Lacunar infarcts: no black holes in the brain are benign.

Lacunar infarcts--small subcortical infarcts that result from occlusion of a single penetrating artery--account for about one quarter of all ischaemic strokes. However, there are many diagnostic pitfalls, and causes other than penetrating small vessel disease in up to one third of cases. Recent studies have shown that the prognosis after lacunar infarcts is not benign; the risk of recurrent stroke is no lower than for other ischaemic stroke subtypes, and there is an increased risk for cognitive decline, dementia and death in the long term. Furthermore, silent small vessel disease in the brain at the time of an index stroke has significant prognostic implications. In the acute phase, response to intravenous thrombolysis appears to be similar to other subtypes of ischaemic strokes. Antiplatelet drugs, careful blood pressure control, statins and modification of lifestyle risk factors are key elements in secondary prevention after lacunar infarcts.