OVERVIEW
大脑深部小动脉闭塞引起多个小面积梗死灶
可无症状，也可出现肢体无力、麻木、头痛、头晕等表现
多因脑部小动脉硬化所致
以药物治疗为主
Definition
Cavernous cerebral infarcts are infarcts of varying sizes in the deep white matter of the cerebral hemispheres and the brainstem caused by occlusion or embolization of small perforating arteries or microarterioles, which may be asymptomatic or cause neurologic impairment.
These infarct foci are small in size and are called “lacunae,” which are generally judged to be <1.5 cm in diameter, but some criteria suggest <2.0 cm. They are commonly found in the basal nuclei, thalamus, internal capsule, and pontine areas of the cerebral cortex that are supplied by the arteries.
The number of infarct foci varies and may be single or, more often, multiple. Clinically, lacunar cerebral infarction with ≥2 infarcts is called “multiple lacunar cerebral infarction”.
Morbidity
There are no authoritative data on the incidence of multiple lacunar infarcts.
The annual incidence of lacunar cerebral infarction is 13.4 per 100,000 people, accounting for 20% to 30% of all ischemic cerebrovascular diseases.
It is mostly seen in middle-aged and old people, and the incidence rate increases significantly after 55 years of age.
It is more common in men than in women.
Causes
Causes
Multiple lacunar cerebral infarction is mostly related to lipid hyalinosis of small arteries, and is closely related to hypertension and diabetes mellitus. It generally involves distal perforating arteries with a diameter of 200 μm or less due to the fact that it often leads to multiple, small, asymptomatic lesions and cerebral white matter sparing.
Prolonged hypertension acts on small arteries, causing vascular vitellosis, atherosclerotic lesions and fibrinoid necrosis, causing lumen occlusion and triggering lacunar cerebral infarction. Increased diastolic blood pressure is a common cause of multiple lacunar cerebral infarction.
Risk factors
People with the following conditions are at a higher risk of developing the disease and are advised to have regular medical checkups and pay attention to preventing the disease.
Primary hypertension or diseases that can cause hypertension, such as glomerulonephritis, pheochromocytoma, and primary aldosteronism.
Suffer from metabolic diseases such as diabetes mellitus, hyperlipidemia, hyperhomocysteinemia, etc.
Lifestyle habits: long-term smoking and drinking, stress, late nights, lack of exercise, high salt diet.
Family history: someone in the family has this disease or other cerebrovascular diseases.
Symptoms
The clinical manifestations of multiple lacunar cerebral infarction vary depending on the location and number of lesions.
It can be asymptomatic or can manifest as various lacunar syndromes.
Main symptoms
Pure motor mild hemiparesis: weakness of only one side of the face, arm and leg.
Pure sensory stroke: hypoplasia and numbness of only one side of the face, arm and leg.
Sensory-motor stroke: Sensory deficits on one side of the body followed by mild hemiparesis.
Dysarthria-hand clumsiness syndrome
说话含糊不清，发音不准，口吃，讲话变慢。
一侧手轻度无力，进行书写、绘画等精细动作时动作笨拙。
Ataxic mild hemiparesis
走路不稳、说话含糊不清、吞咽困难、喝水容易呛咳等。
一侧肢体无力，且下肢重于上肢。
Other symptoms
Some patients may have mild headache, dizziness, vomiting, and blackness before the eyes.
Complications
In addition to the accumulation and exacerbation of the above symptoms, those with multiple recurrent episodes may develop significant psychiatric, cognitive, swallowing, and motor deficits.
Vascular dementia
Patients with multiple subcortical lacunar infarct lesions are 5 to 25 times more likely to develop vascular dementia.
It is characterized by mental decline, memory loss, depression, apathy, unsteady walking, and inability to control urination.
Pseudo medullary palsy
Difficulty in swallowing and articulation.
Sudden onset of uncontrollable crying and laughing, with no apparent relationship to emotion (strong crying and laughing).
Vascular Parkinson’s syndrome
Manifested by movement disorders such as unsteady, slow walking and difficulty in starting.
Consultation
Department of Medicine
Neurology
If you experience symptoms such as weakness, clumsiness, decreased sensation, dizziness, or choking on water, it is recommended that you consult a doctor promptly.
