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Lacunar Stroke

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Management Algorithm:
Lacunar Stroke
  Diagnostic Criteria:   Differential Dx:
  • Clinical Lacunar Syndrome
  • Brain imaging consistent with small vessel occlusive disease
  • Absence of proximal ipsilateral large vessel stenosis or occlusion
  • Recognized risk factors for small vessel occlusive disease
 Phase 1   Additional Diagnostic Testing   Prevention of Acute Recurrent Stroke
 
  • Consider fasting lipids, lipoprotein (a), B12, folate, homocysteine
  • Consider antiplatelet therapy (e.g., aspirin, clopidogrel, ticlopidine, persantine, integrilin, reopro)
  • Consider iv heparin for fluctuating deficit
 
  • If suspicious of large vessel atheroma producing penetrator infarction, refer to algorithm for Large Vessel disease
  • Consider using low molecular weight heparin to anticoagulate those who are at low risk for embolic disease and are awaiting carotid or cardiac ultrasound
  • Consider neuroprotective therapies
 Phase 2   Subacute Medical Management   Functional Assessment and Acute   Rehabilitation
  Communicate with PCP


  • Consider BP goals in context of large vessel stenoses, chronicity of hypertension, and co-morbid medical illness
  • Avoid hyperthermia, hypo- or hyperglycemia
  • Consider Intensive Care management (e.g., airway compromise, severe hypertension, acute MI, major organ dysfunction)
 Communicate with other healthcare personnel
  • Safety for ADL, ambulation
  • Urinary and fecal continence
  • Tone and splinting
  • Exercise tolerance
  • Cognitive function
  Ongoing Assessments:
  • DVT risk if immobile
  • Ability to urinate; UTI
  • Ability to swallow; Aspiration; need for feeding tube
  • GI/GU bleeding
  • Cardiopulmonary function; need for tracheostomy
  
 Phase 3   Discharge Planning   Long term Secondary Prevention
  Discuss with patient and family:
  1. treatment and prognosis
  2. risk factors and risk reduction strategies
 Risk factor modification
  1. Hypertension control
  2. Lipid reduction
  3. Smoking cessation
  4. Nutrition counseling and glycemic control
  5. Weight reduction and increased physical activity
  6. Antiplatelet therapy
  Assess subacute rehabilitation needs and eligibility (consider PM&R consult)
  1. Short v. long term care needs
  2. Inpatient rehabilitation v. skilled nursing facility rehabilitation
  3. Home v. outpatient services
 Medical Considerations


  1. Choice of antiplatelet therapy
  2. Consider statins for mild hyperlipidemia
  3. Provide adequate followup with stroke specialist
  4. Consider secondary prevention or recovery trials
  Assess financial resources to cover cost of:
  1. Inpatient, outpatient rehabilitation services
  2. Medications
  3. Assistive devices (e.g., commode, cane, wheelchair, hospital bed, etc.)
  4. Long term care
 Patient education


  1. Patient/family understands stroke diagnosis
  2. Patient/family understands how to lower risk

Clinical Lacunar Syndrome

Lacunar strokes tend to occur in patients with diabetes, hyperlipidemia, smoking or chronic hypertension and may be clinically silent or present as pure motor hemiparesis, pure sensory loss, or a variety of well-defined syndromes (e.g., dysarthria-clumsy hand, ataxic-hemiparesis). Descending compact white matter tracts or brainstem gray matter nuclei are injured, often producing widespread and striking initial deficits. However, the prognosis for recovery with lacunar stroke is better than with large artery territory stroke, and for this reason many centers favor using antiplatelet therapy (aspirin, clopidogrel) or conservative management rather than thrombolytic therapy for uncomplicated lacunar stroke. The risk of hemorrhagic transformation or edema in these patients is extremely low. Because initial clinical presentation may be deceiving particularly in the posterior circulation, all patients presenting with acute ischemic symptoms should undergo some form of neurovascular imaging to establish large vessel patency (CTA, MRA, ultrasound or angiography).

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In the News

The MGH Neurology Department placed 4th in US News Neurology / NeuroSurgery rankings for 2007.

Educational Video

Still from the Stroke Evaluation simulation

This video simulation of an Emergency stroke evaluation illustrates the care of patients with acute stroke by the MGH Acute Stroke team.