Lacunar Infarcts
Lacunar infarcts are small, deep brain infarcts typically measuring 2–20 mm in diameter, resulting from occlusion of a single small perforating artery supplying subcortical regions such as the deep white matter, basal ganglia, thalamus, internal capsule, or pons13. They are a hallmark of cerebral small vessel disease (SVD) and contribute significantly to stroke and vascular cognitive impairment.
Pathophysiology
- The fundamental cause is occlusion of small penetrating arteries (40–900 μm in diameter) due to pathological changes such as lipohyalinosis (degeneration and thickening of vessel walls) and microatheroma formation3.
- These changes lead to vessel wall thickening, fibrinoid necrosis, and luminal narrowing, resulting in ischemia of deep brain structures.
- Lacunar infarcts often occur at distal branches of small vessels and may be asymptomatic or cause lacunar stroke syndromes.
Clinical Significance
- Lacunar infarcts account for approximately 25% of ischemic strokes6.
- They are associated with cognitive decline, vascular dementia, gait disturbances, and mood disorders5.
- Despite their small size, lacunar strokes are not benign; about 30% of patients may become dependent, and up to 25% experience recurrent strokes within 5 years1.
- Incident lacunar infarcts can develop even under guideline-based secondary stroke prevention, highlighting the need for improved therapies7.
Diagnosis
- Detected primarily by MRI, showing small, deep infarcts and associated white matter lesions8.
- Clinical diagnosis involves recognizing characteristic lacunar stroke syndromes (pure motor hemiparesis, pure sensory stroke, ataxic hemiparesis, etc.) and correlating imaging findings.
Risk Factors
- Hypertension is the most important modifiable risk factor.
- Other vascular risks include diabetes, smoking, age, and carotid atherosclerosis5.
- Women may have more marked progression of lacunar infarcts and white matter lesions compared to men5.
Management
- Focuses on controlling vascular risk factors, especially blood pressure.
- Antiplatelet therapy and lifestyle modifications are standard.
- Current secondary prevention may be insufficient to prevent incident infarcts, necessitating further research into novel treatments7.
Summary Table
| Aspect | Details |
|---|---|
| Definition | Small (2–20 mm) infarcts in deep brain regions due to occlusion of small penetrating arteries |
| Common Locations | Deep white matter, basal ganglia, thalamus, internal capsule, pons |
| Pathophysiology | Lipohyalinosis, microatheroma, vessel wall thickening, luminal narrowing |
| Clinical Impact | Stroke (~25% ischemic strokes), cognitive decline, vascular dementia, gait and mood disorders |
| Diagnosis | MRI detection of small infarcts and white matter lesions; clinical stroke syndromes |
| Risk Factors | Hypertension, diabetes, smoking, age, carotid atherosclerosis |
| Treatment | Vascular risk control, antiplatelets, lifestyle changes; need for improved secondary prevention |
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References
- Lacuna Infarcts (Small Vessel Disease) – Physiopedia
https://www.physio-pedia.com/Lacuna_Infarcts_(_Small_Vessel_Disease) - Fisher CM. Lacunar infarcts and small vessel disease. Neurology. 2014;
https://pmc.ncbi.nlm.nih.gov/articles/PMC4325635/ - Lacunar Stroke – StatPearls – NCBI Bookshelf, 2024
https://www.ncbi.nlm.nih.gov/books/NBK563216/ - Wardlaw JM, et al. Prevention and Management of Cerebral Small Vessel Disease. J Stroke. 2015;
https://www.j-stroke.org/journal/view.php?doi=10.5853/jos.2015.17.2.111 - Debette S, Markus HS. The clinical importance of white matter hyperintensities on brain magnetic resonance imaging: systematic review and meta-analysis. BMJ. 2010;341:c3666.
https://doi.org/10.1136/bmj.c3666 - Maclagan LC, et al. Lacunar stroke: mechanisms and therapeutic implications. J Neurol Neurosurg Psychiatry. 2021 Aug;92(8):823-830.
https://doi.org/10.1136/jnnp-2020-325302 - Banerjee G, et al. Incident Infarcts in Patients With Stroke and Cerebral Small Vessel Disease. Neurology. 2024 Sep 10;
https://doi.org/10.1212/WNL.0000000000209750 - Cerebral small vessel disease – Radiopaedia
https://radiopaedia.org/articles/cerebral-small-vessel-disease
Lacunar infarcts are small but clinically significant strokes caused by small vessel occlusion, contributing to stroke burden and cognitive decline. Effective management requires aggressive vascular risk factor control and ongoing research into prevention strategies.