Preparation for medical treatment
Consultation: Registration, Preparation of Documents, Frequently Asked Questions
Tips for the doctor
If you have the habit of recording your blood pressure and blood glucose every day, you can provide the records to the doctor.
Family members are recommended to accompany you to the doctor, avoid driving or riding to the doctor by yourself.
Preparation Checklist
症状清单
Pay particular attention to the time of onset of symptoms, special manifestations, etc.
Is there any weakness or numbness of one side of the limb?
Are there any clumsy movements, slurred speech, choking on water?
Do you have dizziness or headache?
Do the symptoms get worse? Are there any obvious triggers?
Any other uncomfortable symptoms?
病史清单
Are you suffering from hypertension, glomerulonephritis, pheochromocytoma, primary aldosteronism, etc.?
Do you have diabetes, hyperlipidemia, hyperhomocysteinemia, etc.?
Do you have long-term smoking and drinking, high stress, late night, lack of exercise, high salt diet?
Does anyone in the family have this disease or other cerebrovascular diseases?
检查清单
Test results in the last six months, which can be brought to the doctor
Laboratory tests: blood routine, blood glucose, liver and kidney function tests, blood lipid tests.
Imaging examination: cranial CT examination, cranial MRI examination.
Other tests: vascular ultrasound, angiography.
用药清单
Medication used in the last 3 months, if there is a box or package of medication, you can bring it to the doctor’s office
Blood pressure lowering drugs: nifedipine, verapamil, captopril, etc.
Other common medications: aspirin, clopidogrel, atorvastatin, metformin, insulin, etc.
Diagnosis
Diagnosis is based on
Medical history
Suffering from hypertension, glomerulonephritis, pheochromocytoma, primary aldosteronism.
Suffering from diabetes mellitus, hyperlipidemia, hyperhomocysteinemia, etc.
Long-term smoking and drinking, mental stress, late nights, lack of exercise, high salt diet.
Someone in the family has this disease or other cerebrovascular diseases.
Clinical manifestations
症状
Weakness and numbness of one side of the limbs, awkward movements, slurred pronunciation, choking on water, dizziness, headache and other symptoms.
体征
The doctor will conduct tests on muscle strength, muscle tone, nerve reflexes, cognition and swallowing function.
Muscle strength check: The patient’s muscle condition is determined by movements such as lifting hands, sitting up, standing and walking.
Tendon reflex examination: The doctor uses a percussion hammer to strike the tendons of the patient’s elbow and knee joints to observe the contraction of the muscles of the upper arms and thighs.
Pathological reflex examination: the doctor uses a blunt bamboo stick to gently stroke the patient’s soles, dorsums and other corresponding parts of the foot to see if the toe flexion and extension reactions are abnormal.
Cognitive function test: The patient’s intelligence level can be assessed through general knowledge quizzes, calculations, and picture recognition.
Swallowing function test: Observe whether there is choking when drinking water to assess whether there are swallowing problems and the degree of impairment.
Dysarthria: Observe for abnormalities in volume, pitch, and breath by asking the patient to speak in complete sentences.
Laboratory Tests
Routine laboratory tests, such as blood tests, biochemistry, coagulation, arterial blood gas analysis, etc., are usually performed in order to understand the status of various systems in the body.
Fasting, i.e., 6 hours of fasting and 4 hours of abstinence from food and drink, is required before the full biochemical test.
Cranial Magnetic Resonance Imaging (MRI) / Cranial CT Examination
It can examine the structure of the brain, clarify the presence of lesions, and rule out the presence of brain hemorrhage or tumors.
The detection rate of MRI is significantly better than that of CT, especially for cavernous infarct lesions in the brainstem and cerebellum.
Conventional MRI can show multiple lesions in the brain at an early stage, which are round, oval or fissure shaped, with a diameter of <1.5~2.0cm.
CT scanning is difficult to detect in the acute stage, and with the development of necrosis and edema, it can gradually show round, oval or small stripes.
Precautions
有假牙、体内有金属植入者，如心脏支架等，需告知放射科医生，根据具体磁共振机器决定是否能行MRI检查。
CT检查简便、快捷，尤其可迅速鉴别脑出血，但检查有一定辐射量，孕妇禁忌。
Cognitive assessment
The most commonly used assessment scales are the Montreal Cognitive Assessment Scale (MoCA), and the Brief Mental Status Examination (MMSE).
