Small vessel, Lacunar Infarction

Small vessel, Lacunar Infarction

These strokes have distinctive clinical syndromes with a small zone of ischemia confined to the territory of a single vessel. They are understood to reflect arterial disease of the vessels penetrating the brain to supply the internal capsule, basal ganglia, thalamus, corona radiata and paramedian regions of the brainstem. There are disagreements about the pathogenesis of lacunar infarcts with some favoring the use of the term “lacune” to describe size and location without indicating a specific pathology. Only a handful have been pathologically studied by serial section and documented a tiny focus of microatheroma or lipohyalinosis stenosing one of the deep penetrating arteries. The arterial damage is usually the result of long-standing hypertension or diabetes mellitus. Less common causes include stenosis of the middle cerebral artery stem or micr0embolization to penetrant arterial territories. The vast majority of radiologically-defined, small’, deep infarcts do not have significant large artery atherosclerosis, lack even a potential cardiac source of embolism and occur in vascular territories less likely to be occluded by emboli.

Many lacunar strokes are diagnosed by clinical characteristics alone. Clinical syndromes include pure motor hemiparesis, pure sensory, clumsy hand dysarthria, ataxic hemiparesis and sensorimotor stroke. When brain imaging is positive, a strategically placed small, deep infarct is usually found. Because the vascular lesion lies in small vessels, it is no surprise that cerebral angiography is normal. Incidental large vessel disease may be found in some series, but whether etiologically related to the site of infarction is often unclear.

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