Risk for poor outcomes appears higher in diabetic patients with lacunar stroke

Patients with diabetes who have lacunar stroke are at higher risk for death and recurrent stroke than patients without diabetes, according to a recent study.

Researchers performed a cohort study that compared patients with and without diabetes who had lacunar strokes and were participating in the international Secondary Prevention of Small Subcortical Strokes (SPS3) trial. The goal of the study was to analyze data on patient characteristics, infarct locations, and recurrent vascular strokes in diabetic patients with lacunar stroke. Features at study entry and prognosis during 3.6-year follow-up were compared in patients with and without diabetes. The study results were published online July 17 by Stroke.

A total of 3,020 patients were included in the analysis, 1,106 of whom (37%) had diabetes mellitus. The mean duration of diabetes was 11 years in patients with a diagnosis of diabetes at study entry. An independent association was observed between diabetes and slightly younger age (63 vs. 64 years; P<0.005), Hispanic ethnicity (36% vs. 28%; P<0.0001), ischemic heart disease (11% vs. 6%; P=0.002), and peripheral vascular disease (5% vs. 2%; P<0.0004).

Intracranial stenosis of 50% or greater and infarcts of the brain stem or cerebellum were significantly more common in patients with diabetes (P<0.0001 for both comparisons). More extensive abnormalities of the white matter were also more common in diabetic patients, but the between-group difference was not significant after the authors adjusted for additional independent predictors (P=0.11). Recurrent stroke (hazard ratio [HR], 1.8; 95% CI, 1.4 to 2.3), recurrent ischemic stroke (HR, 1.8; 95% CI, 1.4 to 2.4), disabling or fatal stroke (HR, 1.8; 95% CI, 1.2 to 2.9), myocardial infarction (HR, 1.7; 95% CI, 1.0 to 2.8), and death (HR, 2.1; 95% CI, 1.6 to 2.8) were all more common in patients with diabetes than in those without. Risk of nonvascular death (HR, 1.6; 95% CI, 0.9 to 2.6) or major extracranial hemorrhages (HR, 0.88; 95% CI, 0.6 to 1.3) did not differ significantly by diabetes status.

The authors noted that they had no data about control of diabetes mellitus during follow-up and that the inclusion and exclusion criteria for the SPS3 trial may have introduced selection bias. However, they concluded that patients with diabetes and lacunar strokes have a distinctive risk factor profile along with infarct location, have double the prevalence of systemic and intracranial atherosclerosis, and “carry a substantially worse prognosis compared with patients without diabetes mellitus.” They recommended further study of this high-risk subgroup.