title: Examining Subcortical Infarcts in the Era of Acute Multimodality CT Imaging.
abstract: BACKGROUND
  Lacunar infarct has been characterized as small subcortical infarct. It is postulated to occur from "in situmicroatheroma or lipohyalinosis" in small vessel or lacunar mechanism. Based on this idea, such infarcts by lacunar mechanism should not be associated with large area of perfusion deficits that extend beyond the subcortical region to the cortical region. By contrast, selected small subcortical infarcts, as defined by MR imaging in the subacute and chronic stage, may initially have large perfusion deficit or related large vessel occlusions. These infarcts with "lacunar" phenotype may also be caused by disease in the parent vessel and may have very different stroke mechanism from small vessel disease. Our aim is to describe differences in imaging characteristics between patients with small subcortical infarction with "lacunar phenotype" from those with lacunar mechanism.
  
  
  METHODS
  Patients undergoing acute CT perfusion/angiography (CTP/CTA) within 6 h of symptom onset and follow-up magnetic resonance imaging (MRI) for ischemic stroke were included (2009-2013). Lacunar infarct was defined as a single subcortical infarct ≤20 mm on follow-up MRI. Presence of perfusion deficits, vessel occlusion, and infarct dimensions was compared between lacunar infarcts and other topographical infarct types.
  
  
  RESULTS
  Overall, 182 patients (mean age 66.4 ± 15.3 years, 66% males) were included. Lacunar infarct occurred in 31 (17%) patients. Of these, 12 (39%) patients had a perfusion deficit compared with those with any cortical infarction (120/142, 67%), and the smallest lacunar infarct with a perfusion deficit had a diameter of <5 mm. The majority of patients with lacunar infarction (8/12, 66.7%) had a relevant vessel occlusion. A quarter of lacunar infarcts had a large artery stroke mechanism evident on acute CTP/CTA. Lacunar mechanism was present in 3/8 patients with corona radiata, 5/10 lentiform nucleus, 5/6 posterior limb of internal capsule (PLIC), 3/5 thalamic infarcts, 1/2 miscellaneous locations. There was a trend to significant with regards to finding lacunar mechanism among patients with thalamic and PLIC infarcts versus lentiform nucleus and corona radiata infarcts (p= 0.13).
  
  
  CONCLUSIONS
  Diverse stroke mechanisms were present among subcortical infarcts in different locations. When available acute CTP/CTA should be combined with subacute imaging of subcortical infarct to separate "lacunar phenotype" from those with lacunar mechanism.
authors.affiliation: Stroke and Aging Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University , Melbourne, VIC , Australia.
authors.forename: Mindy Y Q
authors.initials: MY
authors.lastname: Tan
authors.affiliation: Stroke and Aging Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia; Stroke Unit, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia.
authors.forename: Shaloo
authors.initials: S
authors.lastname: Singhal
authors.affiliation: Stroke and Aging Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia; Stroke Unit, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia.
authors.forename: Henry
authors.initials: H
authors.lastname: Ma
authors.affiliation: Monash Imaging, Monash Health , Melbourne, VIC , Australia.
authors.forename: Ronil V
authors.initials: RV
authors.lastname: Chandra
authors.affiliation: Stroke and Aging Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University , Melbourne, VIC , Australia.
authors.forename: Jamie
authors.initials: J
authors.lastname: Cheong
authors.affiliation: Stroke and Aging Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia; Stroke Unit, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia.
authors.forename: Benjamin B
authors.initials: BB
authors.lastname: Clissold
authors.affiliation: Stroke and Aging Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia; Stroke Unit, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia.
authors.forename: John
authors.initials: J
authors.lastname: Ly
authors.affiliation: Stroke and Aging Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia; Stroke Unit, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia.
authors.forename: Velandai
authors.initials: V
authors.lastname: Srikanth
authors.affiliation: Stroke and Aging Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia; Stroke Unit, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia.
authors.forename: Thanh G
authors.initials: TG
authors.lastname: Phan
keywords: MR imaging; angiography; lacunar; occlusion; perfusion imaging