Lacunar infarction: what it is, causes and treatment

Strokes are one of the debilitating diseases that exist, as their condition is not limited to the hours in which it has occurred or to hospital care.

In this sense, cerebral infarctions, including lacunar infarctions, can represent a barrier or an impediment to the daily life of the individual and their loved ones.

If you want to learn about this kind of heart attacks, we will provide you with everything you need to know in the following article.

What is a lacunar infarction?

Lacunar infarctions refer to a subtype of stroke (also known asstroke), in which there are problems or insufficiencies of blood flow in small vessels.

They are small infarcts (2-20 mm in diameter) deep in the cerebral cortex, basal nuclei and pons.

They are the result of an occlusion of small perforating vessels, which supply blood to the subcortical regions of the brain. They account for one-fifth of all stroke types and one-quarter of ischemic strokes.

Causes of lacunar infarction

The pathophysiology of lacunar infarctions is unknown exactly, but it is known that there are multiple causes, cardiac, metabolic, environmental factors, that increase the risk of suffering a lacunar infarction.

Below, we will mention some of these causes or risk factors.

Heart problems

Heart problems are more likely to cause cortical than subcortical (lacunar) infarctions, but they are still part of the classic risk factors for embolic events.

Among these, we have atrial fibrillation, cardioembolism, recent myocardial infarction, infective endocarditis, mechanical valves, mitral stenosis, atrial myxoma and much more.

Hypertension

Microscopic images taken of the small affected arteries reveal the characteristic lipohyalinosis, a pathology of the small blood vessels (arteries, arterioles, and capillaries) in the brain .

Lipohyalinosis is characterized by a disorganization of the arterial wall: thickening of the wall, narrowing of the lumen, and the presence of fibrinoid necrosis.

These same findings can be found in other small vessels affected by arterial hypertension. This mechanism is believed to be caused by a dysfunction of the arterial walls and a dysfunction of the blood-brain barrier.

The dysfunction of these two vascular elements, in turn, is caused by an intricate network of elements that interact with each other: oxidative stress and genetic predisposition, for example, and risk factors such as hypertension.

Diabetes

The relationship between diabetes and vascular diseases has been extensivelystudied . The debilitating capacity of this metabolic condition comes, in part, from its ability to affect the blood vessels of different organs.

The blood vessels thicken and lose their functions, progressively. This leads to retinopathy, kidney disease, heart disease and, in the brain, cognitive decline and Alzheimer’s disease.

As in hypertension, it is due to a dysfunction of the endothelial cells, responsible for synthesizing molecules that maintain adequate blood flow.

This dysfunction is caused by insulin resistance, hyperglycemia, and the production of free fatty acids, which lead to a proinflammatory and prothrombotic state.

High cholesterol

Hypercholesterolemia is a risk factor with frequent association that leads to hypertension, atherosclerosis and type II diabetes mellitus.

Circulating fatty acids can leak through openings in the walls of blood vessels and cause a pro-inflammatory state, atheroma production and reduced blood flow, eventually leading to circulatory problems.

Alcohol and cigarette consumption

Cigarettes are packed with more than 300 pro-inflammatory and pre-cancer substances that, when metabolized in the body, trigger a series of harmful metabolic reactions throughout our body.

The release of pro-inflammatory cytokines is promoted, the production of nitric oxide (responsible for the relaxation of blood vessels and increased blood flow) and changes in the vascular wall are hindered.

In relation to alcohol, excessive and prolonged alcohol consumption increases the risk of peripheral arterial disease and stroke, according to studies published in Circulation: Genomic and Precision Medicine .

Consumption of psychoactive substances

The abuse of certain drugs , especially in young people, is associated with an increased risk of suffering a stroketag. Among these, we have amphetamines, heroin, morphine, and androgenic anabolic steroids.

Among the most frequent types of stroke that can be caused by these substances are the hemorrhagic and ischemic types. Certain causative mechanisms have been identified, such as arrhythmias, cardioembolism, hypoxia, toxicity, and vascular spasms.

Inadequate diet and sedentary lifestyle

The mechanism by which these can cause these kinds of heart attacks is more indirect than the rest. An inappropriate lifestyle (chronic stress, poor diet, lack of exercise, alcohol consumption, etc.) can be harmful to health.

