MNJ (Malang Neurology Journal) Vol. 9, No.

1, January 2023

http://mnj.ub.ac.id/
DOI: 10.21776/ub.mnj.2023.009.01.5
eISSN: 2442-5001 pISSN: 2407-6724
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RESEARCH ARTICLE OPEN ACCESS

CHARACTERISTICS OF ACUTE ISCHEMIC STROKE

PATIENTS DUE TO SMALL VESSEL OCCLUSION
Richard Suherlim1, Nyoman Angga Krishna Pramana2, Kumara Tini3, Ida Bagus Kusuma Putra2, Ida Ayu Sri Indrayani2

Correspondence: [email protected]
1Neurology Resident, Faculty of Medicine, Universitas Udayana/Sanglah Hospital Denpasar, Bali, Indonesia.
2Neurology Consultant, Faculty of Medicine, Universitas Udayana /Sanglah Hospital Denpasar, Bali, Indonesia.
3Neurology Consultant, Faculty of Medicine, Universitas Udayana/Univesitas Udayana Hospital, Bali, Indonesia.

Article History: ABSTRACT

Received: June 22, 2022
Accepted: October 28, 2022 Background: Ischemic stroke account for about 87% of all stroke cases. This study will focus on
Published: January 1, 2023 ischemic stroke due to small vessel occlusion as one of the subtypes based on TOAST (trial of ORG
10172 in acute stroke treatment).
Cite this as: Objective: To determine the characteristics of ischemic stroke patients caused by small vessel
Suherlim R, Pramana NAK, Tini occlusion and are expected to be used as a basis for further research.
K, Putra IBK, Indrayani IAS. Methods: A descriptive observational retrospective study regarding the characteristics of acute
Characteristics of acute ischemic ischemic stroke patients due to small vessel occlusion at Sanglah Hospital. Secondary data were
stroke patients due to small vessel obtained from patient medical records.
occlusion. Malang Neurology Results: The total number of cases of small vessel occlusion was 338. The majority of the sample
Journal; 2023.9:24-27. DOI: were men (64.5%) between 40-60 years old (53.6%). Most of the samples were patients who had
http://dx.doi.org/10.21776/ub.mnj
experienced an ischemic stroke for the first time (75.1%) with NIHSS (National Institute of Health
.2023.009.01.5
Stroke Scale) scores showing mild (48.2%) and moderate (51.5%) symptoms. Around half of them
had a history of hypertension (60.1%), dyslipidemia (59.5%), and diabetes mellitus (44.1%). The most
common location of infarction was in the anterior circulation (77.5%) with almost the same ratio of
right and left hemisphere locations.
Conclusion: Ischemic stroke due to occlusion of small vessels at Sanglah Hospital Denpasar for 3
years was 35.2% of the total ischemic stroke cases. Half of the total sample had classic vascular risk
factors. Further research is needed to determine another effective treatment strategy other than just
secondary prevention such as life style moderation to prevent recurrency.
Keywords: Ischemic stroke, small vessel occlusion, characteristics

Introduction ischemic strokes patients 62.3% have hypertension, 58.1%

have dyslipidemia, 34.7% are diabetics, and 41.3% are
Acute ischemic stroke (AIS) is a sudden loss of blood flow cigarette smokers.4
to an area of the brain resulting in neurological deficits. In 1993, a classification of ischemic stroke was introduced
Ischemic stroke account for about 87% of all stroke cases, based on the etiologic mechanism thought to cause the
while the rest are hemorrhagic strokes. Ischemic stroke can stroke to test the efficacy of the drug in improving
be caused by a thrombotic process or embolism in the outcomes among patients with ischemic strokes with. The
anterior or posterior circulation. Vascular territory and the classification is known as TOAST (The Trial of Org 10172
volume of ischemic brain tissue determine the type and in Acute Stroke Treatment) which divides ischemic stroke
severity of the neurological deficits that arise.1,2 In 2013, into 5, namely large vessel occlusion, small vessel
there were 25.7 million people living after stroke. In occlusion, cardio embolism, other determined etiology, dan
Indonesia, the prevalence of stroke is 0.02-8/1000 people. undetermied etiology.5
In 2010, the disability-adjusted life years lost/100.000
people in Indonesia was 3,382 years due to ischemic This study will focus on ischemic stroke due to small vessel
stroke.3 occlusion, because based on daily practice, small vessel
occlusions ischemic stroke presents with non life
Stroke is a disease that is considered as a result of exposure threatening conditions, so the patient usually forget about
to risk factors in the long term. Stroke risk factors are their stroke and moving on with their life without adjusting
divided into non-modifiable and modifiable. Non- their life style nor taking the medicine and it leads to high
modifiable risk factors include gender, age, ethnicity, and reccurency of the stroke. Ischemic stroke due to small
race. Modifiable risk factors include hypertension, vessel occlusion is defined as a lacunar syndrome without
dyslipidemia, diabetes, atrial fibrillation, smoking, alcohol cortical symptoms, with CT or MRI imaging showing a
use and drug abuse. Previous studies has shown that lesion less than 1.5 cm in diameter.5

