Impact of white matter hyperintensity on the long-term outcome in stroke patients with large artery atherosclerosis

Abstract

Background: The presence of white matter hyperintensity (WMH) is related with poor long-term outcomes. Previous studies showed that the highest mortality rates were reported in patients with large atherosclerosis (LAA) or cardioembolism, and the lowest with lacunar strokes. However long-term outcome is unknown in patients with LAA and WMH. We investigated the impact of WMH on the long-term outcome in patients with LAA. Methods : From May 1999 to June 2007, consecutive patients with acute ischemic stroke were included. They were followed for a median of 7.7 years (interquartile range, 5.5–9.9). Long-term mortality and causes of death were identified using death certificates or telephone interviews. Degree of WMH was assessed by Fazekas grade on fluid-attenuated inversion recovery image. Severe WMH was defined as Fazekas grade ≥2. Results: Among 2913 patients, the stroke subtype was LAA in 753 patients (25.8%). After excluding patients with unavailable FLAIR images, data of 556 patients were analyzed. Mean age was 65.6 ± 10.3 years and 66.9% were men. Severe WMHs were found in 286 patients (51.4%). During follow-up, 208 patients (37.4%) died. The Kaplan-Meier survival analysis showed that old age, diabetes, initial national institutes of health stroke scale, and severe WMH were associated with long-term mortality. The Cox regression analysis showed that severe WMH was an independent predictor for long-term mortality. LAA patients with severe WMH showed 1.57-fold (95% CI, 1.17-2.11) higher mortality rate compared to those without. Conclusion: The degree of WMH might be one of surrogate markers for long-term outcome in patients with LAA. Atherosclerotic burdens in both small and large arteries might impact on long-term prognosis in ischemic stroke patients.