Periventricular white matter lucencies in patients with lacunar stroke. A marker of too high or too low blood pressure?

Background: Periventricular white matter lucencies (PWML) have been described in stroke patients with arterial hypertension, hypotensive episodes, or increased nocturnal fall of blood pressure (BP). As a result of these mixed factors, the relationship between PWML and BP remains unsettled and the appropriate management of arterial BP in stroke patients with PWML is unknown.

Objective: To clarify the relationship between PWML, arterial BP, and cerebral hemodynamics.

Design: Cohort study followed up 6 months after index stroke.

Setting: Referral center.

Patients: In 41 consecutive patients with first-ever lacunar infarction, the extent of PWML detected on brain magnetic resonance images was measured. Six months after stroke, BP values were monitored during a 24-hour period and transcranial Doppler examinations were performed at rest and following the administration of acetazolamide.

Main Outcome Measures: Correlation of cerebral hemodynamics and BP values with the extent of PWML.

Results: The severity of PWML varied substantially among patients, suggesting that PWML and lacunar infarctions could be due to several different mechanisms. Older age, elevated awake systolic BP, increased cerebrovascular tone, and the interaction between history of heart disease and the lowest heart rate were the strongest independent predictors of the severity of PWML. Diastolic BP and the vasodilatory capacity of the resistance vessels did not predict the severity of PWML.

Conclusions: Overall, PWML are markers of systolic damage in older lacunar stroke patients with stiffer arteries. In addition, hemodynamic failure may be relevant in patients with concomitant heart disease.