New Concepts in Lacunar Stroke Etiology: The Constellation of Small-Vessel Arterial Disease

Abstract

Objective: To update the less frequent etiologies causing lacunar infarcts (LIs). To highlight recent advances in risk factors, clinical syndromes, topography, complementary tests and long-term prognosis in this subtype of ischemic stroke. Patients and Methods: The most important studies are analyzed, from CM Fisher works, selecting those referring to LIs of unusual etiology, and recent advances and controversies in the clinical management of LI are discussed. Results: LIs are found in approximately 11% of patients admitted with stroke. The pure motor hemiparesis (55%) constitutes the most usual lacunar syndrome. However, lacunar syndromes may not be caused by LIs in 10–20% of cases. LIs caused by microembolism and cholesterol embolism from the aortic arch are reviewed. Hematological diseases can also cause LI, such as polycythemia rubra vera, essential thrombocythemia and primary antiphospholipidic antibody syndrome. Other etiologies are carotid plaque embolism, severe stenosis of a perforated arteriole and amyloid angiopathy. Infectious arteritis by neurolues, neurocysticercosis, neuroborreliosis, by AIDS or Helicobacter pylori infection have also been associated with the presence of LIs. Likewise, inflammatory arteritis in systemic lupus erythematosus or granulomatous angiitis, cocaine abuse and panarteritis nodosa have been related to LI, although in the latter LI would be caused by a thrombotic microangiopathy and not by vasculitis. Conclusions: LI is an ischemic stroke subtype with a characteristic clinical presentation and a short-term favorable prognosis. Although high blood pressure constitutes the main risk factor and the main etiology, LIs may be caused, in less than 5% of cases, by various etiologies, mainly hematological diseases and infectious or inflammatory arteritis. It is essential to make a correct etiological diagnosis for LI as treatment will be different according to its etiology.

Ethnic Differences in Arterial Responses and Inflammatory Markers in Afro-Caribbean and Caucasian Subjects

“…This suggests that AfroCaribbean subjects have selective impairment of small artery, but not large artery, function associated with inflammatory activation, which may be responsible for the higher prevalence of small vessel disease in Afro-Caribbean subjects. These findings are consistent with studies showing few atherosclerotic changes in the large arteries of patients with small vessel disease 23 and hyperinsulinaemia in black, but not white, hypertensive subjects with end organ damage. 15 Increased carotid intima media thickness 24 and attenuated vascular reactivity 10,14 but better large vessel function [25][26][27][28] have been described in Afro-Caribbeans previously, but this is the first study in which all of these aspects have been examined together in community settings.…”

Magnesium for Treatment of Acute Lacunar Stroke Syndromes

“…11 Diffusion-weighted imaging is the most sensitive and specific imaging method for detection of subcortical ischemic lesions during the acute phase of stroke. 12 Diffusion-weighted imaging, in conjunction with the apparent diffusion coefficient map, can differentiate between acute and nonacute lesions. However, diffusion-weighted imaging was the routine acute imaging method at only very few centers worldwide during the IMAGES recruitment period.…”

Inverse mismatch and lesion growth in small subcortical ischaemic stroke

“…Such collateral vascular supply may not be present in small subcortical infarcts (SSI) which involve the small terminal vessels of the subcortical cerebrum and brainstem [10]. They are typically characterised by a regular shape that is frequently rounded or tube-like with a diameter of 0.2 -2 cm [11][12][13].…”

“…They are typically characterised by a regular shape that is frequently rounded or tube-like with a diameter of 0.2 -2 cm [11][12][13]. SSI account for up to 25% of all strokes [14] and occur predominantly in patients with small vessel disease, such as diabetes and hypertension [10].…”