Other Cerebrovascular Syndromes

Lacunar Strokes

Small ischemic infarcts due to occlusion of small penetrating arterioles, usually with sustained hypertension. Location: distribution of deep penetrating arteries (basal ganglia, deep hemispheric white matter, brainstem, cerebellum). Often clinically silent.

Pathophysiology: mechanism unknown; pathology described as “lipohyalinosis.”

Prognosis usually good, if hypertension is controlled.

Lacunar Syndromes

Certain syndromes characteristic of lacunar stroke. However, these can also be caused by other types of stroke.

Examples

Pure hemiplegia: face, arm, or leg affected, or combination, without sensory loss. Disruption of corticospinal tracts in internal capsule or pons.
Pure hemisensory stroke: numbness or paresthesias of face, arm, leg. Lacunes usually in sensory nucleus of thalamus.
Others: ataxic hemiparesis; dysarthria-clumsy hand syndrome.

Hypertensive Encephalopathy

Encephalopathy with accelerated hypertension. Headache, confusion, drowsiness, blurring of vision, occasional seizures, infrequent focal signs. Attributed to generalized arteriolar constriction, loss of cerebral autoregulation.

Examination: diastolic pressure usually >140 mm Hg (lower in children and postpartum women); papilledema.
Imaging: posterior leukoencephalopathy on MRI.
Differential diagnosis: stroke; systemic disorders (uremia, electrolyte imbalance); cyclosporine toxicity.
Treatment: hypotensive agents (e.g., sodium nitroprusside, labetalol) to reduce mean arterial pressure by 15% to 20%, but not below 125 mm Hg, initially. Sustained hypertension may be life-threatening. However, excessive reduction of blood pressure (BP) may result in watershed infarct. Neurologic symptoms reverse with BP reduction.

Fibromuscular Hyperplasia

Fibromuscular bands of unknown origin cause segmental narrowing in large arteries. Usually middle-aged women.

Manifestations: asymptomatic carotid bruit (most common), TIAs, ischemic infarcts. Hypertension common, with renal artery involvement. Characteristic syndrome: carotid and renal artery bruits, hypertension.
Imaging: “string of pearls” appearance on cerebral angiogram.
Treatment: antiplatelet drugs, anticoagulation, surgical dilation may reduce frequency of TIAs.

Multi-Infarct or Vascular Dementia

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