Lacunar stroke is an ischemic stroke that covers a small area of cerebral tissues, in which a lacuna is then formed. The foci of stroke can be multiple in nature. The clinical picture consists of various focal symptoms that do not reach a severe degree of severity. In the future, the progression of cognitive deficits is possible. Diagnostics is carried out by clinical and instrumental studies, taking into account the fact that small gaps may not be registered by neuroimaging methods. Complex treatment includes etiopathogenetic, vascular, neuroprotective and symptomatic therapy.
ICD 10
I63.2 Cerebral infarction caused by unspecified blockage or stenosis of the precerebral arteries
General information
Lacunar stroke (lacunar cerebral infarction) is a type of acute cerebral circulatory disorder, the morphological outcome of which is the formation of a small cavity (lacuna) at the site of cerebral tissue that died as a result of ischemia. The term “lacuna” appeared in practical medicine in 1843 thanks to Fendal, who for the first time gave such a name to the cerebral cavities identified at the autopsy of patients with arterial hypertension. Lacunar cerebral infarction was described in detail in 1965. Fischer, who determined its connection with hypertensive encephalopathy.
Nowadays, lacunar stroke accounts for about a third of all ischemic strokes. Due to the small size of lacunae (from 1 to 15-20 mm), moderate and even mild clinical manifestations, lacunar cerebral infarction was considered relatively benign. However, clinical observations have led experts in the field of neurology to the conclusion that this pathology is the cause of the formation of cognitive deficits, secondary Parkinsonism and mental disorders.
Causes
Lacunar stroke occurs due to a violation of the passage of blood through one of the perforant arterial vessels of the brain. In 80% of cases, the infarction zone is located in the white cerebral substance of subcortical structures and the inner capsule, in other cases — in the bridge of the brain and the trunk. In most cases, lacunar cerebral infarction occurs against the background of chronic arterial hypertension and is associated with changes in the wall of perforant vessels caused by it — cerebral microangiopathy. Morphologically, it can be hyalinosis, intravascular deposition of lipid layers, fibrous replacement of muscle and elastic structures of the vascular wall, fibrinoid necrosis. Such changes entail a significant narrowing and occlusion of the artery lumen, as a result, the blood supply to the area of cerebral tissues fed by it is disrupted. Ischemia and necrosis develop in this zone. Over time, a lacuna forms in place of the dead cells.
Cerebral microangiopathy accounts for about 75% of lacunar infarcts. Among its etiofactors, along with hypertension, are atherosclerosis, diabetes mellitus, alcoholism, chronic obstructive pulmonary disease, chronic renal failure with increased creatinine concentration in the blood, in rare cases — infectious and autoimmune vascular lesions. A quarter of cases of lacunar infarcts are caused by atherosclerosis and cardioembolism (with cardiosclerosis after myocardial infarction, atrial fibrillation, valvular heart defects), occlusion of brachiocephalic arteries.
Symptoms
Lacunar stroke is often characterized by a debut with rapid development of focal symptoms within 1-2 hours. However, a gradual onset is also possible with an increase in symptoms in the period from 3 to 6 days. In some cases, previous transient ischemic attacks are noted. Characteristic is the absence of cerebral manifestations, cortical disorders and meningeal symptom complex, the preservation of consciousness. There may be hemiparesis, sensory disorders of the hemitype, ataxia, dysarthria, pelvic dysfunction, pseudobulbar syndrome. Isolated motor, ataxic or sensory disorders are possible, as well as mixed neurological manifestations. Depression and mild cognitive impairment are often observed.
Cognitive deficits may consist in difficulty remembering new information, deterioration of memory for current events, decreased ability to concentrate attention and the quality of intellectual activity. There is a certain slowness of thought processes, difficulty with switching attention from one task to another or, conversely, with concentration on the performance of one task. Over time, after suffering a lacunar infarction, cognitive disorders can increase significantly. Severe memory disorders develop, the ability to perceive and assimilate information decreases (gnosis), motor skills are lost (praxis).
