8/2/2019 Management of Lacunar Strokes

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Management of Lacunar StrokesA detailed discussion of the treatment of lacunar strokes is beyond the scope of this article, but a briefoverview 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, anddecubitus 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 Disordersand 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 strokeonset, confer a small survival benefit. Angiotensin-converting enzyme inhibitors are also used forsecondary stroke prevention.[19, 20]

Anticoagulant agents are employed for prophylaxis of deep vein thrombosis (DVT) and pulmonaryembolism.

Some patients with spasticity or joint contractures following a lacunar stroke may benefit from the injectionof 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 andfamily of available government resources, to facilitate discharge planning, and to coordinate communityservices.

Outpatient Management ConsiderationsIf the patient who has had a lacunar stroke is functionally independent, can return safely home, and wouldbenefit 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 begiven only within 3 hours of stroke onset.[18]

Medical follow-up is necessary to assess neurologic and functional improvement, to monitor and treat riskfactors, and to monitor drug compliance. Outpatient physical, occupational, and/or speech therapy maybe recommended.

Discharge on aspirin and ramipril. If the patient remains nonambulatory and is at high risk of deep veinthrombosis, continue subcutaneous heparin.