The Role of Blood Pressure in Lacunar Strokes Preceded by TIAs

Abstract

Lacunar strokes (LS) are often preceded by repetitive transitory ischaemic attacks (TIAs) known as ‘capsular warning syndrome’. The treatment of these symptoms remains controversial. Anticoagulants are often used in this situation, most of the time, however, with no or little benefit. Since it is not rare that these TIAs lead to a definite stroke, the therapeutic approach in the acute phase is very important. We report six patients presenting LS preceded by TIAs. All patients showed intermittent decrease of blood pressure (BP) coinciding with clinical worsening and leading to definite stroke in four of them. All were treated with full-dose intravenous heparin, which did not prevent further clinical deterioration. One patient received noradrenalin, which allowed stabilisation of the blood pressure values and complete resolution of the neurological symptoms. This observation suggests that in lacunar strokes preceded by TIAs monitoring and, if necessary, pharmacological increase of BP may prevent some patients from developing a definite stroke. Thus the ‘capsular warning syndrome’ could reflect a haemodynamic failure rather than repeated thrombo-embolism within the lumen of a single perforating arteriole.

Population-based study of capsular warning syndrome and prognosis after early recurrent TIA

“…Moreover, specific treatments for capsular warning syndrome are lacking, although thrombolysis, hydration, blood pressure elevation, and dual antiplatelet and anticoagulant treatment have been shown to be beneficial in case reports. [31][32][33][34][35] Our results show that despite improvements in processes of care, the prognosis of capsular warning syndrome is similar to that when it was first described in the 1980s. The trend toward a reduced risk of early stroke in patients given an immediate loading dose of antiplatelet drugs is encouraging, and this approach is probably justified despite the lack of trial data.…”

Very prolonged capsular warning syndrome

“…High-grade atherosclerotic stenosis of the proximal portion of penetrating arteries is presumed to lead to hemodynamic hypoperfusion in the territories of lenticulostriate arteries [1][2][3]. Moreover, as MCA stenosis was not observed, sever stenosis of the proximal portion of lenticulostriate artery was suggested in the present case.…”

“…The mechanism is believed to be small single perforating artery disease. A hemodynamic ischemic process in the territory of the penetrating arteries caused by high-grade stenosis of proximal penetrating arteries due to microatherosclerosis has been postulated [1][2][3]. The risk of developing a capsular stroke is considered to be high in patients with CWS [1,4].…”

High-resolution MRI findings in patients with capsular warning syndrome

“…Different treatment modalities, including hydration, antiplatelet agents, intravenous thrombolysis and intracranial artery angioplasty, have been proposed in patients with CWS [1,8,9,11,16]. It remains a challenge to develop therapies that may prevent irreversible damage to occur in patients with CWS.…”