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Международный неврологический журнал Том 16, №5, 2020

Clinical syndromes of thalamic stroke in the central vascular territory: a prospective hospital-based cohort study

Авторы: S.M. Vinychuk(1), M.M. Prokopiv(2), L.M. Trepet(1), O.Ye. Fartushna(3)
(1) — Oleksandrivska Clinical Hospital, Kyiv, Ukraine
(2) — Bogomolets National Medical University, Kyiv, Ukraine
(3) — Ukrainian Military Medical Academy, Kyiv, Ukraine

Рубрики: Неврология

Разделы: Клинические исследования

Актуальність. У статті проаналізовані й описані патофізіологічні особливості та закономірності виникнення судинних синдромів таламічного інсульту центральної судинної території. Висвітлюються особливості неврологічної клініки, топічної, клінічної та нейровізуалізаційної діагностики таламічного інсульту центральної судинної території за результатами проспективного клінічного когортного дослідження. Мета дослідження: описати та проаналізувати клініко-нейровізуалізаційні особливості судинних синдромів таламічного інсульту центральної судинної території в проспективному клінічному когортному дослідженні. Матеріали та методи. Ми провели проспективне клінічне когортне дослідження 319 хворих iз гострим інсультом, які надійшли до неврологічного центру Олександрівської клінічної лікарні (м. Київ, Україна) протягом перших 24 годин з моменту розвитку інсульту. Усі пацієнти пройшли комплексне клініко-неврологічне, лабораторне, ультразвукове та нейровізуалізаційне обстеження. Результати та висновки. Серед 319 обстежених хворих із гострим інсультом нейровізуалізаційно підтверджений таламічний інсульт діагностовано у 34 (10,6 %) пацієнтів: у 22 (середній вік 61,9 ± 10,2 року) — гострий ізольований інфаркт таламуса, а в 12 (середній вік 59,0 ± 9,6 року) — гострий таламічний крововилив. Проаналізовані, порівняні та описані специфічні неврологічні особливості клінічних судинних синдромів таламічного інсульту центральної судинної території.

Актуальность. В статье проанализированы и описаны патофизиологические особенности и закономерности возникновения сосудистых синдромов таламического инсульта центральной сосудистой территории. Освещаются особенности неврологической клиники, топической, клинической и нейровизуализационной диагностики таламического инсульта центральной сосудистой территории по результатам проспективного клинического когортного исследования. Цель исследования: описать и проанализировать клинико-нейровизуализационные особенности сосудистых синдромов таламического инсульта центральной сосудистой территории в проспективном клиническом когортном исследовании. Материалы и методы. Мы провели проспективное клиническое когортное исследование 319 пациентов с острым инсультом, поступивших в неврологический центр Александровской клинической больницы (г. Киев, Украина) в течение первых 24 часов с момента развития инсульта. Все пациенты прошли комплексное клинико-неврологическое, лабораторное, ультразвуковое и нейровизуализационное обследованиe. Результаты и выводы. Среди 319 обследованных больных с острым инсультом нейровизуализационно подтвержденный таламический инсульт диагностирован у 34 (10,6 %) пациентов: у 22 (средний возраст 61,9 ± 10,2 года) — острый изолированный инфаркт таламуса, а у 12 (средний возраст 59,0 ± 9,6 года) — острое таламическое кровоизлияние. Проанализированы, сравнены и описаны специфические неврологические особенности клинических сосудистых синдромов таламического инсульта центральной сосудистой территории.

Background. The article covers pathophysiological features and patterns of the occurrence of neurological, neuropsychological, and clinical vascular syndromes of thalamic stroke in the central vascular territory. The features of neurological clinical picture, topical, and neuroimaging diagnosis of thalamic stroke in the central vascular territory are analyzed and described in a prospective hospital-based cohort study. The purpose of this study is to determine the features of clinical vascular syndromes of acute thalamic stroke in the lower lateral and adjacent (central, posterolateral) vascular territories in a prospective hospital-based cohort study, providing a comprehensive clinical and neuroimaging analysis. Materials and methods. We have prospectively recruited 319 acute stroke patients, admitted to the Neurological Center at an academic hospital (Oleksandrivska Clinical Hospital) in Kyiv, Ukraine, within 24 hours from the onset of the stroke symptoms. Comprehensive neurological, clinical, laboratory, ultrasound, and neuroimaging examinations were performed to all study patients. Results. MRI-/CT-proven thalamic stroke was diagnosed in 34 (10.6 %) of 319 people, forming a study group. Twenty-two of 34 patients (average age 61.9 ± 10.2 years) were diagnosed with acute isolated ischemic thalamic stroke, and 12 (average age 59.0 ± 9.6 years) had acute thalamic hemorrhage. Conclusions. Specific neurological features of clinical vascular syndromes of acute thalamic stroke in the central vascular territory were analyzed, compared, and described.

