Journal of The Association of Physicians of India Vol.

63 June 2015 41

Original Article

Lacunar Syndromes Where is the Lesion?

Uma Sundar1, Vijay Ghuge2

Abstract Editorial Viewpoint

Objectives: The study aimed to evaluate different imaging localizations Hypertension and tobacco
of the classical Lacunar syndromes, including multiplicity of lacunes. usage are common risk
factors.
Materials and Methods: This prospective study was conducted in a
tertiary care municipal hospital over 2 years. Patients with clinical Lacunar Pure motor strokes are
syndromes, confirmed on imaging, were evaluated for etiopathogenetic the commonest forms of
factors, lesion localization, and presence of multiple simltaneous lacunes. lacunar syndrome.
Angiographic data and cognitive evaluation was done in a subset of the P o s t l a c u n a r s y n d r o m e
cohort. with executive
dysfunction is seen in
Results: 82 patients were studied, 12 undergoing DSA and 46 being
two-thirds of the patients.
evaluated cognitively. Commonest risk factors were Hypertension
(97%) and tobacco usage(62%). Pure motor stroke( PMS-70.7%) was the
commonest lacunar syndrome, Internal capsular lesions accounting for Methodology
53.4% of this syndrome. Among PMS, localisation to Carotid territory was
The study was conducted in a
seen in 84.4%, to vertebrobasilar territory in 10.3% and to both in 5.1%
tertiary care municipal hospital
of patients. Sensorimotor lacunar syndrome was seen in 14.6% patients,
in a metropolitan city over a 2
half of them having a thalamic lesion. Overall, 17% patients had multiple year period. Serially recruited
simultaneous lacunes, over half of these being cortical, and multiplicity patients with a clinical lacunar
being seen in PMS most commonly. Of 46 patients tested for cognition, syndrome, confirmed by CT/MRI
69.5% showed significantly low scores on ACER, with a significant imaging to have an infarct of 2 cm
association with multiplicity of lacunes in this group. size or less, were evaluated for
Conclusions: In our study, Pure motor stroke was the commonest lacunar demographic and epidemiological
syndrome, 84% of PMS being due to Anterior circulation stroke. Multiple factors, correlation of clinical
lacunes of similar age were seen in 17% patients, the predominantly syndrome with lesion on imaging
cortical localization of these raising a possibility of embolism. Postlacunar and the presence of additional
stroke executive dysfunction was seen in over two-thirds of our patients. simultaneous lacunes. Residual
c o g n i t i ve d y s f u n c t i o n a n d i t s
relation to subclinical multiple
lacunes was assessed by the revised
Background territories. 1 Lacunes in lentiform
Addenbrookes scoring system
nucleus may present as gradual

A
restricted area of infarction
(2-20 mm) due to ischemia in
the territory of a single perforating
artery causes the classical ischemic
lacune. 1 Lacunar strokes constitute
a quarter of all ischemic strokes,
and are generally attributed to
lipohyalinosis. 2,3
The common lacunar syndromes
(pure motor, sensori-motor, pure
sensory, ataxia-hemiparesis,
dysarthria-clumsy hand) can each
be caused by lesions in different
cerebral / brainstem areas, from
anterior or posterior circulation
(ACE-R), in a subset of patients
cognitive decline. 4 The findings of
who had been cognitively normal
widespread, same-age lacunes,
prior to the stroke, according to
and cortical lacunes, leads to
their relatives.
consideration of embolisation as
the etiology of these lacunes. 5,6 All patients underwent standard
testing for stroke risk factors.
This study aimed to study
A subset (using computer-
lacunar syndromes so as to
generated randomisation numbers)
determine the variability in lesion
u n d e r we n t d i g i t a l s u b t r a c t i o n
localisation, that can present with
angiography (DSA).
similar clinical syndromes.
1
Prof. of Medicine, In-charge Neurology Services, 2Former Senior Resident, Lokmanya Tilak Mun. Med. College
and Hospital, Mumbai, Maharashtra
Received: 12.11.2013; Revised: 10.03.2014; Accepted: 15.04.2014
 42 Journal of The Association of Physicians of India Vol. 63 June 2015

