From the Guidelines
Hypertension is strongly correlated with lacunar infarction, serving as the most important modifiable risk factor for this type of stroke. Lacunar infarctions are small, deep brain infarcts (typically 3-15mm in size) that occur when small penetrating arteries in the brain become blocked, causing damage to subcortical areas. Chronic hypertension leads to pathological changes in these small vessels, including lipohyalinosis (degeneration of vessel walls) and fibrinoid necrosis, which narrows the vessel lumen and compromises blood flow. This process, known as arteriolosclerosis, makes these vessels more susceptible to occlusion and subsequent infarction. The relationship is dose-dependent, with higher blood pressure levels and longer duration of hypertension associated with greater risk 1.
Key Points
- Effective blood pressure control is essential for preventing lacunar strokes, with a target of <130/80 mmHg generally recommended 1.
- First-line medications typically include ACE inhibitors (like lisinopril 10-40mg daily), ARBs (such as losartan 25-100mg daily), calcium channel blockers (amlodipine 5-10mg daily), or thiazide diuretics (hydrochlorothiazide 12.5-25mg daily) 1.
- For secondary prevention after a lacunar stroke, aggressive blood pressure management combined with antiplatelet therapy (aspirin 81-325mg daily or clopidogrel 75mg daily) is typically indicated 1.
- Lifestyle modifications including sodium restriction, regular exercise, weight management, and limiting alcohol consumption are also crucial components of hypertension management for reducing lacunar stroke risk 1.
Management
The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline recommends restarting antihypertensive treatment in patients with a previous history of stroke or TIA, with a goal of achieving a blood pressure of <130/80 mmHg 1. The choice of antihypertensive agent is less important than achieving the target blood pressure, but specific agents such as diuretics, ACE inhibitors, and ARBs have shown benefit in reducing the risk of recurrent stroke 1.
Evidence
The evidence from recent studies, including the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline, supports the importance of blood pressure control in preventing lacunar strokes 1. A post hoc analysis of an RCT suggests that the effectiveness of antihypertensive treatment for secondary stroke prevention diminishes as initial baseline BP declines 1. However, achieving an SBP level <130 mm Hg may be beneficial in reducing the risk of future intracerebral hemorrhage (ICH) in patients with a lacunar stroke 1.
From the Research
Correlation between Hypertension and Lacunar Infarction
The relationship between hypertension and lacunar infarction has been studied in several research papers.
- A study published in the European Journal of Neurology in 2015 found that the reverse-dipper pattern of blood pressure may predict lacunar infarction in patients with essential hypertension 2.
- The study analyzed 362 hypertensive patients and found that the percentage of lacunar infarction was the highest in patients with the reverse-dipper pattern of blood pressure.
- Another study published in Archives of Neurology in 1998 found that changes in circadian blood pressure patterns are associated with the occurrence of lacunar infarction 3.
- The study analyzed 118 hospitalized patients and found that patients with lacunar infarction were significantly older and had more often a history of arterial hypertension, elevated average daytime blood pressure values, and a reduced circadian blood pressure variation.
Risk Factors for Lacunar Infarction
Several risk factors have been identified for lacunar infarction, including:
- Arterial hypertension: A study published in Stroke in 1996 found that patients with silent infarctions had higher systolic and diastolic blood pressure at stroke onset 4.
- Age: The same study found that age greater than 60 years was the only risk factor associated with silent infarction.
- Circadian blood pressure variation: The study published in Archives of Neurology in 1998 found that a reduced systolic circadian blood pressure variation was correlated with the occurrence of lacunar infarction 3.
- Reverse-dipper pattern of blood pressure: The study published in the European Journal of Neurology in 2015 found that the reverse-dipper pattern of blood pressure was directly associated with lacunar infarction 2.
Treatment and Management
While the studies do not provide direct evidence for the treatment and management of lacunar infarction, they suggest that controlling blood pressure and managing hypertension may be important in preventing lacunar infarction.
- A study published in JAMA in 2002 found that thiazide-type diuretics are superior in preventing major forms of cardiovascular disease and are less expensive 5.
- Another study published in Expert Opinion on Drug Metabolism & Toxicology in 2009 found that calcium channel blockers, such as lercanidipine, may be effective in treating essential hypertension with fewer side effects 6.