They are the cause of metabolic diseases (insulin resistance, hypercholesterolemia, increased LDL), cardiac (coronary disease) and vascular (such as stroke and many more). As we have seen, all these pathologies can lead to lacunar infarction.

Sleep apnea

Sleep is carefully regulated by a series of autonomic factors that regulate blood flow, blood pressure, tissue metabolism, and much more, during REM and non-NREM cycles .

During NREM, the autonomic nervous system provides an opportunity for the heart-brain axis to recover from all the stressors that occur throughout the day.

Any alteration of the cyclical mechanism of sleep exerts a negative charge on the cardiovascular and nervous systems. A compromised cardiovascular system increases the risk of suffering strokes, arrhythmias or heartattacks .

Pregnancy

Pregnant women or just after giving birth are at greater risk of developing thrombotic diseases, capable of generating heart attacks, such as lacunar ones.

During pregnancy, conditions occur (Virchow’s triad) that allow the formation of thrombi that can detach and wreak havoc in regions distant from the site of their formation.

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Lacunar infarction symptoms

The neurological syndromes that lacunar infarction can cause depend on its onset time and its location. By definition, lacunar infarcts have a picture characterized by symptoms lasting minutes, hours and even more.

In total, more than 20 syndromes have been described. However, we will mention only a few below.

Paralysis of face and extremities

Caused by lacunar infarction of the pure sensory type, characterized by unilateral weakness and paralysis of the facial muscles and muscles of the extremities.

In the face, it is known as central facial paralysis, generally associated with lacunar infarcts produced at the level of the internal capsule of the brain or affection of the blood vessels directed to the pons.

Weaknesses on one side of the body are known as hemiparesis. They can be caused by infarcts that affect the circulation of the anterior part of the brain, of the vessels that go to the internal capsule or of the corona radiata.

Weakening of the eye muscles

Ocular phenomena caused by cerebrovascular accidents is a direct relationship that has been studied intensively since the last century. In fact, risk factors for these, hypertension and diabetes, can cause retinopathies.

In this case, the weakening of the muscles is called ophthalmoparesis and the paralysis is known as ophthalmoplegia. Among the possible reasons why they occur is due to infarcts in specific nerve tracts of the white matter and the frontal eye fields.

Engine Difficulties

Hemiataxia (paralysis or weakening of the muscles on one side of a body) are another class of common phenomena that occur in strokes.

They are frequent in lacunar infarcts, which affect the communication pathways between the deep nuclei of the cerebellum, the thalamus , and the red nucleus, since these cross the internal capsule, a region frequently affected in lacunar infarcts.

This series of anatomical structures are related to the fine coordination of complex movements. In this case, the aforementioned pathways send information received by the cerebellum to the cerebral cortex.

speech difficulties

Motor speech difficulties are signs that are part of the syndromes of ataxia-hemiparesis or dysarthria and difficulty in moving the hands. Generally, they occur due to infarcts produced in the front portion of the pons.

Inside it, are the white matter fibers relevant to the corticospinal tract, related to the contraction and relaxation of the pharyngeal muscles, allowing the articulation and intonation of words.

Also in lacunar infarcts of cerebellar connections, speech can be affected, including another series of motor functions, generating the so-called ataxic disorders.

muscle numbness

Motor disorders originating from cerebrovascular disorders tend to manifest as hypertonicity and hyperreflexia of the muscles.

Muscle tone is a small, prolonged contraction that keeps muscles working passively, keeping us in balance when walking, standing, or sitting.

The affections of the “superior” neurons (because they are in the brain), uncontroll this continuous electrical activity, generating muscle numbness and preventing the patient from controlling it.

Types of lacunar infarction

They are classified into 5 types of lacunar infarction, these are the so-called classic ones, because they are the most frequent and the only ones with sufficient neuropathological verification compiled in the various studies carried out over the years.

pure motor disorder

Pure motor hemiparesis is the most frequent syndrome of lacunar infarcts, and was described by Fisher and Curry as an incomplete hemilateral paralysis of the face, arm, and leg, without objective sensory alterations.

Lesions are most often located in the posterior arm of the internal capsule, in the corona radiata, or at the base of the pons.

The deficit can be complete (facio-brachio-crural, that is, face-arms-legs), although it can sometimes be incomplete (faciobrachial or brachiocrural), it is important to note that monoplegia is not included.