Table 1 : Risk factor profile in lacunar PMS was seen in 6 patients, and more standard lacunar lesion.
strokes (n=82) a combination of pontine with Multiple lesions were seen most
Risk factors No. of patients (%) capsular strokes in three. Clear often in PMS; 8/58 (13.7%) PMS
TIA 18 (21.9) localisation to carotid territory having multiple lesions, and
Hypertension 65 (79.2) was seen in 49/58 patients (84.4%), 8/14 (57.1%) multiple lesions
Diabetes 43 (52.4) l o c a l i s a t i o n t o ve r t e b r o b a s i l a r belonging to PMS category. Of
IHD 11 (13.4) territory in 6/58 patients (10.3%), all the 82 patients, 64 had the
Tobacco use 51 (62.1) and localisation to both in 3/58 lacune clearly in carotid territory
Alcohol 24 (29.2) patients (5.1%). (excluding 12 brainstem strokes
Past stroke 17 (20.7) Multiple simultaneous lacunes and 6 thalamic strokes). Of the
Family h/o stroke 9 (10.9) were seen in 8 patients with PMS, 5 53 patients undergoing carotid
Echo
having an ipsilateral small cortical Doppler, 41 belonged to this group
Hypertensive heart 34 (41.4)
lacune, and 3 having an ipsilateral with a clear carotid territory lacune,
disease (HHD) single or multiple. Concordant,
brainstem lacune (2 pontine). Of
Ischemic heart 5 (6.1)
these 5 patients, 3 had an MRI-DWI, ipsilateral carotid stenosis of over
disease (IHD)
hence it was clear that the lesions 70% was seen in 10/41 investigated
Both HHD and 19 (23.1)
IHD were all acute; 2 patients were patients, and in 4 of remaining
Carotid Doppler* 14 diagnosed on CT brain only, but 18 patients with the lacune in
*
Carotid Doppler was done in 53 patients. 14 the appearance of the hypodense posterior circulation territory. Due
patients had internal carotid stenosis greater lesion was similar, pointing to to paucity of numbers, this data
than 70% in diameter, 10 of these patients
simultaneously occurring lacunes. could not be statistically compared.
having a concordant ipsilateral carotid
territory lacune. The differentiation of PMS due O u t o f 8 2 p a t i e n t s , 3 6 we r e
to carotid territory stroke from not tested for cognition (7
Statistics: Tests of significance-P that due to vertebrobasilar stroke having a possible mild cognitive
value with CI 95%. is usually easy, as the latter dysfunction prior to index stroke
is characterised by a crossed as per information gathered from
Results h e m i p l e g i a . H o we ve r , i n t h e relatives, 8 being unable to co-
Eighty-two patients were present series, a clear involvement operate fully for testing, and 21
included in the study (average age of contralateral LMN 7 th was not being unavailable for testing at 2
59.2 years; 63 males). ACE-R was present in 2/6 pontine strokes; in all weeks). Of 46 tested patients (Table
done in 46 patients, and 12 patients 3 of the patients with PMS showing 3), 32 (69.5%), showed a low ACER
underwent DSA. capsular and pontine lesions, the score, the median score in this group
facial paresis was of UMN type, being significantly lower than that
Hypertension (79%) and tobacco
ipsilateral to the hemiparesis. in the group scoring over 87. The 2
usage (62%) were the commonest
Sensorimotor stroke was seen in groups were comparable in mean
risk factors noted (Table 1).
12/82 (14.6%) patients in present age and education levels, although
Pure motor stroke (PMS- 58/82- males were marginally more in
series, half of them having the
70.7%) was the commonest lacunar the former group. Multiplicity of
lesion in contralateral thalamus.
syndrome (Table 2), a complete, lacunes was significantly associated
Ataxia hemiparesis (AH) was
dense hemiparesis being seen with poor ACER scores (P <0.05).
diagnosed in 5 patients, and
in 42/58 (72.4%) patients. Dense Among all the clinical syndromes,
dysarthria-clumsy hand in 3
hemiplegia was seen in all the the pure motor syndrome was
patients.
patients with the lesion in the most commonly associated with
internal capsule (IC-31/58- 53.4%). Fourteen out of 82 (17%) patients
poor cognitive performance on
Pontine strokes accounting for the had multiple infarcts, 11 having
cortical infarcts in addition to a
Table 2: Correlation of clinical syndrome with lesion localization on imaging
Clinical syndrome Internal capsule Gangliocapsular Corona radiata Gangliocapsular + Multiple* Thalamic Brainstem
ipsilateral cortical
Pure motor (58) 31 8 5 5 3 - 6
Sensorimotor (12) 2 - 1 3 - 6 -
Ataxia-hemiparesis (5) - - - 3 - - 2
Dysarthria-clumsy hand (3) 3 - - - - - -
Pure dysarthria (1) - - - - - - 1
Lateral medullary syndrome (2) - - - - - - 2
Fovilles syndrome (1) - - - - - - 1
*
capsular + brainstem

