Lacunar Stroke (Stroke)

What is Lacunar Stroke (Stroke)?

Stroke is the second leading cause of death globally and the main cause of disability in the United States. Ischemic strokes, which involve interruption of blood to the brain, make up 62% of all strokes globally as of 2019. Some are hemorrhagic or involve bleeding in the brain. About 25% of all ischemic strokes are lacunar strokes, which are small strokes that occur in noncortical, or deeper, areas of the brain. Classic definitions say these strokes are less than 15 mm in diameter, but recent studies suggest the size has more to do with the specific arteries affected. It could be anywhere from 2 to 20 mm.

Lacunar, from the Latin word meaning pond or pit, refers to the final condition of small spaces in the grey or white matter of the brain filled with cerebral spinal fluid. These gaps are caused by the blockage of small, deep arteries from the circle of Willis, a circular network of arteries supplying blood to the brain and surrounding structures. Because these arteries are end arteries, they don’t have any secondary networks for support. Many lacunar strokes remain symptomless due to the small size of the vessels affected. However, 20% to 50% of older individuals were found to have symptomless lacunar strokes upon imaging. But, the accumulation of multiple minor lacunar infarcts can cause significant physical and mental disabilities over time.

Despite not having the same disastrous impacts as larger vessel strokes, lacunar strokes are still serious. Around 25% of people will die from the stroke or related complications, 20% will experience another stroke or similar event, and 30% will have functional impairment five years later. Certain clinical symptoms are typical of lacunar strokes, but these are not always present. For instance, large vessel cortical strokes can display the same symptoms as lacunar strokes, and other factors such as disease in large cerebral vessels or embolic sources can cause lacunar strokes rather than the normally associated clot formation or lipohyalinosis that is usually linked with these strokes.

What Causes Lacunar Stroke (Stroke)?

Ischemic strokes happen when the blood supply to a certain part of the brain gets blocked and causes damage to the brain tissue. A particular type of this stroke is a ‘lacunar infarction,’ where the small blood vessels that provide blood to the deeper parts of the brain get blocked. Various reasons, like certain vascular diseases or small fragments of clots from the heart, can cause these blockages. In some cases, a bigger blood vessel disease blocking the small brain arteries may also cause these strokes.

Lacunar strokes usually develop because of small vessel disease, which is often linked to health conditions like high blood pressure and diabetes. Certain lifestyle factors like smoking, bad cholesterol levels, and other vascular diseases can also increase the risk. There’s also a genetic aspect involved: specific genetic factors can make a person more likely to develop small vessel disease, thus leading to these types of strokes.

A rare genetic disorder, CADASIL, can cause small blood vessel disease too. This disorder, caused by a mutation in a particular gene, is a leading hereditary cause of stroke and dementia in adults. Symptoms usually start appearing around the third or fourth decade of life and may include recurrent strokes, progressive brain tissue degeneration, memory loss, severe migraines, and various psychiatric symptoms. There’s a characteristic substance that can be seen near blood vessels in skin biopsies under an electron microscope in people with CADASIL. Over time, this leads to blood vessel degeneration, and the disease is incurable and fatal. On brain imaging, certain areas of white matter in the brain appear brighter in people with CADASIL. Other genes can also predispose to small vessel disease in the brain, and one of these genes also increases the risk for Alzheimer’s disease.

Risk Factors and Frequency for Lacunar Stroke (Stroke)

Stroke is a major health concern around the world, causing roughly 12% of global deaths, or 3.29 million people, in 2019. It is also a significant cause of disability, accounting for an estimated 63.49 million disability-adjusted life years. People above the age of 25 have a 25% chance of having a stroke in their lifetime, and an 18% chance of having an ischemic stroke.

Stroke causes around 12% of all deaths worldwide, affecting 3.29 million individuals in 2019.
The disease results in approximately 63.49 million years lived with disability.
If you’re over 25, you run a 25% risk of suffering a stroke and an 18% risk of suffering an ischemic stroke in your lifetime.