Motor sensory disorder

It is a pyramidal syndrome that generates weakness of the face, arm and leg on one side of the body, completely (all three) or incompletely (one or two regions), associated with a global or partial sensory deficit of the same hemibody.

This weakness or incapacity on one side of the body is called hemiparesis, which can subsequently progress to a tingling, aching, burning sensation, or even total motor loss (hemiplegia) of that half of the body.

The neurological lesion is located in the posterolateral nucleus of the thalamus on the opposite side of the body, with demyelination of the posterior arm of the internal capsule.

That is to say, that the conditions of the left thalamus of the body affect the arm or leg on the right side of the body. During diagnosis, it can be confused with a frontoparietal cortex infarction due to its clinical similarities.

Pure sensory disorder

It consists of a sensory deficit syndrome (hypoesthesia) or irritative ( Paresthesia) or both; global (affects superficial and deep sensitivity) or partial (affects only one of them). It usually presents a facio-brachio-crural distribution.

The cheiro-oral form (with perioral and hand involvement on the same side of the lacunar infarct) and the cheiro-oro-podal form (with perioral, hand and foot involvement on the same side of the lacunar infarct) are less frequent.

The usual lesion topography is located in the Thalamic ventroposterolateral nucleustag. Other less frequent regions affected are infarcts of the sensory pathways at the level of the brain stem or at the level of the thalamocortical projections.

hemiparesis ataxia disorder

Generally, they are produced by infarcts at the level of the posterior arm of the internal capsule or the pons, where the pathways connecting the cerebral cortex, the pons, the cerebellum, the red nucleus, and the thalamic nuclei are affected.

They are clinical conditions that usually affect the limbs on one side of the body (the same where the infarction occurred), presenting ataxia (lack of coordination of movements) and hemiparesthesia.

Movement disturbances usually occur to a greater degree in the leg than in the arm. It is also accompanied by sensory deficits, where there is a decrease in sensitivity (hypoesthetic ataxic hemiparesis).

Dysarthria and difficulty in the hands

Also called dysarthria-clumsy hand. It is an infrequent syndrome and not as lethal as the previous ones. Caused by infarcts in the pons, the anterior arm of the internal capsule, the corona radiata, the basal ganglia, or the cerebral peduncles.

As its name indicates, it is characterized by motor deficits, where there is an inability to properly articulate words: intonation, pronunciation, fluency, and much more.

In addition, it is accompanied by a motor clumsiness when writing or any manual skill. Other concomitant symptoms are facial paresis and hyperreflexia of one side of the body (i.e., muscles hyperreactive to stimuli).

Treatment for lacunar infarction

Treatments for lacunar infarcts are broadly similar to treatments for cortical infarcts. If you or someone you know is presenting symptoms similar to those of a stroke, do not hesitate to go to the emergency room.

Anticoagulant drugs

The speed and effectiveness of the treatments during the first hours, once the symptoms have been established, is the main factor that determines the course of the disease and the degree of condition of the patient.

But, beyond the treatments during the first hours, secondary treatments must be established that help prevent new clinical episodes. For this, anticoagulants and antiplatelets are used.

Among the latter, we have aspirin, ticlopidine and clopidogrel. In patients with transient ischemic attacks or strokes, the incidence of recurrent episodes even decreased to 22%.

As for anticoagulants, the most widely used worldwide is warfarin. It is used exclusively in patients who demonstrate recurrent neurological episodes, despite being under antiplatelet treatment.

Neuropsychological rehabilitation

Depending on their location, lacunar infarcts can cause cognitive and behavioral impairment. Neuropsychology is responsible for studying the relationships between behavior and the brain.

Neuropsychology seeks to provide different types of attention (focused, sustained, selective, alternating …), because it allows the therapist to identify which cognitive abilities remain conserved and which others are affected.

In such a way, that individualized treatments are allowed to be drawn up that allows the specialist to understand what is the cause that underlies the observable symptoms, to assess possible sequelae and the effectiveness of rehabilitation.

Physiotherapy

Physical therapy allows the patient to recover lost motor skills, regain the independence they possessed before the stroke and reduces the risk of future ischemic neurological episodes.

The National Institute for Health and Care Excellence (NICE) outlined a series of recommendations for physiotherapy treatment: a minimum of 45 minutes of physiotherapy, five days a week, as part of the rehabilitation service.

