• 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


Content available only for logged-in subscribers (registration will be available soon)
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)
Content available only for logged-in subscribers (registration will be available soon)
  • 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

Content available only for logged-in subscribers (registration will be available soon)


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)

You cannot copy content of this page

Send this to a friend
you may find this topic useful:

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