Among patients with acute lacunar stroke, those with chronic cerebral small vessel disease had higher vascular risk factor burden consistent with hypertensive arteriopathy, while those without SVD more frequently had alternative mechanisms such as PFO-related stroke.
Among 486 patients with acute lacunar stroke, 36% had chronic cerebral small vessel disease as defined by an SVD score ≥2.
Patients with CSVD had a higher burden of vascular risk factors compared to those without CSVD.
PFO-related stroke mechanism was less frequent in patients with CSVD compared to those without CSVD.
High SVD burden in lacunar stroke patients was interpreted as consistent with hypertensive arteriopathy as the predominant underlying etiology.
Minimal SVD burden in lacunar stroke patients may indicate alternative stroke mechanisms such as PFO-related stroke.
This research examined 486 patients who had a type of small stroke called a lacunar stroke, which occurs deep in the brain and is often linked to damage in tiny blood vessels. The researchers divided patients into two groups: those who had visible signs of long-term small vessel disease (SVD) on brain MRI scans, and those who did not. About one-third of patients (36%) had significant chronic small vessel disease based on a scoring system that combines several MRI findings such as white matter changes, old silent strokes, tiny bleeds, and enlarged fluid spaces around blood vessels. The study found that patients with chronic small vessel disease tended to have more traditional cardiovascular risk factors—like high blood pressure, diabetes, previous strokes, and irregular heart rhythm—and came into the hospital with more severe symptoms and higher blood pressure. In contrast, patients without significant chronic small vessel disease were more likely to have a hole in the heart (called a patent foramen ovale, or PFO) as the probable cause of their stroke, occurring in about 10% of that group compared to just 1% of those with high SVD burden. However, when accounting for other factors in a statistical model, this difference was not statistically significant, likely because PFO-related strokes were rare overall. This research suggests that the presence or absence of chronic small vessel disease on brain imaging could help doctors better understand why a lacunar stroke occurred and tailor their diagnostic workup and prevention strategies accordingly. For example, patients with minimal chronic SVD changes might benefit from more thorough cardiac investigation, while those with extensive SVD may be better served by aggressive blood pressure and cardiovascular risk factor management. The findings highlight that lacunar stroke is not a single uniform condition but may have different underlying causes that imaging can help distinguish.
Vynckier J, Jaques L, Maamari B, Goeldlin M, Grunder L, Giannakakis M, et al.. (2026). Lacunar stroke with and without chronic imaging biomarkers of small vessel disease: clinical profiles and stroke etiology.. Frontiers in neurology. https://doi.org/10.3389/fneur.2026.1840105