Dixon Yang, MD

International Stroke Conference 2022
February 9–11, 2022

Session: Incidental Lacunes on Brain Imaging: How to Manage Them
Moderators: Dr. Christopher Lewandowski, Dr. Edip Gurol
Panelists: Dr. Hugo Aparicio, Dr. Eric Smith, Dr. Myriam Fornage, Dr. Jose Gutierrez

This invited symposium overviewed incidentally discovered lacunar infarcts on brain imaging. Dr. Aparicio from Boston University began by discussing prevalence and risk factors for incidental lacunar infarcts. Based on data from the Rotterdam Scan Study and Cardiovascular Health Study, “covert” brain infarcts (CBI) are not uncommon, making up about 1 in 10 in late middle age and 1 in 4 in the elderly, with an overall prevalence of 8-28% amongst predominantly non-Hispanic White and Asian study populations. Lacunar infarcts make up the majority of CBIs (83%) and share risk factors for stroke, especially age and hypertension; however, CBIs possibly have as high as 5-fold increased incidence when compared to stroke.

Genetic involvement in CBIs may also be more prevalent than previously thought. Dr. Fornage of the University of Texas Health Science Center shared her work that though the genetic cerebral small vessel disease syndromes themselves are rare, carriers of related genes may be more common in the general population. For instance, carriers of NOTCH3, implicated in CADASIL, made up 1 in 452 participants of a United Kingdom biobank. These carriers may have a significantly higher risk of incidental lacunes.

Dr. Smith (University of Calgary) shared implications of incidental lacunar infarcts in brain health. Given their potential to interrupt white matter tracts, incidental lacunes should not be considered benign. CBI has been linked to increased incident of future stroke and vascular dementia in the general population. Further, the Rotterdam Scan Study and LADIS (Leukoaraiosis and Disability) Study have both shown corresponding decline in neuropsychiatric measures, particularly processing speed and executive dementia, among those with CBIs.

To conclude the session, Dr. Gutierrez from Columbia University Irving Medical Center discussed treatment of incidental lacunar infarcts. Though no specific randomized control trial or explicit consensus-based guidelines exist, Dr. Gutierrez argued these infarcts should be treated by secondary prevention principles based on observational data and biological plausibility. Especially as incidental lacunes are likely more common than reported and the risks of aggressive vascular risk factor management are low, he justified screening for vascular health and working towards targets used in secondary stroke prevention, such as BP<130/80, HbA1c<7%, and LDL <70. This importantly includes lifestyle management of diet, exercise, and smoking cessation. Further work-up into large artery disease and occult cardioembolism after incidentally discovered lacunar infarct without history of stroke is not yet proven to be cost effective.