From the Guidelines
The management of a lacunar stroke, which is caused by a small blockage or narrowing of a brain artery, typically involves immediate medical intervention followed by long-term preventive strategies. Initially, if the patient presents within 4.5 hours of symptom onset, intravenous tissue plasminogen activator (tPA) may be administered to dissolve the clot, at a dose of 0.9 mg/kg with a maximum of 90 mg (10% as bolus, remainder over 60 minutes) 1. For secondary prevention, antiplatelet therapy is the cornerstone of treatment, usually starting with aspirin 325 mg daily for the first 21 days, then transitioning to aspirin 81 mg daily or clopidogrel 75 mg daily for long-term use. Blood pressure control is crucial, aiming for targets below 130/80 mmHg using medications like ACE inhibitors (e.g., lisinopril 10-40 mg daily), ARBs, calcium channel blockers, or thiazide diuretics. Cholesterol management with high-intensity statins such as atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily is recommended regardless of baseline cholesterol levels 1. Lifestyle modifications are essential and include smoking cessation, limiting alcohol consumption, maintaining a low-sodium diet, regular physical activity (150 minutes of moderate exercise weekly), and weight management. These interventions work together to reduce the risk of recurrent stroke by addressing the underlying mechanisms of small vessel disease, including hypertension, atherosclerosis, and platelet aggregation. Some key points to consider in the management of lacunar stroke include:
- Determining the most probable ischemic stroke subtype to provide useful prognostic information and guide treatment decisions 1
- Classifying ischemic stroke subtypes using schemes such as TOAST, which categorizes strokes into large-artery atherosclerosis, cardioembolism, small-artery or lacunar stroke, and other types 1
- Recognizing that patients with small-vessel disease may have a lower risk of cardiac-related death compared to those with other stroke subtypes 1
From the Research
Definition of a Small Blockage or Narrowing of a Brain Artery
- A small blockage or narrowing of a brain artery is also known as a lacunar stroke, which is a type of ischemic stroke that occurs when the small arteries that supply blood to the brain's deep structures become blocked 2.
- Lacunar strokes account for nearly one-third of all ischemic strokes and can cause significant intellectual and physical disabilities despite their small size 2.
Management and Treatment of Lacunar Stroke
- The management and treatment of lacunar stroke typically involve antiplatelet therapy, such as aspirin or clopidogrel, to prevent further stroke and improve outcomes 3, 4, 5.
- Studies have shown that dual antiplatelet therapy with aspirin and clopidogrel may be more effective than monotherapy with aspirin alone in reducing the risk of recurrent stroke in patients with minor ischemic stroke or high-risk transient ischemic attack (TIA) 5.
- However, dual antiplatelet therapy also increases the risk of major hemorrhage, and the decision to use this treatment approach should be individualized based on the patient's risk factors and medical history 5.
- Other treatment approaches, such as intravenous thrombolysis with alteplase, may also be considered in certain cases, although the evidence for their use in lacunar stroke is limited 3, 4.
Pathophysiology of Lacunar Stroke
- The pathophysiology of lacunar stroke is complex and involves the narrowing and blockage of small arteries in the brain, which can be caused by a variety of factors, including hypertension, diabetes, and atherosclerosis 2.
- Recent advances in understanding the clinical mechanisms, imaging characteristics, and genetic basis of lacunar stroke have improved our knowledge of this condition, but further research is needed to develop effective treatments and preventions 2.