Research has shown different incidence rates for a specific type of stroke known as a ‘lacunar infarct’. In a community study primarily involving white individuals, the incidence rate was 29 per 100,000 people. Another study, mainly involving black individuals, showed an incidence rate of 52 per 100,000 people. Overall, lacunar stroke affects an estimated 25 to 50 people in every 100,000.

A study involving mostly white people showed 29 in 100,000 people experiencing a lacunar infarct, a specific type of stroke.
A similar study involving mostly black people showed this rate to be 52 in every 100,000 people.
Overall, lacunar stokes occur in 25 to 50 people out of every 100,000.

Following a lacunar infarct, individuals are found to develop dementia 4 to 12 times more frequently than in the average population. Lacunar strokes happening at an older age also result in significantly worse long-term disabilities.

People with a lacunar infarct are 4 to 12 times more likely to be diagnosed with dementia than the average population.
Lacunar strokes occurring at an older age can lead to severe long-term disabilities.

Signs and Symptoms of Lacunar Stroke (Stroke)

Lacunar infarcts, a type of stroke, typically present suddenly with neurological deficits. Alternatively, they may appear in a stuttering pattern, with symptoms becoming worse over time. This type of stroke occurs frequently in the deep parts of the brain, including the thalamus, basal ganglia, pons, and internal capsule. Sometimes, lacunar infarcts can occur without any symptoms and are only discovered through imaging.

The symptoms of lacunar infarcts are influenced by the area of the brain affected. For instance, lacunar infarcts in the centrum semiovale may not result in any symptoms and are discovered incidentally. However, some lacunar infarcts can present with severe hemiplegia, which is paralysis of one side of the body. These strokes usually do not affect memory, language, and judgement.

There are about 20 different types of lacunar syndromes described in medical literature. The most common include:

Pure motor hemiparesis: This syndrome, which results in weakness on one side of the body. It affects the face, arm, and leg, and may also involve mild speech difficulties. This is the most common presentation, accounting for almost half of all lacunar strokes.
Ataxic-hemiparesis: This presentation is characterised by a lack of muscle control on one side of the body and a lack of co-ordination. It contributes to between 10 to 18% of cases.
Pure sensory: In this form, there’s impaired or abnormal sensation on one side of the body including the face, arm, and leg. It accounts for 7% of cases.
Dysarthria-clumsy hand: This syndrome affects speech and hand coordination often causing difficulty in subtle movements.
Sensory-motor: This stroke affects both sensory and motor functions. It is the second most common type of lacunar strokes, accounting for 20% of cases.

More than 40% with subcortical infarct deteriorate neurologically within the first week of onset of stroke symptoms. Of these, one-third may spontaneously reverse, but the rest end up with a physical disability. Lacunar strokes are a common cause of mild cognitive impairment and early dementia.

Testing for Lacunar Stroke (Stroke)

The STRIVE criteria is a set of guidelines used to detect and classify cerebral small vessel disease. This disease could be diagnosed based on brain imaging studies, focusing on characteristics such as recent small subcortical infarcts, white matter hyperintensities, perivascular spaces, microbleeds, and brain atrophy.

Another useful non-invasive procedure is called Transcranial Doppler. It provides valuable information about the structure, function, and blood flow velocity of cerebral blood vessels. A higher pulsatility index from this procedure suggests increased small vessel disease and acute infarct size. It can also measure cerebral autoregulation, which is often decreased in a stroke situation.

Computed Tomography or CT scan is preferred in an emergency setting due to its availability and speed. It helps in ruling out severe conditions such as internal brain bleeding or dangerous brain swelling. CT scans might not catch lacunar ischemic infarcts right away due to their small size. However, they can still provide useful information such as the presence of a thrombus in a large artery or early signs of an infarct.

A CT angiogram can be done to detect a filling defect which represents a clot blocking a vessel. It can also show chronic arterial diseases such as in the carotid arteries, suggesting possibilities of embolism. A CT perfusion study can aid in determining areas of irreversible and reversible ischemia which is particularly useful in thrombectomy decision-making.

MRI scans are highly effective in detecting lacunar infarctions in acute and subacute stages. It helps distinguish between acute and chronic infarctions. It can detect lesions as small as 0.2 mm, which might be missed in a CT scan. Recent technological advancements have enabled MRI to image even tiny cerebral arteries.

