What is the management approach for a lacunae infarct?

From the Guidelines

The management of a lacunar infarct should focus on acute treatment, secondary prevention, and rehabilitation, with a comprehensive approach that includes antiplatelet therapy, blood pressure control, statin therapy, and lifestyle modifications to reduce the risk of recurrent stroke and improve quality of life. In the acute phase, if diagnosed within 4.5 hours of symptom onset, intravenous thrombolysis with alteplase (0.9 mg/kg, maximum 90 mg, with 10% given as bolus and remainder over 60 minutes) should be considered. For secondary prevention, antiplatelet therapy is the cornerstone, typically starting with aspirin 325 mg daily for the first 21 days, then transitioning to long-term therapy with either clopidogrel 75 mg daily or aspirin 81 mg plus extended-release dipyridamole 200 mg twice daily. Some key points to consider in the management of lacunar infarct include:

• Blood pressure control is crucial, aiming for targets below 130/80 mmHg using medications like ACE inhibitors, ARBs, or calcium channel blockers, as supported by guidelines such as those from the Canadian Stroke Best Practice Recommendations 1.
• Statin therapy (such as atorvastatin 40-80 mg daily) is recommended regardless of baseline cholesterol levels, to achieve a target LDL cholesterol consistently less than 2.0 mmol/L or >50% reduction of LDL cholesterol, from baseline 1.
• Lifestyle modifications including smoking cessation, limited alcohol consumption, regular physical activity, and a Mediterranean or DASH diet are important.
• Blood glucose control in diabetic patients (targeting HbA1c <7%) is crucial, as diabetes is a significant risk factor for stroke and recurrent stroke, as highlighted in guidelines such as those from the American Heart Association/American Stroke Association 1.
• Rehabilitation services including physical, occupational, and speech therapy should be implemented as needed to improve functional outcomes and quality of life. The goal of this comprehensive approach is to address the underlying small vessel disease pathology, reduce the risk of recurrent stroke by approximately 25-30%, and improve morbidity, mortality, and quality of life outcomes for patients with lacunar infarct.

From the Research

Management Approach for Lacunae Infarct

The management approach for lacunae infarct involves the use of antiplatelet therapy to reduce the risk of recurrent stroke and other serious vascular events.

• Antiplatelet agents such as aspirin, clopidogrel, and dipyridamole are effective in reducing the risk of recurrent stroke and other serious vascular events 2, 3, 4, 5.
• The combination of aspirin and dipyridamole has been shown to be more effective than aspirin alone in reducing the risk of recurrent stroke and other serious vascular events 4.
• Cilostazol has also been shown to be effective in reducing the risk of recurrence in patients with ischemic stroke, mostly lacunar stroke 2.
• The use of warfarin is recommended in patients with non-valvular atrial fibrillation (NVAF) who are at high risk of stroke, while aspirin can be used as an alternative in patients without any risk factors for stroke 2.
• The combination of aspirin and clopidogrel may be considered in certain patients, but its use is not without risks and the benefits do not always match the risks 3, 6, 4.

Antiplatelet Therapy

Antiplatelet therapy is a cornerstone in the treatment of acute arterial thrombotic events and in the prevention of thrombus formation.

• Aspirin, clopidogrel, and dipyridamole are commonly used antiplatelet agents 2, 3, 6, 4, 5.
• New antiplatelet agents such as adenosine 5'-diphosphonate receptor antagonists, sarpogrelate, terutroban, and SCH 530348 are being investigated for use in secondary stroke prevention 6.
• The choice of antiplatelet agent and the duration of therapy depend on the individual patient's risk factors and the underlying cause of the stroke 2, 4.