SMALL VESSEL

LACUNAR STROKE

What is Stroke?
Definition
Clinical syndrome.
Characterized by rapidly developing clinical symptoms and/or
signs of focal, and at times global, loss of cerebral function.
Symptoms lasting more than 24 hours or leading to death.
No apparent cause other than that of vascular origin.

Stroke Facts
Stroke is a global health problem and is the second
commonest cause of death and a leading cause of adult
long term disability worldwide.
20% of survivors require institutional care after 3
months and 15% to 30% are permanently disabled.
Life-changing event that affects both stroke patients
and caregivers.
Effective prevention remains the best approach for
reducing the burden of stroke.
Those who practice a healthy lifestyle have an 80%
lower risk of first stroke compared with those who do
not.

Risk Factors for Stroke That Cannot

Be Changed
Increased age
Being male
Race (e.g., African-Americans)
Diabetes mellitus
Prior stroke/transient ischemic attacks
Family history of stroke
Asymptomatic carotid bruit

Risk Factor For Stroke: Treatable

Major
Hypertension
Heart disease, esp. atrial fibrillation
Cigarette smoking
Transient ischemic attacks
Dyslipidemia
Physical inactivity
Obesity

Less Well Documented

Excessive alcohol intake / drug abuse
Acute infection*

Types of Stroke

Ischemic, 80%
- thrombosis, 50% (small & large-vessel)
- embolism, 30%

Hemorrhagic, 20%
- intracerebral (HTN as risk)
- subarachnoid (aneurysm)

Transient Ischemic Attack vs

Ischemic Stroke
American Stroke Association (2009): TIA
A transient episode of neurological dysfunction caused by focal
brain, spinal cord, or retinal ischemia without acute infarction.

Clinical Practice Guidelines for Management of Ischemic

Stroke (2012):
A Clinical syndrome characterized by an acute loss of focal
cerebral or monocular function with symptoms lasting less than
24 hours
due to inadequate cerebral or ocular blood supply as a result of
arterial thrombosis or embolism

Ischemic stroke

Anischemic strokemay be due

to:
1. Cerebral thrombosis: blood
clot (thrombus) forms in a main
artery leading to the brain,
cutting off body supply.
2. Cerebral embolism: blood clot
forms in a blood vessel
elsewhere in the body, and is
carried in the bloodstream to the
brain.
3. Intracranial small vessel

Etiology of Ischemic Stroke

LARGE VESSEL THROMBOTIC (most common cause):

Virchows Triad
Blood vessel injury: Hypertension, Atherosclerosis,
Vasculitis
Stasis/turbulent blood flow: Atherosclerosis, Atrial
fibrillation, Valvular disorders, decreased myocardial
contractility, massive hemorrhage, others.
Hypercoagulable state:
Increased number of platelets
Deficiency of anti-coagulation factors
Presence of pro-coagulation factors
Cancer

Pathophysiology
The brain is protected against focal interruption of
blood supply by a number of extra- and intracranial
collateral vessels.
Actual size of the cerebral ischemia depends on:
Number and vascular tone of collateral channels.
Blood viscocity
Blood perfusion pressure

 Atherothrombotic
occlusion of larger
arteries
Embolism: Artery-to
artrey, cardiogenic
Primary small vessel
disease
(lipohyalinosis)

Pathophysiology
TIME IS BRAIN:
SAVE THE PENUMBRA

Penumbra

Penumbra is zone of
reversible ischemia
around core of irreversible
infarctionsalvageable in
first few hours after
ischemic stroke onset
Penumbra damaged by:
Hypoperfusion
Hyperglycemia
Fever
Seizure

Core

Clot in
Artery

Symptoms
Signs and symptoms depend on: type, location and
the extent of the affected brain tissue.
Usually presents with sudden or rapid onset of focal
neurological symptoms, within minutes to an hour.
Some may have a stepwise or gradual worsening or
waxing and waning symptoms.
A third of all strokes occur during night sleep, therefore,
the symptoms are first noted on awakening.

