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. 2024 Mar;9(1):5-68.
doi: 10.1177/23969873231219416. Epub 2024 Feb 21.

European stroke organisation (ESO) guideline on cerebral small vessel disease, part 2, lacunar ischaemic stroke

Joanna M Wardlaw  1 , Hugues Chabriat  2 , Frank-Erik de Leeuw  3 , Stéphanie Debette  4 , Martin Dichgans  5 , Fergus Doubal  6 , Hanna Jokinen  7 , Aristeidis H Katsanos  8 , Raffaele Ornello  9 , Leonardo Pantoni  10 , Marco Pasi  11 , Aleksandra M Pavlovic  12 , Salvatore Rudilosso  13 , Reinhold Schmidt  14 , Julie Staals  15 , Martin Taylor-Rowan  16 , Salman Hussain  17 , Arne G Lindgren  18
Affiliations

European stroke organisation (ESO) guideline on cerebral small vessel disease, part 2, lacunar ischaemic stroke

Joanna M Wardlaw et al. Eur Stroke J. 2024 Mar.

Abstract

A quarter of ischaemic strokes are lacunar subtype, typically neurologically mild, usually resulting from intrinsic cerebral small vessel pathology, with risk factor profiles and outcome rates differing from other stroke subtypes. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations to assist with clinical decisions about management of lacunar ischaemic stroke to prevent adverse clinical outcomes. The guideline was developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We addressed acute treatment (including progressive lacunar stroke) and secondary prevention in lacunar ischaemic stroke, and prioritised the interventions of thrombolysis, antiplatelet drugs, blood pressure lowering, lipid lowering, lifestyle, and other interventions and their potential effects on the clinical outcomes recurrent stroke, dependency, major adverse cardiovascular events, death, cognitive decline, mobility, gait, or mood disorders. We systematically reviewed the literature, assessed the evidence and where feasible formulated evidence-based recommendations, and expert concensus statements. We found little direct evidence, mostly of low quality. We recommend that patients with suspected acute lacunar ischaemic stroke receive intravenous alteplase, antiplatelet drugs and avoid blood pressure lowering according to current acute ischaemic stroke guidelines. For secondary prevention, we recommend single antiplatelet treatment long-term, blood pressure control, and lipid lowering according to current guidelines. We recommend smoking cessation, regular exercise, other healthy lifestyle modifications, and avoid obesity for general health benefits. We cannot make any recommendation concerning progressive stroke or other drugs. Large randomised controlled trials with clinically important endpoints, including cognitive endpoints, are a priority for lacunar ischaemic stroke.

Keywords: Guideline; alteplase; antihypertensive; antiplatelet; lacunar stroke; lipid lowering; small vessel disease; stroke; systematic review; thrombolysis.

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Conflict of interest statement

Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. For details, please see Supplemental Table 1.

Figures

Figure 1.
Figure 1.
The effect of alteplase versus placebo on favourable functional outcome (OHS 0–2 in IST-3)/excellent functional outcome (mRS 0–1 in NINDS and Wake-up trials) in patients with acute lacunar ischaemic stroke.
Figure 2.
Figure 2.
Meta-analysis of immediate antihypertensive therapy in suspected lacunar ischaemic stroke on functional outcome (mRS 3-6 vs 0-2), (a) continuing versus stopping antihypertensive treatment and (b) transdermal GTN versus no GTN.
Figure 3.
Figure 3.
Meta-analysis of immediate antihypertensive therapy in suspected lacunar ischaemic stroke on MACE.
Figure 4.
Figure 4.
Meta-analysis of immediate antihypertensive therapy in suspected lacunar ischaemic stroke, subgroup analysis comparing with versus without thrombolytic treatment on functional outcome (mRS 3-6 vs 0-2), (a) continuing versus stopping antihypertensive treatment and (b) transdermal GTN versus no GTN.
Figure 5.
Figure 5.
Meta-analysis of immediate antihypertensive therapy in suspected lacunar ischaemic stroke on functional outcome analysed using ordinal shift analysis of the mRS, (a) continuing versus stopping antihypertensive treatment and (b) transdermal GTN versus no GTN.
Figure 6.
Figure 6.
PICO 6 Antiplatelet drugs in secondary prevention of any recurrent stroke in patients with lacunar ischaemic stroke: (6a.) Antiplatelets versus Placebo. (6b.) Cilostazol versus placebo. (6a. + 6b.) combined. (6c.) Cilostazol added to other antiplatelets.
Figure 7.
Figure 7.
PICO 6 Antiplatelet drugs in secondary prevention of recurrent ischaemic stroke in patients with lacunar ischaemic stroke: (7a.) Antiplatelets versus Placebo. (7b.) Cilostazol added to other antiplatelets.
Figure 8.
Figure 8.
PICO 6 Antiplatelet drugs in secondary prevention of MACE in patients with lacunar ischaemic stroke: (8a.) Antiplatelets versus Placebo. (8b.) Aspirin + Dipyridamole versus Aspirin. (8c.) Cilostazol added to other antiplatelets.
Figure 9.
Figure 9.
Network Meta-analysis of antiplatelet trials including the outcome ‘Any stroke’. a. ESPS-2 (Ariesen; 2006) b. AAASPS (Gorelick; 2003) c. CSPS 2 (Shinohara; 2010) d. ECLIPSE (Han; 2013) e. SPS3 (Benavente; 2012) f.  CATS (Gent; 1989, Kwok; 2015), g. PRoFESS (Sacco; 2008) h. PRASTRO-I (Kitazono; 2021) i.  MAESTRO (Han; 2017)
Figure 10.
Figure 10.
Network Meta-analysis of antiplatelet trials including the outcome ‘Ischaemic stroke’. a. AICLA (Bousser; 1983) b. ECLIPSE (Han; 2013) c. S-ACCESS (Shinohara; 2008) d. SPS3 (Benavente; 2012) e. CSPS.com (Nishiyama; 2023) f. MATCH (Diener; 2004) g. PASTRO-I (Kitazono; 2021) h. CSPS (Matsumoto; 2006)
Figure 11.
Figure 11.
Network Meta-analysis of antiplatelet trials including the outcome major adverse cardiovascular event (MACE) in patients with lacunar ischaemic stroke. aPERFORM (Bousser; 2011) bSOCRATES (Amarenco; 2017) cESPS-2 (Ariesen; 2006) dESPRIT (ESPRIT; 2006) eSPS3 (Benavente 2012)165
Figure 12.
Figure 12.
PICO 7. Long term intensive versus guideline BP reduction to prevent recurrent stroke in patients with lacunar ischaemic stroke.
Figure 13.
Figure 13.
PICO 7. Long term intensive versus guideline BP reduction to prevent death in patients with lacunar ischaemic stroke.
Figure 14.
Figure 14.
PICO 8. Effect of lipid lowering on recurrent stroke or TIA in patients with lacunar ischaemic stroke.
See this image and copyright information in PMC

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