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Hypertension and diabetes mellitus are risk factors that are ischemic stroke for the first time (75.1%) with NIHSS
highly correlated with the incidence of small vessel scores showing mild (48.2%) and moderate (51.5%)
ischemic stroke. The proportion of patients who were symptoms. Most of the samples experienced disturbances in
independent after lacunar stroke was 42% after 3 years after the cranial nerves and motor system and only 9.5% of the
stroke.6 This study aims to obtain the characteristics of samples experienced symptoms of sensory disturbances.
ischemic stroke patients caused by small vessel occlusion. Based on the risk factors studied, around half of the
It is vital to start collecting these datas, so they can used as samples had a history of hypertension (60.1%),
the basis for further research on prognosis or good dyslipidemia (59.5%), and diabetes mellitus (44.1%).
therapeutic methods in ischemic stroke patients due to Meanwhile, only a small part of the total sample is an
small vessel occlusion. active smoker or has a history of smoking (16.9%).
The results of the CT scan show various infarct locations.
Methods In this study, the most common location of infarction was
This is a descriptive observational retrospective study in the anterior circulation (77.5%) such as the internal
regarding the characteristics of patients with acute ischemic capsule and basal ganglia. The comparison of the locations
stroke due to small blood vessel occlusion at Sanglah of the infarcted hemispheres is almost the same, namely on
Hospital, Denpasar, Bali during the period 2019 to 2021. the right side of 145 samples and on the left side of 141
The sample was taken based on the patient's medical samples.
record, where all patients who met the inclusion criteria
were included in this study. In this study, the number of Ischemic Stroke TOAST
samples was 338 patients and all was collected by 1 person. Classification
This research has been approved by Udayana University
Ethic Committee and received ethical examption 400 338 365
No:1958/UN14.2.2.VII.14/LT/2022. 350
300 219
The inclusion criteria for samples were as follows: (1) A 250
200
clinical diagnosis of acute ischemic stroke (2) A CT scan or 150
100 30 6
MRI of the head was performed (3) Meeting the clinical or 50
radiological criteria for small vessel occlusion (4) Data of 0
the history taking and risk factors are available (5) Data of
vital signs and neurological examinations are available (6)
Data of lipid profiles and blood sugar are available.
Exclusion criteria for patients were patients with decreased
consciousness and cardiac arrhythmias. The data were
inputted in the microsoft excel 2019 in time order, starting Figure 1. TOAST classification of acute ischemic stroke Sanglah
demographic data, risk factors, CT, and neurological Hospital 2019-2021. The majority was large and small artery
deficits. Those data transferred to SPSS to be analyzed. oclussion.
The collected data is demographic characteristics on the Table 1. Characteristics of the Research Sample
distribution of the research sample which includes age, Variable n (%) Variable n (%)
gender, and other risk factors such as hypertension, diabetes Gender Age (years old)
mellitus, dyslipidemia, cigarette smoking, location of Male 218 (64,5) < 40 13 (3,8)
infarct on CT, grade of paralysis, NIHSS on admission to Female 120 (35,5) 40-60 181 (53,6)
determine symptoms severity, and choice of anti-platelet > 60 144 (42,6)
aggregation. Hypertension, diabetes, dyslipidemia, and NIHSS Infarct
cigarette smoking were determined by history taking and 0-4 163 (48,2) Location 262 (77,5)
laboratory results on admission . The infact location was 5-15 174 (51,5) Anterior 24 (7,1)
determined by the radiologist. 16-20 1 (0,3) circulation 52 (15,4)
>20 0 Posterior
circulation
Results Normal
Risk Factors Antiplatelet
This study used a sample of acute ischemic stroke patients Diabetes 149 (44,1) aggregation
who were treated at Sanglah Hospital Denpasar from Mellitus 203 (60,1) drug 259 (76,6)
January 2019 to December 2022. The total number of acute Hypertension 201 (59,5) Aspirin 12 (3,6)
ischemic stroke patients was 958. From the 958 samples, Dyslipidemia 57 (16,9) Clopidogrel 63 (18,6)
samples were re-selected that met the criteria for stroke due Cigarette DAPT 4 (1,2)
to small vessel occlusion, so that the sample in this study is smoking Others
338 (35.2%). Demographic data, risk factors, symptom Infarct Site
Right 145 (42,9)
severity from the NIHSS score, location of infarction,
Left 141 (41,7)
recurrency, and the type of antiplatelet aggregation therapy Normal 52 (15,4)
used in those samples are noted. *DAPT: Double Anti-Platelet Therapy
The majority of the sample in this study were men (64.5%)
with the highest age range between 40-60 years (53.6%).
Most of the samples were patients who had experienced an

