Frailty and outcomes in lacunar stroke



      Lacunar strokes (LS) are ischemic strokes of the small perforating arteries of deep gray and white matter of the brain. Frailty has been associated with greater mortality and attenuated response to treatment after stroke. However, the effect of frailty on patients with LS has not been previously described.


      To analyze the association between frailty and outcomes in LS.


      Patients with LS were selected from the National Inpatient Sample (NIS) 2016-2019 using the International Classification of Disease, 10th edition (ICD-10) diagnosis codes. The 11-point modified frailty scale (mFI-11) was used to group patients into severely frail and non-severely frail cohorts. Demographics, clinical characteristics, and complications were defined. Health care resource utilization (HRU) was evaluated by comparing total hospital charges and length of stay (LOS). Other outcomes studied were discharge disposition and inpatient death.


      Of 48,980 patients with LS, 10,830 (22.1%) were severely frail. Severely frail patients were more likely to be older, have comorbidities, and pertain to lower socioeconomic status categories. Severely frail patients with LS had worse clinical stroke severity and increased rates of complications such as urinary tract infection (UTI) and pneumonia (PNA). Additionally, severe frailty was associated with unfavorable outcomes and increased HRU.


      Severe frailty in LS patients is associated with higher rates of complications and increased HRU. Risk stratification based on frailty may allow for individualized treatments to help mitigate adverse outcomes in the setting of LS.



      Lacunar Strokes ((LS)), hypertension ((HTN)), modified frailty index 11 ((mFI-11)), National Surgical Quality Improvement Project ((NSQIP)), National Inpatient Sample ((NIS)), healthcare resource utilization ((HRU)), atrial fibrillation ((A fib)), hyperlipidemia ((HLD)), chronic renal failure ((CRF)), obstructive sleep apnea ((OSA)), acute kidney injury ((AKI)), aspiration pneumonitis ((AP)), urinary tract infection ((UTI)), pneumonia ((PNA)), deep vein thrombosis ((DVT)), pulmonary embolism ((PE)), length of stay ((LOS)), National Institute of Health stroke scale ((NIHSS)), diabetes mellitus ((DM)), chronic kidney disease ((CKD))
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Stroke and Cerebrovascular Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Sacco S
        • Marini C
        • Totaro R
        • Russo T
        • Cerone D
        • Carolei A.
        A population-based study of the incidence and prognosis of lacunar stroke.
        Neurology. 2006; 66: 1335-1338
        • Bejot Y
        • Catteau A
        • Caillier M
        • et al.
        Trends in incidence, risk factors, and survival in symptomatic lacunar stroke in Dijon, France, From 1989 to 2006: a population-based study.
        Stroke. 2008; 39: 1945-1951
        • Nakamura K
        • Saku Y
        • Ibayashi S
        • Fujishima M.
        Progressive motor deficits in lacunar infarction.
        Neurology. 1999; 52 (29-29)
        • Serena J
        • Leira R
        • Castillo J
        • Pumar JM
        • Castellanos M
        • Dávalos A.
        Neurological deterioration in acute lacunar infarctions: the role of excitatory and inhibitory neurotransmitters.
        Stroke. 2001; 32: 1154-1161
        • Chung JW
        • Park SH
        • Kim N
        • et al.
        Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification and vascular territory of ischemic stroke lesions diagnosed by diffusion-weighted imaging.
        J Am Heart Assoc. 2014; 3e001119
        • Decavel P
        • Vuillier F
        • Moulin T.
        • Paciaroni M
        • Agnelli G
        • Caso V
        • Bogousslavsky J
        Lenticulostriate Infarction.
        Frontiers of Neurology and Neuroscience. 2012; 30 (KARGER): 115-119
      1. Gore M, Bansal K, Asuncion RMD. Lacunar Stroke. In: StatPearls. StatPearls Publishing; 2022. Accessed February 12, 2022.

