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Lacunar Infarct and Syndromes
Lacunar Infarct and Syndromes
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.
Types of Stroke
Ischemic, 80%
- thrombosis, 50% (small & large-vessel)
- embolism, 30%
Hemorrhagic, 20%
- intracerebral (HTN as risk)
- subarachnoid (aneurysm)
Ischemic stroke
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
Circle of Willis
Anterior
circulation- MCA,
ACA, and Anterior
choroidal artery
Posterior
circulationVertebral artery,
Basilar artery and
Posterior cerebral
artery
Internal Carotid
Artery
Left ACA
Right ACA
Left MCA
Right MCA
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
- 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
Lenticulostritae
branches of MCA
Perforating
arteries of basilar
artery
Perforating
arteries of
anterior choroidal or
PCOM
-
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)
Diagnosis
History
Physical examinations:
Vital signs, general assessments
Full neurological examinations
Diagnostic tests
To determine
whether
ischemic or
hemorrhagic
stroke
Acute Treatment
General management (supportive care and prevention of
complications)
Reperfusion Therapy
IV thrombolytic therapy
Restore circulation to penumbra and normalize metabolism to
prevent further damage.
Recommended agent: Recombinant Tissue Plasminogen
Activator (rt-PA)
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.
Primary Prevention
Goals
Health management for the well individual
Education and management of modifiable risk factors to
prevent a stroke
Anti-Thrombotic Therapy
High-flow states:
platelets cause clots
large-artery
atherosclerosis
small-artery
disease
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