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Discussion Cigarette smoking habit itself has become a risk factor that
is agreed to play a role in the process of stroke. In this
In this 3-year observation study, 958 cases of acute study, the prevalence was 16.9% which was lower than the
ischemic stroke were hospitalized at Sanglah Hospital, research in India by Nair et al (28.8%) or in Indonesia by
Denpasar. After categorizing stroke subtypes based on Harris et al (28.6%). Among the four risk factors,
TOAST classification, acute ischemic stroke patients due to hypertension was the factor that had the highest role in
occlusion in small arteries amounted to 338 or equivalent to increasing the risk of lacunar stroke (OR 1.71) compared to
35.2% of all ischemic strokes. This result is higher when diabetes (OR 1.24), dyslipidemia (OR 1.26), and cigarette
compared to several epidemiological studies in Europe, smoking (OR 1.08).8,13
where the presentation of stroke due to small vessel The results of the CT scans in this study did not all show
occlusion ranges from 16-23%.7 Data in Indonesia based on abnormalities but were still included in the sample because
research by Harris et al from 18 hospitals during 2012- there was a neurological deficit that clearly indicated a
2014, acute ischemic stroke due to small vessel occlusion stroke. The majority of abnormal CT scan results showed
was 1635 cases out of a total of 3627 cases (45.07%).8 abnormalities in the anterior circulation system such as the
In this study, the majority of samples were male (64,5%). internal capsule, basal ganglia, and corona radiata which
Several studies have shown that the incidence of ischemic reached 77.5%. Meanwhile, strokes in the posterior
stroke is more in men than women. These data are circulation system such as the thalamus and brain stem are
consistent with a study by Sanchez et al which showed that only 7.1%. This is also in accordance with the study by
men 1.67 times more likely to have small vessel occlusion Nair et al where the number of strokes in the anterior
strokes than women. However, when viewed in more circulation was more than the stroke in the posterior
detail, based on research data, women are more at risk of circulation, but the ratio was 66.7% in the posterior
suffering from ischemic stroke, with post-stroke mortality circulation and 33.3% in the posterior circulation.13 The
and morbidity which are also higher than men.9,10,11 study by Nair et al used MRI while in this study a CT scan
The majority of the sample in this study were the age group was used. MRI is much better at showing posterior
40-60 years (53.6%) and the age group above 60 years old circulation lesions than CT scan, so it is possible that
(42.6%). This data is in accordance with research data by posterior circulation lesions in this study were
Harris et al, where for both ischemic stroke and underdiagnosed. This also explains the many normal
hemorrhagic stroke groups, the 40-60 years old group is features on CT scans that can result from illegible posterior
always the group with the highest prevalence. For ischemic circulation lesions or unseen acute lesions.14
stroke in small vessels, the study by Harris et al also In this study, the majority of the sample had NIHSS which
showed similar results, namely 49.22% for the 40–60 years showed mild to moderate symptoms where 99.7% of the
old group and 46.2% for age group above 60 years old.8 sample had NIHSS <16. The severity of stroke is assessed
If combined, in this study the age group over 40 years old by the severity of the neurological deficit. The parameter
reached 96.2% of the total sample. This is because the older that can be used to assess the degree of neurological deficit
you get, the higher the individual's risk of having a stroke. is the NIHSS (National Institute of Health Stroke Scale)
