Different Variables Between Patients with Left and Right

Hemispheric Ischemic Stroke

Hirono Ito, MD, Osamu Kano, MD, PhD, and Ken Ikeda, MD, PhD

We studied whether some variables differ between patients with right and left
hemispheric ischemic stroke. A total of 383 cases were obtained from our depart-
ment-based records between April 2003 and March 2006. Age distribution, sex,
intracranial localization of anterior (carotid artery distribution) or posterior (verte-
brobasilar artery distribution) circulation, mechanism subtypes according to Trial
of Org 10172 in Acute Stroke Treatment (TOAST) criteria, cerebrovascular risk
factors, and time from clinical onset to admission were analyzed between the right
and the left hemispheric ischemic stroke groups. In all, 200 patients had left hemi-
spheric stroke and 183 patients had right hemispheric stroke. Age, sex, vascular
risk profile, stroke subtypes, and mechanism subtypes were not statistically differ-
ent between patients with right- and left-sided ischemic stroke. Time interval from
neurologic onset to admission within 6 hours was significantly associated with left
hemispheric cerebral infarction. Furthermore, patients with left-sided small-vessel
occlusion visited our hospital earlier, up to 6 hours as compared with patients
with right-sided small-vessel occlusion (P , .05). We suppose that patients with
right-sided small-vessel occlusion may take time to be aware of neurologic deficits
because of nondominant language or hand function. Our data indicate that
different medical attention exists between patients with right and left hemispheric
ischemic stroke. We should pay more attention to the difficulty in recognizing the
neurologic deficits in patients with right hemisphere ischemic stroke, so that those
patients delay hospital visit. Key Words: Left and right hemisphere—ischemic
stroke—differences—hospital.
Ó 2008 by National Stroke Association

Neurologic symptoms and signs as a result of stroke lo-
cation contribute to prognosis of cerebrovascular events.
A recent population-based study by hospital registries re-
ports a higher frequency of cerebral infarction in the left
hemisphere than in the right hemisphere.1 There has
been little discussion regarding those differences in Japa-
nese patients with stroke. The left hemisphere contains
From the Department of Neurology, Toho University Omori Medi-
cal Center, Tokyo, Japan.
Received January 17, 2007, revision received October 26, 2007;
accepted November 7, 2007.
Address correspondence to Ken Ikeda, MD, PhD, Department of
Neurology, Toho University Omori Medical Center, 6-11-1, Omori-
nishi, Ota-ku, Tokyo, 143-8541, Japan. E-mail: keni@med.toho-u.ac.jp.
1052-3057/$—see front matter
Ó 2008 by National Stroke Association
doi:10.1016/j.jstrokecerebrovasdis.2007.11.002
the language-dominant area in 99% of right-handed per-
sons and 60% of left-handed persons.2 Such difference
of language predominance may relate to the frequency.
Other reports also suggest that the severity and size of
stroke differs between the right- and left-sided hemi-
sphere.3,4,5 Hemispatial neglect occurs at higher fre-
quency and severity after right than left hemisphere
damage.6 When patients with stroke initially visit the
emergency department, time interval from clinical onset
influences the prognosis and therapeutic strategy. Most
stroke scales emphasize deficits associated with patho-
gnomonic lesions in the left hemisphere.5 The back-
ground increases the likelihood that patients with left
hemisphere stroke may notice neurologic deficits quickly
and receive earlier treatment, in comparison with patients
who have stroke in the right hemisphere. We evaluated
whether several variables differ between patients with
right and left hemispheric ischemic stroke.

Journal of Stroke and Cerebrovascular Diseases, Vol. 17, No. 1 (January-February), 2008: pp 35-38 35
36 H. ITO ET AL.