Table 3: Correlation of ACER scores with clinical lacunar syndrome and lesion
ACER score Deficit / location
No. tested-46 pure motor
No. pts.
87 or more (14 pts.) 10
Median ACER-92 Internal capsule 8
Range ACER 87-94 Corona radiata 2
Mean age 59 yrs
Under 87 (32 pts.)* 28
Median ACER-74 Internal capsule 22
Range ACER 54-86 Capsular+brainstem 2
Mean age 60.3 yrs Gangliocapsular +
cortical 4
*
9 patients had multiple lacunes
the ACER, but this did not attain
statistical significance.
Discussion
The association of pure motor
strokes and lacunes was noted
i n t h e e a r l y 2 0 th c e n t u r y . I t i s
the most frequent of all lacunar
syndromes, as seen in the present
series, and exemplifies the core
features of all lacunar syndromes
Fishers original report of 9
autopsied cases of PMS, included
lacunes in IC in 6, and in pons in
3 patients. 10 Since then, PMS has
been described with lacunes in the
corona radiata, cerebral peduncle
and the medullary pyramid. 7,8 In
fact, more restricted deficits, such
as face+arm, or arm+leg, localise
to lacunes in the corona radiata
or its junction with the internal
capsule. 1,7,8
Sensorimotor (SM) strokes, seen
in 12/82 (14.6%) patients in present
series, have been attributed to
lesions in the posterior limb of the
IC interrupting the thalamocortical
fibres, or the thalamus medially. 1,9
In the stroke data bank, SMS was
the second commonest syndrome
after PMS, the lesion being in the
IC in 44% patients, in CR in 22%
patients and in thalamus in only
9% patients. 9 Thalamic lesions
accounted for 50% of our SM
strokes, with simultaneous cortical
lesions being seen in 25% patients.
We had no cases of pure sensory
syndrome. This syndrome, localised
to posteroventral thalamus and
o f t e n m i s s e d o n C T, h a s b e e n
Journal of The Association of Physicians of India Vol. 63 June 2015
Deficit / location Deficit / location
sensorimotor ataxia-hemiparesis
No. pts. No. pts.
2 2
Thalamocapsular 2 Brainstem 2
2 2
Gangliocapsular + Brainstem 1
cortical 2 Gangliocapsular +
cortical 1
reported to occur in 6-7% patients. 10
Pure sensory strokes may be missed
if only CT is done (our series did
not have MRI for all patients).
Restricted sensory symptoms may
also be misdiagnosed as sensory
radiculopathies and not referred
to the hospital.
In our 5 cases of AH, 3 patients
had a cortical lesion in addition
to a gangliocapsular lesion. Of a
total of 8 patients with AH or DCH,
only 2 had a brainstem lesion.
The clinical dictum to be derived
from a study of this syndrome, is
that limb ataxia, in the presence
of ipsilateral pyramidal signs,
does not necessarily imply a
cerebellar stroke, but may be due
to pontine or basal ganglia lacunes.
In Fishers original series of AH/
DCH syndrome, the lesion was
localised to contralateral pons.
Later MRI studies have localised
the lesion to IC in 40% cases, and
to lesions in CR as well as ACA
territorial infarcts. 11
In this study, 24.3% of
investigated patients with a
lacune in carotid territory, had
an ipsilateral, concordant carotid
stenosis over 70%, whereas 22.2%
of patients with a lacune in the
posterior circulation territory
had a concordant significant
carotid stenosis. Due to paucity
of numbers, this data could not be
statistically compared. Ipsilateral
carotid stenosis 12 has been well
documented to show association
with large artery atherosclerosis
as the cause of infarct, rather
43
than with lacunes. However, it is
possible that atheroma at the site of
carotid stenosis could be a source
for embolus, especially when
multiple ipsilateral lacunes are