Physiotherapy shows that the rehabilitation and integration of the patient after a stroke is not limited only to practitioners of the neurology specialty, but also to other branches, to achieve intersectoral treatments.

Speech therapy

Speech therapy seeks to alleviate as much as possible the symptoms of dysarthria, dysphagia, apraxia and motor speech problems that are established after certain lacunar infarcts.

Therapists specialized in this area are part of the multidisciplinary rehabilitation team, assess the degree of severity of speech problems, train health professionals to promote communication with the patient and seek the best possible help.

Psychological and occupational therapy

Like the previous ones, occupational therapy is an instrument that is part of interdisciplinary care in each of the rehabilitation stages, inside and outside the hospital.

Among the objectives of occupational therapy is: the creation of an appropriate environment in which the patient can develop (both in the community and at work) and address sensory, motor, cognitive and visual deficits.

Also, the therapist creates recommendations on the person’s lifestyle, so that they can resume their daily activities (academic, work, leisure…) and the adoption of new lifestyle habits.

Prevention of lacunar infarction

Lacunar infarcts, like other strokes of ischemic or hemorrhagic origin, can be prevented if we make conscious decisions about our lifestyle, reducing the risk of suffering from them. Next, we will show you some examples.

Maintain a healthy diet

Reducing the consumption of trans fats and processed sugar is a big step in the right direction. The first, increases circulating LDL, responsible for transporting cholesterol from the liver to other tissues in the body.

The second, generates fluctuations in blood sugar levels, which, in the long run, leads to insulin resistance (type II diabetes mellitus or DM II). Both metabolic phenomena are harmful to almost all tissues in our body.

However, the greatest risk comes from involvement of the cardiovascular system. Metabolic pathologies increase inflammation and oxidative stress, which damage blood vessels and therefore circulation (to the brain, for example).

Another demonstration of the dangers of a poor diet is that an association has been found between neurodegenerative diseases (such as Alzheimer’s) and problems in the transport and uptake of glucose (such as DM II).

Blood pressure control

The regulation of blood pressure is the result of a fine balance between forces that favor the relaxation of the vessels, favoring blood flow, and forces that constrict the vessels and regulate blood flow.

Systolic blood pressure beyond 140 mmHG is an alarming trait in a patient, especially if they develop some other pathology, such as arteriosclerosis and diabetes mellitus.

These modify the arterial walls and generate disturbances of blood flow, which particularly affect parts of the brain, whose small and medium-sized blood vessels are very susceptible to pathological changes.

Control cholesterol levels

Although hypertension and arteriosclerosis are not the only causes of lacunar infarcts, they do act as risk factors. Fatty acids, dead cell debris, and inflammatory cells are deposited in the thickness of the arteriolar walls.

So, to avoid this, we recommend a more balanced diet and exercise. Low-fat, high-carbohydrate diets should be avoided, as processed sugar only encourages inflammation and metabolic disease.

Foods rich in omega-3 and 6, fiber, vitamins, minerals and reducing sodium intake help control inflammation, keep the lipid profile under control, promote immune action and cerebral circulation.

Avoid smoking and psychoactive substances

Does quitting tobacco have substantial health benefits? Yes. Numerousstudies have shown that those who stop smoking demonstrate a better quality of life and quality of health compared to those who do not.

In addition, multiple studies have shown, over the years, that tobacco represents an independent risk factor for stroke of any type.

In that same sense, the harmful effects of substances, such as heroin or amphetamines, is something very well documented. We recommend avoiding, under any circumstances, the consumption of these.

Doing physical activity

There are few non-pharmacological approaches as effective as exercise. It’s not even about intense cardio; Easy walks or jogs help significantly reduce the risk of chronic diseases.

Exercise promotes immune activity, which decreases oxidative stress, delaying cellular aging as well as inflammation. This promotes circulation, improves cognitive activity and lifts mood.

The intensity and regularity needed to achieve the best effects is quite individual and also a topic on which scientists have not reached a consensus.

Go for regular medical check-ups

As we age, our metabolism slows down and that can have neurological and cognitive consequences.

Going to the doctor periodically so that he can carry out a general check-up is important, since it allows us to have control and knowledge about the current state of our body and what we should be more attentive to.