The Potential Impact of Neuroimaging and Translational Research on the Clinical Management of Lacunar Stroke.

Salvatore Rudilosso,Xabier Urra,Adrià Arboix,Alejandro Rodríguez-Vázquez

doi:10.3390/ijms23031497

Abstract

Lacunar infarcts represent one of the most frequent subtypes of ischemic strokes and may represent the first recognizable manifestation of a progressive disease of the small perforating arteries, capillaries, and venules of the brain, defined as cerebral small vessel disease. The pathophysiological mechanisms leading to a perforating artery occlusion are multiple and still not completely defined, due to spatial resolution issues in neuroimaging, sparsity of pathological studies, and lack of valid experimental models. Recent advances in the endovascular treatment of large vessel occlusion may have diverted attention from the management of patients with small vessel occlusions, often excluded from clinical trials of acute therapy and secondary prevention. However, patients with a lacunar stroke benefit from early diagnosis, reperfusion therapy, and secondary prevention measures. In addition, there are new developments in the knowledge of this entity that suggest potential benefits of thrombolysis in an extended time window in selected patients, as well as novel therapeutic approaches targeting different pathophysiological mechanisms involved in small vessel disease. This review offers a comprehensive update in lacunar stroke pathophysiology and clinical perspective for managing lacunar strokes, in light of the latest insights from imaging and translational studies.

Highlights

Lacunar ischemic strokes are caused by small infarctions that occur in regions supplied by one perforating artery and represent from 11 to 27% of acute strokes, according to different series [1]
Despite the high prevalence of lacunar strokes, and the socio-economic impact related to serious long-term-prognostic implications, no specific small vessel disease (SVD) treatment is available and most of the treatments do not differ from the management of non-cardioembolic ischemic strokes
Lacunar stroke defined as infarct volume

Summary

Introduction

Clinical Relevance and Aims of the ReviewLacunar ischemic strokes are caused by small infarctions that occur in regions supplied by one perforating artery and represent from 11 to 27% of acute strokes, according to different series [1]. About half of the patients with a first-ever lacunar ischemic stroke have mild cognitive impairment of subcortical vascular features, and its presence may be a predictor of subcortical vascular dementia in the medium-long-term [3]. Lacunar strokes are not isolated cerebrovascular events, but often represent the tip of the iceberg of a systemic disease affecting the microcirculation, defined as small vessel disease (SVD), which is considered to be the second cause of dementia, as well as the cause of other severe neuropsychiatric disorders, extrapyramidal symptoms, and frailty in the elderly [4]. Despite the high prevalence of lacunar strokes, and the socio-economic impact related to serious long-term-prognostic implications, no specific SVD treatment is available and most of the treatments do not differ from the management of non-cardioembolic ischemic strokes.

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