Lacunar stroke: mechanisms and therapeutic implications

Abstract

Lacunar stroke is a marker of cerebral small vessel disease and accounts for up to 25% of ischaemic stroke. In this narrative review, we provide an overview of potential lacunar stroke mechanisms and discuss therapeutic implications based on the underlying mechanism. For this paper, we reviewed the literature from important studies (randomised trials, exploratory comparative studies and case series) on lacunar stroke patients with a focus on more recent studies highlighting mechanisms and stroke prevention strategies in patients with lacunar stroke. These studies suggest that lacunar stroke is a heterogeneous disease with various mechanisms, including most commonly lipohyalinosis and less commonly atheromatous disease and cardioembolism, highlighting the importance of a careful review of brain and neurovascular imaging, a cardiac and systemic evaluation. A better understanding of pathomechanisms of neurological deterioration may lead to investigating the utility of novel treatment strategies and optimisation of short-term antithrombotic treatment strategies to reduce the risk of neurological deterioration and prevent long-term disability in patients with lacunar stroke.

Prevalence and Clinical Characteristics of Lacunar Stroke: A Hospital-Based Study

“…In an epidemiological review, the estimated prevalence of LS ranged from 8.9–59.7% among acute ischemic stroke subtypes in the Middle East [ 21 ]. Internationally, many reports consider up to 30% of ischemic stroke as LS [ 6 , 7 , 22 , 23 ]. The prevalence of LS in our cohort is relatively higher than those in England (27%), Germany (25.8%), France (26.8%), Indonesia (26.7%), and Iran (22.5%) [ 24 , 25 , 26 , 27 , 28 ].…”

“…T2DM and HTN have been linked to the formation of systemic and intracranial atherosclerosis leading to arterial segmentation, disorganization, and lipohyalinosis, thus increasing the intrinsic pathology of the small penetrating arteries [ 6 , 30 , 31 , 32 ]. In this study, 74% of the LS patients had a history of HTN; however, it was insignificant compared to those in the non-LS group.…”

“…TOAST defines SVO, lacunar stroke (LS), as “small sub-cortical brain infarcts visible on MRI (normal computed tomography scan if evaluated in the acute phase) <1.5 cm in axial diameter and associated with one of the traditional clinical lacunar syndromes” [ 4 , 5 ]. The prevalence of LS is about 20% among all cases of ischemic stroke [ 6 , 7 , 8 ]. In Saudi Arabia, reports addressing LS are limited.…”

Cerebral small vessel disease and heart rate variability: A quest for nontraditional risk factors

“…A very recent review of lacunar stroke mechanisms emphasized again the heterogeneous nature of this phenomenon and the various mechanisms involved, ranging from lipohyalinosis as the most common but also including atheromatous disease and cardioembolism. 6 …”

“…The European Stroke Organisation recently presented guidelines on covert cSVD, 4 while the management of different aspects of overt SVD has recently been reviewed in several publications. 3 , 6 , 11 Addressing cardiovascular risk factors is currently the most effective approach to managing both overt and covert cSVD. With this goal in mind, there is a potential for genetic stratification of high‐risk patients and genetically assisted selection of drug targets in prevention trials.…”