It is also related to the increasing number of degenerative with a value range of 0-42 which classifies stroke
diseases suffered as risk factors such as diabetes mellitus, symptoms as mild, moderate, moderate-severe, and severe.
hypertension, dyslipidemia, exposure to free radicals such A study conducted by Aldriweesh et al also showed that the
as cigarette smoke which makes the anatomy of blood NIHSS value of lacunar stroke was significantly lower than
vessels and physiology of blood flow in the elderly not as the other TOAST subclassifications.15 This is because a
good as young individuals.12 smaller infarct area will result in minimal neurologic
deficits compared to occlusion that occurs in a larger area.
In this study, the majority of the samples were male
(63.6%) with an average sample age of 60.8 years. This In this study, all samples received antiplatelet aggregation
study identified the incidence of lacunar stroke in patients therapy. Most received monotherapy with aspirin (76.6%)
with risk factors for hypertension, diabetes mellitus, or clopidogrel (3.6%), while 18.6% of the sample received
dyslipidemia, smoking, heart disease, and cancer. There combination therapy with 2 antiplatelet agents (aspirin and
was a similar study conducted by Nair et al regarding the clopidogrel). Therapeutic guidelines for small vessel
risk factors for lacunar stroke in India. This study included ischemic stroke are essentially risk factor control.
4 of the 6 risk factors presented by Nair et al, excluding Pharmacological therapy in the form of antiplatelet
heart disease and cancer.13 aggregation can also be given. According to the AHA/ASA
guidelines, combination therapy with 2 anti-platelet
This study found that the percentage of patients with
aggregation as secondary prevention therapy for ischemic
hypertension is 60.1% and diabetes mellitus is 44.1%,
stroke or in cases of transient ischemic attack in the first 90
which was almost similar to a study by Nair et al who
days is superior to monotherapy, with approximately the
found the prevalence of hypertension was 74.2% and
same bleeding risk. However, if continued for more than 90
diabetes mellitus 37.9% in lacunar stroke. Meanwhile, for
days, the efficacy becomes similar while there is an
dyslipidemia, the results in this study were much higher,
increased risk of bleeding. Therefore, for lacunar stroke, the
namely 59.5% compared to 17.4% in the Indian study. This
use of antiplatelet aggregation monotherapy for long-term
is due to the different definitions of dyslipidemia used. In
secondary prevention of stroke is an appropriate option.16,17
the study by Nair et al, dyslipidemia was defined as LDL
cholesterol levels > 160 while in this study, LDL > 100 and The literature has shown that lacunar stroke has a high
triglycerides > 150 were used.13 recurrence rate. Arboix et al found that over an 18-year
observation period in hospital, 122 of 695 (17.5%) lacunar

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stroke patients had a previous history of lacunar stroke. 18 DOI: 10.1161/STROKEAHA.119.024148

Despite of all therapeutic strategies including antiplatelet 7. Sedova P, Brown RD, Zvolsky M, Belaskova S,
therapy, the recurrence rate is still high. Effective Volna M, Baluchova J, et al. Incidence of stroke and
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of general ischemic stroke patients due to small vessel Registry 2012–2014. SAGE Open Med; 2018.
occlusion. The limitations are there are still some non- 6:205031211878431.
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limitations of patients medical history data such as cardiac 9. Beg MA, Ahmad K, Renjen P. Epidemiological study
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MNJ (Malang Neurology Journal) Vol. 9, No. 1, January 2023