Lacunar infarction

Prevention
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By Catalina Ionita MD

Although the management of hypertension is the single most important preventive strategy for lacunar infarctions, optimal primary prevention involves the management of all modifiable risk factors for atherosclerosis and ischemic stroke:

  1. Hypertension control. Diuretics, beta blockers, and calcium channel blockers can be used. The ACE inhibitors ramipril or perindopril may have stroke risk reduction effects independent of antihypertensive effect.
  2. Smoking cessation. Cigarette smoking is associated with lacunar infarction more frequently than with other types of strokes (Sacco et al 2006).
  3. Glycemic control is recommended to reduce microvascular complications. Hypertension control in both type1 and type 2 diabetics, however, is the most effective stroke prevention strategy.
  4. Moderate to high grade (greater than 60% and less than 100%) asymptomatic carotid stenosis may be addressed by endarterectomy performed by a surgeon with less than 3% morbidity and mortality surgical risk. However, the benefit of carotid endarterectomy for asymptomatic disease is still controversial; it offers an absolute risk reduction of 1% per year for a disease that has a 2% per year risk of stroke. Further, there are no data specifically addressing prevention of lacunar stroke in patients with asymptomatic carotid disease.
  5. Antithrombotic therapy (warfarin or aspirin) can be considered for patients with nonvalvular atrial fibrillation, although the preventive effect of warfarin remains unproved.
  6. Patients with elevated cholesterol and heart disease should receive treatment with statins. Independent of lipid lowering properties, statins may have other vascular effects: improved endothelial function, plaque stabilization, and antithrombotic and neuroprotective properties; pravastatin was shown to improve cerebral vasomotor reactivity in patients with small vessel disease.

Other modifiable risk factors that may have a role in primary prevention of stroke include: obesity, physical inactivity, alcohol abuse, hyperhomocysteinemia, and drug abuse (Goldstein et al 2001).

Secondary prevention is the prevention of recurrent stroke. In the context of lacunar infarction, because lacunar infarcts or leukoaraiosis may be asymptomatic, secondary prevention principally refers to the use of antithrombotic agents. Aspirin (160 mg or 325 mg) reduces the risk of early recurrent ischemic stroke (absolute risk reduction = 0.7%) (Coull 2002). Aspirin in a dose as low as 30 mg daily, dipyridamole, and the combination of extended-release dipyridamole with aspirin are available measures for secondary prevention of lacunar infarcts (Albers 1998). Clopidogrel and ticlopidine are alternatives for patients intolerant to aspirin. Given the potential for life-threatening leukopenia induced by ticlopidine, close monitoring of patients is recommended. Long-term oral anticoagulation in patients with atrial fibrillation and endarterectomy for significant carotid stenosis may be considered in secondary preventions of lacunes related to these conditions (Coull 2002).

In This Article

Introduction
Historical note and nomenclature
Clinical manifestations
Etiology
Pathogenesis and pathophysiology
Epidemiology
Prevention
Differential diagnosis
Diagnostic workup
Prognosis and complications
Management
Pregnancy
References cited
Contributors