Ключевые слова

таламус; інсульт; таламічний інсульт; клінічні особливості; синдром; центральна судинна територія

таламус; инсульт; таламический инсульт; клинические особенности; синдром; центральная сосудистая территория

thalamus; stroke; thalamic stroke; clinical features; syndrome; central vascular territory

doi: http://dx.doi.org/10.22141/2224-0713.16.5.2020.209245

Introduction

Notably, stroke is a leading cause of mortality and disability worldwide, and the economic costs of treatment and post-stroke care are substantial. Every two seconds, someone in the world has a stroke [1–9]. In addition, more young people are affected by stroke in low- and middle-income countries. The incidence of stroke is highest in East Asia, followed by the Eastern Europe, whereas the lowest rates were in Central America [8, 20–22]. As populations age, and low- and middle-income countries go through the epidemiological transition from infectious to non-communicable diseases as the predominant cause of morbidity, together with a concomitant increase in modifiable risk factors, it is expected that the burden of stroke will further increase until effective stroke prevention strategies are more widely implemented [20, 21]. Thalamic strokes, both alone and in combination with strokes involving other structures, are not rare, accounting for approximately 11 to 23–25 % of all posterior circulation strokes, especially in combination with damage to other structures [23–25].

The thalamus, with its cortical, subcortical, and cere-bellar connections, is a critical node in networks supporting cognitive and motor functions, managing our sensitivity to a temperature, light, and physical touch. It controls the flow of visual, auditory, and motor information, being also involved in different aspects of learning, memory, speech, language understanding, motivation, attention and wakefulness, being in charge of our sense of balance and awareness of our arms and legs. It controls how we experience pain, and even emotional experiences, expressions, and our personalities involve the thalamus. However, currently, there are not enough published prospective hospital-based cohort studies that report and analyze pathophysiological features and patterns of the occurrence of neurological, neuropsychological, and clinical vascular syndromes of thalamic stroke in the central vascular territory, and their topical diagnosis using clinical, neurological, and neuroimaging methods in a prospective hospital-based cohort study [25–31]. Given all this, we performed a comprehensive clinical and neuroimaging analysis of the treatment results and assessed the outcome of the disease in 34 patients with thalamic stroke: 22 of them had isolated thalamic infarction and 12 — hemorrhage in the thalamus.

The purpose of this study is to describe and analyze the clinical and neuroimaging features of vascular syndromes of thalamic stroke in the central vascular territory in a prospective hospital-based cohort study, providing a comprehensive clinical and neuroimaging analysis.

Materials and methods

Study setting and patients

We have conducted a prospective hospital-based cohort study of acute thalamic stroke patients. All participants were admitted to the Neurological Center of Oleksandrivska Clinical Hospital (Kyiv, Ukraine) within the first 24 h since the first stroke symptoms occurred. The Neurological Center of Oleksandrivska Clinical Hospital consists of an admission department, clinical department of neurology, department of cerebrovascular pathology with intensive care/stroke unit, and a research department of neurology. Study subjects were recruited from the hospital emergency departments, and hospital wards between 2001 and 2011. All stroke patients were reviewed by at least two board-certified neurologists with training in cerebrovascular diseases. Clinical history, 12-lead electrocardiogram, blood testing, carotid ultrasound, head computed tomography (CT) and/or brain magnetic resonance imaging (MRI) were obtained for all participants.

Patient inclusion and exclusion

The methods of the study, inclusion and exclusion criteria have been reported in detail previously [29–31, 46–48]. In brief, only acute thalamic stroke patients aged 18 years or older were included.

Study endpoints and risk factors definitions

Study endpoints of interest were acute ischemic and/or hemorrhagic thalamic strokes. Stroke was defined according to the criteria of the World Health Organization, American Heart Association/American Stroke Association guidelines for adult stroke, and was confirmed by neuroimaging [32, 33]. The etiology of stroke was classified according to the TOAST criteria [34]. The National Institutes of Health Stroke Scale, the Modified Rankin Scale, the Barthel index, and the Charlson Comorbidity Index were determined for all participants. Secondary stroke prevention was prescribed according to the American Heart Association/American Stroke Association and the European Stroke Organisation guidelines, immediately after the stroke diagnosis was made [35–41]. Stroke education programs were provided to all study participants [11, 16, 30, 42–48].

