Functional, Cognitive, Physical, and Vascular Outcomes 9 Years After Lacunar and Mild Cortical Ischemic Stroke

Abstract

Background and objectives: Data on outcomes after minor stroke, especially lacunar stroke, are lacking or based on short follow-up. Outcome differences between lacunar and cortical stroke remain unclear but may provide insights into small vessel disease (SVD) etiology and prognosis. We report on dementia, death, recurrent stroke, and function up to 9 years after lacunar or minor cortical ischemic stroke.

Methods: In this 9-year longitudinal observational cohort study, we prospectively recruited participants presenting with mild, nondisabling lacunar or cortical ischemic stroke to Lothian Stroke Services in Edinburgh, United Kingdom. At baseline, we collected data on sociodemographics, vascular risk factors, dependence, cognition, and brain MRI. At 9 years, we used questionnaires (including items from the Stroke Impact Scale) and hospital/general practitioner records to assess dementia, recurrent stroke, death, cardiac diseases, vascular risk factors, dependence, recovery, and functionality.

Results: We recruited 264 participants; clinical data were available for 243 participants (92%) (baseline mean age 67 years (SD 12), 42% female, 44% with lacunar stroke) and self-reported functional data for 96 (36%) at a mean follow-up of 8.5 years (SD 0.57). Dementia was diagnosed in 9.4% of participants with lacunar stroke and 12.4% of those with cortical stroke, with risk increasing with age (odds ratio [OR] 1.08; CI 1.030-1.130). Recurrent stroke occurred in one-third of all participants; risk increased with the presence of vascular risk factors (OR 2.27; CI 1.287-4.032). Participants with cortical stroke were more likely to die compared with those with lacunar stroke (χ² = 8.2; p = 0.004). Age (OR 1.09; CI 1.051-1.133), male sex (female OR 0.40, CI 0.196-0.818), and white matter hyperintensities (OR 1.36; CI 1.112-1.664) increased risk of death. Moderate/severe disability was reported by 12% of participants and cognitive concerns by 49%-55%. Affected limb recovery and balance were worse after lacunar stroke (W = 705.5, p = 0.00).

Discussion: Long-term outcomes after minor stroke were frequently suboptimal and varied by stroke subtype, highlighting the lasting impact of both lacunar and mild cortical ischemic strokes on quality of life. Improving long-term outcomes after mild stroke remains an important target for refining clinical care and shaping future research directions.

Figure 1. Participant Flowchart

Participant flowchart for clinical outcomes (left) based on a combination of general practitioner records, hospital record data, and participant questionnaire response and for functional and self-reported well-being outcomes (right) based on a postal questionnaire sent to participants 9 years after initial study recruitment.

Figure 2. Stroke Subtype and Clinical Outcomes at 9 Years

Logistic regression results for the association between possible predictors (including stroke subtype) and clinical outcomes: dementia, recurrent stroke, death, and cardiac diseases. ICV = intracranial volume; NIHSS = NIH Stroke Scale; WMH = white matter hyperintensity.

Figure 3. Kaplan-Meier Survival Curves Comparing Death Rates Between Cortical and Lacunar Stroke at 9 Years After Stroke (n = 143)

The log-rank test indicated a significant difference in survival probabilities between the groups, where cortical stroke may have worse survival outcomes compared with lacunar stroke (χ² = 8.2; p = 0.004).

Figure 4. Participants With Diagnosed Hypertension, Diabetes, Hypercholesterolemia, and/or Atrial Fibrillation at Baseline, Along With New Diagnoses Acquired Between Baseline and the 9-Year Follow-Up, in Cases of Lacunar or Cortical Ischemic Stroke

Figure 5. Longitudinal Disability and Functional Independence at Baseline and 9 Years After Minor Ischemic Lacunar (Dark Pink) or Cortical Stroke (Light Pink) (n = 93)

mRS = modified Rankin Scale.