In the Caucasian population, lacunar infarction has an age- and sex-adjusted incidence comparable with the incidence of large vessel atherosclerotic stroke (ie, 25 out of 100,000 and 27 out of 100,000 persons respectively), with no significant sex-related differences (Petty 1999). In patients older than 85 years the incidence is higher in women (56.4%) than in men (37.3%) (Arboix 2000). Lacunar infarctions are the most common type of stroke in Japanese population, with an incidence almost double in men (3.8 out of 1000 persons-years) than in women (2.0 out of 1000 persons-years) (Taniazaki 2000). In Western countries, lacunes account for 15% to 20% of all strokes, whereas in Japan they represent 30% to 40% of all strokes (Yamamoto 2002). The Northern Manhattan Stroke Study reported a 28% incidence of lacunar infarctions, nearly twice as frequent in those of African descent (31%) and Hispanics (31%) than in Caucasians (17%) (Gan 1997). The African-American population of the metropolitan area of Cincinnati, Ohio has a higher lacunar stroke incidence of 52 out of 100,000, comparable with the incidence of cardioembolic stroke (56 out of 100,000 people). TOAST (trial of danaparoid in acute stroke) trial also reported a higher incidence of lacunar infarction in the African-American population with a poorer prognosis (Hassaballa 2001). A recent study of a multiethnic stroke population, comparing the clinical characteristics, risk factors, and prevalence in different racial-ethnic groups, reported the highest prevalence of lacunar infarcts in Caribbean blacks (44%), primarily associated with hypertension (Koch et al 2013). Smoking and dyslipidemia were more frequent in African Americans and Caribbean Hispanics, resulting in a similar prevalence of lacunar infarcts (25% and 22%, respectively), whereas only 7% of non-Hispanic whites were found to have lacunar infarcts. In a large multiracial cohort of patients with recent lacunar infarcts, MRI analysis demonstrated distinct imaging patterns associated with gender, vascular risk factors, and race-ethnicity. Multiple lacunar infarcts were associated with increased age (1.2 per 20 years; 95% CI1.1, 1.5) and prior stroke (3.8 CI2.9,5.0). Moderate-to-severe white matter hyperintensities were associated with increased age (4.3 per 20 years, CI 3.4, 5.4), hypertension (1.8 per 20 mmHg CI 1.4, 2.3), and prior stroke (3.3 CI 2.3, 4.5). Blacks and Hispanics had more infarcts in the brainstem/cerebellum (P < 0.001) than non-Hispanic whites, and women often had more thalamic lacunes than men (P < 0.001) (Benavente et al 2014).