Additional diagnostic tests include a carotid ultrasound which may detect a narrowing of the extracranial carotid artery. This is particularly important as patients with severe carotid artery stenosis have a higher risk of stroke. Depending on clinical symptoms, significant stenosis can range between 50% and 99%. Furthermore, comprehensive heart and blood vessel tests might be necessary in certain situations, such as in young patients with no apparent medical issues. Blood tests including blood glucose levels, complete blood count, troponin, prothrombin time, international normalized ratio (INR), activated partial thromboplastin time, complete metabolic panel, lipid panel, hemoglobin A1c, and toxicology screen are also conducted to assess underlying stroke risk factors.

Treatment Options for Lacunar Stroke (Stroke)

Managing a lacunar stroke, a type of stroke caused by the blockage of small blood vessels deep within the brain, follows the same principles as treating any other acute ischemic stroke. The primary goal of treatment during the acute stage is to stabilize the patient and determine if they’re suitable for a treatment called thrombolysis. This treatment involves injecting a drug called a tissue plasminogen activator (tPA) to dissolve clots and restore blood flow to the brain. To be most effective, this drug needs to be administered within 4.5 hours after stroke symptoms begin. If the patient’s blood pressure is within the recommended range and there’s no sign of bleeding in the brain, thrombolysis can be a crucial part of the acute treatment.

In some cases, if symptoms started more than 4.5 hours ago and the stroke is suspected to be due to clotting in the larger blood vessels of the brain, specific types of brain scans can be done to determine if a procedure to mechanically remove the clot (thrombectomy) is an option. This can be done anywhere from 6 to 24 hours after the patient was last known to be symptom-free. Studies have shown that this extended treatment window can be beneficial. Heparin is a blood-thinning medication that has been studied for use in acute lacunar stroke, but it has been found to increase the risk of bleeding without any significant benefit.

For patients who came out of the critical period of acute lacunar stroke without needing tPA, a combination of two blood-thinning drugs, aspirin and clopidogrel, can be given within 24 hours of when symptoms started and continued for 21 days. This combination has been shown to effectively lower the risk of another stroke for up to 90 days.

One large study evaluated the effect of setting a blood pressure goal of lower than130 mm Hg in patients and found it to significantly reduce the risk of stroke caused by bleeding in the brain. The study also found that adding clopidogrel to existing aspirin treatment doesn’t lower the risk of stroke recurrence, but instead increases the risk of significant bleeding and death.

Management of high blood pressure involves gradual reduction unless it’s extremely high; in this scenario, blood pressure should be reduced by 15% during the first 24 hours. Diabetes management aims to avoid low and high blood sugar, with desirable blood glucose levels at 60 to 180 mg/dL.

Preventing strokes, whether first-time or recurrent, is an essential part of the treatment plan. Measures include managing high blood pressure, diabetes and cholesterol, quitting smoking, eating healthily, losing weight and exercising. Blood thinning medications also play a role, though long-term use of both clopidogrel and aspirin hasn’t shown any added advantage in reducing the risk of a repeat stroke.

Finally, physical therapy and rehabilitation are critical for patients who have experienced some form of physical disability as a result of their stroke. The aim of these therapies is to maximize recovery, maintain independence, and preserve quality of life.

There are numerous medical situations that can mimic the symptoms of a stroke. When diagnosing a type of stroke called a “lacunar infarct”, doctors will consider the following possibilities:

Large vessel stroke, which affects a bigger region of the brain, can be distinguished from lacunar strokes by signs such as changes in mental status, difficulty speaking, or inattention to one side of the body.
Intracranial hemorrhages, or bleeding within the brain, can usually be detected with brain CT scans.
Seizures, resulting from excess brain activity, are typically characterized by convulsive movements. Symptoms generally improve after the seizure, and patients may feel confused or drowsy afterwards.
Complicated migraines are usually accompanied by headache and aura. An aura is a sign that a migraine is about to occur and may involve visual disruptions, unusual sensations, muscle weakness, or speech issues.
Brain tumors can be identified by their unique appearance on MRI scans.

