Lacunar stroke with and without chronic imaging biomarkers of small vessel disease: clinical profiles and stroke etiology.

Introduction: Chronic cerebral small vessel disease (CSVD) may help distinguish different etiological mechanisms in acute lacunar stroke; this study aimed to compare vascular risk factors and stroke etiology in patients with and without CSVD. Methods: In this observational study, consecutive patients with magnetic resonance imaging (MRI)-confirmed acute lacunar stroke were included from a prospective stroke database covering the years 2015-2019. CSVD was defined as a summary small vessel disease (SVD) score ≥2 based on established MRI markers, including white matter hyperintensities, lacunes, cerebral microbleeds, and enlarged perivascular spaces. Associations between CSVD, vascular risk factors, and stroke etiology were examined using descriptive statistics and multivariable regression analysis. Results: Among 486 patients with acute lacunar stroke, 175 (36%) had CSVD. Median age was 72 years, 40.5% were female, and the median National Institutes of Health Stroke Scale (NIHSS) score on admission was 3. Patients with CSVD had a higher burden of vascular risk factors, including hypertension, previous stroke, diabetes, and atrial fibrillation, and presented with higher NIHSS scores and blood pressure on admission. A patent foramen ovale (PFO)-related stroke mechanism was less frequent in patients with CSVD (1.1% vs. 10.0%), although this association was not statistically significant in multivariable analysis (odds ratio 0.30, 95% CI 0.06-1.38). Discussion: A high SVD burden is consistent with hypertensive arteriopathy as the predominant underlying etiology, whereas minimal SVD may indicate alternative mechanisms such as PFO-related stroke. Recognition of these differences may support more tailored diagnostic evaluation and secondary prevention strategies.