Comments and Opinions Is Investigating for Carotid Artery Disease Warranted in

Abstract—Carotid intervention in severe carotid stenosis after an anterior circulation ischemic event reduces the risk of further infarcts if the surgery is performed soon after the incident event. At present, there is no recommendation to differentiate among subtypes of anterior circulation infarcts or transient ischemic events. However, evidence is mounting that demonstrates a difference in pathophysiology of lacunar and nonlacunar (large artery) infarcts. The natural history of lacunar strokes is different from large artery infarcts for recurrence and mortality. Stroke is a heterogenous disease and consideration needs to be directed to manage different stroke subtypes differently. Lacunar infarcts mostly do not arise from large artery atheromatous disease or by cardioembolic phenomena, and there is a negative predictive value for severe carotid stenosis in lacunar strokes. Thus, current evidence suggests that lacunar strokes may not warrant investigation for carotid stenosis. (Stroke. 2011;42:217-220.) Key Words: carotid artery disease lacunar infarct stroke Lacunar infarcts, which are small deep infarcts rangingfrom 2 to 20 mm in size (the size varies in different studies) resulting from occlusion of a penetrating artery, account for approximately 25 % of ischemic strokes.1,2 The term “lacune ” has been used to describe small holes in the deep cerebral tissue for almost 150 years; Fisher,3 in 1968