New ESO Guidelines Provide Evidence-Based Recommendations for Lacunar Ischaemic Stroke Management

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A lacunar stroke is a type of stroke that occurs due to an abnormal small blood vessel deep within the brain. These small vessels, also known as arterioles, capillaries and venules, supply blood to deeper structures of the brain. Lacunar strokes typically result when a small arteriole becomes abnormal, affects the blood supply, and leads to brain damage in the affected area. This cerebral small vessel disease (cSVD) is usually different to other types of ischaemic stroke that result from atheroma in the large arteries or embolism from the heart. 

Lacunar ischaemic strokes comprise a quarter of all ischaemic strokes and are often relatively mild neurologically, but long-term implications of lacunar stroke include heightened risks of cognitive impairment as well as recurrent stroke, or dependency.  

Developed in accordance with ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology, the new guidelines address both acute treatment and secondary prevention for lacunar ischaemic stroke.  

The authors prioritise acute treatments (like thrombolysis) and secondary prevention (like antiplatelet drugs, blood pressure lowering, lipid lowering, lifestyle modifications), and other interventions, with a focus on their potential effects on outcomes such as recurrent stroke, dependency, major adverse cardiovascular events, death, cognitive decline, mobility, gait, and mood disorders. 

This publication follows ESO Guideline on Cerebral Small Vessel Disease Part 1: covert cerebral small vessel disease, which addressed cSVD found on scanning done for some other reason in patients who have not yet had a stroke or cognitive impairment.  

"Our goal with this guideline is to equip cerebrovascular disease care providers with clear recommendations for assessing and managing patients suspected or presumed to have lacunar ischemic stroke. By providing thorough investigation and evidence-based management strategies, we aim to use the information that is currently available as best as possible to minimise the risk of bad long-term outcomes after lacunar ischaemic stroke” - Professor Joanna Wardlaw, Chair of Applied Neuroimaging; Head of Neuroimaging Sciences and Edinburgh Imaging; Row Fogo Centre Director, co-lead of the European Stroke Organisation Guidelines on Cerebral Small vessel Disease. 

A meticulous review of the existing literature and evidence assessment formed the basis for the formulation of evidence-based recommendations and expert consensus statements. Despite encountering limited direct evidence, mostly of low quality, the guidelines provide crucial insights for healthcare professionals managing lacunar ischaemic stroke cases. 

For acute treatment, the guidelines recommend intravenous alteplase, antiplatelet drugs, and advise against blood pressure lowering in alignment with current acute ischaemic stroke guidelines. In secondary prevention, the ESO Guideline suggests long-term single antiplatelet treatment, careful blood pressure control, and lipid lowering, in accordance with prevailing guidelines. Additionally, lifestyle modifications such as smoking cessation, regular exercise, and avoiding obesity are strongly recommended for general health benefits. 

The guidelines refrain from making specific recommendations regarding progressive lacunar stroke or other drugs due to the current scarcity of direct evidence. The ESO Guideline emphasises the urgent need for large randomised controlled trials with clinically important endpoints, including cognitive endpoints, as a top priority in the field of lacunar ischaemic stroke research. 

These guidelines will help inform the landscape of lacunar ischaemic stroke management, providing clinicians with evidence-based recommendations to prevent adverse clinical outcomes and improve patient care. 

For more information, please click here. 

About the European Stroke Organisation (ESO): 

The European Stroke Organisation is a pan-European society of stroke researchers, physicians, and other healthcare professionals dedicated to improving stroke care and prevention. ESO strives to foster collaboration and innovation in the field of stroke research and clinical practice.  

For more information, click here. To review all the ESO guidelines, please click here.