From the Guidelines
A lacunar stroke in the cerebellar arteries is a small, deep infarction occurring in the cerebellum due to occlusion of small penetrating arteries that supply this region, typically measuring less than 15mm in diameter and resulting from lipohyalinosis or microatheroma of small vessels, most commonly affecting patients with chronic hypertension or diabetes. These strokes are part of a broader category of ischemic strokes, which account for approximately 85% of all strokes, with lacunar strokes specifically accounting for 15% to 20% of ischemic lesions 1. The pathophysiology of lacunar strokes is closely linked to the small vessel changes associated with hypertension of long duration, making blood pressure control a critical aspect of both acute and long-term management.
Clinical Presentation
When occurring in the cerebellar territory, patients with lacunar strokes may present with sudden onset of vertigo, ataxia, difficulty with coordination, nausea, vomiting, and sometimes headache. Unlike larger cerebellar strokes, lacunar infarcts may cause more subtle symptoms that can be mistaken for inner ear problems. It's essential to recognize these symptoms early to initiate appropriate management.
Management and Prevention
Management of lacunar strokes includes immediate blood pressure control, antiplatelet therapy, and addressing underlying vascular risk factors. Keeping systolic BP <180 mmHg is crucial in the acute phase, and antiplatelet therapy (typically aspirin 81-325mg daily, clopidogrel 75mg daily, or combination therapy depending on risk factors) is initiated to prevent further ischemic events. Long-term prevention focuses on blood pressure control (target <130/80 mmHg), diabetes management, statin therapy (such as atorvastatin 40-80mg or equivalent), and lifestyle modifications including smoking cessation, regular exercise, and dietary changes 1. Rehabilitation may be necessary to address residual coordination deficits, emphasizing the importance of a multidisciplinary approach to patient care.
Key Considerations
Unlike larger cerebellar strokes, lacunar infarcts rarely cause significant edema or require surgical intervention. However, they can still significantly impact the patient's quality of life due to residual neurological deficits. Therefore, early recognition and management of lacunar strokes, along with comprehensive secondary prevention strategies, are critical to improving outcomes and reducing morbidity and mortality. By prioritizing blood pressure control, addressing modifiable risk factors, and implementing evidence-based therapies, clinicians can significantly improve the prognosis for patients with lacunar strokes in the cerebellar arteries.
From the Research
Definition and Causes of Lacunar Stroke
- Lacunar stroke is a type of stroke caused by the occlusion of a single penetrating artery, resulting in small subcortical infarcts 2.
- It is a marker of cerebral small vessel disease and accounts for up to 25% of ischemic strokes 3, 4.
- The most common mechanisms of lacunar stroke include lipohyalinosis and atheromatous disease, with cardioembolism being less common 3.
Location and Impact of Lacunar Stroke
- Lacunar infarcts can occur in various locations, including the cerebellar arteries, and are associated with a high risk of recurrent stroke, cognitive decline, dementia, and death 3, 2.
- The prognosis after lacunar infarcts is not benign, with a risk of recurrent stroke similar to other ischemic stroke subtypes 2.
Treatment and Prevention of Lacunar Stroke
- Aspirin has been shown to reduce the risk of recurrent stroke in patients with lacunar stroke 5.
- Antiplatelet drugs, careful blood pressure control, statins, and modification of lifestyle risk factors are key elements in secondary prevention after lacunar infarcts 2.
- The effectiveness of antiplatelet therapy for secondary prevention has been studied, with mixed results regarding the addition of clopidogrel to aspirin 6.
Cerebellar Arteries and Lacunar Stroke
- While the provided studies do not specifically focus on lacunar stroke in the cerebellar arteries, they do discuss the general mechanisms and treatment of lacunar stroke 6, 3, 5, 2, 4.
- Lacunar stroke can occur in the cerebellar arteries, but more research is needed to fully understand the specific characteristics and treatment of cerebellar lacunar strokes.