title: Small deep infarction in patients with atrial fibrillation: evidence of lacunar pathogenesis.
abstract: BACKGROUND
  It is difficult to clarify whether small deep infarction is caused by cardioembolism or intrinsic small vessel disease in patients with atrial fibrillation (AF). The purpose of this study was to determine whether preexisting small vessel disease would differ according to the presenting infarct pattern and to determine the factors associated with acute single small deep infarction in stroke patients with AF.
  
  
  METHODS
  Between January 2008 and August 2012, 1,592 consecutive patients with acute ischemic stroke presenting within 7 days of symptom onset were entered in a prospectively maintained stroke registry. For the present study, 231 stroke patients with AF were enrolled irrespective of the stroke subtype. We divided these patients into 2 groups (lacunar infarct pattern, n = 20, vs. nonlacunar infarct pattern, n = 211) according to the acute infarct pattern on diffusion-weighted imaging. Patients with acute single small deep infarction on diffusion-weighted imaging were assigned to the lacunar infarct pattern group. We assessed the severity of preexisting small vessel disease by grading white matter lesions (WMLs) according to the Fazekas scale (periventricular WML score ranging from 0 to 3 and deep WML score ranging from 0 to 3 were added to give a total WML score ranging from 0 to 6), multilacunar state (number of chronic lacunes ≥2) and the presence of microbleeds. Demographic characteristics, vascular risk factors and neuroimaging data were compared between the two groups.
  
  
  RESULTS
  Patients with a lacunar infarct pattern showed more severe WMLs than those with a nonlacunar pattern [median total WML score 2.5 (range 2-4) vs. 1.0 (0-2); p < 0.001]. A multilacunar state was more prevalent in the lacunar infarct pattern group compared with the nonlacunar pattern group (65 vs. 28.9%; p = 0.001). However, the presence of microbleeds did not differ between the groups. Multiple logistic regression analyses revealed periventricular WMLs [odds ratio (OR) 4.12, 95% confidence interval (CI) 2.14-7.92], deep WMLs (OR 3.42, 95% CI 1.75-6.66) and multilacunar state (OR 7.85, 95% CI 2.45-25.6) as the predictors of a lacunar infarct pattern.
  
  
  CONCLUSIONS
  The severity of WMLs and chronic lacunes were independent predictors of the incident infarct pattern, which suggested that acute single small deep infarction might be caused by intrinsic small vessel disease despite the presence of concomitant AF.
authors.affiliation: Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Yong-shik
authors.initials: YS
authors.lastname: Park
authors.forename: Pil-Wook
authors.initials: PW
authors.lastname: Chung
authors.forename: Yong Bum
authors.initials: YB
authors.lastname: Kim
authors.forename: Heui-Soo
authors.initials: HS
authors.lastname: Moon
authors.forename: Bum-Chun
authors.initials: BC
authors.lastname: Suh
authors.forename: Won Tae
authors.initials: WT
authors.lastname: Yoon
authors.forename: Kyung Jae
authors.initials: KJ
authors.lastname: Yoon
authors.forename: Yong-Taek
authors.initials: YT
authors.lastname: Lee
authors.forename: Yu Sam
authors.initials: YS
authors.lastname: Won
authors.forename: Kwang-Yeol
authors.initials: KY
authors.lastname: Park
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001281:Atrial Fibrillation / Q000150:complications / Q000473:pathology*; D001921:Brain / Q000098:blood supply / Q000473:pathology; D020520:Brain Infarction / Q000150:complications / Q000473:pathology*; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D012307:Risk Factors; D012720:Severity of Illness Index