Lacunar infarction

Pathogenesis and pathophysiology
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By Catalina Ionita MD

The following are multiple microvascular pathologies causing lacunar infarction:

  1. Lipohyalinosis is a focal, destructive angiopathy involving vessels smaller than 200 microns. The arterial wall is disorganized and replaced by connective tissue and fatty macrophages; this results in occlusion of the arterial lumen (Fisher 1969). It is associated with hypertension and may cause multiple lacunar infarcts.
  2. Nonhypertensive small vessel disease associated with diabetes, ischemic heart disease, mild (less than 50%) bilateral carotid artery stenosis (Wiszniewska 2000), and old age is a common source of diffuse white matter disease and multiple lacunar infarctions.
  3. Microatheroma of penetrating arteries that accompanies intracranial atheromatous branch disease is considered the most common arteriolopathy causing single, large, symptomatic lacunes (Fisher 1991). Branch atheromatous disease has a poorer prognosis than lacunar infarcts and clinically presents more frequently as a progressive stroke (worsening of the NIHSS score with > 2 points within 48 h of onset). The most common risk factors are poorly controlled diabetes and dyslipidemia (Nakase et al 2011).
  4. CADASIL is a cerebral autosomal dominant arteriopathy caused by mutation in the Notch 3 gene, with inheritance linked to chromosome 19p13.1. In this condition, the small penetrating arteries are concentrically thickened and show a granular degeneration of the media. Diffuse white matter changes and lacunar infarcts are common and frequently give rise to progressive dementia. Hyperhomocysteinemia may have a role in the pathogenesis of coexistent lacunar infarcts in CADASIL.
  5. Although the role of inflammatory processes in atherosclerosis and coronary artery disease pathogeneses is well recognized, the relationship between inflammation and lacunar infarct remains undemonstrated (Wada et al 2008b).

In This Article

Historical note and nomenclature
Clinical manifestations
Pathogenesis and pathophysiology
Differential diagnosis
Diagnostic workup
Prognosis and complications
References cited