Identification of embolic stroke patterns by diffusion-weighted MRI in clinically defined lacunar stroke syndromes

Background - A number of clinical syndromes describing the presentation of deep brain infarcts are called lacunar syndromes resulting from small vessel occlusion (SVO). To verify the reliability of the clinical diagnosis lacunar syndrome, the value was investigated with diffusion-weighted MRI (DWI). Methods and Results - A total of 73 patients ( mean age 66 years; range 35 to 83 years) with sudden onset of a classical lacunar syndrome were enrolled. On the basis of the DWI findings, patients were divided into 3 groups: group 1, single subcortical lesion ( <15-mm lesion; 43 patients; 59%); group 2, large ( >= 15 mm) or scattered lesions in 1 vascular territory ( 16 patients; 22%); and group 3, multiple lesions in multiple vascular territories ( 14 patients; 19%). A stroke mechanism other than SVO could be identified in 17 ( 23%) patients. Cardiac work-up revealed a cardiac embolic source in 8 patients (11%). Duplex sonography revealed symptomatic stenosis in 9 patients (12%). Based on the work-up information, 29 patients (40%) were found to have a potential cause of stroke other than SVO. A significant correlation with >1 single lesion on DWI-MRI and a clinical proven embolic source was observed ( P = 0.002). In 9 patients with MRI suspicious for a pathomechanism other than SVO, no embolic source was found. Conclusions - The use of DWI-MRI improves the accuracy of the subtype diagnosis of stroke. Inaccuracy has to be expected in approximately one third if lacunar diagnosis is based on clinical and computed tomography findings. Most of these false-positive cases are attributable to large artery or cardiogenic embolic stroke.