title: A comparison of location of acute symptomatic vs. 'silent' small vessel lesions.
abstract: BACKGROUND
  Acute lacunar ischaemic stroke, white matter hyperintensities, and lacunes are all features of cerebral small vessel disease. It is unclear why some small vessel disease lesions present with acute stroke symptoms, whereas others typically do not.
  
  
  OBJECTIVE
  To test if lesion location could be one reason why some small vessel disease lesions present with acute stroke, whereas others accumulate covertly.
  
  
  METHODS
  We identified prospectively patients who presented with acute lacunar stroke symptoms with a recent small subcortical infarct confirmed on magnetic resonance diffusion imaging. We compared the distribution of the acute infarcts with that of white matter hyperintensity and lacunes using computational image mapping methods.
  
  
  RESULTS
  In 188 patients, mean age 67 ± standard deviation 12 years, the lesions that presented with acute lacunar ischaemic stroke were located in or near the main motor and sensory tracts in (descending order): posterior limb of the internal capsule (probability density 0·2/mm(3)), centrum semiovale (probability density = 0·15/mm(3)), medial lentiform nucleus/lateral thalamus (probability density = 0·09/mm(3)), and pons (probability density = 0·02/mm(3)). Most lacunes were in the lentiform nucleus (probability density = 0·01-0·04/mm(3) ) or external capsule (probability density = 0·05/mm(3)). Most white matter hyperintensities were in centrum semiovale (except for the area affected by the acute symptomatic infarcts), external capsules, basal ganglia, and brainstem, with little overlap with the acute symptomatic infarcts (analysis of variance, P < 0·01).
  
  
  CONCLUSIONS
  Lesions that present with acute lacunar ischaemic stroke symptoms may be more likely noticed by the patient through affecting the main motor and sensory tracts, whereas white matter hyperintensity and asymptomatic lacunes mainly affect other areas. Brain location could at least partly explain the symptomatic vs. covert development of small vessel disease.
authors.affiliation: Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
authors.forename: Maria del C
authors.initials: Mdel C
authors.lastname: Valdés Hernández
authors.affiliation: Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
authors.forename: Lucy C
authors.initials: LC
authors.lastname: Maconick
authors.affiliation: Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
authors.forename: Susana
authors.initials: S
authors.lastname: Muñoz Maniega
authors.affiliation: Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
authors.forename: Xin
authors.initials: X
authors.lastname: Wang
authors.affiliation: Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
authors.forename: Stewart
authors.initials: S
authors.lastname: Wiseman
authors.affiliation: Department of Cardiovascular Sciences, University of Sheffield, Sheffield, UK.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Armitage
authors.affiliation: Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
authors.forename: Fergus N
authors.initials: FN
authors.lastname: Doubal
authors.affiliation: Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Makin
authors.affiliation: Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.|Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK.
authors.forename: Cathie L M
authors.initials: CL
authors.lastname: Sudlow
authors.affiliation: Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
authors.forename: Martin S
authors.initials: MS
authors.lastname: Dennis
authors.affiliation: Centre for Cognitive Ageing and Cognitive Epidemiology, Department of Psychology, University of Edinburgh, Edinburgh, UK.
authors.forename: Ian J
authors.initials: IJ
authors.lastname: Deary
authors.affiliation: Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.|Centre for Cognitive Ageing and Cognitive Epidemiology, Department of Psychology, University of Edinburgh, Edinburgh, UK.
authors.forename: Mark
authors.initials: M
authors.lastname: Bastin
authors.affiliation: Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.|Centre for Cognitive Ageing and Cognitive Epidemiology, Department of Psychology, University of Edinburgh, Edinburgh, UK.
authors.forename: Joanna M
authors.initials: JM
authors.lastname: Wardlaw
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D001921:Brain / Q000473:pathology*; D002544:Cerebral Infarction / Q000473:pathology*; D059345:Cerebral Small Vessel Diseases / Q000473:pathology* / Q000503:physiopathology*; D005260:Female; D006801:Humans; D007091:Image Processing, Computer-Assisted; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D020521:Stroke / Q000473:pathology
keywords: acute lacunar infarct; lacunar stroke; lacunes; small vessel disease; stroke; white matter hyperintensities