Symptoms
The most common stroke symptoms
are:
Sudden numbness or weakness of face, arm or leg,
especially on one side of the body
Sudden confusion, trouble speaking or understanding
Sudden blurred vision in one or both eyes
Sudden trouble walking, dizziness, loss of balance or
coordination
Sudden severe headache with no known cause

Major Blood Vessels Of The Brain

Circle of Willis
Anterior
circulation- MCA,
ACA, and Anterior
choroidal artery
Posterior
circulationVertebral artery,
Basilar artery and
Posterior cerebral
artery

 Lacunes are caused by occlusion of a single penetrating

artery.
The deep penetrating arteries are small, nonbranching
end arteries (usually smaller than 500 m in diameter)
Arise directly from much larger arteries (eg, the middle
cerebral artery, anterior choroidal artery, anterior
cerebral artery, posterior cerebral artery, posterior
communicating artery, cerebellar arteries, basilar
artery).

Control Centers of the Brain

Large vessel stroke syndromes (anterior

circulation) assuming left hemispheric dominance
Vascular territory

Signs and Symptoms

Internal Carotid
Artery

- Combined ACA + MCA

- Ipsilateral monocular visual loss ( amurosis)
secondary to CRAO

Left ACA

- Right leg numbness and weakness

- Transcortical motor aphasia
- Ideomotor apraxia

Right ACA

- Let leg numbess and weakness

- Motor neglect
- Possibly ideomotor apraxia

Left MCA

- Right face/arm > leg numbness and

weakness
- Aphasia
- Left gaze preference

Right MCA

Left face/arm > leg numbness and weakness

Left hemispatial neglect
Right gaze preference
Agraphesthesia / astereoagnosia

 Motor/Broca aphasia localized to posterior inferior

frontal lobe
Sensory/Wernickes aphasia posterior superior
temporal/inferior parietal

Lacunar syndromes
Syndrome

Signs/Symptom
s

Localization

Vascular supply

Pure motor

Contralesional
hemiparesis

- Internal
capsule
posterior limb
- Corona
radiata
- Basis pontis

Pure sensory

Contralesional
hemisensory
loss

- VPL nucleus of
thalamus

-Lenticulostriate
branches of the
MCA or
-perforating
arteries from
basilar artery
- Lenticulostriat
e branches of
MCA
- Small
thalamoperfo
rators of PCA

Sensorimotor

Contralesional
weakness and

- Thalamus and
adjacent

Lenticulostriate

Lacunar syndromescontn.
Syndrome

Signs/Symptoms

Localization

Vascular supply

Dysarthia-clumsy
hand

Slurred speech and

weakness of
contralateral hand
(fine motor)

- Basis pontis
( between rostral
1/3rd and caudal
2/3rd )

- Basillar artery
perforators

Ataxia- hemiparesis

Contralesional
Hemiparesis and
ataxia out of
proportion to
weakness

Contralesional limb
flailing / dyskinesis

- Subthalamic
nucleus

Hemiballismus/
Hemichorea

Internal capsuleposterior limb

Basis pontis

Lenticulostritae
branches of MCA
Perforating
arteries of basilar
artery

Perforating
arteries of
anterior choroidal or
PCOM
-

 Lacunar strokes present with fluctuating

symptoms capsular warning
syndrome
Often thrombolysis withheld due to
rapidly improving symptoms

Classification of Stroke
For prognostic purposes
Guides cost effective investigations for underlying
cause
Aids decisions for therapy and secondary stroke
prevention strategies
Aids in epidemiological studies.
Eg : Oxfordshire Community stroke Project Classification
(OCSP)

Oxfordshire Community Stroke

Project (OCSP)
Categorizes stroke syndromes into 4
subtypes:
total anterior circulation infarcts (TACI),
partial anterior circulation infarcts
(PACI),
lacunar infarcts (LACI),
posterior circulation infarcts (POCI).
used to predict early mortality, functional outcome, and whether
the infarct was likely due to large- or small-vessel occlusion.

Diagnosis
History
Physical examinations:
Vital signs, general assessments
Full neurological examinations

Diagnostic tests

To determine
whether
ischemic or
hemorrhagic
stroke

Plain CT-Brain Scan (the primary diagnostic test for stroke)

Additional studies:
Lab investigation (Eg: FBC, Coagulation profile, Electrolytes, blood sugar, renal and hepatic
profile, lipid profile, etc)
To identify
Lipid profile
source of
ECG/ Echocardiogram
thrombi or
Carorit ultrasound
Cerebral angiography
emboli

Transcranial Doppler flow studies

Magnetic resonance imaging (MRI) of the brain, neck, or
both
Xenon-enhanced CT scan
single photon emission CT (SPECT) scan

