Definitions for Lacunar Syndromes, Lacunar Strokes,
Lacunar Infarcts and Lacunes: from Clinical to Neuroimaging
Adri¨¤
Arboix, Maria Jos¨¦ S¨¢nchez
Adri¨¤
Arboix, Cerebrovascular
Division, Department of Neurology, Hospital Universitari del Sagrat Cor,
University of Barcelona, Barcelona, Catalonia, Spain
Maria
Jos¨¦ S¨¢nchez, Medical Library, Hospital Universitari del Sagrat Cor, University of
Barcelona, Barcelona, Catalonia, Spain.
Correspondence to: Adri¨¤ Arboix, MD, PhD, Cerebrovascular
Division, Department of Neurology, Hospital Universitari del Sagrat Cor, C/
Viladomat 288, E-08029 Barcelona, Catalonia, Spain
Email: aarboix@hscor.com
Telephone: +34-93-4948940
Fax:
+34-93-4948906
Received: January 22,
2014 Revised: March 23, 2015
Accepted: March 28, 2015
Published online: May 13, 2015
ABSTRACT
A
rational use of nomenclature concerning lacunar infarcts is necessary. The term
"lacunar syndrome" involves a clinical and semiological aspect; the
definition "lacunar stroke" entails a clinical, semiological and
neuroimaging aspect; the term "lacunar infarct" implies a particular
subtype of ischemic stroke and the definition of "lacune" relates to
neuroimaging findings. It would be suitable to use a precise nomenclature when
we talk about the cerebral small vessel diseases and, specifically, about
cerebral strokes of lacunar type, since this will result in a more accurate,
appropriate and wise definition and will improve the quality of studies and
investigations.
© 2015 ACT. All
rights reserved.
Key words: Lacunar stroke; Small vessel disease; Lacunar
infarction; Lacunar syndrome; Lacune
Arboix A, S¨¢nchez
MJ. Definitions for Lacunar Syndromes, Lacunar Strokes, Lacunar Infarcts and
Lacunes: from Clinical to Neuroimaging. International
Journal of Neurology Research 2015; 1(2): 68-71 Available from: URL:
http://www.ghrnet.org/index.php/ijnr/article/view/1026
INTRODUCTION
Lacunar infarcts or small subcortical infarcts, one of the phenotypic
subtypes of the cerebral small vessel disease, account for 20-25% of all acute
cerebral strokes[1-3]. Lacunar infarcts have a favorable short term
prognosis, with a low early mortality and reduced functional disability at
hospital discharge. However, the mid- and longer-term prognoses have an
increased risk of death, stroke recurrence and dementia. Based on neuroimaging,
lacunar infarcts are usually defined as an ischemic subcortical stroke of less
than 15 mm in diameter. The other typical neuroimaging manifestations of the
cerebral small vessel diseases or microangiopathy are leukoaraiosis or white
matter hyperintensities, cerebral microbleeds, and prominent or enlarged
perivascular spaces and these are the most important predictors of cognitive
impairment and subcortical vascular dementia in the first-ever lacunar infarct
patients[4,5].
The
nomenclature used to define and analyze the lacunar infarcts is sometimes
misleading, since very often tend to overlap or confuse with clinical concepts
(e.g. lacunar syndrome), with concepts of etiologic stroke subtype (e.g.
lacunar infarction or lacunar stroke) and neuroimaging concepts (e.g. lacunes).
It would be
suitable to use a precise nomenclature when we refer to the cerebral small
vessel diseases and, specifically, to the cerebral strokes of lacunar type,
since this will result in a more accurate, appropriate and wise definition and
will improve the quality of studies and investigations.
In order to
meet the objectives of the current study we drew on the experience of the
Sagrat Cor Hospital of Barcelona Stroke Registry[6] together with a
non-systematic hand search of Pubmed and Scopus for neurological studies
published in the last 5 years using the following search terms: lacunar stroke,
small vessel disease, lacunar infarction, lacunar syndrome, lacune.
Lacunar
syndromes
We should consider the definition of "lacunar syndromes" in a
purely semiological view, regardless of etiology. Lacunar syndromes are usually
caused by lacunar strokes in over 70-90% of cases, according to the
"lacunar hypothesis" described by Miller Fisher[1], and
the remaining 10-30% of cases may be due to other different entities, mainly
non-lacunar ischemic strokes (thrombotic, cardioembolic, essential or unusual
etiology), small cerebral hemorrhages or even other conditions different from
acute stroke as demyelinating diseases, expansive processes, or subdural
hematomas (Table 1)[7-9].
Typically,
classic lacunar syndrome occurs semiologically as a pure motor hemiparesis[1,10],
a pure sensory syndrome[3,4], a sensorimotor syndrome, an ataxic
hemiparesis or a dysarthria-clumsy hand[1,11]. Atypical lacunar
syndrome occurs as a paucisymptomatic form of a classic lacunar syndrome, such
as pure dysarthria ¨Cpartial form of dysarthria-clumsy hand syndrome-, or as
isolated dysarthria-facial paresis syndrome ¨Cpartial or frustrated form of pure
motor hemiparesis- or also as an uncommon neurological syndrome such as hemichorea-hemiballismus)[12].
