Clinical Manifestations Of Cerebral Small Vessel Disease In Ischemic Stroke Patients

Background:Cerebral small vessel disease (CMB) is a hot spot for research nowadays.Up to now, the relationship between cerebral small vessel disease and risk factors, stroke subtype and cognitive impairment is not so clear.Objective:We carried out both retrospective and perspective studies to explore risk factors of small vessel disease (white matter disease and cerebral microbleeds) in ischemic stroke patients. We also tried to look for the correlation between small vessel disease and stroke subtypes. We focused on cerebral microbleeds to study the relationship between cerebral small vessel disease and cognitive impairment together with possible underlying mechanisms.Methods:1)Retrospective Study:We collected 427 patients from May,2007 to Feb. 2010 in Huashan hospital, Fudan University. All patients were above the age of 40 and within the time frame of 1 month when diagnosed as acute ischemic stroke or transient ischemic attack (TIA). We analyzed all risk factors of the patients and divided them into different groups according to the white matter grades determined by Fazekas scale so as to exlplore the independent risk factors of white matter disease and the relationship between white matter disease and stroke subtypes.2)Perspective Study:We collected 51 patients between 45 to 85 who were diagnosed as ischemic stroke or TIA within 2 weeks since onset of symptoms.Those with frontal lobe or thalamus lesions or malignant ischemic lesions were excluded. All patients underwent Susceptibility Weighted Imaging (SWI) and Magnetic Resonance Imaging (MRI).We analyzed risk factors, the severity of white matter disease and the number of cerebral microbleeds of all patients. Referring to the Cholinergic Pathways Hyperintensities Scale (CHIPS), we established Cerebral microbleeds-CHIPS (CMB-CHIPS) to evaluate the impact of CMB on cholinergic pathway.We also used the Beijing Version of the Montreal Cognitive Assessment(MoCA) to evaluate the cognitive function of the patients.Results:1)Retrospective Study:Of the 427 patients,277 were male(64.9%)and 150 were female(35.1%)with an mean age of 62.99±10.68.All patients were divided into 3 groups according to severity of white matter disease.166(38.9%)patients were classified as mild or no lesion,186 (43.6% moderate and 75(17.6%)severe.Age(OR 1.044;95% CI 1.021-1.068).past history of stroke(OR 1.884,95%CI 1.004-3.537) were indepent risk factors of white matter disease;The type of small artery occusion of TOAST was related with white matter disease(OR2.364,95%CI 1.280-4.366);273 of the 427 patients had artety stenosis.There was no statistically significant relationship between the presence of artery stenosis, the lesion site and the severity of stenosis(p>0.05).Both the mild group and the severe group had more stenosis than the moderate group (p=0.016;p=0.035).2) Perspective Study:Of the 51 patients, there were 34 male and 17 female (66.7% and 33.3%) with an age spectrum of 45-84. The mean age was 63.59±9.44.The rate of cerebral microbleeds was 39.2%.We divided these patients into 2 groups:CMB and non-CMB.MoCA scores(OR0.845;95%CI 0.720-0.992),severe white matter disease(OR 9.3;95%CI 1.245-69.445) were independently related to cerebral microbleeds;The rate of cerebral microbleeds was not different among different TOAST subtypes.CMB was negtively correlated with MoCA scores(r=-0.361,p=0.009)while CMB and CMB-CHIPS had positive correlation CMB(r=0.858,p=0.000).We also found the negative correlation between CMB-CHIP and MoCA scores(r=-0.284,p=0.043); Those with CMB had a tendency of lower scores in visual-spatial and executive scores, language scores and abstract ablitity with no statistic significance. The scores of visual-spatial and executive abilities decreased in CMB group in comparison with the non-CMB group (p<0.05).Conclusions:1)Age and past stroke history are independent risk factors of white matter disease; Small artery occlusion of modified TOAST classification is related with white matter disease; 2) Severe white matter disease is an independent risk factor of cerebral microbleeds; Cerebral microbleeds has its correlation with both the severity and progression of cognitive impairment; the multi-filed impairment might be connected with cholinergic pathways lesions.