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Abstract
Symptomatic lacunar ischemic stroke (25% of all brain infarctions) results from occlusion of a single penetrating artery by microatheromas or lipohyalinosis and rarely from an intracranial atheromatous branch disease. Recurrent lacunar stroke may be associated with more severe clinical features and has been involved in producing lacunar state and vascular subcortical dementia. In the first multicenter randomized clinical trial (SPS3) focused on stroke prevention among patients with recent lacunar stroke, the addition of clopidogrel to aspirin not only did not reduced significantly the risk of recurrent stroke, but also increased significantly the likelihood of hemorrhage and fatal outcome. If lacunar stroke is primarily non-atherothromboembolic, secondary prevention aimed at preventing atheroma progression may not be very effective. The efficacy of drugs that improve endothelial function in lacunar stroke patients remains to be studied in the future.
Acknowledgements
The authors thank M Grau-Olivares, J Massons, M Oliveres, E Comes, MJ Vidal, N Amorós, A Cartanyà, M Lowak, M Pizarro, R Rouco and S Estévez for their help in the care of patients with lacunar infarcts of the Sagrat Cor Hospital of Barcelona Stroke Registry. We also thank M Pulido, for editing the manuscript.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.
No writing assistance was utilized in the production of this manuscript.
Key issues
Lacunar stroke accounts for one-fourth of all cerebral infarctions.
Lacunar stroke are not a benign vascular condition; by contrast, they present a high risk of recurrence and vascular dementia in the mid- and long-term.
Recurrent lacunar stroke may be associated with a more severe clinical picture and is one of the major factors involved in producing lacunar state and vascular subcortical dementia.
Recurrent strokes are more likely to be lacunar if the index event was lacunar.
Progressive lacunar stroke may suggest the presence of branch atheromatous disease. In these cases, stroke recurrence after the acute phase may be possible.
High-resolution MRI can be used to study the morphology of intracranial artery vessels and can on the elucidation of stroke mechanisms.
To determine optimal strategies for secondary prevention, precise differentiation of the underlying pathologies of lacunar infarction is an important issue.
Hypertension is the most important modifiable risk factor in lacunar stroke.
If lacunar stroke is primarily non-atherothromboembolic, then secondary prevention aimed at preventing atheroma progression may not be very effective.
Drugs that improve endothelial function, blood pressure lowering, lipid-lowering agents, angiotensin-converting enzyme inhibitors and non-steroidal anti-inflammatory agents may act on the circulation to reduce stroke through mechanisms other than simply by preventing atheroma, and therefore may be effective in preventing lacunar stroke.
Aspirin is accepted as standard antiplatelet therapy in patients with lacunar stroke.
Among patients with recent lacunar stroke, the addition of clopidogrel to aspirin does not seem to reduce significantly the risk of recurrent stroke but increases significantly the risk of bleeding and death.
The value of prasugrel, ticagrelor and cangrelor, a new-generation P2Y12 receptor antagonists, in stroke prevention remains to be established.
Non-vitamin-K-antagonists (apixaban, dabigatran and rivaroxaban) seem to be an attractive option for stroke prevention for patients with lacunar stroke of cardioembolic origin.