seen in the area of carotid supply.
We could perform a DSA in 12 /82
patients. Seven of these 12 showed
evidence of intra- or extracerebral
arteriopathy, 5 of these lesions
being concordant with the territory
of lacune. These angiopathies were
in large or mid-size arteries, and
could, theoretically, have led to
embolization or a local low-flow
state, causing the lacune. Due to
various constraints, angiographic
correlation with multiplicity or
cortical involvement, could not be
done in this study.
What is the importance of
mult iple lacunes, espec i a l l y i f
pertaining to different vascular
territories or to localisation in the
cortex? While various studies have
postulated possible proximal
embolic sources in the subgroup
of multiple lacunes, 13,14 other
authors have suggested that
multiple lacunes represent a more
severe small arterial disease. 15,16
In a summary of studies dealing
with additional lesions in lacunar
strokes, Warlaw et al conclude
that overall, about 10% of patients
presenting with a clinical lacunar
syndrome have a relevant lesion
other than a deep infarct or bleed
on the scan, which might explain
the deficit. 17 In studies using CT,
evaluating all lacunar syndromes,
t h i s r a n g e d f r o m 4 - 1 7 % ; 18 i n
MRI-DWI studies upto 53 hours
post-stroke, 2-68 % patients had an
additional lesion; 19 both modalities
of imaging reporting the highest
rates of multiple lesions with the
sensorimotor syndrome (5-21%).
Traditionally, lacunar strokes
are not investigated aggressively
with angiography, as the risk of
recurrence is considered to be low,
and the pathology, well-delineated.
However, where multiple, same-
age or cortical lacunes are shown,
an argument could be made for
 44 Journal of The Association of Physicians of India Vol. 63 June 2015
looking for a proximal embolic
source. 15,16
Lacunes in the lentiform nucleus
are known to be associated with
a slowly progressive subcortical
dementia, with or without an index
stroke. Of 46 tested patients in our
study, 32 (69.5%), showed a low
ACER score, the median score in
this group being significantly lower
than that in the group scoring over
87. Post-lacunar stroke cognitive
dysfunction has been reported to
be 47% by Jacova et al, 20 and 20%
by Maken et al, 21 in recent studies.
Despite the small size of the lesion,
the association with small vessel
disease appears to cause significant
executive dysfunction in these
patients. 21 The higher percentage
o f p a t i e n t s s h o w i n g c o g n i t i ve
dysfunction in our series could be
due to early assessment, at 2 weeks
post-stroke.
In conclusion, our study
confirms that PMS is the
commonest lacunar syndrome,
85% of these being due to anterior
circulation strokes. Brainstem
lacunes, singly or in combination,
accounted for 15/82 (18.3%) lesions
in this series. Multiple lacunes
of similar appearance were seen
in 14/82 (17%) patients, 11 of
these being in the cortex, raising
a p ossib ili t y of e mboli from a
proximal arterial or cardiac source.
In the present study, arteriographic
and echocardiogram data were
not compared in the subset with
cortical lacunes versus the subset
with no cortical lacunes. This is an
area which requires further study.
The presence of simultaneous
lacunes in different arterial
territories, especially when cortical,
should probably be investigated for
embolic pathogenesis, especially
in view of Asian propensity
for intracranial atherosclerosis.
Additionally, post-lacunar stroke
executive dysfunction needs to be
recognised and addressed.
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