blood flow values are considered reliable.
There was no significant difference in sex and age among the three groups, but the rate of association of hypertension was significantly higher in the single and multiple lacunar infarctions groups than in the control group in the present study; this is in agreement with a previous report.2
Our finding that the rate of association of diabetes mellitus was significantly higher in the multiple lacunar infarctions group than in the single lacunar infarction group is in accordance with the report15 that glucose intolerance occurred significantly more frequently in the group with silent lesions than in the group with CT evidence of acute stroke. Silent lacunar lesion on MRI in neurologically normal persons without a past history of cerebrovascular disease was reported to be closely related to decrease of cerebral circulation and may be an important risk factor for symptomatic cerebrovascular disease.16 rCBF was significantly lower in the multiple lacunar infarctions group than in the single lacunar infarction group in the present study as well.
Moreover, cerebrovascular acetazolamide reactivity in the cerebral cortex was significantly lower in the multiple lacunar infarctions group than in the single lacunar infarction group in the present study. Acetazolamide dilates cerebral arterioles by inhibiting carbonic anhydrase and increasing arteriolar CO217 18 and is useful for examining cerebrovascular dilatory reserve capacity.18 Acetazolamide may also be useful in identifying arteriosclerosis.19 The present study suggests that arteriosclerosis is more advanced in the multiple lacunar infarctions group than in the single lacunar infarction group. Boiten et al3 postulated a hypothesis that there are two clinically distinct lacunar infarct entities: (1) single lacunar infarction caused by microatheromatous disease and (2) multiple lacunar infarctions related to arteriolosclerosis. No report has examined the difference in cerebral blood flows between the two. The present study supports the hypothesis of Boiten et al.
Received January 21, 1997; revision received March 31, 1997; accepted April 8, 1997.
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References |
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