In addition, the condition known as Multiple Sclerosis (MS) can result in sudden bouts of uncontrolled movement and speech problems. MRI scans help doctors tell the difference between MS and a stroke. Other tests can be conducted as well to identify different types of lesions within the brain. An important sign of MS is the presence of specific proteins discovered during a spinal fluid test.

Hypoglycemia or low blood sugar can also simulate stroke symptoms such as reduced consciousness and even specific symptomatic deficits. A simple blood sugar test should always be done when symptoms of a stroke are noticed. There’s also a condition called transient global amnesia, where a person experiences a short-term memory loss without other symptoms. These symptoms generally disappear within 24 hours and are not linked with abnormalities detected in brain imaging.

What to expect with Lacunar Stroke (Stroke)

Past research has implied that lacunar stroke tends to have a better outcome compared to other types of strokes. It’s typically marked by a high survival rate, a low chance of occurring again, and a relatively good return to normal function. In fact, lacunar strokes generally have a more favorable prognosis.

However, even with these positives, the long-term prognosis does carry an increased risk of death, primarily due to heart-related conditions. The likelihood of a stroke happening again is about the same as with other types of strokes. Additionally, patients who have multiple small vessel diseases stand a higher risk of cognitive decline and developing dementia.

Possible Complications When Diagnosed with Lacunar Stroke (Stroke)

Lacunar strokes are often considered the main reason for vascular dementia and a decline in cognitive skills. Having multiple lacunar strokes can also lead to complications from physical disability. These include:

Aspiration pneumonia – a type of lung infection that happens when you inhale food, drink, or saliva into your lungs
Deep vein thrombosis – a blood clot in a deep vein, usually in the leg
Pulmonary embolism – a blockage in one of the pulmonary arteries in your lungs
Urinary tract infection – an infection in any part of your urinary system
Depression
Decubitus ulcers – also known as bedsores or pressure sores

Recovery from Lacunar Stroke (Stroke)

Most people who experience lacunar strokes (small strokes deep within the brain) tend to see significant improvements in their neurological condition. After being discharged from the hospital, therapies such as physical, speech, and occupational therapy, as well as rehabilitation services, are crucial. These therapies help patients regain their strength and functionality to the greatest extent possible following their stroke.

Preventing Lacunar Stroke (Stroke)

Patients should be aware of factors that can increase the risk of a stroke. It’s crucial to take medication to prevent strokes from recurring, keep to a healthy diet, have regular exercise, avoid smoking, and limit alcohol consumption. Doing this can lessen the chances of experiencing a stroke. For those with conditions like high blood pressure, abnormal cholesterol, or diabetes, regular check-ups with their doctor are necessary to keep these additional risks in check.

The journey to recovery from a small ‘lacunar’ stroke is different for each person. It’s very important to keep the home safe as physical disabilities from the stroke can increase the risk of falling. Many people who have had a stroke can often feel depressed and this should not be ignored if it starts happening. Memory problems due to multiple small strokes can gradually develop into a condition called vascular dementia – which needs careful monitoring.

Frequently asked questions

Lacunar stroke refers to small strokes that occur in noncortical areas of the brain, typically less than 15 mm in diameter. These strokes are caused by the blockage of small, deep arteries from the circle of Willis, resulting in small spaces filled with cerebral spinal fluid in the brain. While many lacunar strokes may not have noticeable symptoms, they can still lead to significant physical and mental disabilities over time.

Lacunar strokes occur in 25 to 50 people out of every 100,000.

