• lacunar stroke (lacunar cerebral infarct – LACI) is defined as a small subcortical lesion ≤ 1.5 cm in diameter that is caused by the occlusion of small penetrating arteries
    • penetrating arteries arise at sharp angles from larger vessels and are, therefore, anatomically prone to stenosis and occlusion
    • the term “lacune” was first described in the late 19th and early 20th centuries – it usually describes a small, chronic cavity that represents the healed phase of a lacunar infarct
    • etiology of the lacunar infarct is not necessarily of arteriolopathic origin ⇒ various mechanisms can cause occlusion!
    • the most frequently affected structures are:
      • basal ganglia (globus pallidus, putamen, thalamus, and caudate)
      • pons
      • subcortical white matter structures (internal capsule and corona radiata)
  • lacunar stroke syndrome (LACS) is a clinical manifestation of lacunar stroke; the most common are:
    • pure motor hemiparesis
    • pure sensory stroke
    • sensorimotor stroke
    • ataxic hemiparesis
    • dysarthria-clumsy hand syndrome

Etiopathology

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Penetrating artery disease with a parent artery atherosclerosis
Arteriolopathy - small vessel disease (TOAST 3)

Clinical presentation

  • lacunar infarcts usually cause symptoms within minutes but may also exhibit a more gradual progression
  • symptoms usually do not include cortical signs ( agnosia, aphasia, neglect, apraxia, or hemianopsia)
    • cortical functions must be tested to differentiate the MCA stroke and the subcortical stroke (thalamus, internal capsule)
  • most common syndromes are:
    • pure motor hemiparesis
    • pure sensory stroke (unilateral numbness of the face, arm, and leg; affecting all sensory modalities)
    • ataxic hemiparesis (unilateral limb ataxia that is disproportionate to the strength/motor deficit)
    • sensorimotor stroke (unilateral weakness and numbness)
    • dysarthria-clumsy hand syndrome (unilateral facial weakness, dysarthria, dysphagia, and dysmetria/clumsiness in one upper extremity)
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  • a silent lacunar infarction (SLI) is an incidental finding on imaging, without any prior history of stroke symptoms
  • silent strokes are much more common than previously believed
  • SLIs increase the risk of a future major stroke, and multiple lesions may eventually become symptomatic (lacunar state)
  • multiple lesions can affect various aspects of a person’s mood, personality, and cognitive functions (lacunar state / Binswanger’s disease)

Diagnostic evaluation

  • brain imaging (CT/MRI)
    • excludes hemorrhage
    • DWI is more sensitive in detecting acute infarcts compared to other MRI sequences or CT scans
    • in the acute phase, CT or even MRI may be negative; later, a small noncortical infarct may be visible
  • vascular imaging (CTA/MRA)
    • excludes large vessel occlusion/stenosis
    • small perforating arteries are difficult to visualize effectively with CTA and MRA
    • high-resolution MRI can detect the ostial microatheroma in penetrating artery; larger lesions are found in such cases (Sun, 2018)
  • the definitive diagnosis is established by a combination of a typical lacunar syndrome + negative findings on CTA/MRA + small, noncortical infarct visible on CT/MRI
    • history of longstanding diabetes, hypertension, and hyperlipidemia is typical
    • such a stroke is classified as TOAST 3
  • for young patients without traditional risk factors, further evaluation may be necessary to exclude an embolic source
Lacunar stroke in the left thalamus
Thalamic lacunar strokes

Differential diagnosis

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Management

Acute stroke therapy

  • IV thrombolysis in eligible patients
  • for patients ineligible for thrombolytic therapy, aspirin or dual antiplatelet therapy is recommended
  • routine symptomatic treatment of acute stroke + early rehabilitation with speech and physiotherapy

Prevention of cerebrovascular disease

  • antiplatelet therapy – according to the CHANCE and POINT trials, dual antiplatelet therapy (DAPT – ASA+CLP) for 3 weeks followed by single antiplatelet therapy provides the best results
  • aggressive treatment of other vascular risk factors (most commonly hypertension, diabetes, dyslipidemia, etc.)
    • high-dose statin
    • aggressive treatment of hypertension  (target BP of <130/80 mmHg in the absence of significant extra-or intracranial stenosis and if tolerated)

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Lacunar stroke
link: https://www.stroke-manual.com/lacunar-stroke/