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Title: Leukoaraiosis as a factor in the prognosis after an ischemic stroke

Abstract:

Leukoaraiosis, also called white matter hyperintensities or white matter disease, is a type of chronic symmetrical lesions of white matter in the brain, visible in neuroimaging, which are caused by a chronic disease of small cerebral blood vessels. Leukoaraiosis may occur in elderly people who do not have any neurological symptoms.Leukoaraiosis occurs much more frequently in the population of patients suffering from different neurological diseases related to age or, ex. degenerative diseases or cerebral vessel diseases than in the general population. The significance of leukoaraiosis as a factor to determine a prognosis after a cerebrovascular accident has been an object of only few pieces of research whose results are ambiguous.The aim of the study was to verify if leukoaraiosis detected on brain magnetic resonance (MR) is a factor to determine a prognosis in patients suffering from cerebral infarction. The detailed objectives were as follows: 1) How often does leukoaraiosis found on MR occur in the examined group of patients who suffer from acute ischemic stroke and how advanced is it in evaluation, using the Fazekas scale? 2) What are leukoaraiosis risk factors evaluated by means of the Fazekas scale and does leukoaraiosis correlate with a size of an ischemic focus assessed in DWI MR with the use of ASPECTS and pc-ASPECTS? 3) Is leukoaraiosis an independent factor to determine a short-term prognosis at discharge assessment by means of the modified Rankin scale? 4) Is leukoaraiosis an independent factor to determine a long-term survival after a cerebrovascular accident (3 years on average)?Demographic and clinical data, as well as the results of MR scans performed prospectively in patients suffering from ischemic stroke were subjected to a meticulous retrospective analysis. The group of the sick was composed of 256 people aged over 18 who were treated in the Stroke Unit of the Department of Neurology between 2005 and 2011 and whose survival had been reported by 30th June 2013. The participants of the study included patients who suffered from acute ischemic stroke , aged at least 18, who had an MR scan done within 7 days from the moment of falling ill. The exclusion criteria were the following: 1) a lack of consent for taking part in the investigation; 2) a record of cancer in medical history; 3) a head neurosurgery; 4) a record of head trauma in medical history. In all the patients the demographic data (age, sex) and risk factors (arterial hypertension, ischaemic heart disease, diabetes, atrial fibrillation, hypercholesterolaemia, obesity, nicotine addiction) were analysed. In each case the results of basic biochemical tests at the admission, such as cholesterol level, blood glucose level, a number of white cells and fibrinogen level, were examined. MR head scans were performed in CUMRiK’s Medical Imaging Institute of the University Hospital in Cracow on a 1,5T GE HDxt MR scanner. All the patients had the scans, viewed in coronal, horizontal and sagittal planes, in 2 mm and 5 mm layers, in frFSE T2, 3DT1 FSPGR, FSE PD, FLAIR T2 sequences, as well as DWI and 3DT1 FSPGR and SE T1 done, and the latter two - after an intravenous administration of 3,5 ml of the Multihance contrast agent. The presence and intensity of leukoaraiosis in head MR evaluation (the Fazekas scale), as well as a size of an ischaemic focus in DWI MR (ASPECTS and pc-ASPECTS) were analysed. In all the subjects of the study the following clinical data were investigated: a neurological deficit at the admission to and discharge from the Department of Neurology (the NIHSS) and their independence at the discharge (the modified Rankin scale). The information on a long-term survival was obtained Department of Internal Affairs of the City of Krakow, where it was possible to apply for access to such data with the agreement of the Bioethics Committee. ; Having summed the number of points in the Fazekas scale granted during the assessment of periventricular and deep structures' lesions, 60 patients received 0 points (23,4%), 55 patients received 1 point (21,5%), 43 patients received 2 points (16,8%), 37 patients received 3 points (14,5%), 24 patients received 4 points (9,4%), 11 patients received 5 points (4,3%) and 26 patients received 6 points (10,1%). The analysis of the demographic, biochemical and clinical data indicated that the patients with advanced leukoaraiosis (at least 3 points in the Fazekas scale) were older, suffered more often from arterial hypertension, diabetes and ischaemic heart disease, and had a higher level of cholesterol, fibrinogen and blood glucose than the others. Linear regression analysis based on the assumption that the Fazekas scale was treated as an infinitely variable proved that an old age and arterial hypertension are independent leukoaraiosis factors. Logistic regression analysis based on the assumption that the Fazekas scale was treated as a dichotomous variable (at least 3 points vs. less than 3 points) showed that an old age, arterial hypertension and fibrinogen are independent factors of advanced leukoaraiosis. No correlation between the number of points in the Fazekas scale and the number of points in ASPECTS (r=0,06, p=n.s.) was found.Linear regression analysis based on the assumption that both the modified Rankin scale and the Fazekas scale were treated as infinitely variables indicated that arterial hypertension and an advanced neurological deficit assessed by the NIHSS at the moment of falling ill are factors to determine a degree of disability graded according to the modified Rankin scale at a discharge. Linear regression analysis based on the assumption that the modified Rankin scale was treated as an infinitely variable and that the Fazekas scale was treated as a dichotomous variable proved that arterial hypertension, diabetes, a number of white cells and an advanced neurological deficit assessed by the NIHSS at the moment of falling ill are factors to determine a degree of disability graded according to the modified Rankin scale at a discharge. The testing of factors determining a degree of a neurological deficit at a discharge based on the assumption that the modified Rankin scale was analysed as a dichotomous variable did not reveal any factors to determine an early prognosis. Leukoaraiosis did not transpire to be a factor determining an early prognosis in any of the above-mentioned models.The Kaplan–Meier analysis showed that patients with no signs of leukoaraiosis (0 points in the Fazekas scale) or in whom its extent is relatively small (1-2 points) have a considerably higher long-term survival rate than those who suffer from advanced leukoaraiosis. An estimated survival in the first group amounts to 83,4 months, whereas in the second group it is 68,9 months. This difference is statistically significant (p=0,015). An univariate analysis indicated that arterial hypertension (HR=3,77; 95%CI:1,15-12,35; p=0,03) and advanced leukoaraiosis (HR=2,71; 95%CI:1,34-5,50; p<0,01 ) are death risk factors. A multivariate analysis stated that only advanced leukoaraiosis was an independent death factor (HR=2,13; 95%CI:1,02-4,45; p=0,04).Leukoaraiosis in an acute stroke phase occurs in approximately 80% of patients and in half of the cases it is very extensive. An old age and arterial hypertension are risk factors of advanced leukoaraiosis in an acute stroke phase. The intensity of leukoaraiosis diagnosed in an acute stroke phase does not correlate with a size of an ischaemic focus. Leukoaraiosis is not an independent factor to determine a short-term prognosis evaluated by means of the modified Rankin scale. The most significant factor responsible for a short-term prognosis is a neurological deficit at the moment of falling ill. Leukoaraiosis is an independent factor to determine a long-term postictal mortality.

Place of publishing:

Kraków

Level of degree:

2 - studia doktoranckie

Degree discipline:

neurologia ; radiologia

Degree grantor:

Uniwersytet Jagielloński. Collegium Medicum. Wydział Lekarski.

Promoter:

Tadeusz Popiela

Date issued:

2016

Format:

application/pdf

Identifier:

oai:dl.cm-uj.krakow.pl:4114

Call number:

ZB-124973

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Language:

pol

Access rights:

tylko w bibliotece

Location of original object:

Biblioteka Medyczna Uniwersytetu Jagiellońskiego- Collegium Medicum

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Last modified:

May 24, 2021

In our library since:

Sep 20, 2016

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