        • Arboix A
        • García-Eroles L
        • Sellarés N
        • Raga A
        • Oliveres M
        • Massons J.
        Infarction in the territory of the anterior cerebral artery: clinical study of 51 patients.
        BMC Neurol. 2009; 9: 30
        • Marinkovi? S
        • Gibo H
        • Milisavljevi? M
        • ?etkovi? M
        Anatomic and clinical correlations of the lenticulostriate arteries.
        Clin Anat. 2001; 14: 190-195
        • McHutchison CA
        • Cvoro V
        • Makin S
        • Chappell FM
        • Shuler K
        • Wardlaw JM.
        Functional, cognitive and physical outcomes 3 years after minor lacunar or cortical ischaemic stroke.
        J Neurol Neurosurg Psychiatry. 2019; 90: 436-443
        • Hirsch JA.
        The pincer movement of cost and quality in neurointerventional care: resource management as an imperative.
        J Neurointerventional Surg. 2019; 11: 323-325
        • Appleton JP
        • Woodhouse LJ
        • Adami A
        • et al.
        Imaging markers of small vessel disease and brain frailty, and outcomes in acute stroke.
        Neurology. 2020; 94: e439-e452
        • Tsiouris A
        • Hammoud ZT
        • Velanovich V
        • Hodari A
        • Borgi J
        • Rubinfeld I.
        A modified frailty index to assess morbidity and mortality after lobectomy.
        J Surg Res. 2013; 183: 40-46
        • Karam J
        • Tsiouris A
        • Shepard A
        • Velanovich V
        • Rubinfeld I.
        Simplified frailty index to predict adverse outcomes and mortality in vascular surgery patients.
        Ann Vasc Surg. 2013; 27: 904-908
        • Johnson MS
        • Bailey TL
        • Schmid KK
        • Lydiatt WM
        • Johanning JM.
        A frailty index identifies patients at high risk of mortality after tracheostomy.
        Otolaryngol Neck Surg. 2014; 150: 568-573
        • Jung I
        • Kwon H
        • Park SE
        • et al.
        Increased risk of cardiovascular disease and mortality in patients with diabetes and coexisting depression: a nationwide population-based cohort study.
        Diabetes Metab J. 2021; 45: 379-389
        • AL-Khamis A
        • Warner C
        • Park J
        • et al.
        Modified frailty index predicts early outcomes after colorectal surgery: an ACS-NSQIP study.
        Colorectal Dis. 2019; 21: 1192-1205
        • Kumar L
        • Satheesan KN
        • Rajan S
        • Vasu BK
        • Paul J.
        Predictors and outcomes of postoperative pulmonary complications following abdominal surgery in a south indian population.
        Anesth Essays Res. 2018; 12: 199-205
        • Langhorne P
        • Stott DJ
        • Robertson L
        • et al.
        Medical complications after stroke: a multicenter study.
        Stroke. 2000; 31: 1223-1229
        • Indredavik B
        • Rohweder G
        • Naalsund E
        • Lydersen S.
        Medical complications in a comprehensive stroke unit and an early supported discharge service.
        Stroke. 2008; 39: 414-420
        • Miller CM
        • Behrouz R.
        Impact of infection on stroke morbidity and outcomes.
        Curr Neurol Neurosci Rep. 2016; 16: 83
        • Hirsch C.
        In older adults with acute ischemic stroke, the clinical frailty scale predicted mortality at 28 days.
        Ann Intern Med. 2020; 172: JC57
        • Golubnitschaja O
        • Potuznik P
        • Polivka J
        • et al.
        Ischemic stroke of unclear aetiology: a case-by-case analysis and call for a multi-professional predictive, preventive and personalised approach.
        EPMA J. 2022; (Published online November 17): 1-11
        • Mantero V
        • Filizzolo M
        • Botto E
        • et al.
        Size, shape and location of lacunar strokes and correlation with risk factors.
        Clin Neurol Neurosurg. 2020; 190105665
        • Evans NR
        • Wall J
        • To B
        • Wallis SJ
        • Romero-Ortuno R
        • Warburton EA.
        Clinical frailty independently predicts early mortality after ischaemic stroke.
        Age Ageing. 2020; 49: 588-591
        • Gugganig R
        • Aeschbacher S
        • Leong DP
        • et al.
        Frailty to predict unplanned hospitalization, stroke, bleeding, and death in atrial fibrillation.
        Eur Heart J - Qual Care Clin Outcomes. 2021; 7: 42-51
        • Smithard D.
        Stroke in frail older people.
        Geriatrics. 2017; 2: 24
        • Pinho J
        • Küppers C
        • Nikoubashman O
        • et al.
        Frailty is an outcome predictor in patients with acute ischemic stroke receiving endovascular treatment.
        Age Ageing. 2021; 50: 1785-1791
        • Assar ME
        • Laosa O
        • Rodríguez Mañas L.
        Diabetes and frailty.
        Curr Opin Clin Nutr Metab Care. 2019; 22: 52-57
        • Blaum CS
        • Xue QL
        • Michelon E
        • Semba RD
        • Fried LP.
        The association between obesity and the frailty syndrome in older women: the women's health and aging studies: obesity and frailty in older women.
        J Am Geriatr Soc. 2005; 53: 927-934
        • Soysal P
        • Veronese N
        • Thompson T
        • et al.
        Relationship between depression and frailty in older adults: a systematic review and meta-analysis.
        Ageing Res Rev. 2017; 36: 78-87
        • Mayerl H
        • Stolz E
        • Freidl W.
        Frailty and depression: reciprocal influences or common causes?.
        Soc Sci Med. 2020; 263113273
        • Wang S
        • Cardieri B
        • Mo Lin H
        • Liu X
        • Sano M
        • Deiner SG
        Depression and anxiety symptoms are related to pain and frailty but not cognition or delirium in older surgical patients.
        Brain Behav. 2021; 11
        • Jan Z
        • AI-Ansari N
        • Mousa O
        • et al.
        The role of machine learning in diagnosing bipolar disorder: scoping review.
        J Med Internet Res. 2021; 23: e29749
        • Nia AM
        • Branch DW
        • Maynard K
        • et al.
        Metabolic syndrome associated with increased rates of medical complications after intracranial tumor resection.
        World Neurosurg. 2019; 126: e1055-e1062
        • Passias PG
        • Poorman GW
        • Delsole E
        • et al.
        Adverse outcomes and prediction of cardiopulmonary complications in elective spine surgery.
        Glob Spine J. 2018; 8: 218-223
        • Chao CT
        • Lee SY
        • Wang J
        • Chien KL
        • Huang JW.
        Frailty increases the risk for developing urinary tract infection among 79,887 patients with diabetic mellitus and chronic kidney disease.
        BMC Geriatr. 2021; 21: 349
      2. Saliba W, Nitzan O, Chazan B, Elias M. Urinary tract infections in patients with type 2 diabetes mellitus: review of prevalence, diagnosis, and management. Diabetes Metab Syndr Obes Targets Ther. Published online February 2015:129. doi:10.2147/DMSO.S51792

