Prevalence Features and Early Predictors of Symptomatic Lacunar Infarction in Villages and Towns in Northern China

Background: A higher incidence of symptomatic lacunar infarction (LI) was confirmed in metropolitan areas. The aim of this study was to determine the prevalence characteristics and early predictors of LI in a population of elderly outpatients in northern China. Methods: From February 2011 to March 2012, a retrospective cohort of new patients was selected for study, all registered neurologic outpatients of the tertiary teaching hospital in northern China. A total of 453 outpatients, clinically only having had an initial visit and a magnetic resonance imaging study of the brain, were enrolled. The prevaleence characteristics and vascular risk factorsof LI were assessed. Results: Of 453 symptomatic outpatients, 258(57.0%) patients had symptomatic LI. We found that the main types of symptomatic LI were nonfocal symptoms, such as dizziness and headache, dizziness/vertigo, and migraine/headache. Age, BMI, smoking, history of hypertension, duration of hypertension, existing hypertension, headache and dizziness, pure motor hemiparesis, blood glucose, hypercholesterolemia, systolic blood pressure, and ABCD2 score, were significantly higher in patients with LI than in those without LI (P<0.05). Multivariate logistic regression confirmed that hypertension ≥3years in duration (odds ratio=1.092; 95% CI, 1.019 -1.170) and a median mABCD score ≥4 (odds ratio=3.912; 95% CI, 2.9555.180) were independent, early predictors of symptomatic LI. Conclusions: The incidence of LI in Northern China was located at the higher end of range in northern China, and common type of symptomatic LI was nonfocal symptoms. Hypertension of long duration and highrisk ABCD scores are early predictors of symptomatic LI. DOI : 10.14302/issn.2470-5020.jnrt-15-726 Corresponding Author : Dr. Dao-Ming. Tong (be also known as Yan-Song. Tong), Department of Neurology, Shuyang People' Hospital, Xuzhou Medical College, No. 9, Yingbin Road, Shucheng, Jiangsu, China,Email: tongdaoming@163.com, or yansongt@sina.com


Introduction
Some studies even suggest that small emboli from the heart may also be an important mechanism of LI. 6,7 Deep brain gray and white matter are typically involved, as well as white matter near cortex.The macrovascular complications of LI are often a consequence of cardiovascular damage and generally carry a worse prognosis than small-artery disease. 5With increasing longevity, a higher incidence of symptomatic LI(31.4%-43%) was confirmed in metropolitan areas. 8,9Pivotal work by Fisher (since 1965) cites 21 variants of lacunar syndrome, based on studies of neurology inpatients.However, very little information, particularly in terms of incidence and clinical characterization, has come from neurology outpatient sources in the villages and towns.The purpose of this study is to explore incidence, clinical features, and early predictors of symptomatic LI in neurology outpatients from a county town and villages in northern China.On MRI, diagnostic criteria of recent LI were as follows:

Patients and Methods
(1) a round or ovoid lesion of increased signal relative to white or deep gray matter on DWI, FLAIR, or T2; (2)   hypointensity on the apparent diffusion coefficient map (or decreased attenuation relative to white/gray matter on CT); (3) maximum diameter ≤20 mm; and (4) location in cerebral hemispheric white matter, in basal ganglia, or in the brain stem. 10 We identified asymptomatic LI as sharply demarcated hyperintense lesions <20 mm on T2-weighted images with corresponding hypointense lesions with a hyperintense rim on FLAIR.In LI patients, the lesion could not be compatible with the clinical syndromes.
One point was awarded when one or more asymptomatic LI were present.
The nonfocal symptoms such as isolated headache or dizziness which can be attributed to the LI, were defined as follow.
Migraine/headache: migraine/headache is a common risk factor for cerebrovascular disease [11][12][13] and is a common complaint (with or without aura) in neurologic outpatient clinics.The problem is usually recurring, affecting the forehead, temporal or occipital areas, or the entire head.Duration of symptoms can be from minutes to hours (generally <24 hours), although some may be recurrent or continuous for a few days or more.
Dizziness/vertigo: Dizziness or vertigo, also known as acute vestibular syndrome, 11 refers to the sudden onset of head movement can not be tolerated, masonic instability, nausea or vomiting, or nystagmus.Dizziness is a top-heavy feeling, but may encompass an element of spatial movement (tilting or shake).Vertigo can be described as the brain suddenly swinging back and forth like an obstruction, severe loss of balance, and the entire space itself greatly to the side of the rotation, and even fell to the ground.Dizziness or vertigo is often recurrent (lasting seconds to minutes; usually <24 hours) and may occur in continuous repeated episodes, of several days or longer, or persistent episodes, lasting more than a few days.
5][16] It is a posterior circulation symptom, but is also may be reflected a symptom of anterior circulation.
Generally speaking, vertigo differs from dizziness only in terms of severity, but the boundaries here are blurred.3).