The signs and symptoms of Lacunar Stroke (Stroke) can vary depending on the area of the brain affected. Some lacunar infarcts may not result in any symptoms and are only discovered incidentally through imaging. However, when symptoms do occur, they can include: - Sudden onset of neurological deficits - Stuttering pattern of symptoms that worsen over time - Severe hemiplegia, which is paralysis of one side of the body - Weakness on one side of the body, affecting the face, arm, and leg (Pure motor hemiparesis) - Lack of muscle control and coordination on one side of the body (Ataxic-hemiparesis) - Impaired or abnormal sensation on one side of the body, including the face, arm, and leg (Pure sensory) - Difficulty in speech and hand coordination (Dysarthria-clumsy hand) - Both sensory and motor function impairment (Sensory-motor) It is important to note that lacunar strokes usually do not affect memory, language, and judgement. Additionally, more than 40% of individuals with subcortical infarct may deteriorate neurologically within the first week of onset of stroke symptoms, and lacunar strokes are a common cause of mild cognitive impairment and early dementia.

Lacunar strokes occur when the small blood vessels that provide blood to the deeper parts of the brain get blocked. This can be caused by various reasons such as certain vascular diseases, small fragments of clots from the heart, or a bigger blood vessel disease blocking the small brain arteries. Factors like high blood pressure, diabetes, smoking, bad cholesterol levels, and other vascular diseases can increase the risk of developing lacunar strokes. There is also a genetic aspect involved, as specific genetic factors can make a person more likely to develop small vessel disease and experience these types of strokes.

The doctor needs to rule out the following conditions when diagnosing Lacunar Stroke (Stroke): - Large vessel stroke - Intracranial hemorrhages - Seizures - Complicated migraines - Brain tumors - Multiple Sclerosis (MS) - Hypoglycemia - Transient global amnesia

The types of tests that are needed for Lacunar Stroke (Stroke) include: 1. Brain imaging studies, such as CT scans or MRI scans, to detect and classify cerebral small vessel disease. 2. Transcranial Doppler, a non-invasive procedure that provides information about the structure, function, and blood flow velocity of cerebral blood vessels. 3. CT angiogram to detect a clot blocking a vessel and to show chronic arterial diseases. 4. CT perfusion study to determine areas of irreversible and reversible ischemia. 5. Carotid ultrasound to detect narrowing of the extracranial carotid artery. 6. Blood tests, including blood glucose levels, complete blood count, troponin, prothrombin time, international normalized ratio (INR), activated partial thromboplastin time, complete metabolic panel, lipid panel, hemoglobin A1c, and toxicology screen, to assess underlying stroke risk factors.

Managing a lacunar stroke follows the same principles as treating any other acute ischemic stroke. The primary goal of treatment during the acute stage is to stabilize the patient and determine if they're suitable for thrombolysis, which involves injecting a drug called a tissue plasminogen activator (tPA) to dissolve clots and restore blood flow to the brain. Thrombolysis should be administered within 4.5 hours after stroke symptoms begin. If the patient is not eligible for thrombolysis or if the stroke occurred more than 4.5 hours ago, specific brain scans can be done to determine if a thrombectomy, a procedure to mechanically remove the clot, is an option. Blood-thinning medications like aspirin and clopidogrel can also be given to lower the risk of another stroke. Managing high blood pressure, diabetes, and cholesterol, as well as lifestyle changes like quitting smoking, eating healthily, losing weight, and exercising, are also important in preventing strokes. Physical therapy and rehabilitation are critical for patients with physical disabilities resulting from the stroke.

The side effects when treating Lacunar Stroke (Stroke) can include: - Aspiration pneumonia: a lung infection that occurs when food, drink, or saliva is inhaled into the lungs. - Deep vein thrombosis: a blood clot in a deep vein, typically in the leg. - Pulmonary embolism: a blockage in one of the pulmonary arteries in the lungs. - Urinary tract infection: an infection in any part of the urinary system. - Depression: a mood disorder characterized by persistent feelings of sadness and loss of interest. - Decubitus ulcers: also known as bedsores or pressure sores, which are injuries to the skin and underlying tissue caused by prolonged pressure on the skin.

Lacunar strokes generally have a more favorable prognosis compared to other types of strokes. They are typically marked by a high survival rate, a low chance of occurring again, and a relatively good return to normal function. However, the long-term prognosis does carry an increased risk of death, primarily due to heart-related conditions. Patients who have multiple small vessel diseases also have a higher risk of cognitive decline and developing dementia.

A neurologist.

Aphasia Facial Paralysis Headache Stroke