Should computed tomography appearance of lacunar stroke influence patient management?

Patients with a lacunar stroke syndrome may have cortical infarcts on brain imaging rather than lacunar infarcts, and patients with the clinical featu res of a small cortical stroke (partial anterior circulation syndrome, PACS ) may have lacunar infarcts on imaging. The aim was to compare risk factors and outcome in lacunar syndrome (LACS) with cortical infarct, LACS with la cunar infarct, PACS with cortical infarct, and PACS with lacunar infarct to determine whether the clinical syndrome should be modified according to br ain imaging. As part of a hospital stroke registry, patients with first ever stroke from 1990 to 1998 were assessed by a stroke physician who assigned a clinical c lassification using clinical features only. A neuroradiologist classified r ecent clinically relevant infarcts on brain imaging as cortical, posterior cerebral artery territory or lacunar. Of 1772 first ever strokes, there were 637 patients with PACS and 377 patie nts with LACS who had CT or MRI. Recent infarcts were seen in 395 PACS and 180 LACS. Atrial fibrillation was more common in PACS with cortical than la cunar infarcts (OR 2.3, 95% confidence interval (95% CI) 0.9-5.5), and in L ACS with cortical than lacunar infarcts (OR 3.9, 1.2-12). Severe ipsilatera l carotid stenosis or occlusion was more common in PACS with cortical than lacunar infarcts (OR 3.5, 1.3-9.5); and in LACS with cortical than lacunar infarcts (OR 3.7, 1.1-12). In conclusion, patients with cortical infarcts are more likely to have seve re ipsilateral carotid stenosis or atrial fibrillation than those with lacu nar infarcts irrespective of the presenting clinical syndrome. Brain imagin g should modify the clinical classification and influence patient investiga tion.