Statistical analysis

Parametric and non-parametric statistic methods were applied. The log-rank test was used for univariate comparisons of event-free survival between groups. A two-sided p < 0.05 was considered significant for all analyses. All statistical analyses were performed using IBM SPSS Statistics Version 22.

Results and discussion

Basic characteristics of study population

In total, 319 adult patients with acute MRI-/CT-proven stroke were screened, 34 of them were diagnosed with thalamic stroke, forming a study group. Twenty-two (12 men, 10 women aged 50–84 years; average age 61.9 ± 10.2 years) of 34 study group patients were diagnosed with acute isolated ischemic thalamic stroke, and in the rest 12 patients (5 men, 7 women aged 57–75 years; average age 59.0 ± 9.6 years), thalamic hemorrhage was detected.

Vascular symptoms of stroke in the central thalamic vascular territory

Stroke of the central vascular territory was detected in 2 (9.1 %) patients. This area consists of few thalamic zones that are mainly located between the paramedian, upper and lower lateral territories. These zones are the distal territories of three arterial systems: paramedian, tuberothalamic, and thalamogeniculate. Strokes of the central vascular territory were caused by arterial hypertension and accompanied by impaired consciousness, short-term verbal and visual memory, cognitive impairment, contralateral homonymous hemianopsia, emotional central paresis of facial muscles, vertical gaze palsy, hemihypesthesia, and sensitive ataxia on the side opposite to the lesion.

Isolated thalamic infarction of the central vascular territory is often manifested itself by hemianesthesia, bianesthesia associated with ataxia due to damage to the middle part of the ventral posterolateral nucleus. At the same time, a variety of neuropsychological disorders are revealed. In our study, in one patient we determined the asymmetry of the face that appears during pain, smile, and laughter, so-called emotional central paresis of the facial muscles. However, all voluntary facial movements (frowning, closing eyes, grinning) persisted. This symptom was described by the one of the most eminent research workers and clinicians in the second half of the 19th century, an Austrian physician Hermann Nothnagel. The occurrence of this particular symptom is associated with the damage to the Luys body and the psychoreflex pathway for mimic movements, the sensitive part of which is represented by the thalamus, and the motor part is represented by the extrapyramidal system. The role of the mimic center is attributed to the median nuclei of the thalamus [30]. Thalamic stroke in the central vascular territory interrupts this arc, and, as the result, emotional paresis of the facial muscles develops. Mimic disorders in this case are one-sided. Abnormal upward gaze is an expected symptom due to a pathological effect on the supranuclear pathways responsible for vertical gaze control.

Clinical and anatomical correlation of thalamic strokes

For a better understanding of the vascular syndromes that occur after thalamic stroke, we analyzed a clinical and anatomical correlation of thalamic strokes based on the detailed description of neurological symptoms and arterial localization of stroke foci, verified by the neuroimaging methods (Table 1).

Thus, isolated thalamic strokes represent a heterogeneous group of strokes that are divided to those of the anterior, paramedian, lower lateral, and posterior vascular and anatomical territories.

The results of our study indicate that thalamic strokes are more often localized in the classical vascular territories — the lower lateral (40.9 %) and paramedian (27.3 %), and less often — in the borderline vascular zones: posterolateral (22.7 %) and central (9.1 %) [29–31, 46–48].

Conclusions

Summarizing, we would like to highlight that the loss of consciousness, contralateral hemianesthesia, hemiataxia, homonymous hemianopsia, emotional central paresis of facial muscles and cognitive impairment were detected in patients with stroke in the central vascular territory.

Conflicts of interests. Authors declare the absence of any conflicts of interests and their own financial interest that might be construed to influence the results or interpretation of their manuscript.

Author contributions

S.M. Vinychuk — study concept and design, statistical analysis, interpretation of data, literature overview, critical revision of the manuscript for important intellectual content; M.M. Prokopiv — study concept and design, data acquisition, statistical analysis, interpretation of data, lite-rature overview, critical revision of the manuscript for important intellectual content; L.M. Trepet — study design, data acquisition, statistical analysis, interpretation of data; O.Ye. Fartushna — study concept and design, literature overview, statistical analysis, interpretation of data, article concept and design, drafting the article, critical revision of the manuscript for important intellectual content.

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