What is the most accurate statement about small-vessel (lacunar) stroke, considering risk factors such as hypertension and age?

Small-Vessel (Lacunar) Stroke: Key Characteristics

The most accurate statement is B: The most common risk factors for small-vessel strokes are hypertension and age. This is consistently supported across multiple high-quality guidelines and research studies 1, 2, 3.

Epidemiology and Proportion

• Small-vessel disease accounts for approximately 25% of all ischemic strokes, not 50% 4, 2
• This makes statement A incorrect—lacunar infarcts represent about one-quarter of cerebral infarctions, not half

Risk Factor Profile

• Hypertension is the primary and most critical modifiable risk factor for lacunar stroke 1, 2, 3, 5
• Age is a major non-modifiable risk factor, with cerebral small vessel disease found at autopsy in over 50% of people aged ≥65 years 3
• Diabetes mellitus is another major risk factor for lacunar stroke 2
• Patients with penetrating artery disease (lacunar stroke) had significantly higher frequency of hypertension compared to those with large-vessel atherosclerotic disease 1

Prognosis and Recovery

• Statement C is incorrect—recovery from small-vessel strokes is actually MORE favorable than from large-vessel strokes in the short term 1, 6
• Patients with small-artery occlusion have the highest survival rate (85% at 2 years) among all stroke subtypes 1, 6
• The 1-year mortality after lacunar stroke is only 1.4%, compared to 8.1% after atherosclerotic stroke and 30% after cardioembolic stroke 1
• Within 30 days, only 2 of 133 lacunar stroke patients died of cardiac causes, compared with 6 of 209 patients with anterior circulation infarcts 1, 6
• The 90-day death rate for microangiopathy is 3.3%, the lowest among all stroke subtypes 1

Important Caveat About Long-Term Prognosis

• Despite favorable short-term outcomes, lacunar strokes carry increased risk of death, stroke recurrence, and dementia in the mid- to long-term 2
• Asymptomatic progression of small-vessel disease is a typical feature 2
• Lacunar infarction should be regarded as a potentially severe condition requiring rigorous management and follow-up, not a benign disorder 2

Evaluation Considerations

• Statement D is incorrect—embolic sources should NOT be automatically excluded 6
• Proper diagnosis requires excluding potential sources of cardioembolism and ipsilateral large-artery stenosis 6
• While lacunar strokes are primarily caused by small vessel disease, a thorough evaluation is necessary to rule out other etiologies before confirming the diagnosis 6