Decreased abilities in attention/executive function, memory, language, and visuospatial function may be present.
Precautions
测试结果需考虑被测试者的受教育程度。
认知评估量表的使用和解读需要由专业人员完成，不建议自测。
Differential Diagnosis
Cerebral hemorrhage
Similarities: both may present with limb weakness, numbness, headache, and a history of hypertension.
Differences
脑出血多在活动中或情绪激动时起病，病情进展快，头痛、恶心、呕吐多见，常出现意识障碍。
头颅CT可快速发现颅内出血，有助于明确诊断。
Subarachnoid hemorrhage
Similarities: both may present with limb weakness, headache, and vomiting.
Differences
蛛网膜下腔出血多在活动状态下急性起病，头痛剧烈，可有颈部僵硬、有意识障碍。
头颅CT可快速发现颅内出血，有助于明确诊断。
Multiple sclerosis
Similarities: both may present with limb weakness, numbness, facial paralysis, etc.
Differences
多发性硬化多见于中年女性为主，症状可反复发作-缓解。
头颅MRI检查病灶以脑白质病变为主，还可伴有视神经及脊髓病变。脑脊液中可发现特殊抗体、免疫复合物。
Intracranial space-occupying lesions
Similarities: both may present with dizziness, weakness of one limb, etc.
Differences
颅内占位性病变以颅内肿瘤、脑脓肿、脑囊肿最为常见，虽可急性发作，但多为慢性渐进性病情发展。
头颅CT扫描、MRI等可见颅内占位，有助于疾病鉴别。
Treatment
Aim of treatment: improve cerebral blood supply, correct or relieve the symptoms of cerebral ischemia, actively prevent and treat complications, and avoid recurrence.
Treatment principle: Drug treatment is the mainstay.
Supportive treatment
Bed rest, close monitoring of consciousness, pupil, pulse, respiration and blood pressure.
Nutritional support can be provided through nasal feeding tube or intravenous route when there is swallowing disorder.
Medication
Antihypertensive drugs
Antihypertensive drugs should be used under doctor’s supervision, commonly used antihypertensive drugs are as follows.
β-blockers: e.g. bisoprolol, metoprolol, etc.
Calcium channel antagonists: such as nifedipine, verapamil, etc.
Angiotensin-converting enzyme inhibitors: e.g. captopril, enalapril, etc.
Angiotensin receptor blockers: e.g., chlorosartan, irbesartan, etc.
Diuretics: e.g. hydrochlorothiazide, furosemide, etc.
Start with a small dose of medication, give preference to long-acting agents, and use a combination of medications.
Antiplatelet drugs
Can inhibit platelet adhesion and aggregation, reduce the risk of thrombosis.
Commonly used drugs: aspirin, clopidogrel, tegretol, etc.
Adverse reactions: gastrointestinal discomfort and gastrointestinal bleeding may occur.
Most people with asymptomatic multiple lacunar cerebral infarcts do not need to use them, but they need to be analyzed comprehensively in combination with other medical history and so on.
Anticoagulants
Anticoagulant drugs, also known as anticoagulants, are drugs that prevent or reduce blood clotting and prolong clotting time.
Commonly used drugs: warfarin, dabigatran, rivaroxaban, apixaban and so on.
It is suitable for patients with combined heart diseases such as atrial fibrillation.
Gastrointestinal discomfort, gastrointestinal bleeding and other discomforts may occur.
Same as anti-platelet aggregation drugs, most people with asymptomatic multiple lacunar cerebral infarction do not need to use, but need to be combined with other medical history and other comprehensive analysis.
Other drugs
Lipid-regulating drugs: e.g. simvastatin, atorvastatin, ezetimibe, probucol, etc.
Glucose-lowering drugs: such as metformin, acarbose, glibenclamide, reglaneride, and insulin.
Drugs to improve microcirculation: butalbital, nimodipine, flunarizine, and ginkgo biloba extract, etc.
Improve cognitive function: memantine, donepezil, carboplatin, galantamine, etc.
Control of psychiatric symptoms: e.g. risperidone, olanzapine, quetiapine, etc.
