Review Question - QID 106438

This patient with subtle neurologic deficits and hypertension with the demonstrated MRI has sustained a lacunar infarct. The strongest risk factor for the development of lacunar infarct is hypertension, which greatly increases the risk of an abdominal aortic aneurysm.

Systemic hypertension results in the development of lipohyalinosis and vasculopathy of small vessels, particularly those in the central nervous system. The lenticulostriate branch arteries that supply the basal ganglia and surrounding area are often affected, and are typically the culprit vessels involved in lacunar infarcts. Symptoms of lacunar infarcts include pure, unilateral motor or sensory deficits. Neurologic deficits may be subtle. Treatment generally centers around management of underlying risk factors, notably control of hypertension. Aspirin and statin therapy are generally also utilized for secondary stroke prevention.

As Yew et al. note, lacunar strokes refer to a subtype of stroke that results from occlusion of an artery that provides blood to the brain's deep structures (a subcortical stroke). These can be "silent" (asymptomatic) or symptomatic. If the lacunar stroke is symptomatic, it can present with a variety of symptoms depending on the lesion, including pure motor or pure sensory symptoms, sensorimotor stroke, or ataxic hemiparesis.

Figure A shows a small lacunar infarct on MRI of the brain. Note the typical location of these infarcts in and around the basal ganglia.

Incorrect answers:
Answer 2: Lung cancer is commonly associated with cigarette smoking. While this patient does have a smoking history, hypertension would not necessarily be associated strongly with lung cancer.

Answer 3: Prinzmetal angina occurs due to vasospasm of coronary arteries that is triggered by substances such as tobacco, caffeine, or cocaine in predisposed individuals. Vasospasm is not involved in the pathophysiology of lacunar infarcts.

Answer 4: Pulmonary embolism most often occurs due to deep venous thrombosis and hypercoagulable conditions such as malignancy. Hypertension is not the strongest risk factor for the development of pulmonary embolism.

Answer 5: Raynaud phenomenon occurs due to vasospasm of small, distal arterioles thought to be due to impaired local autoregulation. It is often associated with autoimmune disease.

Bullet Summary:
Hypertension is the strongest risk factor for the development of lacunar infarcts and also predisposes to the development of abdominal aortic aneurysm.