Where is the future of “lacunar infarction in imaging reports”?

Author: Wang Han Beijing Hui Hospital

Reviewer: He Yanbo, deputy chief physician, Beijing Huimin Hospital

As a neurologist, I am often asked by the elderly people in my neighborhood, and even young people in their 40s and 50s: "I feel a little dizzy, so I went to the hospital for a head CT scan. The report said that I had a 'cavitary infarction'. Is this serious? Is the dizziness caused by a 'cavitary infarction'?" Now let's get to know this "cavitary infarction". "Cavity infarction", the full name of which is lacunar infarction, is a local ischemic injury to brain tissue caused by occlusion of cerebral arterioles. The lesions are generally 3 to 15 mm, usually occurring in the deep brain tissue, and can also occur in the cerebral cortex. With the continuous development of imaging technology, more and more patients have found imaging clues of "cavitary infarction" in an accidental examination, but no obvious clinical symptoms have appeared, such as limb numbness, weakness, slurred speech or unsteady walking. This type of asymptomatic lacunar infarction is called asymptomatic, latent or silent infarction in the medical community. When seeing such a report, if you do not have relevant medical knowledge, you will usually have two reactions: some people will feel panic: "Oh my God, I actually had a cerebral infarction, what should I do?", and some people will be full of doubts: "This is out of thin air, I eat well, sleep well, and move freely, how could I have a cerebral infarction? " So, how should we correctly view this silent cerebral infarction?

Figure 1 Copyright image, no permission to reprint

First of all, the lesions of silent cerebral infarction are usually small blood vessels, and they occur in brain areas that are not enough to cause neurological dysfunction. Therefore, before the cause is clear, do not worry too much. Its existence is like a horn before dawn, alerting us. Its exact mechanism is still unclear. There may be three pathogenesis mechanisms: first, the risk factors persist and are not controlled. Over time, the walls of small blood vessels become thicker and harder, that is, glassy degeneration, and even occlusion occurs, resulting in blood flow obstruction; second, lipid substances in the blood are deposited on the walls of large blood vessels to form plaques, blocking the openings of small perforating arteries from the trunk, resulting in poor blood flow; third, small cardiogenic emboli fall off and block small blood vessels. All three of the above situations will cause local cell ischemia and necrosis in brain tissue, followed by the formation of lacunar infarction foci in imaging. Just like a big tree, the trunk is still intact, but some branches cannot grow due to their own lesions, or they fall off due to external force, or they wither due to insect pests. If we can find the causes of the withering and falling of branches and leaves in time and intervene, the tree can still grow luxuriantly. The same phenomenon applies to cerebral blood vessels: if "cavities" are accidentally discovered before the main trunks of these blood vessels are damaged, and if the relevant risk factors are actively sought and intervened, the risk of impaired brain function can be reduced, and even serious strokes can be avoided.

Figure 2 Copyright image, no permission to reprint

Black cats and white cats are both cats. Although silent cerebral infarction itself does not directly cause serious clinical symptoms, its existence is an early signal for the development of cerebrovascular disease. Studies have shown that the incidence of silent cerebral infarction is 5 to 10 times that of symptomatic cerebral infarction, especially in the elderly population, the prevalence can even be as high as 28%. These lesions are closely related to the risk of gait disorders, mild movement disorders, cognitive decline, dementia, mental disorders, and daily life activities disorders. At the same time, silent cerebral infarction will also significantly increase the risk of acute stroke in the future, and the probability of stroke is 1.5 to 3.3 times that of the normal population.

Therefore, once imaging examinations indicate the presence of lacunar cerebral infarction, even if there are no symptoms, potential risk factors should be actively traced, including age, smoking, hypertension, diabetes, cardiovascular diseases (such as coronary heart disease, atrial fibrillation, valvular heart disease), hyperlipidemia, internal carotid atherosclerosis, chronic kidney disease, obstructive sleep apnea, hyperhomocysteinemia, etc. Please check whether you have the above risk factors. If so, please pay great attention to it and conduct regular imaging screening of intracranial and extracranial blood vessels in order to detect and intervene early. In addition, the risk of silent cerebral infarction should be reduced by controlling relevant risk factors, including: ① Control of underlying diseases: Optimize the treatment of diseases such as hypertension, diabetes, and hyperlipidemia; Whether to use antiplatelet aggregation therapy such as aspirin should be decided after visiting a specialist hospital for relevant risk assessment. ② Lifestyle intervention: Maintaining healthy living habits, such as healthy diet, regular exercise, quitting smoking and limiting alcohol, are all crucial prevention and treatment measures.

In daily life, specific health interventions include:

(1) Control fat intake: Reduce the intake of foods high in saturated fat (such as beef, pork, lamb, sausage, bacon, etc.) and trans fat (such as cakes, milk tea, fried chicken, ice cream, etc.). It is recommended to eat more foods containing healthy fats, such as olive oil, nuts, etc.; appropriately increase the intake of fish, especially deep-sea fish.

(2) Increase dietary fiber: Eating more whole grains, vegetables and fruits can help lower blood lipids and control blood sugar.

(3) Low-salt diet: Daily salt intake should be controlled within 6 grams, which helps reduce the risk of high blood pressure.

(4) Moderate exercise: aerobic exercise and strength training. Common aerobic exercises include brisk walking, jogging, swimming and cycling. It is recommended to exercise at least 3 to 4 times a week, with at least 40 minutes of moderate-intensity aerobic exercise each time, which helps improve cardiovascular health and reduce the risk of cerebral infarction.

(5) Control your weight: Maintaining a healthy weight (BMI 18.5-23.9) is crucial to reducing the risk of cerebral infarction. Being overweight or obese increases the risk of hypertension and diabetes, thereby increasing the likelihood of cerebral infarction.

(6) Quit smoking and limit alcohol consumption: Smoking is a risk factor for arteriosclerosis and vascular obstruction, so smoking should be quit as soon as possible. Daily alcohol intake should be controlled to no more than 2 drinks for men and no more than 1 drink for women to avoid the cardiovascular risks caused by excessive drinking.

(7) Develop good sleeping habits: 7 to 8 hours of sleep every night helps maintain the health of the brain and body, and avoids health problems such as high blood pressure caused by lack of sleep.

(8) Mental health management: Long-term mental stress can lead to high blood pressure, anxiety and other problems, and increase the risk of cerebral infarction. You can relax yourself through meditation, yoga, deep breathing, etc. Maintaining an optimistic attitude is conducive to physical and mental health and reduces the risk of cardiovascular disease.

Figure 3 Copyright image, no permission to reprint

Although silent cerebral infarction is more common in the elderly, it is not limited to this age group. In the face of this health challenge, we do not need to worry too much, nor should we turn a blind eye. We should face it with a calm attitude, seek medical treatment in time, screen potential risk factors, cultivate a healthy lifestyle, and adopt scientific medical interventions to effectively control related risk factors, thereby achieving comprehensive risk prevention and control and ensuring good health.