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Differences in retinal vessels support a distinct vasculopathy causing lacunar stroke

From the Division of Clinical Neurosciences (F.N.D., P.E.H., M.S.D., J.M.W.), University of Edinburgh; Wellcome Trust Clinical Research Facility (T.J.M.), Western General Hospital, Edinburgh; Princess Alexandra Eye Pavilion (B.D.), University of Edinburgh; and SFC Brain Imaging Research Centre (J.M.W.), University of Edinburgh, UK.

Address correspondence and reprint requests to Fergus N. Doubal, Bramwell Dott Building, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK fergus.doubal{at}ed.ac.uk

Background: Lacunar stroke is common, but the etiology of the small vessel abnormality is unknown. Retinal vessels share ontogeny, size, and physiologic characteristics with cerebral small vessels, and retinopathy is associated with stroke. We compared retinal microvessel appearance as a surrogate for cerebral small vessels in patients with lacunar and large artery cortical ischemic stroke.

Methods: We prospectively recruited patients with lacunar ischemic stroke and cortical stroke controls. We took digital retinal photographs of each eye. We assessed central retinal artery equivalent (CRAE) and central retinal vein equivalent (CRVE) diameters and arteriovenous ratios (AVRs) using semiautomated computer software methods and quantified arteriovenous nicking and focal arteriolar narrowing.

Results: Among 212 patients (105 lacunar, 107 cortical strokes) of mean age 68 years (SD 12 years), AVR was decreased (0.76 vs 0.78, p = 0.03) and CRVE was increased (44.9 pixels/218 µm vs 42.8 pixels/208 µm, p = 0.01) in lacunar patients compared with cortical patients, but CRAE did not differ (33.2 pixels/161 µm vs 33.7 pixels/163 µm, p = 0.4). On multivariable analysis, increased CRVE was associated with lacunar stroke subtype (p = 0.03) and younger age (p < 0.001) after correcting for other vascular risk factors. Arteriovenous nicking and focal arteriolar narrowing did not differ between ischemic stroke subtypes.

Conclusions: Retinal venules are wider and arteriovenous ratios are smaller in patients with lacunar strokes compared with those in patients with cortical strokes.

Abbreviations: AVN = arteriovenous nicking; AVR = arteriovenous ratio; CI = confidence interval; CRAE = central retinal artery equivalent; CRVE = central retinal vein equivalent; FAN = focal arteriolar narrowing; FLAIR = fluid-attenuated inversion recovery; MR = magnetic resonance; NA = not applicable; NASCET = North American Symptomatic Carotid Endarterectomy Trial; NIHSS = NIH Stroke Scale; OR = odds ratio.

Supplemental data at www.neurology.org

F.N.D. is funded by the Wellcome Trust (075611). The Chief Scientists Office (Scotland) funded the brain imaging (CZB-4-281).

Disclosure: The authors report no disclosures.

Medical Devices: 1.5T Signa Horizon MR/I 1.5T HDX scanner (operating under a research collaboration with GE Medical Systems, Milwaukee, WI, operating as IGE in the UK); digital retinal camera (CR-DGi; Canon USA Inc., Lake Success, NY).

Received September 11, 2008. Accepted in final form February 18, 2009.