Counting cavitating lacunes underestimates the burden of lacunar infarction.
OBJECTIVE
On brain imaging, lacunes, or cerebrospinal fluid-containing cavities, are common and are often counted in epidemiological studies as old lacunar infarcts. The proportion of symptomatic lacunar infarcts that progress to lacunes is unknown. Noncavitating lacunar infarcts may continue to resemble white matter lesions.


METHODS
We identified patients with acute lacunar stroke, with or without an acute lacunar infarct on computed tomography or MRI, who had follow-up imaging. A neuroradiologist classified lacunar infarcts progressing to definite or possible cavities on follow-up imaging. We tested associations between cavitation and patient-related, stroke-related, and imaging-related features, including other features of small vessel disease.


RESULTS
Among 90 patients (mean age 67 years), any cavitation was present on follow-up imaging in 25 (28%), and definite cavitation in 18 (20%). Definite cavitation was associated with increasing time to follow-up imaging (median 228 days, range 54 to 1722, versus no cavitation 72 days, range 6 to 1440; P=0.0003) and deep cerebral atrophy (P=0.03) but not with age, stroke severity, larger initial infarct size, or other features of small vessel disease. Hypertension and diabetes were negatively associated with cavitation (P=0.01 and 0.02, respectively).


CONCLUSIONS
Definite cavitation occurs in one fifth of symptomatic lacunar ischemic strokes, implying that most continue to resemble white matter lesions. Epidemiology and pathophysiology studies of lacunar stroke, which have only counted lacunes as lacunar infarcts, may have substantially underestimated by as much as 5 times the true burden of lacunar stroke disease.
Potter
Gillian M
GM
Division of Clinical Neurosciences and SINAPSE Collaboration, University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom.
Doubal
Fergus N
FN
Jackson
Caroline A
CA
Chappell
Francesca M
FM
Sudlow
Cathie L
CL
Dennis
Martin S
MS
Wardlaw
Joanna M
JM
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000375:Aging / Q000473:pathology; D001160:Arterioles / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology; D001284:Atrophy / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology; D001921:Brain / Q000000981:diagnostic imaging / Q000473:pathology*; D020520:Brain Infarction / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000473:pathology*; D002533:Cerebral Angiography; D002536:Cerebral Arteries / Q000473:pathology*; D015897:Comorbidity; D003920:Diabetes Mellitus / Q000453:epidemiology; D018450:Disease Progression; D005260:Female; D006801:Humans; D006973:Hypertension / Q000453:epidemiology; D002537:Intracranial Arteriosclerosis / Q000000981:diagnostic imaging / Q000473:pathology*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009413:Nerve Fibers, Myelinated / Q000473:pathology; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed