Is this patient's presentation more consistent with a lacunar infarct (LACI) or a partial anterior circulation infarct (PACI) given reduced consciousness, aphasia, and bilateral upper limb weakness with a history of Diabetes Mellitus (DM), Hypertension (HTN), Chronic Kidney Disease (CKD), and Hyperlipidemia (HPL)?

Clinical Stroke Classification: PACI, Not LACI

This patient's presentation is most consistent with a Partial Anterior Circulation Infarct (PACI), not a lacunar infarct (LACI). The presence of reduced consciousness (GCS E3V1M5-6), aphasia, and bilateral upper limb weakness with cortical features definitively excludes a lacunar syndrome.

Why This is PACI, Not LACI

Key Clinical Features That Exclude LACI

• Aphasia is a cortical sign that does not occur with pure lacunar infarcts, which affect only subcortical structures 1, 2, 3
• Reduced consciousness (GCS drop from full to E3V1M5-6) indicates cortical involvement and is incompatible with lacunar stroke, which presents with preserved consciousness 4
• Bilateral upper limb involvement suggests cortical or multiple territory involvement rather than a single penetrating artery occlusion characteristic of LACI 1, 2

What Defines a True Lacunar Infarct

• Lacunar infarcts are subcortical strokes measuring <1.5 cm in diameter affecting penetrating arteries in the basal ganglia, brain stem, or deep white matter 1, 2, 3
• Patients present with classical lacunar syndromes (pure motor hemiparesis, pure sensory syndrome, sensorimotor stroke, ataxic hemiparesis, or dysarthria-clumsy hand) without cortical signs 1, 2, 4
• Consciousness is always preserved in lacunar stroke 4
• No aphasia, no visual field defects, no neglect - these cortical features exclude LACI 1, 5

PACI Classification Criteria

Clinical Features Supporting PACI

• Cortical dysfunction (aphasia in this case) is a defining feature of anterior circulation infarcts 3
• Motor deficits with cortical signs distinguish PACI from pure lacunar syndromes 3
• The pattern of bilateral upper limb predominance with altered consciousness suggests cortical involvement in the dominant hemisphere affecting language and consciousness centers 5

Important Diagnostic Caveat

• Isolated aphasia is strongly associated with cardioembolic stroke (adjusted OR 2.94,95% CI 2.16-4.01), particularly atrial fibrillation, and warrants careful cardiac screening 5
• This patient requires comprehensive workup including extended cardiac monitoring to detect paroxysmal atrial fibrillation, as anticoagulation rather than antiplatelet therapy may be indicated 1, 5

Critical Management Implications

Why Classification Matters for Treatment

• Misclassification has therapeutic consequences: if this were misdiagnosed as LACI but the patient has atrial fibrillation, antiplatelet therapy alone would be inadequate - anticoagulation is required 1
• The presence of multiple small chronic infarcts with cerebral atrophy on CT suggests underlying vascular cognitive impairment and small vessel disease burden, but does not change the acute stroke classification 6

Required Diagnostic Workup

• Vascular imaging (CTA or MRA) must be obtained urgently to exclude large vessel occlusion, even with presumed cortical stroke 1
• Transthoracic echocardiography at minimum and extended cardiac rhythm monitoring are mandatory given the aphasia and cortical presentation 1, 5
• MRI is superior to CT for detecting acute cortical infarcts and distinguishing them from chronic lacunar infarcts 6

Clinical Pitfall to Avoid

Do not assume small vessel disease alone explains this presentation simply because the CT shows chronic lacunar infarcts. The acute clinical syndrome with aphasia and reduced consciousness indicates a new cortical event (PACI) superimposed on chronic small vessel disease 6, 1. The chronic infarcts represent background cerebrovascular disease burden but do not define the current acute stroke subtype 6.