Need for extensive diagnostic work-up for patients with lacunar stroke

Objective Small-vessel disease is the most frequent cause of lacunar stroke. The aims of this study were to evaluate: 1) alternative causes of lacunar stroke other than small-vessel disease; 2) functional outcome of lacunar strokes due to small vessel disease compared to lacunar strokes due to alternative causes. Methods Consecutive patients with first-ever ischemic lacunar stroke were prospectively followed-up for at least 3 months. At discharge patients were divided into 2 groups: lacunar stroke due to small vessel disease (L-SVD) and lacunar stroke due to possible other etiologies (L-non SVD) (e. g. cardioembolism, atherosclerosis or other causes). Main outcome measures were the combined end point of death or disability (mRS >= 3) and recurrent stroke at the end of follow-up. Results 535 patients with acute stroke were seen during the study period. Out of these, 196 patients (126 males) with a mean age of 71.6 years (SD = 10) had lacunar stroke. L-SVD was seen in 142 patients (72.4%) and L-nonSVD in 54 patients (27.6%). After 16.4 months, 12 patients had died (6.2%; annual mortality rate 4.4%), 63 were disabled (32.5%) and 27 had stroke recurrence (13.9%; annual recurrence rate 9.9%). Forty-nine patients with L-SVD (34.7%) and 26 with L-nonSVD (49%) had died or become disabled. Sixteen patients with L-SVD (11.3%) and 11 with L-nonSVD (20.4%) had stroke recurrence. On multivariate analysis, L-nonSVD (OR=2.87,95% CI 1.08-7.65; p = 0.034) and age (OR=1.07, 95% CI 1.02-1.12; p = 0.01) were associated to more severe outcome. L-nonSVD was independently associated with recurrence (OR=5.03, 95 % CI 1.54-16.44; p = 0.006). Conclusions Twenty-seven percent of patients with lacunar stroke have causes other than small vessel disease. These patients have a severe outcome in terms of recurrence, mortality or disability. These findings support the need for a comprehensive diagnostic work-up for patients with lacunar stroke.