What is the immediate treatment for a patient with a lacunar infarct?

Immediate Treatment for Lacunar Infarct

The immediate treatment for a patient with a lacunar infarct should include rapid assessment, administration of aspirin within 24-48 hours after stroke onset, and careful blood pressure management. 1, 2

Initial Management

• Perform a rapid assessment within 10-20 minutes of arrival to the emergency department, including a 12-lead ECG to confirm diagnosis 2
• Administer oxygen via nasal prongs, especially for patients who are breathless, to maintain adequate oxygenation 2
• Establish continuous cardiac monitoring immediately with emergency resuscitation equipment readily available 2
• Provide adequate analgesia with intravenous opioids and concurrent antiemetics for patient comfort 2

Antiplatelet Therapy

• Administer aspirin within 24-48 hours after stroke onset (for those treated with IV thrombolysis, aspirin administration should be delayed until >24 hours) 1
• Single antiplatelet therapy with either aspirin 75-100 mg daily or clopidogrel 75 mg daily is recommended for ongoing treatment 3
• Avoid delaying aspirin administration while waiting for definitive diagnosis, as early initiation is crucial in preventing early recurrent strokes 2

Blood Pressure Management

• Maintain blood pressure below 180/105 mm Hg for at least the first 24 hours after acute reperfusion treatment 1
• Target a systolic blood pressure of <130 mm Hg for long-term management to reduce the risk of future intracerebral hemorrhage 2, 3
• Underestimating the importance of blood pressure control is a common pitfall, as hypertension is a major risk factor for lacunar stroke 2, 4

Anticoagulation Considerations

• Routine anticoagulation with heparin or low-molecular-weight heparins is not recommended for lacunar infarcts 2
• Patients who are suitable for anticoagulation should not receive antiplatelets for secondary stroke prevention 1

Additional Management

• Encourage gradual early mobilization and use thigh-high intermittent pneumatic compression devices for patients with limited mobility 1
• Monitor body temperature and treat fever (temperature >38°C), investigating and treating sources of fever 1
• Antiseizure medications are only indicated for documented secondary seizures 1
• Screen for and manage other vascular risk factors, particularly diabetes mellitus, which is a significant risk factor for lacunar stroke 3, 5, 4

Monitoring and Follow-up

• Patients with lacunar infarcts require careful monitoring despite their initially favorable prognosis, as they have an increased risk of death, stroke recurrence, and dementia in the mid- and long-term 5, 6
• Regular follow-up is essential to manage risk factors and prevent recurrence 5

While lacunar infarcts may appear to have a favorable short-term prognosis with low early mortality, they should be treated aggressively due to the increased long-term risks of recurrent stroke and cognitive decline 5, 6.