From the Guidelines
An acute lacunar infarct in the right pons typically presents with characteristic clinical findings, including pure motor hemiparesis, dysarthria, and ataxia, and requires prompt management to minimize morbidity and mortality. The clinical findings of an acute lacunar infarct in the right pons can vary depending on the exact location and size of the infarct, but common symptoms include:
- Pure motor hemiparesis affecting the left side of the body (face, arm, and leg)
- Dysarthria (slurred speech)
- Ataxia (incoordination)
- Vertigo
- Diplopia
- Horizontal gaze palsy Initial management includes:
- Immediate brain imaging with CT or MRI to confirm diagnosis and exclude hemorrhage
- For eligible patients within 4.5 hours of symptom onset, intravenous recombinant tissue plasminogen activator (rtPA, alteplase) at 0.9 mg/kg (maximum 90 mg) with 10% given as bolus and remainder over 60 minutes should be considered 1
- Antiplatelet therapy with aspirin 325 mg should be initiated within 24-48 hours after symptom onset if thrombolysis is not given, or after 24 hours if thrombolysis was administered Long-term secondary prevention includes:
- Daily aspirin 81-100 mg or clopidogrel 75 mg daily
- High-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily)
- Blood pressure control targeting <130/80 mmHg
- Management of other vascular risk factors such as diabetes and smoking Rehabilitation should begin early with physical, occupational, and speech therapy as needed. The pathophysiology involves occlusion of small penetrating arteries (typically branches of the basilar artery) due to lipohyalinosis or microatheroma, often related to chronic hypertension or diabetes, leading to small deep infarcts in the pons 1.
From the Research
Clinical Findings
- Patients with an acute lacunar infarct in the right pons may present with a classical lacunar syndrome, which includes pure motor hemiparesis, pure sensory syndrome, sensorimotor stroke, ataxic hemiparesis, or dysarthria-clumsy hand 2.
- The clinical presentation may also include atypical lacunar syndromes, which are less frequent 2.
- Hypertension and diabetes mellitus are major risk factors for lacunar stroke, and patients with these conditions may be more likely to experience an acute lacunar infarct in the right pons 2.
Management
- Antiplatelet drugs, careful blood pressure control, the use of statins, and modification of lifestyle risk factors are key elements in secondary prevention after lacunar stroke 2.
- For patients with acute ischemic stroke, including those with lacunar infarcts, administration of i.v. tissue plasminogen activator (tPA) within 3 hours of clearly defined symptom onset is recommended 3.
- Early aspirin therapy, 160 to 325 mg qd, is also recommended for patients with acute ischemic stroke who are not receiving thrombolysis 3.
- Low-molecular-weight heparin (LMWH) may be used to prevent venous thromboembolism, but its risks and benefits in early ischemic stroke are still being studied 4.
- Thrombolysis may be beneficial for patients with lacunar strokes, with improved outcomes compared to other clinical ischemic stroke sub-types 5.
Prognosis
- Lacunar infarcts show a paradoxical clinical course with a favorable prognosis in the short term, characterized by a low early mortality and reduced functional disability on hospital discharge 2.
- However, patients with lacunar infarcts are at increased risk of death, stroke recurrence, and dementia in the mid- and long term 2.
- Asymptomatic progression of small-vessel disease is a typical feature of lacunar infarcts, and patients require adequate and rigorous management and follow-up to prevent further complications 2.