Management of Lacunar Strokes

A detailed discussion of the treatment of lacunar strokes is beyond the scope of this article, but a brief overview follows. The role of anticoagulation or carotid endarterectomy in patients with lacunes has not been fully defined. Although a study showed that the benefit of endarterectomy in patients with lacunes is smaller than it is in patients with nonlacunar strokes, the procedure is superior to medical therapy. The prevention of deep venous thrombosis (DVT), aspiration pneumonia, urinary tract infection, and decubitus ulcers are important considerations for any patient following stroke. Transfer may be required for further diagnostic evaluation and treatment, including rehabilitation.

Pharmacotherapy
The medications used in the management of lacunes are not specific to this stroke subtype. Fibrinolytic agents are used to improve stroke outcome. The National Institute of Neurological Disorders and Stroke (NINDS) study on recombinant tissue-type plasminogen activator (rt-PA) showed an 11-13% absolute increase in the number of ischemic stroke patients with a favorable outcome at 3 months with tissue plasminogen activator (t-PA).[17, 18] Antiplatelet agents are used for secondary stroke prevention, and if commenced within 48 hours of stroke onset, confer a small survival benefit. Angiotensin-converting enzyme inhibitors are also used for secondary stroke prevention.[19, 20] Anticoagulant agents are employed for prophylaxis of deep vein thrombosis (DVT) and pulmonary embolism. Some patients with spasticity or joint contractures following a lacunar stroke may benefit from the injection of botulinum toxin or neurolytic agents.

Surgical intervention
Surgery (eg, gastrostomy/jejunostomy) is rarely required as a result of a lacunar stroke, but patients with severe dysphagia may require long-term tube feeding.

Consultations
A social worker should be consulted to assess personal and family resources, to inform the patient and family of available government resources, to facilitate discharge planning, and to coordinate community services.

Outpatient Management Considerations

If the patient who has had a lacunar stroke is functionally independent, can return safely home, and would benefit from intensive inpatient rehabilitation, transfer him/her to a rehabilitation facility. Educate the patient and family about the common stroke symptoms. Inform them early about the importance of presentation, because tissue plasminogen activator (t-PA) (which may be indicated) can be given only within 3 hours of stroke onset.[18] Medical follow-up is necessary to assess neurologic and functional improvement, to monitor and treat risk factors, and to monitor drug compliance. Outpatient physical, occupational, and/or speech therapy may be recommended. Discharge on aspirin and ramipril. If the patient remains nonambulatory and is at high risk of deep vein thrombosis, continue subcutaneous heparin.