Lacunar Stroke Symptoms and Management
Lacunar strokes present with distinct clinical syndromes including pure motor hemiparesis, pure sensory syndrome, sensorimotor stroke, ataxic hemiparesis, and dysarthria-clumsy hand syndrome, and require management focused on antiplatelet therapy, blood pressure control, and statin therapy regardless of baseline cholesterol levels. 1
Clinical Presentation
Lacunar strokes are small subcortical infarcts (less than 1.5 cm in diameter) located in the basal ganglia, brain stem, or deep white matter, caused by occlusion of a single penetrating artery 1. They account for approximately 25% of all ischemic strokes 2.
Classic Lacunar Syndromes:
- Pure motor hemiparesis: Unilateral weakness of face, arm, and leg without sensory deficit
- Pure sensory syndrome: Unilateral sensory symptoms without weakness
- Sensorimotor stroke: Combined motor and sensory deficits
- Ataxic hemiparesis: Weakness with ipsilateral ataxia
- Dysarthria-clumsy hand syndrome: Dysarthria with clumsiness of the hand 1
Additional Symptoms:
- Memory, speech, or hearing difficulties 1
- Language dysfunction including aphasia 1
- Transient, fluctuating, or persistent unilateral weakness (face, arm, and/or leg) 3
- Transient, fluctuating, or persistent language/speech disturbance 3
Diagnosis
Diagnosis of lacunar stroke requires:
- Clinical presentation with a typical lacunar syndrome
- Neuroimaging (CT or MRI) showing a small subcortical infarct or normal findings
- Exclusion of other potential causes of symptoms 1
MRI is more sensitive than CT for detecting small infarcts, particularly in the brainstem and posterior fossa 1. Urgent brain imaging (CT or MRI) and non-invasive vascular imaging (CTA or MRA from aortic arch to vertex) should be completed within 24 hours 3.
Management
Acute Management:
- Immediate medical attention: Patients with stroke symptoms should call emergency services immediately, even if symptoms resolve 3
- Oxygen therapy: Administer supplementary oxygen to hypoxemic stroke patients (oxygen saturation <94%) or those with unknown oxygen saturation 3
- Blood pressure management: Unless the patient is hypotensive (systolic BP <90 mm Hg), prehospital intervention for blood pressure is not recommended 3
- Intravenous thrombolysis: Consider if presenting within the treatment window 1
Secondary Prevention:
Antiplatelet therapy:
- For high-risk TIA or minor ischemic stroke patients presenting within 24-48 hours of symptom onset, dual antiplatelet therapy with ASA (81 mg daily) and clopidogrel (75 mg daily) is recommended for 21-30 days, followed by antiplatelet monotherapy 3
- In dysphagic patients, ASA and clopidogrel may be given by enteral tube or ASA by rectal suppository 3
Blood pressure control: Aggressive management is crucial as hypertension is a major risk factor for lacunar infarcts 1
Statin therapy: Recommended regardless of baseline cholesterol levels 1
Additional measures:
Prognosis
Lacunar strokes have a paradoxical clinical course:
- Short-term: Generally favorable prognosis with low early mortality
- Long-term: Less favorable with increased risk of:
Patients with small-artery occlusion have the highest survival rate (85% at 2 years) compared to other stroke subtypes 1.
Important Considerations
- Escalation of antithrombotic treatments beyond standard single antiplatelet agents has not been effective in long-term lacunar stroke prevention and increases intracerebral hemorrhage risk 5
- Age, vascular risk factors, high nocturnal blood pressure, and severity of cerebral small-vessel disease at onset have significant prognostic implications 4
- The incidence of cerebral lacunes has declined since the introduction of antihypertensive therapy, indicating that therapy is effective 6
Early recognition using the FAST (Face, Arms, Speech, and Time) acronym and immediate medical attention are crucial for improving outcomes in lacunar stroke patients 3.