Patients and Methods Table 1. Demographic data

Patients Left (n 5 200) Right (n 5 183)

A board-certified neurologist examined all patients, Mean age 6 SD, y 68.9 6 14 69.2 6 13
who were consecutively recruited from our department. #50 (n 5 27) 14 (51.9%) 13 (48.1%)
Patients were given the diagnosis of ischemic stroke and 51-60 (n 5 66) 34 (51.5%) 32 (48.5%)
their responsible lesions were confirmed on magnetic res- 61-70 (n 5 110) 64 (58.1%) 46 (41.8%)
onance images, including diffusion-weighted imaging. 71-80 (n 5 118) 60 (50.8%) 58 (49.2%)
Those patients were enrolled in the current study. All .80 (n 5 62) 33 (53.2%) 29 (46.8%)
patients experienced the first stroke and the data were Sex
obtained from our department-based records between Men (n 5 253) 139 (54.9%) 114 (45.0%)
April 2003 and March 2006. Women (n 5 130) 66 (50.8%) 64 (49.2%)

There were no statistical differences of age distribution and sex

Methods between right and left hemispheric ischemic stroke.
The following items were listed: age, sex, time from
clinical onset to admission, stroke localization in the ante-
As far as time interval from clinical onset to admission
rior (carotid artery distribution) or the posterior (verte-
(Table 4), patients who came to our hospital less than 6
brobasilar artery distribution) circulation, mechanism
hours after the onset had the responsible lesion in the
subtypes according to Trial of Org 10172 in Acute Stroke
left hemisphere (,3 hours: left 62.9% v right 37.2%, 3-6
Treatment (TOAST) criteria,7 and cerebrovascular risk
hours: left 64.2% v right 35.8%). Otherwise, after 6 hours
profile. Cerebrovascular risk factors contained hyperten-
from neurologic onset, there were no statistical differ-
sion, diabetes mellitus, hyperlipidemia, and atrial fibrilla-
ences between the left and the right hemispheric groups.
tion. Hypertension was defined as systolic blood pressure
Furthermore, on mechanism subtypes (TOAST), patients
greater than or equal to 140 mm Hg, diastolic blood pres-
with small-vessel occlusion showed significantly more
sure greater than or equal to 90 mm Hg, or current med-
quick admissions in the left-sided group (,3 hours: left
ication. Diabetes mellitus was defined as fasting blood
65.5% v right 34.5%, 3-6 hours: left 64.3% v right 35.7%).
sugar greater than or equal to 126 mg/dL, HgA1c greater
Those statistical data showed different courses from clin-
than or equal to 6.5%, or current medication. Hyperlipid-
ical onset to admission between patients with the right-
emia was defined as low-density lipoprotein cholesterol
and left-sided hemisphere stroke.
greater than or equal to 140 mg/dL, high-density lipo-
protein cholesterol less than or equal to 39 mg/dL, tri-
glyceride greater than or equal to 150 mg/dL, or current Discussion
medication before stroke onset. For the statistical analysis,
We studied the different variables between patients
we used Chi square test with Bonferroni adjustment. The
with right and left ischemic stroke. Number of patients
significant value was set as P less than .05. Specific vari-
did not differ between the right and the left hemispheric
ables were analyzed by logistic regression analysis for
lesion. Male patients, or patients older than 60 years,
trend calculations.
developed the left-sided infarction more frequently, as