Rehabilitation
Rehabilitation training can be carried out for patients with residual cognitive, swallowing, phonological and motor deficits.
Cognitive function training
Individualized thinking, memory, calculation and orientation skills training with the assistance of a therapist or computer to improve the patient’s emotional, behavioral and cognitive conditions.
Memory, calculation and thinking skills are trained by memorizing numbers, doing math problems and reasoning problems.
Swallowing function training
Improve the strength of swallowing muscles by swallowing without food and small amount of food.
Lip, tongue, pharynx, upper and lower jaw exercises are done to enhance the coordination of swallowing and swallowing strength.
Speech and phonological function training
The patient imitates the therapist to perform listening and speaking exercises to improve speech.
Training of facial and pharyngeal muscles to improve the clarity and fluency of articulation.
Motor function training
Under the guidance of the therapist, turn over, get up, keep sitting, stand up and walk.
By twisting the torso from side to side while standing, standing with both feet back and forth, turning in place, standing on one foot, etc., the patient’s torso stability will be increased and balance ability will be improved.
Prognosis
Cure
The overall prognosis of lacunar cerebral infarction is better than other types of cerebral infarction, with lower mortality and disability rates.
Within 1 year after the onset of the disease, 70% to 80% of patients can recover completely or basically return to normal. A small number of patients may have mild motor or sensory impairment.
Multiple lacunar cerebral infarction has a higher recurrence rate than single lacunar cerebral infarction and has a poorer prognosis.
Prognostic factors
Infarcts are mainly located in the brainstem, thalamus and other important parts of the brain, and those with a large number of infarcts have a poor prognosis.
The prognosis is poor if the primary disease is not well controlled.
Harmfulness
The quality of life is less affected when only mild motor or sensory deficits remain.
However, the disease has a high recurrence rate, and quality of life can be seriously affected when multiple recurrences cause vascular dementia, pseudo-dominant myelopathy, and vascular Parkinson’s syndrome.
因严重认知功能障碍导致生活自理能力和社交能力下降。
出现大小便失禁、昼夜颠倒、躁动，加重照顾者负担。
患者可能会发生走失、跌倒、烧伤、烫伤、煤气中毒、药物中毒等意外。
Daily
Daily management
Dietary management
Eat a balanced and varied diet with less than 6 grams of salt intake and 400 grams of fruits and vegetables each per day.
Ensure the supplementation of high quality protein such as eggs, fish and milk.
Reduce the intake of fat, especially trans fatty acids, such as margarine, fried food, phytolacca.
Eat less sugar, additional added or supplemental sugar <25g/day.
Food can be stirred into paste or fed through nasal feeding tube when dysphagia occurs and inability to actively eat.
Life management
Regular routine, ensure sufficient sleep time, no smoking and no alcohol consumption.
For those who are overweight or obese, keep their weight within the standard range.
For those with cognitive impairment, diaries and calendars can be used to help memory, and daily necessities can be fixed in the same place at home.
Family members should encourage and comfort the patients, build up confidence in treating the disease, and create a calm and comfortable environment for them to reduce the impact of adverse emotions.
Disease monitoring
Monitor blood pressure, blood sugar, weight, etc. to control the underlying disease.
Pay attention to and record changes in limb movement, sensation, swallowing and cognitive function.
Follow-up review
Follow-up time: Usually recommended once every 1 to 2 months, and once every 3 to 6 months after stabilization.
Review items: cranial magnetic resonance, laboratory tests, cognitive function evaluation scale.
Prevention
Relapse and progression can be prevented mainly by controlling the underlying disease and lifestyle intervention.
Active control of underlying diseases
Blood pressure control below 140/90mmHg (below 130/80mmHg for combined diabetes)
LDL reduced to below 1.8mmol/L.
Fasting blood glucose less than 6.1 mmol/L and glycosylated hemoglobin less than 7%.
Preventive medications such as aspirin and atorvastatin as per doctor’s request.
Lifestyle Intervention
Do not smoke or drink alcohol.
Low salt, low fat and low sugar diet.
Adhere to complete rehabilitation and exercise training according to the program recommended by the doctor.
Keep your weight within the standard range.
Keep a regular schedule and a positive outlook.
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