Acute Treatment
General management (supportive care and prevention of
complications)

Oxygen and airway support prevent hypoxia, aspiration

Observation
Mobilisation early to prevent complications
Blood sugar control Hyperglycemia associated with
subsequent mortality and impaired neurological recovery
Temperature prevent/treat fever
Nutrition check gag reflex and water swallow test
Prevent raised intracranial pressure head up 20-30 to help
venous drainage, hyperventilate, mannitol, surgical drainage

BP Control in Acute Ischemic

Stroke
High BP can be due :

Stress of cerebrovascular event

Full bladder
Nausea, pain,
Preexisting hypertension
Physiological response to hypoxia to perfuse penumbra
Response to increased intracranial pressure

Failure to canalize results in high BP and poor

neurological outcome.
Lowering BP drastically reduces perfusion in penumbra
and worsens outcome.

BP Control in Acute Ischemic

Stroke
No data to suggest BP >220/120 is dangerous & requires
immediate treatment.
Evidence that BP lowering worsens outcomes is
concerning.
Goal is to avoid overtreating until definitive data available
Only definite indications to reduce BP emergently in AIS:
AMI, CHF, Aorta dissection, ARF, or HTN encephalopathy
Candidate for thrombolysis and BP > 185/110

BP Control in Acute Ischemic

Stroke
Clinical Practice Guidelines for Management of Ischemic
Stroke (2012):
Do not treat hypertension if < 220mmHg systolic or <
120mmHg diastolic. Mild hypertension is desirable at 160180/90-100 mmHg.
Blood pressure reduction should not be drastic.
Proposed substances:
Labetolol 10-20mg boluses at 10 minute intervals up to 150-300mg or
1mg/ml infusion (rate 1-3mg/min)
Captopril 6.25-12.5mg orally

BP Control in Acute Ischemic

Stroke

Reperfusion Therapy
IV thrombolytic therapy
Restore circulation to penumbra and normalize metabolism to
prevent further damage.
Recommended agent: Recombinant Tissue Plasminogen
Activator (rt-PA)

rt-PAShould only be given if:

A physician with expertise in the diagnosis and management
of stroke.
Appropriate neuroimaging tests are available 24 hours a day
Capability to manage the complications of thrombolysis,
particularly intracranial haemorrhage.

Indication of rt-PA

Reperfusion Therapy
Intra-arterial thrombolysis
an option for the treatment of selected patients who have
major stroke of <6 hours duration due to occlusions of the
middle cerebral artery, internal carotid and carotid terminus
who are not otherwise candidates for intravenous rtPA.

Endovascular mechanical thrombectomy

may be performed up to 8 hours duration in selected patients
with major stroke syndrome and ineligible for or failing
intravenous thrombolysis. T
the utility of the device in improving outcomes after stroke is
unclear.

Rehabilitation and Outpatient

Care
Lessening disability and attaining optimal functioning.
Respiratory system: prevent obstruction, aspiration
Musculoskeletal system: prevent contracture, muscle wasting
physiotherapy and occupational therapy
Integumentary system: susceptible to breakdown due to loss
of sensation, reduced circulation and immobility regular
position change, skin hygiene, early mobilisation
GI tract and nutrition oral hygiene
Communication speech therapy, depression
Education self-care, enhance family coping, secondary
prevention

Primary Prevention
Goals
Health management for the well individual
Education and management of modifiable risk factors to
prevent a stroke

Antiplatelet drugs are usually the chosen treatment to

prevent further stroke in patients who have had a TIA
Aspirin is the most frequently used antiplatelet drug

Anti-Thrombotic Therapy
High-flow states:
platelets cause clots

large-artery
atherosclerosis

small-artery
disease

Low-flow & hypercoagulable states:

clotting factors cause clots

cardioembolism

ANTIPLATELET AGENT
aspirin 81-325/d
clopidogrel 75/d
aspirin + dipyridamole XR 25/200 twice/d

hypercoagulable
state

ANTICOAGULANT
warfarin
INR 2.0-3.0
or
INR 2.5-3.5

Antiplatelet Agents
Recommended by Clinical Practice Guidelines
for
Management of Ischemic Stroke (2012):
Aspirin
Ticlodipine : superior to aspirin. SE:
neutropenia
Clopidogrel
Triflusal
Cilostazol
Double/ combined therapy

Thank You