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What causes chronic lacunar onfarction?

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Practicing since : 1988
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Please review my recent MRI. When they first saw the "Chronic Lacunar Infarction" in 2003, they always called it a lesion and did mention a dyleminating process. My spinal tap then was negative and because I had no other symptoms than headache, I was not diagnosed. However they continued to MRI my brain yearly without a change in the 7 years. Why now are they calling it a "Chronic Lacunar Infarction"? What changed it from a lesion to CLI? Both MRIs were done in the same hospital and as you can see they were compared. I was involved a high impact MVA on 5/14/14 and have suffered with severe headaches with right hand numbness, moderate memory loss, and balance issues after the accidentand that was the reason why they did another MRI. Do you think MS or a XXXXXXX Stroke could be my diagnosis. If it is the XXXXXXX stroke, was it caused by the accident. I did not hit my head, but I had a LOC for a short time.

MRI brain 7/8/2014. Comparison 11/19/2009.

Indication: Postconcussion headache.

Technique: The trauma protocol brain was performed without and with

gadolinium, patient was injected with 19 mL Magnevist contrast from a

single dose 20 mL bottle.

Findings: There is no acute hemorrhage, infarction, mass effect, or
midline shift. The ventricles and sulci are stable and age-appropriate. There is a chronic lacunar infarction within the left corona radiata, with a few additional punctate foci of T2 hyperintensity also identified within the right parietal white matter.

There are no suspicious areas of chronic microhemorrhage within the
brain. No obvious prior cortical hemorrhage is identified to suggest
prior injury. There is a right parietal developmental venous anomaly
with no pathologic intracranial enhancement identified. The orbits and
globes are normal. There is minimal mucosal thickening with the
lateral recess of the right sphenoid sinus, the paranasal sinuses and
mastoids are otherwise clear. The major arterial flow-voids are intact.

Impression: Mild chronic ischemic changes with no evidence of acute or
significant chronic traumatic injury to the brain. No acute findings.
Posted Sun, 3 Aug 2014 in Brain and Spine
Answered by Dr. Dariush Saghafi 22 hours later
Brief Answer:
Terminology only

Detailed Answer:
Good Day- My name is Dr. Saghafi and I am happy to answer your questions for you on this forum. Perhaps, it would be helpful to isolate each question for you in the following way.

1. Why now are they calling it a "Chronic Lacunar Infarction"?

>>>The term CHRONIC simply refers to the fact that radiographically this finding appears to have been present for a very long time (usually greater than several months). "Lacunar Infarction" refers to the description of the LESION. Lacunar infarction is the medical term for a small stroke in the brain which has the appearance of a small "lake" or LACUNE. It is likely very small in diameter and located deep within the substance of the brain.

2. What changed it from a lesion to CLI?

>>>>Nothing changed. It is simply terminology which indicates to the reader that the radiologist saw the same LESION (abnormal structural entity) on your subsequent MRI you had for some other reason when comparing it to the first one you had in 2003.

3. Do you think MS or a XXXXXXX Stroke could be my diagnosis?

>>>> I do not see anything in your MRI report that is highly suggestive for a diagnosis of multiple sclerosis based upon the few number of scattered lesions they mention. Radiographically the presence of a lacunar infarct or lesion on the MRI does support the notion that you did have something happen in that area of the brain at some point in the past. The fact is your hand numbness is on the right side and the lacune is on the left so that fits anatomically. Therefore, based on that fact alone I would say the lacunar stroke COULD explain your clinical finding of hand numbness.

4. If it is the XXXXXXX stroke, was it caused by the accident?

>>>> The mechanism by which lacunar infarcts occur in the brain is not believed to be related in any way to traumatic injuries to the brain as would occur in concussions. Therefore, NO I would not agree that this lesion was caused by the accident.

I hope I've answered your questions and invite you to write back with anything else I can clarify on your condition. In the mean time- All the best to you.
Above answer was peer-reviewed by
Follow-up: What causes chronic lacunar onfarction? 7 hours later
Dr. Saghafi,

Thank you for answering all my questions and your attention to detail. If I am diagnosis of XXXXXXX strokes or TIAs, what is the treatment? Prognosis. I have a strong family history of both Stroke and Heart Disease, so I am concerned. How would I know if I am having a stroke if they are XXXXXXX or silent?

Answered by Dr. Dariush Saghafi 6 hours later
Brief Answer:
Lacunar stroke: Identification and Intervention

Detailed Answer:
Good evening Ms. Vargo.

Please consider the following responses to your questions:

1. If I am diagnosis of XXXXXXX strokes or TIAs, what is the treatment?

>>> Allow me to clarify that you did not suffer either a TIA or mini-stroke which is an alternate term. I do not like the term "mini-stroke" precisely for the fact that different people use it in different ways. It should not be thought of as a "small" stroke in any way because of course, that is also confusing. Mini-strokes and TIA's are believed to be caused by either blood clots or slowly moving blood through an area which may be narrowed or obstructed.

TIA's are typically not intervened on with medication unless risk factors are detected such as heart arrhythmias or other problems which cause the blood to become predisposed to clotting and producing emboli that can cause strokes.

Lacunar infarcts are typically intervened on by addressing risk factors, suggesting lifestyle changes, and treating with agents such as aspirin or clopidogrel.

3. How would I know if I am having a stroke if they are XXXXXXX or silent?

>>>>Silent strokes are undetectable unless imaging studies are obtained. When a stroke occurs it is apparent to the individual or medical examiner because of some change in neurological function which is most commonly in the form of the sudden onset of numbness, weakness, or clumsiness of a limb or part of limb. It can also present itself as a sudden change in speech/language comprehension or expression which is usually accompanied by imb weakness on one side of the body or the other.

4. Prognosis.

>>>As far as prognosis is concerned for your right hand numbnes (I assume that is what you're referring to) that would really depend upon when that actually happened, how far back to normal that hand has gotten since it became numb and whether or not you are following any specific regimen of physical or occupational therapy to return it to full function. It is generally written that after about 2-3 months, "what you see is what you get." I happen to have a more OPTIMISTIC viewpoint on stroke rehabilitation in people who dedicate themselves to reducing/eliminating risk factors and working diligently on an ongoing basis despite what people may say (ESPECIALLY insurance companies!). In my practice and training I've seen it time and again that dedicated and motivated patients make improvements as far out as 2 years following an incident.

In summary, you suffered a LACUNAR INFARCT or small vessel ischemic stroke which is NOT classifiable as either a mini-stroke or TIA. The most common treatment for your form of stroke would be identification of risk factors and their correction or elimination. This usually entails lifestyle changes. Medication intervention is generally in the form of drugs such as aspirin, clopidogrel, or similar products +/- medications to lower cholesterol, control diabetes, or control high blood pressure, etc. Medications for stroke treatment in your case are not nearly as effective in the prevention of the next event as control or elimination of risk factors.
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