Vascular Dementia Characterized by Multiple Lacunar Infarcts

Imaging Findings in Vascular Dementia

The American College of Radiology recognizes that classic MRI findings in vascular dementia include encephalomalacia from multiple cortical and subcortical infarcts, small but strategically placed lacunar infarcts, microhemorrhages, and white matter disease 1, 2
MRI with T2 FLAIR imaging can distinguish lacunar infarcts from perivascular spaces, both of which are associated with vascular risk factors and small vessel disease 1
The presence of multiple lacunar infarcts, particularly when combined with white matter signal changes in the corpus callosum, anterior temporal lobes, and external capsule, may indicate specific diagnoses like CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) 1, 2

The Canadian Stroke Best Practice Recommendations recognize that vascular cognitive impairment encompasses multiple presentations, including small-vessel disease with white matter lesions and lacunar infarcts as a predominant etiology 3, 4
Subcortical ischemic vascular dementia, which includes multiple lacunar infarctions as a defining feature, is one of the recognized clinical patterns of vascular cognitive impairment 5
Multi-infarct dementia is another recognized clinical pattern, characterized by the presence of multiple infarcts 5, 4

Lacunar infarcts are defined as cystic lesions smaller than 1 cm in size located in the basal ganglia, brain stem, or deep white matter (but not the cerebral cortex) 6

Mixed pathology is extremely common, with vascular disease frequently coexisting with Alzheimer's disease pathology in up to 38% of cases 5, 7
The presence of multiple lacunar infarcts does not exclude concurrent neurodegenerative processes, and comprehensive evaluation is essential 3, 4