        • Fünfstück R
        • Nicolle LE
        • Hanefeld M
        • Naber KG.
        Urinary tract infection in patients with diabetes mellitus.
        Clin Nephrol. 2012; 77: 40-48
        • Tandogdu Z
        • Cai T
        • Koves B
        • Wagenlehner F
        • Bjerklund-Johansen TE.
        Urinary Tract Infections in Immunocompromised Patients with Diabetes, Chronic Kidney Disease, and Kidney Transplant.
        Eur Urol Focus. 2016; 2: 394-399
        • Curtis GL
        • Hammad A
        • Anis HK
        • Higuera CA
        • Little BE
        • Darwiche HF.
        Dependent functional status is a risk factor for perioperative and postoperative complications after total hip arthroplasty.
        J Arthroplasty. 2019; 34: S348-S351
        • Henig O
        • Kaye KS.
        Bacterial pneumonia in older adults.
        Infect Dis Clin North Am. 2017; 31: 689-713
        • Zhu C
        • Liu H
        • Wang Y
        • et al.
        Prevalence, incidence, and risk factors of urinary tract infection among immobile inpatients in China: a prospective, multi-centre study.
        J Hosp Infect. 2020; 104: 538-544
        • Rozen G
        • Elbaz-Greener G
        • Margolis G
        • et al.
        The obesity paradox in real-world nation-wide cohort of patients admitted for a stroke in the U.S.
        J Clin Med. 2022; 11: 1678
        • Liu Z
        • Sanossian N
        • Starkman S
        • et al.
        Adiposity and outcome after ischemic stroke: obesity paradox for mortality and obesity parabola for favorable functional outcomes.
        Stroke. 2021; 52: 144-151
        • Kvistad CE
        • Oeygarden H
        • Logallo N
        • Thomassen L
        Waje-Andreassen U, Naess H. Is smoking associated with favourable outcome in tPA-treated stroke patients?.
        Acta Neurol Scand. 2014; 130: 299-304
      3. Smajlović D. Strokes in young adults: epidemiology and prevention. Vasc Health Risk Manag. 2015;11:157-164. doi:10.2147/VHRM.S53203

        • Fernando SM
        • McIsaac DI
        • Rochwerg B
        • et al.
        Frailty and invasive mechanical ventilation: association with outcomes, extubation failure, and tracheostomy.
        Intensive Care Med. 2019; 45: 1742-1752
        • Harris DG
        • Olson SL
        • Panthofer AM
        • Matsumura JS
        • DiMusto PD
        A Frailty-Based Risk Score Predicts Morbidity and Mortality After Elective Endovascular Repair of Descending Thoracic Aortic Aneurysms.
        Ann Vasc Surg. 2020; 67: 90-99