Results
A total of 383 patients (mean age 69.0 years [SD 13]) Table 2. Intracranial circulation and stroke mechanism
were admitted to our department during 3 years. In all, (TOAST) between patients with left versus right hemisphere
200 patients had left-sided ischemic stroke and 183 pa- ischemic stroke
tients had ischemic lesions in the right hemisphere. There
No. Left (%) Right (%)
were no statistical differences in patient age and sex be-
tween the right- and the left- sided stroke lesions (Table 1). Intracranial circulation
Stroke regions in anterior or posterior circulation, and Anterior 273 55.7 44.3
mechanism subtypes (TOAST) of ischemic stroke were Posterior 110 48.2 51.8
not significantly statistically different between left and Stroke mechanism (TOAST)
right hemispheric stroke (Table 2). Small-vessel occlusion 196 51.0 49.0
Cerebrovascular risk profile revealed hypertension Cardioembolism 100 56.0 44.0
Large artery 72 56.9 43.1
(60.6%), diabetes mellitus (37.3%), hyperlipidemia
Undetermined 8 50.0 50.0
(22.2%), and atrial fibrillation (19.8%) in our patients.
Other 2 50.0 50.0
There were no statistical differences of those vascular
risk factors between the right and the left hemispheric There were no statistical differences between right and left hemi-
groups (Table 3). spheric ischemic stroke.
DIFFERENCES BETWEEN LEFT–AND RIGHT–SIDED STROKE 37
6,8
Table 3. Cerebrovascular risk factors between left versus neurologic deficits. Right hemispheric events are prob-
right hemisphere ischemic stroke ably perceived by patients or doctors as being less severe
or they can not be identified as stroke symptoms, leading
Left Right to more time from the onset to admission.9 Hernandez
Frequency (%) (%) et al10 addressed that cerebrovascular disease of the left
Vascular risk factors lesion may be related to greater hemodynamic stress,
Hypertension 60.6% (232/383) 51.7 48.3 and stress in the left carotid artery, rather than right-sided
Diabetes mellitus 37.3% (143/383) 54.5 45.5 lesion. Woo et al6 reported that the pathognomonic zones
Hyperlipidemia 22.2% (85/303) 56.6 43.5 of right hemisphere stroke are consistently larger than
Atrial fibrillation 19.8% (76/383) 53.9 44.0 those of left hemisphere stroke. Stroke volumes were
not different in our preliminary study (data not shown).
There were no statistical differences of cerebrovascular profile A previous study of Brott et al11 suggests that 15% more
between right and left hemispheric ischemic stroke.
silent brain infarctions present in the right hemisphere
among patients with high-grade carotid stenosis. In the
compared with right-sided infarction. However, those
current study, evaluation of brain magnetic resonance
components did not differ statistically.
angiography did not differ markedly between patients
Naess et al1 described higher incidence of infarction in
with left and right hemisphere infarction. As compared
left middle cerebral artery territory than right middle ce-
with individuals with right-sided stroke, more patients
rebral artery territory among boys and young men (age
with left hemispheric ischemia were admitted to our de-
15-49 years), whereas the current study did not show
partment for a shorter time. Those clinical courses play
such differences in our patients younger than 50 years.
a crucial role for the treatment of patients with stroke.
Our patients with left hemispheric infarction were admit-
In addition, patients with left-sided small-vessel occlu-
ted more rapidly (,6 hours), in comparison with patients
sion visit our hospital earlier, up to 6 hours. The patients
with right hemispheric stroke. Those different courses
who have right-sided small-vessel occlusion may need
may contribute to several components of brain anatomic
more time to notice their neurologic symptoms, because
and functional structure.
the right cerebral hemisphere usually possesses nondom-
Left hemisphere contains language-dominant areas in
inant language or nondominant-handed motor areas.
99% of right-handed persons and 60% of the left-handed
Thus, our study suggests differences of medical attention
persons.2 By contrast, right hemispheric stroke is usually
between patients with right and left hemispheric stroke.
associated with neglect that patients reduce awareness of
Difficult awareness of symptoms in right hemisphere
ischemic stroke may lose a golden time for treatment in
Table 4. Time to admission between left versus right
the superacute stage of cerebral infarction. We should
hemisphere ischemic stroke
use caution in clinical route; those patients require more
Case Left Right time to visit the hospital.
No. (%) (%)
Acknowledgment: We wish to acknowledge the support
Time to admission, h (total) of Yasuo Iwasaki, MD, Department of Neurology, Toho Uni-
,3 86 62.9 37.2a versity Omori Medical Center.
3-6 59 64.2 35.8a
6-24 61 52.5 47.5
.24 177 51.5 48.5
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