Lacunar CVA

Aka: Lacunar CVA, Lacunar Infarct, Cerebrovascular Accident Involving Lacunar Circulation, Pure Motor Lacunar Infarction, Dysarthria Clumsy Hand Syndrome, Pure Sensory Lacunar Infarction, Lacunar Ataxic Hemiparesis, Pure Sensorimotor Lacunar Infarction, Lacunar Syndrome

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II. Definitions

  1. Lacune
    1. Small cavity (from latin, "small lake") remaining after a deep brain tissue infarct

III. Pathophysiology

  1. Small infarct size (<1.5 cm)
  2. Occlusions in small, deep, penetrating vessels result in microinfarctions in the distal MCA branches
  3. Small deep penetrating or perforating arteries (Lenticulostriate arteries) arising at head of Middle Cerebral Artery
    1. Lenticulostriate arteries (MCA)
    2. Thalmogeniculate arteries (PCA)
    3. Paramedian perforators (Basilar Artery)
  4. Regions affected
    1. Basal Ganglia
    2. Corona radiata
    3. Thalamus
    4. Brainstem (e.g. paramedian pons)
    5. Internal Capsule

IV. Causes

  1. Hypertension
  2. Diabetes Mellitus

V. Findings: Signs and Symptoms

  1. Pure motor or sensory deficits (Lacunar Syndrome)

VI. Findings: Patterns following lacunar stroke

  1. Pure Motor Hemiparesis (33-50% of Lacunar Infarcts)
    1. Affects posterior limb of Internal Capsule or corona radiata
    2. Contralateral Hemiparesis of face, arm or leg
    3. No sensory deficit
    4. Dysarthria may also be present
  2. Ataxic Hemiparesis
    1. Affects Internal Capsule, pons or corona radiata
    2. Contralateral Hemiparesis of the face and leg
    3. Ataxia of the contralateral arm and leg
  3. Pure Sensory Stroke
    1. Affects Thalamus or corona radiata
    2. Contralateral hemisensory loss of face, arm, leg
  4. Sensory-Motor Stroke
    1. Affects Thalamus, Internal Capsule or Putamen-capsule-caudate
    2. Ipsilateral sensory and motor loss of the face, arm, leg
  5. Clumsy Hand Dysarthria
    1. Affects pons or Internal Capsule
    2. Dysarthria and Dysphagia
    3. Contralateral arm and hand clumsiness (dysmetria, weakness, dysdiadochokinesis)
    4. Contralateral facial paresis and Tongue weakness

VII. Imaging

  1. CT Head
    1. CT Head, as part of emergent stroke evaluation, often misses Lacunar Infarcts
  2. MRI Brain (preferred)
    1. Typically identifies small Lacunar Infarcts

VIII. Resources

  1. Lacunar Stroke Syndromes (Case Western School of Medicine)
    1. http://casemed.case.edu/clerkships/neurology/NeurLrngObjectives/Lacunar%20Stroke.htm

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