Predictive value of clinical lacunar syndromes for lacunar infarcts onmagnetic resonance brain imaging

Objectives– We prospectively investigated the predictive value of clinical and CT‐supported lacunar syndromes for lacunar infarcts on magnetic resonance (MR) brain imaging. Patients & methods– The 54 prospective, consecutive patients had clinical lacunar syndromes of acute onset and early computed tomography (CT; on admission day, i.e. ≤48 hours 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 corresponding lacunar lesions was calculated. Results– In 27 (50%) patients, early CT showed a lacunar infarct corresponding to the clinical syndrome, a further 27 (50%) patients had no fresh ischemic lesion. In 51 patients (94%), MR showed a recent lacunar infarct (hyperintense lacune in T2‐weighted scans, no demarcation on T1‐weighted scans and/or positive gadolinium‐enhancement) 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 unrelated 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 lacunar lesions was 0.53 (95% CI: 0.38 to 0.67). Conclusion– Lacunar syndromes were highly predictive for small deep infarcts on MR. Magnetic resonance brain imaging may be redundant in the setting of a lacunar syndrome supported by a CT that excludes non‐ischemic causes of stroke; it may therefore be abandoned in order to reduce costs in the health care system.