The clinical symptoms of cerebral infarction depend on its location. However, with any localization, the neurological deficit remains at the level of mild or moderate degree, and the course is never severe. In some cases, there is a “mute” subclinical course of lacunar stroke, in which there are no manifestations at all. Such imaginary well-being is prognostically unfavorable, since it is often observed with multiple heart attacks, does not allow timely provision of qualified medical care and over time often leads to the formation of severe cognitive disorders.
Diagnostics
When making a diagnosis, a neurologist takes into account the presence in the anamnesis of hypertension, severe arrhythmia, diabetes mellitus, chronic cerebral ischemia, transient ischemic attacks; features of the clinical picture of stroke (mild or moderate focal symptoms in the absence of cerebral manifestations); instrumental diagnostic data. During ophthalmoscopy at an ophthalmologist’s consultation, signs of microangiopathy are often revealed: narrowing of retinal arterioles, dilation of the central retinal vein.
The focus of lacunar stroke can be visualized using CT or MRI of the brain. However, if the stroke area is too small, then it is not visible on tomograms. In such cases, the diagnosis is based mainly on the clinic. As part of the search for the cause of cerebral infarction, ultrasound of the vessels of the head, the study of the lipid spectrum of blood is carried out. In patients younger than 45 years, it is necessary to exclude systemic vasculitis, metabolic diseases, antiphospholipid syndrome, etc. Understanding the etiology of vascular disorders is of leading importance for the construction of adequate prevention of recurrent strokes.
Treatment
The etiopathogenetic component of lacunar stroke therapy is aimed at normalizing and maintaining adequate blood pressure figures, preventing cardioembolism, and correcting lipid metabolism. Patients with hypertension and cardiac pathology are simultaneously supervised by a cardiologist. They are prescribed hypotensive therapy, antithrombotic drugs (warfarin, heparin, acetylsalicylic acid, clopidogrel). Treatment with heparin and warfarin is indicated for patients with cardioembolic etiology of lacunar stroke and a high probability of its recurrence (after myocardial infarction, atrial fibrillation, the presence of an artificial heart valve, etc.). Acetylsalicylic acid is used in the presence of cerebral vascular microangiopathy, taken orally in an individual dose, can be prescribed in combination with dipyridamole. Correction of the lipid composition of the blood is carried out with the help of statins (lovastatin, simvastatin, etc.).
In order to restore cerebral hemodynamics and microcirculation, nicergoline can be used as a cerebral antispasmodic, vinpocetine, pentoxifylline are recommended. In cognitive deficits, neurotropic therapy is performed to prevent dementia, including neuroprotectors (ipidacrine, amantadine, choline), ginkgo biloba pharmaceuticals, nootropics (memantine, piracetam). The positive effect of special classes for training attention, memory and thinking was noted. In the presence of depressive syndrome, the treatment regimen is supplemented with antidepressants (fluoxetine, clomipramine, maprotilin, amitriptyline).
Forecast
The outcome of a lacunar infarction is relatively favorable. Against the background of timely and intensive therapy, a complete regression of neurological deficit is possible. However, within a few years from the moment of a heart attack, 30% of patients develop cognitive disorders leading to the development of vascular dementia and mental disorders. Even more often there are symptoms of vascular parkinsonism. The probability of these complications increases significantly with repeated lacunar strokes, the frequency of which reaches 12%. Studies of long-term consequences have shown that a decade after a lacunar stroke, only a third of patients remained alive, most of whom suffered from dementia.
Prevention
Primary prevention of lacunar infarction implies timely correction of arterial hypertension, regular intake of aspirin by patients in need of antiplatelet therapy with cardiovascular pathology, adequate therapy of chronic cerebrovascular insufficiency. To prevent recurrence of lacunar stroke, long-term aspirin intake is recommended, in the presence of pronounced occlusion of the brachiocephalic arteries, surgical treatment of cerebrovascular insufficiency is possible – carotid endaterectomy, the creation of an extra-intracranial anastomosis. In order to prevent the aggravation of cognitive disorders, patients who have suffered a lacunar stroke need to undergo repeated courses of combined vascular-neurotropic therapy.
