Predictive value of clinical lacunar syndromes for lacunar infarcts on magnetic resonance brain imaging

Objectives - We prospectively investigated the predictive value of clinical and CT-supported lacunar syndromes for lacunar infarcts on magnetic resona nce (MR) brain imaging. Patients and methods - The 54 prospective, consecut ive patients had clinical lacunar syndromes of acute onset and early comput ed tomography (CT; on admission day, i.e. less than or equal to 48 h after onset of symptoms) showing either a small deep infarct or no corresponding lesion. Taking MR (at day 2 to 4 after admission) as the gold standard, the positive predictive value of the CT-supported clinical syndrome for corres ponding lacunar lesions was calculated. Results - In 27 (50%) patients, ear ly CT showed a lacunar infarct corresponding to the clinical syndrome, a fu rther 27 (50%) patients had no fresh ischemic lesion. In 51 patients (94%), MR showed a recent lacunar infarct (hyperintense lacune in T2-weighted sca ns, no demarcation on T1-weighted scans and/or positive gadolinium-enhancem ent) corresponding to the clinical syndrome (positive predictive value 0.94 , 95% CI: 0.88 to 0.98). In 3 (6%) patients MR was normal. Aside from old u nrelated ischemic (macro- and/or microangiopathic) lesions, MR revealed no acute non-lacunar infarct. CT and MR sites of lacunar lesions were matching . Compared to gold standard MR, the sensitivity of early CT for suspected l acunar lesions was 0.53 (95% CI: 0.38 to 0.67). Conclusion - Lacunar syndro mes were highly predictive for small deep infarcts on MR. Magnetic resonanc e brain imaging may be redundant in the setting of a lacunar syndrome suppo rted by a CT that excludes nonischemic causes of stroke; it may therefore b e abandoned in order to reduce costs in the health care system.