Discussions
The earliest epidemiological data showed a 12% incidence of LI in the general population. 18With increasing longevity in this century, existing clinical data indicate a 14%-33% incidence of LI in metropolitan areas in developed countries.From our data, the full spectrum of variables analyzed, including history of hypertension, duration of hypertension, existing hypertension (proportionate), mABCD 2 scores, and more, were significantly higher in patients with LI than in those without LI (P <0.05).
Multiple logistic regression, incorporating these risk factors, found that only hypertension ≥3 years in duration and ABCD 2 scores ≥4 were significantly and independently predictive of LI.Hypertension alone is a recognized risk factor for stroke, 18,19,20,31,32 but our data indicates that long-term hypertension specifically is an early predictor of LI.
Some limitations of our study are conceded.Instances of unexpected stroke are often routed directly from an ambulance or emergency room to the ICU, especially when the consciousness or motor weakness is involved (not uncommon). 33,34This may account for the lower frequency of pure motor LI in our general neurology outpatients.
In conclusion, symptomatic lacunar infarcts have a very

A
retrospective cohort of consecutive new patients was selected for study between February 2011 and February 2012.All were registered neurologic outpatients of the tertiary teaching hospital in northern Jiangsu, China.A total of 453 outpatients, clinically only having had their initial visit and having undergone a magnetic resonance imaging (MRI) study of the brain, were enrolled.The sample consisted of males and females, aged 40 years or older, 93% of subjects from 38 villages or towns and only 7% from one urban in Shuyang of northern China The following risk factors were recorded by an experienced neurologist on two separate occasions (Weeks 1 and 5): gender, age, BMI, history of hypertension, diabetes mellitus, history of heart disease, snoring, alcohol use, smoking, systolic blood pressure, diastolic blood pressure, migraine/headache, dizziness/vertigo, dizziness and headache, numbness or pure sensory stroke, weakness or pure motor hemiparesis, and gait disturbances or ataxia.All patients submitted to MRI of the brain within 24 hours of the first visit.The MRI was performed with 1.5 -T equipment (Siemens).MR sequences included conventional T2, fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted images(DWI) on axial view, from medulla to cortex, at 5-mm section thickness.Select patients underwent MRA, CT, and color-coded Duplex sonography.All MR studies were reviewed by a neuroradiologist and a neurologist.The examiners looked specifically for hyperintense lesions on FLAIR or DWI, measuring maximum diameters when present and attempting to correlate MR findings with clinical status.The number and location of lesions were recorded in detail for each patient.
reports also specify that two-thirds of recent transient symptoms are accompanied by FLAIR-confirmed LI, which validates the TSI concept.In view of these findings, we offer two likely scenarios.Alternatively, it may be that either some lesions on FLAIR are asymptomatic LI, or the transient manifestation is triggered elsewhere in the vasculature of the brain, without demonstrable tissue change.
high prevalence in northern China and common type of symptomatic LI is nonfocal symptoms.Statistical analyses involving a host of variables established hypertension of long duration and high-risk ABCD 2 scores as early predictors of LI.

Freely Available Online www.openaccesspub.org | JNRT CC-license DOI : 10.14302/issn.2470-5020.jnrt-15-726
and ≤ 20 mm in diameter on MRI-DWI and/or FLAIR.Clinically, diagnosis of symptomatic LI was on presenting with one of 21 lacunar syndromes classified by Fisher, or nonfocal or mixed symptoms which can be attributed to an acute LI.

Table 1 .
Clinical characteristics in patients with LI Dizziness and headache: dizziness and headache may develop alternately or together.This dual symptomology reflects a disorder of the anterior circulation, alone or in combination with a posterior circulatory problem.In an outpatient setting, patients'dizziness and headache are commonly linked with transient ischemic attacks (lasting minutes to hours; usually < 24 hours).Yet, dizziness and headache may persist for several days or longer.presentuse of antihypertensive agents or a systolic blood pressure [SBP] >140 mmHg and/or a diastolic BP [DBP] >90 mmHg, measured in a sitting position with least amount of antihypertensive medication); impaired fasting glucose (fasting plasma glucose of 5.6 -6.9 Freely Available Online www.openaccesspub.org|JNRT CC-license DOI : 10.14302/issn.2470-5020.jnrt-15-726Vol-1Issue 1 Pg.no.-31 mmol/L; diabetes (fasting plasma glucose level ≥7.0 mmol/L, A1C ≥6.5%, or random plasma glucose >11.1 mmol/L , associated with symptoms of hyperglycemia); test, Mann-Whitney U test, and Kruskal-Wallis test were used to explore the relationship between baseline patient variables.Univariate and multiple logistic regression analyses were used to determine the risk factors of LI.Data were analyzed using SPSS version 17.0 (SPSS Inc., Chicago, IL, USA), with of significance set at P<0.05.Dizziness with headache in patients with LI occurred in the second (28.3%), and its temporary symptoms are observed 76.7%.The third most common types of symptoms is isolated migraine/ headache (21.7%), the transient symptoms were up to 91.0%.The others were followed by Fisher′ several traditional LI types, including pure sensory stroke or TIA (12.8%), pure motor hemiparesis (3.9%), ataxic hemiparesis (0.8%), and so on.scaleVol-1 Issue 1 Pg.no.-32In addition to a small number of patients (8.1%) were single LI, the remaining 91.9% of the symptomatic patients were multiple LI (median =7).The distributions of lesions were most common in the anterior circulation

Table 2 .
The results of univariate analysis in patients with or without LI

Table . 3
. Multivariate odds ratios for early predictors of LI BMI=Body mass index.ABCD2= Age, blood pressure, clinical features, duration of symptoms, and presence or absence of diabetes; scores range from 0 to 7, with higher scores indicating greater risk of stroke.