Stroke: Highlights of Selected Articles.

In this article, Kaffashian and colleagues sought to determine whether white matter hyperintensities and covert brain infarcts (BI) were associated with different stroke subtypes other than small vessel disease, as has been previously shown. To that end, they prospectively followed 1731 stroke-free participants from the Three-City Dijon Study who had brain magnetic resonance imaging data, for ≤12 years. An automated imaging processing software was used to detect, localize, and measure white matter hyperintensity volume (WMHV). Lesions ≥3 mm with the same signal as cerebrospinal fluid were considered covert BI. In this substudy, the majority of subjects were women (61%), and the mean age was 72±4 years. Mean follow-up was 9.6±2.4 years. All participants had some degree of WMHV, and 9% had >1 covert BI. High total and periventricular WMHV and extensive periventricular WMHV were associated with ischemic and hemorrhagic strokes, especially hemorrhagic strokes. Of the ischemic stroke subtypes, cardioembolic stroke was associated with extensive periventricular WMHV. Conversely, deep WMHV and extensive WMHV were associated with hemorrhagic strokes only. Interestingly, covert BI was associated with incident cerebral hemorrhage but not with incident ischemic stroke. Furthermore, lacunes were associated with both stroke types, but the association was much more robust for incident intracerebral hemorrhage than for incident ischemic stroke. As expected, lacunes were associated with small vessel ischemic stroke. This study’s surprising findings may raise certain considerations regarding the management of patients with covert BI and extensive WMHV, as discussed by the authors. Namely, should antithrombotics be given to patients with covert BI, or could that increase their risk of cerebral hemorrhage? Should atrial fibrillation be sought for in patients with extensive periventricular WMHV? These observations deserve attention, but need to be confirmed in other large prospective studies. See p 1923.