It has also to
be taken into consideration that the lacunar hypothesis is validated when
different lacunar syndromes are analyzed individually. However sensorimotor
stroke is the lacunar syndrome more frequently caused by non-lacunar infarcts
(Table 2)[9], and in a clinical series of lacunar stroke patients,
sensorimotor stroke was caused by a symptomatic intracranial small vessel
disease in 69.5% of cases. Despite that, other stroke subtypes were found in
30.5% of cases, which is a higher percentage than the observed in other lacunar
syndromes.
Lacunar
strokes and lacunar infarcts
We should consider the definition of "lacunar strokes" from
both a semiological and neuroimaging perspective. That is, although the
majority of lacunar strokes would be caused by lacunar infarcts, the term
¡°lacunar stroke¡± may also include hemorrhagic lacunar strokes due to small
capsular, ganglio-basal or thalamic intracerebral hematomas which manifest
clinically as a lacunar syndrome. In a clinical series, hemorrhagic lacunar
stroke accounted for 3.8% of all cases of lacunar syndrome (n=439) and
7.4% of all cases of intracerebral hemorrhage (n=229) entered in the
database. In those cases neuroimaging data confirmed the hemorrhagic etiology
of the lacunar syndrome[8].
We should
define ¡°lacunar infarcts¡± in a semiological and neuroimaging perspective (CT
scan and/or cerebral MRI) plus the results of the supplementary diagnostic
tests routinely performed on patients with acute cerebral ischemia (i.e.:
ultrasound imaging and Doppler sonography, transthoracic echocardiography,
Holter, etc.)[13]. Lacunar infarcts are small cerebral infarctions
(less than 15 mm in diameter) located in the blood supply territory of brain
penetrating arterioles (lenticuloestriate, thalamogeniculate,
thalamoperforating and paramedian pontine) (Figure 1) caused mainly by
microatheromatosis or intracranial atheromatous branch disease, in the absence
of emboligen heart disease, severe stenosis of supra-aortic trunks or another
unusual etiology (i.e.: hematologic, infectious or systemic diseases)[14-16].
Lacunes
Instead, we could define "lacunes" from a strict neuroradiological
view, referring to those lesions observed in brain imaging on CT or MRI
(CSF-like hole in the brain) that are more consistent with silent lacunar
infarcts than with symptomatic ones[17]. The silent lesions tend to
be due to a cerebrovascular lipohyalinosis in the perforating arterioles or
arteriolar endothelial dysfunction[18].
We must bear
in mind that in patients with a first-ever lacunar infarct, 40% of them shows
"lacunes" that are clinically silent[19]. From an academic
point of view, it has been classically considered that lacunar infarcts do not
cause neuropsychological disturbances during the acute phase of the illness.
However recent studies have found that 56% of patients with a first-ever
lacunar infarction may show neuropsychological disorders compatible with mild
cognitive impairment of vascular type[20,21]. Furthermore, current
studies clearly show that neuropsychological dysfunction in the initial phase
relates more to silent lacunar infarction than to leukoaraiosis or
periventricular white matter hyperintensities[22]. This contrasts
with the fact that in more advanced stages of the disease, leukoaraiosis will
have the greatest importance and greater weight in cognitive impairment of
vascular type in patients with cerebral small vessel disease[19,20].
Recurrent lacunar infarction can also cause cognitive impairment. Hypertension
and diabetes mellitus are the main factors predicting recurrent lacunar
infarctions in a recent study[23].
Recently, the
importance of cerebral microbleeds and prominent perivascular spaces has been
emphasized as a significant neuroradiological manifestation of small vessel
disease[17]. Recent contributions to the literature have led to show
that brain atrophy may be related to lacunar infarctions[24] and contribute
to the cognitive impairment of the patients with small vessel disease.
Conclusions
A rational use of nomenclature in the jungle of definitions concerning
lacunar infarcts would be both necessary and useful (Table 3) both in research
and routine clinical practice. The term "lacunar syndrome" involves a
clinical and semiological aspect; the term "lacunar stroke" entails a
clinical, semiological and neuroimaging aspect; the term "lacunar
infarct" implies a particular subtype of ischemic stroke and the term
"lacune" would relate to neuroimaging findings.
Acknowledgements
To Mireia Garcia-Batanero, MD, for the care of many patients with
lacunar stroke included in the Sagrat Cor Hospital of Barcelona Stroke Registry
and to Elisenda Grive, MD, neuroradiologist, for providing the figure that
illustrates the manuscript.
CONFLICT OF INTERESTS
The Authors have no conflicts of interest to declare.
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