What is the recommended treatment and dosage for lacunar infarct?

Treatment of Lacunar Infarct

For patients with lacunar infarct, single antiplatelet therapy (SAPT) with either aspirin 75-100 mg daily or clopidogrel 75 mg daily is recommended as the primary treatment, along with aggressive blood pressure control targeting <130/80 mmHg. 1

Antiplatelet Therapy

• Single antiplatelet therapy is the cornerstone of treatment for lacunar infarct, with either aspirin or clopidogrel being effective options 1
• Recommended dosing:
  • Aspirin: 75-100 mg daily (preferred maintenance dose) 1
  • Clopidogrel: 75 mg daily 1
• Dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel is NOT recommended for long-term secondary prevention after lacunar stroke, as it significantly increases bleeding risk without reducing recurrent stroke risk 2, 1
• The SPS3 trial specifically showed that adding clopidogrel to aspirin in lacunar stroke patients did not significantly reduce recurrent stroke risk (2.5% vs 2.7% per year) but nearly doubled major hemorrhage risk (2.1% vs 1.1% per year) 2

Blood Pressure Management

• Aggressive blood pressure control is crucial for patients with lacunar infarct 3
• Target blood pressure should be <130/80 mmHg 1
• For patients with lacunar stroke specifically, a target systolic BP goal of less than 130 mmHg may be reasonable 1
• Recommended antihypertensive medications:
  • Thiazide diuretics 1
  • ACE inhibitors 1
  • ARBs 1
  • Combination of thiazide diuretic plus ACE inhibitor 1

Additional Management Considerations

• Statin therapy is recommended for lipid management in lacunar stroke patients 3
• Diabetes management is essential, as diabetes is a significant risk factor for lacunar stroke 1
• Lifestyle modifications:
  • Smoking cessation 1
  • Regular physical activity 1
  • Dietary modifications 1

Follow-up and Monitoring

• Regular follow-up is essential as lacunar stroke has a paradoxical clinical course: favorable short-term prognosis but increased risk of death, stroke recurrence, and dementia in the mid- and long-term 3, 4
• Monitor for:
  • Blood pressure control 5
  • Medication adherence 3
  • Development of cognitive decline 4
  • Signs of recurrent stroke 5

Common Pitfalls to Avoid

• Underestimating the long-term risk: Despite favorable short-term outcomes, lacunar infarcts carry significant long-term risks of recurrence, death, and cognitive decline 4, 5
• Using dual antiplatelet therapy for long-term management: The addition of clopidogrel to aspirin increases bleeding risk without significant benefit in preventing recurrent lacunar stroke 2
• Inadequate blood pressure control: Hypertension is a major risk factor for lacunar stroke, and aggressive BP control is essential 3, 1
• Neglecting to screen for and manage other vascular risk factors, particularly diabetes mellitus 1

Risk Stratification

• Factors associated with worse prognosis in lacunar stroke:
  • Advanced age 5
  • Higher initial stroke severity (higher NIHSS score) 5
  • Greater white matter lesion volume on imaging 5
  • Presence of silent lacunes or microbleeds 5
  • Hyperhomocysteinemia 5