Stroke, Lacunar

Key Features

• Small lesions (usually < 1.5 cm in diameter) occur in the distribution of

  • Short, penetrating arteries in the basal ganglia

  • Pons

  • Cerebellum

  • Internal capsule

  • Thalamus

  • Deep cerebral white matter (less common) (Table 24–3)

• Risk factors include poorly controlled hypertension and diabetes mellitus

• Generally has a good prognosis, with partial or complete resolution often occurring over 4–6 weeks

Clinical Findings

• There are several clinical syndromes

  • Contralateral pure motor hemiparesis or pure hemisensory deficit

  • Ipsilateral ataxia with crural paresis

  • Dysarthria with clumsiness of the hand

• Deficits may progress over 24–36 hours before stabilizing

Diagnosis

• Sometimes visible on CT scans as small, punched-out, hypodense areas, but in other patients no abnormality is seen

• In some instances, patients with a clinical syndrome suggestive of lacunar infarction are found to have a severe hemispheric infarct on CT scanning

• Diffusion-weighted MRI is sensitive to acute lesions, which later evolve into areas of T2 hyperintensity and eventually into small, punched-out, cerebrospinal fluid–filled spaces

Treatment

• Treatment is similar to transient ischemic attack and cerebral infarction

• Control hypertension or diabetes mellitus

• Avoid tobacco use

• Anticoagulation is not indicated

• Aspirin, 325 mg once daily orally, is of uncertain benefit