Specialist Referral for Lacunar Infarct
Patients with lacunar infarct should be referred to a neurologist or vascular neurologist for comprehensive stroke evaluation and long-term management, as lacunar stroke requires rigorous follow-up despite its initially favorable presentation. 1, 2
Primary Specialist: Neurology/Vascular Neurology
Neurologists are the appropriate specialists for lacunar infarct management because these small-vessel strokes require specific expertise in stroke subtype classification, secondary prevention strategies, and monitoring for disease progression. 1, 2 Lacunar infarcts account for approximately 25% of all ischemic strokes and result from occlusion of single penetrating arteries supplying deep brain structures. 1, 2
Why Neurology is Essential
Stroke subtype determination is critical for prognosis and treatment planning, as lacunar strokes show a paradoxical clinical course with favorable short-term outcomes but increased mid- to long-term risks of death, recurrent stroke, and dementia. 1, 2, 3
Neurologists can exclude other stroke mechanisms that may mimic lacunar presentation, including cardioembolism and large-artery atherosclerosis, which require different management approaches. 1
Asymptomatic progression of small-vessel disease is a hallmark feature requiring specialized neurological monitoring and serial imaging assessment. 2
Critical Comorbidity Management
Cardiology Consultation Considerations
Cardiology referral should be considered when significant carotid stenosis or cardiac sources are identified during workup, as patients with atherosclerotic carotid disease warrant evaluation for coronary heart disease. 1 However, this is secondary to initial neurological evaluation.
Patients with lacunar stroke and cardiovascular risk factors (hypertension, diabetes, hyperlipidemia) have increased likelihood of underlying structural heart disease. 4, 5
Small-vessel disease patients appear to be at lower cardiac-related mortality risk compared to cardioembolic stroke patients, but cardiac evaluation remains important for comprehensive vascular risk assessment. 1
Primary Care Physician Role
Ongoing primary care management is essential for vascular risk factor control, which is the cornerstone of secondary prevention after lacunar stroke. 2, 3
Hypertension control is paramount, as hypertension shows the strongest association with lacunar infarcts (OR 2.21) and is independently associated with multiple lacunar infarcts (OR 1.54) and moderate-to-severe white matter hyperintensities (OR 2.06). 4, 5
Diabetes management is critical, with diabetes showing strong association with lacunar stroke (OR 2.10). 4, 5
Hyperlipidemia requires statin therapy as a key element in secondary prevention. 2
Long-Term Management Framework
The neurologist should coordinate a comprehensive secondary prevention strategy including:
Antiplatelet therapy (aspirin or clopidogrel) for stroke prevention. 2
Rigorous blood pressure control, particularly nocturnal blood pressure monitoring, as high nocturnal blood pressure has significant prognostic implications. 3
Statin therapy regardless of baseline cholesterol levels. 2
Lifestyle modification including smoking cessation (smoking OR 1.65 for lacunar stroke). 4
Serial cognitive assessment, as patients have increased risk of developing cognitive decline and dementia. 3
Common Pitfalls to Avoid
Do not dismiss lacunar infarcts as benign lesions based on favorable initial presentation—they require the same rigorous management as other stroke subtypes due to high long-term risks. 2, 3 The misconception that lacunar strokes are "relatively benign" can lead to inadequate follow-up and secondary prevention.
Do not delay neurological referral for stroke subtype classification, as determining whether the infarct is truly lacunar versus other mechanisms (cardioembolism, large-artery disease) fundamentally changes management. 1
Ensure renal function monitoring as impaired renal function is independently associated with moderate-to-severe white matter hyperintensities (OR 0.90), indicating more extensive small-vessel disease. 4