Coexisting White Matter Hyperintensities Predicts Poor Outcome In Large Artery Atherosclerosis Stroke Patients

Background and objectivesWhite matter hyperintensities (WMHs) is one of the main type of small vasculardisease, it can be found with lacunar infarction and cerebral microbleeds.44%-86.4%patient of the ischemic stroke also have WMHs. Large artery atherosclerosis is acommon type of ischemic stroke, it is estimated that the crowd accounts for20%to50%of stroke in Asia. Epidemiological evidence demonstrated that intracranial largeand small vessel disease share many of the same risk factors despite well-documenteddifferences, and can coexist in patients. The white matter fiber connections ofLeukoariosis dysfunction and brain tissue perfusion reduction may increase the riskof LAA who coexist WMHs.According to the anatomic position WMHs can bedivided into two parts: periventricular WMHs (PVWMHs) and subcortical WMHs(SWMHs). Previous studies mostly focus on LAA or WMHs, paying little attention toLAA complicated with WMHs let alone the different impact on ischemic stroke ofPVWMHs and SWMHs. This study focus on this point to explore the difference.Patients and MethodsPatients From November2009to October2010, patient with acute ischemic stroke (onset to admission duration within14days) admitted from the single-centerforward-looking stroke registry database of Departmenf of Neurology of the FirstAffiliated Hospital of Zhengzhou University were enrolled and registeredconsecutively in our study.Methods Patients who met the inclusonal criteria were enrolled and registeredconsecutively, the researchers recorded the baseline clinical characteristics in thestandard Case Report Form (CRF).1Written consent: All the patients or their relatives signed the written consent andwere informed of the benefits of parpicipating this trial, they can withdrawl this studyat any time of the study.2Record the baseline data: These include the basic information (demographics,contact information), past history (risk factors, history of stroke, CHD or other relateddiseases), personal history, NIHSS scale within24hours of admission, TOASTclassification, laboratory tests, electrocardiogram (EKG), CTA, TOAST classification,the score of WMHs. All patients underwent3.0Tesla MRI examinations, includingconventional T1-weighted sequences, T2-weighted images, fluid-attenuated inversionrecovery (FLAIR) sequences, diffusion-weighted imaging (DWI) and MRAsequences.3Follow-up: Telephone follow-up for the registered patients was performed at12months after disease onset, the clinical outcome (including stroke recurrence, Poorprognosis) and therapeutic measures for secondary prevention were recorded.4All the clinical data were input to and analyzed by SPSS17.0, Kaplan-Meieranalysis was performed to analyze the recurrence rate difference between patientswith atherogenic dyslipidemia and without atherogenic dyslipidemia, and adjustedmultivariate Cox regressional risk analysis were used to determine the independ riskfactors of stroke recurrence and composite vascular events, p<0.05was regarded forstatistical significance.ResultsA total of1003consecutive patients were admitted with diagnosis of ischemic stroke during the study period. We excluded51patients who were lack of completeclinical data.952cases (94.9%) underwent MRI/MRA/CTA/carotid duplex ulrasound,541were excluded:97(10.2%) cardiac cerebral apoplexy patients,189(19.8%) smallvascular stroke,92(9.7%) other type cerebral apoplexy and163(17.1%) unknowncauses type. Finally,411cases of artery atherosclerotic stroke patients met the criteria.Among the411patients,274were male,166were female, average age59.55±17.41years old(14-94years-old),average NIHSS score was5（2-8）, The percentage ofartery atherosclerotic cerebral stroke complicated with severe WMHS was35.8%,severe PVWMHs47.6%and severe SWMHs47.6%.Through Kaplan-Meier survival analysis,the log-rank test showed that patientswith severe WMHs (P <0.001), severe PVWMHs (P <0.001) increase the risk ofrecurrence after1arge artery atherosclerosis stroke. However, patients with severeSVWMHs have no statistically significan of increasing the risk of recurrence.In order to control other stroke risk factors, multivariate logistic regressionanalysis and Cox survival analysis were used to investigate the effects of severeWMHS of different positions for LAA poor prognosis and recurrence. Thosevariables presented statistical significance in model1and separated severe WMHlocation was entered in the model2. In the model1, There is a positive correlationbetween the severe WMHs and the recurrence after1arge artery atherosclerosis stroke(P <0.001HR=6.7795%CI3.30-13.89), poor prognosis after1arge arteryatherosclerosis stroke (P <0.001HR=3.0495%CI1.69-5.44). In addition, There is apositive correlation between the LDL (P=0.021HR=1.5095%CI1.06-2.11) andthe recurrence after1arge artery atherosclerosis stroke. There is a no correlationbetween the Age (P=0.021HR=1.0395%CI1.01-1.06), NIHSS score (P <0.001HR=1.1995%CI1.12-1.25), LDL (P=0.037HR=1.4295%CI1.00-1.07) and thepoor prognosis after1arge artery atherosclerosis stroke. In model2, There is apositive correlation between the age (P=0.035HR=1.03CI95%1.01-1.07), LDL (P=0.040HR=1.4895%CI1.02-2.15), severe PVWMHs (P=0.013HR=2.4195%CI1.21-4.81) and the recurrence after1arge artery atherosclerosis stroke. There is nocorrelation between the Severe SWMHs (P=0.721HR=0.8995%CI0.46-1.71) andthe recurrence after1arge artery atherosclerosis stroke. There is a positive correlation between the age (P=0.017HR=1.0395%CI1.01-1.06), NHISS score (P <0.001HR=1.1895%CI1.11-1.24), severe PVWMHs (P <0.001HR=3.3495%CI1.83-6.07) and poor prognosis after1arge artery atherosclerosis stroke. But There isno correlation between the severe SWMHs (P=0.806HR=1.0895%CI0.59-1.95)and poor prognosis.ConclusionsThe1arge artery atherosclerotic cerebral stroke patients who coexisted severe WMHS,severe PVWMHs had a significantly higher risk of recurrence and poor prognosisafter stroke.