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From the Department of Neurological and Psychiatric Sciences (Dr. Inzitari), University of Florence, Italy; the Departments of Clinical Neurological Sciences (Drs. Barnett, Eliasziw, and Fox) and Epidemiology and Biostatistics (Dr. Eliasziw), University of Western Ontario, London, Ontario; and the John P. Robarts Research Institute (Drs. Barnett and Eliasziw, and B. Sharpe), London, Ontario, Canada.
Address correspondence and reprint requests to Dr. H.J.M. Barnett, Robarts Research Institute, 100 Perth Drive, PO Box 5015, London, Ontario, Canada, N6A 5K8; e-mail: barnett{at}rri.on.ca
OBJECTIVE: To examine the relationship between carotid artery stenosis, other risk factors, and lacunar stroke.
BACKGROUND: Carotid artery stenosis in patients presenting with lacune stroke may be coincidental or causal. The distinction by risk factor profile is uncertain. The risk and cause of subsequent stroke, and benefit of carotid endarterectomy (CE) is unknown.
METHODS: Stroke in patients entering the North American Symptomatic Carotid Endarterectomy Trial were classified as nonlacunar, possible lacune (symptoms without CT lacunae), or probable lacune (symptoms with CT lacunae).
RESULTS: Of 1,158 patients with hemispheric stroke, 493 had features of lacunar stroke (283 possible and 210 probable). Lacunar stroke presented more commonly in patients with milder (<50%) degrees of internal carotid artery (ICA) stenosis (p = 0.003). History of diabetes and hyperlipidemia, not hypertension, were associated independently even after accounting for the degree of stenosis. Medically treated patients presenting with nonlacunar stroke had a low risk of subsequent lacunar events of 2.9% at 3 years in comparison with 9.2% for probable lacunar presentation (p = 0.03). For patients with 50 to 99% ICA stenosis, the relative risk reductions (RRRs) in stroke from CE were 35% when the presenting stroke was probable lacunar versus 61% when the stroke was nonlacunar. Patients presenting with a possible lacunar stroke had a 53% RRR.
CONCLUSIONS: History of diabetes and hyperlipidemia were more important than arterial hypertension as risk factors for patients with lacunar stroke. Patients presenting with lacunar stroke more often had milder ICA stenosis. Although CE reduced the risk of stroke in all patients with 50 to 99% ICA stenosis, lesser benefits were observed in patients presenting with lacunar stroke.
Key words: Lacunes—Ischemic stroke—Carotid artery stenosis—Carotid endarterectomy—Arteriosclerosis
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