• lacunar stroke (lacunar cerebral infarct – LACI) is defined as a small subcortical lesion ≤ 1.5 cm in diameter, resulting from the occlusion of small penetrating arteries
    • penetrating arteries originate at sharp angles from larger vessels, making them anatomically susceptible to stenosis and occlusion
    • the term “lacune” was first described in the late 19th and early 20th centuries – it commonly 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 lead to their occlusion!
    • typical lacunar stroke locations correspond to lesions of the lenticulostriate arteries, the anterior choroidal artery, thalamoperforant arteries (TPAs), paramedian branches of the basilar artery, and the Heubner´s recurrent artery (originating from the ACA)
      • 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 syndromes are listed below


  • cerebral small vessel diseases (SVDs) encompass a group of disorders that primarily affect small blood vessels in the brain (small arteries, arterioles, capillaries, and venules)
  • cerebral SVD is typically associated with leukoencephalopathy, lacunar strokes, and microbleeds
  • the underlying causes may differ:
    • sporadic forms
    • genetic forms
  • both forms result in impaired blood flow, vessel wall damage, and leakage of blood components into brain tissues; these changes lead to significant morbidity and mortality due to stroke and dementia
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 between the MCA stroke and the subcortical stroke (involving structures like the thalamus and internal capsule)
  • the most common syndromes associated with lacunar strokes 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 ostial microatheroma in penetrating arteries; 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 + presence of small, noncortical infarct visible on CT/MRI
    • a 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 and rare inherited small vessel diseases
Lacunar stroke in the left thalamus
Thalamic lacunar strokes

Differential diagnosis

  • vascular lesions
  • seizures (cortical symptoms) – symptoms resolve
  • complicated migraine events – symptoms resolve


Acute stroke therapy

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 (such as hypertension, diabetes, dyslipidemia)
    • 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/